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Background Current evidence suggests that Brugada syndrome (BrS), far from being a purely electrical condition, is associated with subtle mechanical abnormalities primarily affecting the right ventricle (RV). We aimed to characterize RV function in BrS and investigate the echocardiographic profile of patients with arrhythmic events, with a special focus on parameters of RV dyssynchrony using speckle-tracking echocardiography (STE). Methods An echocardiogram was performed in 71 BrS patients and 25 healthy controls. STE was performed to assess regional and global RV mechanics, including RV outflow tract shortening (RVOTS). RVOT contraction time was considered to calculate the modified RV mechanical dispersion (RVMDm). Arrhythmic events were prospectively evaluated in the BrS cohort. Results Compared to controls, BrS patients showed subtle contractile abnormalities, including impaired RV longitudinal strain, higher RV index of myocardial performance (RIMP) and lower RVOTS. BrS patients also exhibited a greater contraction delay between the lateral and the septal aspect of the RV. After a median follow-up of 7.3 year (IQR 5.2–10.8), 6 patients presented malignant arrhythmic events. RIMP >0.50, RVOTS 42 ms showed high sensitivity for the identification of BrS patients with arrhythmic events during follow-up. Conclusions Subtle RV mechanical abnormalities were present in BrS patients. RIMP and RVOTS, a novel STE-derived parameter, were found to be sensitive markers of arrhythmic events. Adding the RVOT contraction time to the analysis of RVMD may help identify patients at higher risk, reflecting the importance of the RVOT mechanical substrate in the assessment of the arrhythmic risk in BrS.

Introduction Previous studies have found sex differences in implantable cardiac defibrillator (ICD) implantation counseling, especially in primary prevention. Possible explanations to this phenomenon have been described: under-representation of women in clinical trials, patient's preferences, lower overall sudden cardiac death risk in women compared to men, higher prevalence of non-ischemic dilated cardiomyopathy (DCM) in women and better response to cardiac resynchronization therapy in this population. Nevertheless, this gap appears to narrow in most recent registries. Purpose Our aim is to asses if there is still sex discrimination in ICD counseling by comparing ICD implantation between men and women. Methods A single-centre retrospective registry of 160 patients with a reduced left ventricle ejection fraction (LVEF ≤35%) found in a routine transthoracic echocardiogram (TTE) from January 2019 to June 2020. Inclusion and exclusion flow chart is described in Picture 1. Data collected included demographic, clinical and echocardiographic characteristics. Date of heart disease diagnosis, earliest date of LVEF ≤35% diagnosis (with TTE or cardiac magnetic resonance) and date of death when applicable were recorded. Cardiac resynchronization devices with ICD function were also considered for the analysis. In ICD carriers, implantation date and type of prevention for indication were collected. ICD implants and deaths up to December 31, 2020 were included for the analysis. Results Basal characteristics are described in Picture 2. The mean age was 67.5 years and 24.4% of the population were women. Ischemic etiology was the most frequent etiology in the overall population and in the male group. In women, DCM was the most common etiology. Sixty-eight patients carried an ICD. No significant differences between both sexes, neither globally nor according to the implant indication (primary vs. secondary prevention) were observed. In the subgroup analysis of patients with ICD, there were no significant differences in the number of devices between men and women, neither in ischemic or non-ischemic etiology. In primary prevention, there was a non-significant trend towards earlier implantation of the device in women (1.4 years vs 3.4 years, p=0.008) since the diagnosis of LVEF ≤35%. In patients without ICD (n=92), the mean age was significantly higher (72.5 years vs. 60.8 years, p Conclusions Despite under representation of women in pur population, we could not find differences in ICD implantation decision based on gender, even considering differences in underlying cardiomyopathy. There was no delay in implantation depending on sex, and even the trend was towards earlier implantation in women. Funding Acknowledgement Type of funding sources: None. Inclusion and exclusion flow chartBasal characteristics

Sudden cardiac arrest (SCA) is an uncommon but devastating event among young adults. While inherited cardiomyopathies and channelopathies represent an important proportion of sudden deaths, coronary artery disease remains a significant contributor in this age group. ECG findings are essential to guide the first steps of diagnostic work‐up of SCA, but sometimes can overlap between different etiologies. In this article we present a 16‐year‐old female who experienced SCA during vigorous swimming whose ECG was compatible with long QT syndrome. However, evaluation of the coronary anatomy provided the diagnosis of Kawasaki disease., Sudden cardiac arrest is uncommon among young adults. Inherited cardiomyopathies and channelopathies are the most frequently identified cardiac etiologies. However, assessment of coronary artery anatomy is mandatory in order to rule out coronary artery anomalies.

Introduction and objectives: Endomyocardial biopsy (EMB) is an established diagnostic tool in myocardial disease. However, this technique may carry major complications. We present the diagnostic and safety results of our experience in EMB in the non-transplant setting. We also present the results after the implementation of a technical and safety protocol developed at our center. Methods: We retrospectively analyzed the data of all EMBs conducted in non-transplant patients from September 2004 through July 2018. We compared the diagnostic yield and rate of major complications of EMB in two different periods: before and after implementing the protocol. Results: We included 204 EMBs performed in 190 patients. The most frequent indications were the evaluation of ventricular dysfunction or suspected myocarditis (51.5%) and the evaluation of restrictive cardiomyopathy or suspected infiltrative disease (44.6%). One hundred and seventy-two EMBs were performed in the right cardiac chambers (84.3%) and 30 EMBs in the left cardiac chambers (14.7%). The specimens were taken from both ventricles on 2 cases only. Definite diagnosis was reached in 52% of the cases. After the implementation of the protocol, the diagnostic yield significantly improved (42.5% vs 58.1%; P = .030) and the rate of major complications decreased (from 7.5% to 3.2%; P = .167), with a statistically significant lower rate of cardiac perforation (6.3% vs 0.8%; P = .025). Conclusions: The EMB is a diagnostic tool with a great potential in patients with suspected cardiomyopathy. Our experience shows that a technical and safety protocol can help decrease the rate of complications and improve the diagnostic yield of EMB.

espanolIntroduccion y objetivos: La biopsia endomiocardica (BEM) es una tecnica diagnostica fundamental en el diagnostico de distintas miocardiopatias, pero no esta exenta de posibles complicaciones. Se presentan los resultados en terminos de rentabilidad diagnostica y seguridad de la serie de BEM realizadas en corazon no trasplantado en nuestro hospital, asi como las consecuencias de la implementacion de un protocolo de actuacion y seguridad en BEM desarrollado en nuestro centro. Metodos: Se revisaron de forma retrospectiva todas las BEM en corazon no trasplantado realizadas desde septiembre de 2004 hasta julio de 2018. Se comparo la rentabilidad diagnostica y seguridad en dos etapas: antes y despues de la puesta en marcha del protocolo. Resultados: Se incluyeron 204 BEM realizadas en 190 pacientes. La indicacion mas frecuente fue el estudio de disfuncion ventricular o sospecha de miocarditis (51,5%), seguida de estudio de miocardiopatia restrictiva o infiltrativa (44,6%). Se realizaron 172 BEM en cavidades derechas (84,3%) y 30 en cavidades izquierdas (14,7%); solo en 2 de los procedimientos se tomaron muestras de ambos ventriculos. La BEM permitio el diagnostico definitivo en el 52% de los casos. Tras la implementacion del protocolo se observo una mejoria en la rentabilidad diagnostica (42,5 frente a 58,1%; p = 0,030) y una disminucion en la tasa de complicaciones mayores (del 7,5% al 3,2%; p = 0,167), con una reduccion estadisticamente significativa en la tasa de perforaciones cardiacas (6,3 frente a 0,8%; p = 0,025). Conclusiones: La BEM es una tecnica con un gran potencial diagnostico en pacientes con sospecha de miocardiopatia. Aunque puede presentar complicaciones potencialmente graves, la puesta en marcha de un protocolo de actuacion y seguridad se asocia a una reduccion en la tasa de complicaciones y a una mejoria en la rentabilidad diagnostica. EnglishIntroduction and objectives: Endomyocardial biopsy (EMB) is an established diagnostic tool in myocardial disease. However, this technique may carry major complications. We present the diagnostic and safety results of our experience in EMB in the non-transplant setting. We also present the results after the implementation of a technical and safety protocol developed at our center. Methods: We retrospectively analyzed the data of all EMBs conducted in non-transplant patients from September 2004 through July 2018. We compared the diagnostic yield and rate of major complications of EMB in two different periods: before and after implementing the protocol. Results: We included 204 EMBs performed in 190 patients. The most frequent indications were the evaluation of ventricular dysfunction or suspected myocarditis (51.5%) and the evaluation of restrictive cardiomyopathy or suspected infiltrative disease (44.6%). One hundred and seventy-two EMBs were performed in the right cardiac chambers (84.3%) and 30 EMBs in the left cardiac chambers (14.7%). The samples were taken from both ventricles on 2 cases only. Definite diagnosis was reached in 52% of the cases. After the implementation of the protocol, the diagnostic yield significantly improved (42.5% vs 58.1%; P = .030) and the rate of major complications decreased (from 7.5% to 3.2%; P = .167), with a statistically significant lower rate of cardiac perforation (6.3% vs 0.8%; P = .025). Conclusions: The EMB is a diagnostic tool with a great potential in patients with suspected cardiomyopathy. Our experience shows that a technical and safety protocol can help decrease the rate of complications and improve the diagnostic yield of EMB.

Funding Acknowledgements Type of funding sources: None. Introduction The most frequent complications of atrial fibrillation (AF) ablation procedures are those related to the vascular access site, which are associated with increased morbidity and length of hospital stay. Purpose: To assess the safety and efficacy of venous access site closure with a suture-mediated vascular closure device (SVD), as well as the feasibility of early mobilization and same-day discharge protocol after AF ablation procedures. Methods: We conducted a retrospective analysis of all consecutive AF ablation patients in whom a SVD was employed to achieve hemostasis after each venous puncture. The ablation was performed under conscious sedation, using 7 to 12-F introducer sheaths. Anticoagulation was uninterrupted but for the last dose prior to the procedure. Intraprocedural heparin was not reversed. Groin ultrasound was performed in the first 10 patients with adequate SVD deployment. Three conditions were required for the same-day discharge protocol application: 1) uncomplicated procedure, 2) successful SVD deployment and 3) adequate recovery. Recovery followed a three-phase protocol: bed rest (two hours), sitting (one hour) and ambulation. Follow-up included phone call and clinical examination. Patients were offered contact to the electrophysiologist if needed. Results: 63 ablation procedures with SVD closure were performed from May 2019 to October 2020, with a total of 132 access sites analysed. Patient characteristics are shown in the table. The SVD was successfully deployed in 125 (94.7%) and hemostasis immediately achieved. In the remaining 5.3%, failure was attributed to a deficient technique, which missed to advance the knot to the vein. First 10 patients were ultrasound evaluated 24 hours later (no early discharge), showing total absence of complications. 35 subsequent patients (55.6% of the remaining 53) were discharged the same day without ultrasound control. The remaining 18 stayed overnight for reasons not related to the access site (hemodynamic surveillance, initiation of antiarrhythmic drugs or loss of phrenic capture), allowing in any case early mobilization (three hours after the procedure). Mean follow-up was 272 ± 160 days, with no adverse events recorded. Conclusion: SVD are safe and effective in achieving rapid hemostasis, making the early mobilization and same-day discharge protocol after AF ablation feasible in selected patients. Age 63 (57-71) Male 46 (73%) Body mass index (kg/m²) 27,5 (24,2-31,6) Previous anticoagulation- Vitamin K antagonist- Direct oral anticoagulation 50 (79,4%)14 (28%)36 (72%)

Previous studies using conventional echocardiographic measurements have reported subclinical left ventricular (LV) diastolic abnormalities in patients with Marfan syndrome (MFS). Left atrial (LA) strain allows an accurate categorization of LV diastolic dysfunction. We aimed to characterize LV myocardial performance in a cohort of MFS patients using STE-derived measurements (LV and LA strain) along with conventional echocardiographic parameters. We studied 127 adult patients with MFS (no prior cardiac surgery or significant valvular regurgitation) and 38 healthy controls. We performed detailed echocardiograms and selected left atrial reservoir strain (LASr) as a surrogate of impaired relaxation. Additionally, we searched for possible determinants of LASr in patients with MFS, with a special focus on the elastic properties of the aorta. In spite of lower E-wave, septal and lateral e’ velocities and average E/e’ ratio in MFS patients, all participants had normal diastolic function according to current guidelines. MFS patients exhibited reduced LV global longitudinal strain (19.3 ± 2.6 vs 21.6 ± 2.1%, p

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority Background Elevated left ventricular (LV) filling pressure is an important diagnostic feature of heart failure. Objectives To investigate determinants of left atrial (LA) reservoir and pump strain and if these parameters may serve as markers of LV filling pressure. Methods In a multicenter study of 322 patients with cardiovascular disease of different etiologies, LA strain by speckle tracking echocardiography was compared to conventional echocardiographic markers using invasive pressure as reference. Results Left ventricular filling pressure correlated well with LA reservoir and pump strain (r-values ‑0.52 and ‑0.57, respectively) (Figure). However, LV global longitudinal strain (GLS) was the strongest determinant of LA reservoir strain (r = 0.64), and correlated well with LA pump strain (r = 0.51). For both LA strains, association with filling pressure was strongest in patients with reduced LV ejection fraction. In patients with normal GLS (≥18%), atrial strains provided no information regarding filling pressure (Figure). Reservoir strain Conclusions Left atrial reservoir and pump strain may serve as clinical markers of LV filling pressure, but will be useful predominantly in patients with reduced systolic function. Due to limited diagnostic accuracy, LA strain should be used in combination with other indices. Abstract Figure

Implantable cardiac defibrillator (ICD) is the only definitive therapy for prevention of sudden cardiac death in hypertrophic cardiomyopathy (HCM). Conventional transvenous ICDs can provide cardiac pacing unlike new subcutaneous ICD, but the usefulness of cardiac pacing in HCM patients is not well defined. We sought to assess the usefulness of ICD pacing in HCM. We retrospectively analyzed 93 HCM patients who had undergone ICD implantation at our center. Usefulness of pacing was defined as follows: 1) need of pacing due to bradycardia or AV conduction disturbances, 2) improvement of LV outflow tract obstruction by sequential AV pacing, 3) need for CRT pacing, or 4) successful antitachycardia pacing without a subsequent shock. Independent predictors of useful pacing were investigated by multivariable analysis. During a mean follow-up of 91.3 ± 5.5 months, 43 patients (46.2%) reached the composite endpoint. Independent predictors of pacing usefulness were older age (HR 1.36; 95%CI: 1.088–1.709; p=0.007) and NYHA functional class ≥ II (HR 2.15; 95%CI: 1.083–4.301; p=0.029). Twenty-eight (30.1%) patients had appropriate ICD interventions, triggered by a monomorphic ventricular tachycardia (MVT) in 22 of them (78.5%). In 17 individuals with MVT (77%), antitachycardia pacing successfully treated MVT. In our HCM series of patients with ICD, 46% of individuals benefitted from cardiac pacing. MVT were documented in nearly 80% of the patients with ventricular arrhythmias and antitachycardia pacing successfully treated them in 77% of cases.

Introduction Pulmonary hypertension (PH) is defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest, measured by right heart catheterization (RHC). Purpose To describe classical and myocardial deformation echocardiographic parameters in patients with established PH and to identify prognostic variables Methods We prospectively enrolled 76 patients with mPAP ≥25 mmHg undergoing RHC between 2017 and 2018. All subjects underwent transthoracic echocardiography (TTE) according to the latest ASE/EACVI guidelines the same day of the RHC. Strain analysis was carried out by speckle-tracking echocardiography (QLAB 10.7, Philips). Clinical events during the follow-up were: acute heart failure hospitalization, cardiac transplant and all-cause mortality. Results Mean age was 59±12, 43.4% were women and 49 patients (64.5%) belonged to group 2 of PH. The median follow-up was 288 (ICR 92–534) days. Total number of events was 42 (55.3%, 9 deaths). Variables associated to events are shown in Table 1. All classic LV and RV systolic function and strain parameters were associated with a worse prognosis, being free-wall RV longitudinal strain (RVLS) the only one that remained as a prognostic factor in mutivariate analysis. Other variables associated with a worse prognosis were PCP>15 mmHg and NT-proBNP>1800, the latter being independent predictor of events. The attached figure shows event-free survival curves for the global population divided according to whether or not they belong to group II PH. Conclusions Our data highlight the prognostic value of free-wall RVLS and NT-proBNP in patients with established PH. NT-ProBNP was only useful in group II PH while free-wall RVLS identified patients with a higher risk of events in both groups, mainly in patients with heart disease Free event survival Curves Funding Acknowledgement Type of funding source: None

OBJECTIVE Anxiety is often present among patients with atrial fibrillation (AF). This condition has been associated with greater symptom severity and worse quality of life in these patients. However, the influence of anxiety on the risk of AF recurrence is not well known. We aimed to define the level of anxiety in patients with persistent AF undergoing elective cardioversion (EC) and determine whether there is an association between anxiety and the risk of early AF recurrence after EC. METHODS Anxiety was measured before EC using the State-Trait Anxiety Inventory. Early AF recurrence was assessed with a control electrocardiogram at 30-day follow-up. RESULTS We included 107 patients undergoing effective EC. Early AF recurrence was diagnosed in 40 patients (37.4%). Compared with those who remained in sinus rhythm, individuals with early AF recurrence had significantly higher levels of trait anxiety (23.1 [10.4] versus 17.9 [9.5]; p = .013) and larger left atrial volume index (45.8 [12.3] versus 37.9 [13.3] ml/m; p = .004). Both variables remained independently associated with early AF recurrence after multivariate analysis. A predictive model including trait anxiety score >20 and left atrial volume index >41 ml/m showed acceptable accuracy for the diagnosis of early AF recurrence (area under the curve = 0.733; 95% confidence interval = 0.634-0.832; p < .001). CONCLUSIONS Our study shows that trait anxiety is an independent risk factor for early AF recurrence after EC. Further studies are warranted to assess the beneficial role of anxiety-reducing strategies on the outcomes of patients with AF.

Resumen: Objetivo: El bloqueo interauricular (BIA) es una entidad asociada con un mayor riesgo de presentar fibrilación auricular (FA), constituyendo el denominado síndrome de Bayés. El objetivo de nuestro estudio fue definir la prevalencia de BIA en pacientes menores de 65 años sometidos a cirugía cardiaca y determinar si existe una asociación entre la presencia de BIA y la aparición de FA postoperatoria. Método: Se incluyeron un total de 207 pacientes. Se definió BIA parcial como onda P > 120 ms. Se definió BIA avanzado como onda P > 120 ms con morfología bifásica en derivaciones inferiores. Se determinó la frecuencia de aparición de FA postoperatoria y se realizó un análisis comparativo entre los pacientes que presentaron y los que no presentaron esta arritmia. Resultados: La prevalencia de BIA fue del 78.3% (parcial, 66.2%; avanzado, 12.1%). La frecuencia de aparición de FA fue del 28.5% de forma global, siendo mayor en los pacientes con BIA avanzado (44%) comparado con pacientes con BIA parcial (27.7%) y sin BIA (24.4%). Los pacientes que presentaron FA fueron significativamente mayores, con niveles más elevados de NTproBNP y presentaron mayor prevalencia de dilatación auricular y de patología tiroidea. El análisis multivariable demostró una asociación independiente entre BIA avanzado y FA postoperatoria. Conclusiones: El BIA es una entidad frecuente en pacientes sometidos a cirugía cardiaca. En nuestro estudio, el BIA avanzado se asocia de forma independiente con una mayor frecuencia de FA postoperatoria en pacientes menores de 65 años sometidos a cirugía cardiaca. Abstract: Objective: Interatrial block (IAB) is a well-known entity that is associated with an increased risk of atrial fibrillation (AF). This association is called Bayes’ syndrome. The aim of our study was to define the prevalence of IAB among patients younger than 65 years undergoing cardiac surgery and determine whether there is an association between the presence of interatrial conduction delay and postoperative atrial fibrillation (POAF). Method: A total of 207 patients were enrolled. Partial IAB was defined as P-wave > 120 ms. Advanced IAB was defined as P-wave > 120 ms + biphasic morphology in the inferior leads. Ocurrence of POAF was assessed and a comparative analysis was conducted between patients that did and did not develop AF. Results: IAB prevalence was 78.3% (partial 66.2%, advanced 12.1%). POAF occurred in 28.5% of all patients, and was more frequent among patients with advanced IAB (44%) compared to 27.7% and 24.4% of POAF among patients with partial IAB and without IAB, respectively. Patients who developed POAF were significantly older, had significantly higher NTproBNP, higher prevalence of atrial enlargement and thyroid disease. After multivariate analysis, advanced IAB was found to be independently associated with POAF. Conclusions: IAB is a frequent finding among patients undergoing cardiac surgery. According to our results, advanced IAB is independently associated with POAF in younger patients (

A 83-year-old woman with a single-chamber pacemaker implanted 15 years earlier was brought to the ED due to symptomatic bradycardia. ECG continuous monitoring allowed the diagnosis of atrial fibrillation with complete atrioventricular block in the setting of a complete failure to capture. The differing timing cycles of pacing outputs can confirm that sensing is preserved in the absence of a pacemaker programmer.