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Backgroundwide antral pulmonary vein isolation (PVI) is effective for treating paroxysmal atrial fibrillation (PAF), although time-demanding. We investigated the impact of a standardized ablation protocol by using a bidirectional transeptal steerable sheath, high-density mapping and very high-power-short-duration (vHPSD) catheters on procedure timing, efficacy, and safety.Methodsconsecutive PAF patients free from previous ablations undergoing PVI alone between January 2022 and March 2023 were prospectively enrolled. The standardized workflow included general anesthesia, a single transeptal puncture trough with a bidirectional, steerable visualizable sheath introduced into the left atrium accommodated a high density, penta-spline mapping catheter and a contact force sensor ablation catheter enabled to deliver vHPSD. Procedural data and electrophysiology (EP) laboratory times were systematically collected and analyzed. The primary endpoint was any AF or atrial tachycardia recurrence at 12 and 24 month follow up.Resultsthe study cohort was composed by 138 patients (mean age was 59 ± 11 years, 38% female) and successful PVI was achieved in 100% of cases. Overall, first pass isolation (PFI) was 93%, with a LA dwell time of 32 ± 4 min. Significant complications were reported in 3% of patients. Skin-to-skin time and total EP laboratory time were 58 ± 5 min and 85 ± 7 min, respectively. The primary endpoint was achieved by 9% and 12% of cases at 12 and 24 month follow up, respectively. Upper limit skin-to-skin time and missed FPI resulted predictors of the primary endpoint.ConclusionThis standardized workflow resulted in low procedural times and arrhythmias recurrence without compromising the safety.

BackgroundElectrical remodeling has been linked to the progression and recurrence of atrial fibrillation (AF) after catheter ablation (CA). Substrate mapping based solely on a voltage amplitude electrogram (EGM) does not provide a comprehensive understanding of the left atrial (LA) disease. The aim of this study is to assess left atrial spatial entropy (LASE) from voltage maps routinely obtained during AF ablation to further characterize the LA substrate.Materials and MethodsHigh-density electroanatomic maps (EAMs) of 27 patients with paroxysmal or persistent AF undergoing routine CA were prospectively collected. Computational post-processing was performed on the voltage maps. Using the Shannon entropy model, the probability distribution of the amplitude range values associated with each point of the map was used to measure LASE. Finally, correlations between LASE and clinical and electrophysiological characteristics of AF were explored.ResultsLASE differentiated between patients with paroxysmal and persistent AF (6.45 ± 0.41 vs. 5.87 ± 0.53; p = 0.028) and patients with normal and abnormal LA substrate (6.42 ± 0.42 vs. 5.87 ± 0.56; p = 0.043), independent of the basal rhythm during EM acquisition (6.33 ± 0.41 vs. 6.11 ± 0.63; p = 0.619). Accordance between LASE and EAMs was assessed by ROC analysis (AUC: 0.81; C.I.: 0.62–0.99; Youden index: 6.06; sensitivity: 80%; and specificity: 80%). Patients with the lowest LASE reported AF recurrence at the follow-up.ConclusionLASE may play a role in the further characterization of the LA substrate and the type of AF, independent of basal rhythm.

Key Clinical Message A 46‐year‐old woman with congenitally corrected transposition of the great arteries (ccTGA) associated with dextrocardia, situs viscerus inversus, and left superior vena cava persistence presented with an incessant supraventricular tachycardia. Electrophysiological study was not conclusive in differential diagnosis of atrial tachycardia versus atypical atrioventricular (AV) nodal reentrant tachycardia, also due to the unconventional anatomy of the coronary sinus. By a comprehensive mapping of cardiac chambers, a double side slow‐pathway was localized in both atrial chambers and subsequently ablated by radiofrequency delivery without tachycardia changes. Aortic root and cusps were devoid of electrical activity. The muscular part of the sub‐pulmonary ventricle at the level of interatrial septum showed an earliest activation signal of −90 ms and ablation of this site was effective in abolish the tachycardia. This is the first case to report technical concerns of septal atrial tachycardia ablation in ccTGA associated with multiple anatomical malformations. Moreover, some peculiarities have been reported for the first time including the presence of double‐side AV nodal slow‐pathway and atypical localization of the tachycardia origin into the muscular part of the sub‐pulmonary ventricle instead of posterior pulmonary cusp.

Cardiac amyloidosis is the most frequent infiltrative disease caused by the deposition of misfolded proteins in the cardiac tissue, leading to heart failure, brady- and tachyarrhythmia and death. Conduction disorders, atrial fibrillation (AF) and ventricular arrhythmia (VA) significantly impact patient outcomes and demand recognition. However, several issues remain unresolved regarding early diagnosis and optimal management. Extreme bradycardia is the most common cause of arrhythmic death, while fast and sustained VAs can be found even in the early phases of the disease. Risk stratification and the prevention of sudden cardiac death are therefore to be considered in these patients, although the time for defibrillator implantation is still a subject of debate. Moreover, atrial impairment due to amyloid fibrils is associated with an increased risk of AF resistant to antiarrhythmic therapy, as well as recurrent thromboembolic events despite adequate anticoagulation. In the last few years, the aging of the population and progressive improvements in imaging methods have led to increases in the diagnosis of cardiac amyloidosis. Novel therapies have been developed to improve patients’ functional status, quality of life and mortality, without data regarding their effect on arrhythmia prevention. In this review, we consider the latest evidence regarding the arrhythmic risk stratification of cardiac amyloidosis, as well as the available therapeutic strategies.

Condition Monitoring (CM) is an extremely critical application of the Internet of Things (IoT) within Industry 4.0 and Smart City scenarios, especially following the recent energy crisis. CM aims to monitor the status of a physical appliance over time and in real time in order to react promptly when anomalies are detected, as well as perform predictive maintenance tasks. Current deployments suffer from both interoperability and management issues within their engineering process at all phases– from their design to their deployment, to their management–, often requiring human intervention. Furthermore, the fragmentation of the IoT landscape and the heterogeneity of IoT solutions hinder a seamless onboarding process of legacy devices and systems. In this paper, we tackle these problems by first proposing an architecture for CM based on both abstraction layers and toolchains, i.e., automated pipelines of engineering tools aimed at supporting the engineering process. In particular, we introduce four different toolchains, each of them dedicated to a well-defined task (e.g., energy monitoring). This orthogonal separation of concerns aims to simplify both the understanding of a complex ecosystem and the accomplishment of independent tasks. We then illustrate our implementation of a complete CM system that follows said architecture as a real Structural Health Monitoring (SHM) pilot of the Arrowhead Tools project, by describing in detail every single tool that we developed. We finally show how our pilot achieves the main objectives of the project: the reduction of engineering costs, the integration of legacy systems, and the interoperability with IoT frameworks.

Over the past decade, remote monitoring (RM) has become an increasingly popular way to improve healthcare and health outcomes. Modern cardiac implantable electronic devices (CIEDs) are capable of recording an increasing amount of data related to CIED function, arrhythmias, physiological status and hemodynamic parameters, providing in-depth and updated information on patient cardiovascular function. The extensive use of RM for patients with CIED allows for early diagnosis and rapid assessment of relevant issues, both clinical and technical, as well as replacing outpatient follow-up improving overall management without compromise safety. This approach is recommended by current guidelines for all eligible patients affected by different chronic cardiac conditions including either brady- and tachy-arrhythmias and heart failure. Beyond to clinical advantages, RM has demonstrated cost-effectiveness and is associated with elevated levels of patient satisfaction. Future perspectives include improving security, interoperability and diagnostic power as well as to engage patients with digital health technology. This review aims to update existing data concerning clinical outcomes in patients managed with RM in the wide spectrum of cardiac arrhythmias and Hear Failure (HF), disclosing also about safety, effectiveness, patient satisfaction and cost-saving.

Abstract Modeling ferroelectric materials from first principles is one of the successes of density-functional theory and the driver of much development effort, requiring an accurate description of the electronic processes and the thermodynamic equilibrium that drive the spontaneous symmetry breaking and the emergence of macroscopic polarization. We demonstrate the development and application of an integrated machine learning model that describes on the same footing structural, energetic, and functional properties of barium titanate (BaTiO3), a prototypical ferroelectric. The model uses ab initio calculations as a reference and achieves accurate yet inexpensive predictions of energy and polarization on time and length scales that are not accessible to direct ab initio modeling. These predictions allow us to assess the microscopic mechanism of the ferroelectric transition. The presence of an order-disorder transition for the Ti off-centered states is the main driver of the ferroelectric transition, even though the coupling between symmetry breaking and cell distortions determines the presence of intermediate, partly-ordered phases. Moreover, we thoroughly probe the static and dynamical behavior of BaTiO3 across its phase diagram without the need to introduce a coarse-grained description of the ferroelectric transition. Finally, we apply the polarization model to calculate the dielectric response properties of the material in a full ab initio manner, again reproducing the correct qualitative experimental behavior.

Fluoroscopy has always been the cornerstone imaging method of interventional cardiology procedures. However, radiation exposure is linked to an increased risk of malignancies and multiorgan diseases. The medical team is even more exposed to X-rays, and a higher incidence of malignancies was reported in this professional group. In the last years, X-ray exposure has increased rapidly, involving, above all, the medical team and young patients and forcing alternative fluoroless imaging methods. In cardiac electrophysiology (EP) and pacing, the advent of 3D electroanatomic mapping systems with dedicated catheters has allowed real-time, high-density reconstruction of both heart anatomy and electrical activity, significantly reducing the use of fluoroscopy. In addition, the diffusion of intracardiac echocardiography has provided high anatomical resolution of moving cardiac structures, providing intraprocedural guidance for more complex catheter ablation procedures. These methods have largely demonstrated safety and effectiveness, allowing for a dramatic reduction in X-ray delivery in most arrhythmias’ ablations. However, some technical concerns, as well as higher costs, currently do not allow their spread out in EP labs and limit their use to only procedures that are considered highly complex and time-consuming and in young patients. In this review, we aim to update the current employment of fluoroless imaging in different EP procedures, focusing on its strengths and weaknesses.

The Web of Things (WoT) paradigm was proposed first in the late 2000s, with the idea of leveraging Web standards to interconnect all types of embedded devices. More than ten years later, the fragmentation of the IoT landscape has dramatically increased as a consequence of the exponential growth of connected devices, making interoperability one of the key issues for most IoT deployments. Contextually, many studies have demonstrated the applicability of Web technologies on IoT scenarios, while the joint efforts from the academia and the industry have led to the proposals of standard specifications for developing WoT systems. Through a systematic review of the literature, we provide a detailed illustration of the WoT paradigm for both researchers and newcomers, by reconstructing the temporal evolution of key concepts and the historical trends, providing an in-depth taxonomy of software architectures and enabling technologies of WoT deployments and, finally, discussing the maturity of WoT vertical markets. Moreover, we identify some future research directions that may open the way to further innovation on WoT systems.

Open History Map, an open map of the past that was already presented as a concept a few years ago, is now in its first year of functioning infrastructure and collects around 150GB of data from around 90 sources. The platform is open in all of its aspects and enables research groups to create new importers for their own open datasets. In addition to that, OHM enables the visualization of "ephemeral" datasets, i.e. representation of vicinity for historical characters and vehicles, battles and events. The present work will analyze the status of the project and the contributions it is doing to the general DH and PH sector, specifically on source quality management and general cloud first architectures. OHM is based on the collection of open datasets available online. The geographic precision as well as the informational quality varies a lot between sources, research teams, projects. These factors higlight the need of a tool to manage the data quality, which we called OHM Open Data Index, (https:// index.openhistorymap.org) where we collect all sources we find and all datasets we import in order to analyze and display the general quality and/or lack of data. The complexity of the infrastructure behind a project such as Open History Map required an original and cloud-first approach, enabling the optimization of every single aspect of the development as well as the deployment and the usage of the system. For this reason a cloud-first approach was used, trying to harness all the features of the most common FLOS software platforms in order to maximize the quality of the final product.

Intraprocedural stroke is a well-documented and feared potential risk of cardiovascular transcatheter procedures (TPs). Moreover, subclinical neurological events or covert central nervous system infarctions are concerns related to the development of dementia, future stroke, cognitive decline, and increased risk of mortality. Cerebral protection devices (CPDs) were developed to mitigate the risk of cardioembolic embolism during TPs. They are mechanical barriers designed to cover the ostium of the supra-aortic branches in the aortic arch, but newer devices are able to protect the descending aorta. CPDs have been mainly designed and tested to provide cerebral protection during transcatheter aortic valve replacement (TAVR), but their use in both Catheterization and Electrophysiology laboratories is rapidly increasing. CPDs have allowed us to perform procedures that were previously contraindicated due to high thromboembolic risk, such as in cases of intracardiac thrombosis identified at preprocedural assessment. However, several concerns related to their employment have to be defined. The selection of patients at high risk of thromboembolism is still a subjective choice of each center. The aim of this review is to update the evidence on the use of CPDs in either Cath labs or EP labs, providing an overview of their structural characteristics. Future perspectives focusing on their possible future employment are also discussed.

The difference between subcutaneous implantable cardioverter defibrillators (S-ICDs) and transvenous ICDs (TV-ICDs) concerns a whole extra thoracic implantation, including a defibrillator coil and pulse generator, without endovascular components. The improved safety profile has allowed the S-ICD to be rapidly taken up, especially among younger patients. Reports of its role in different cardiac diseases at high risk of SCD such as hypertrophic and arrhythmic cardiomyopathies, as well as channelopathies, is increasing. S-ICDs show comparable efficacy, reliability, and safety outcomes compared to TV-ICD. However, some technical issues (i.e., the inability to perform anti-bradycardia pacing) strongly limit the employment of S-ICDs. Therefore, it still remains only an alternative to the traditional ICD thus far. This review aims to provide a contemporary overview of the role of S-ICDs compared to TV-ICDs in clinical practice, including technical aspects regarding device manufacture and implantation techniques. Newer outlooks and future perspectives of S-ICDs are also brought up to date.

Atrial flutter (AFL) is a common atrial arrhythmia typically characterized by electrical activity propagating around specific anatomical regions. It is usually treated with catheter ablation. However, the identification of rotational activities is not straightforward, and requires an intense effort during the first phase of the electrophysiological (EP) study, i.e., the mapping phase, in which an anatomical 3D model is built and electrograms (EGMs) are recorded. In this study, we modeled the electrical propagation pattern of AFL (measured during mapping) using network theory (NT), a well-known field of research from the computer science domain. The main advantage of NT is the large number of available algorithms that can efficiently analyze the network. Using directed network mapping, we employed a cycle-finding algorithm to detect all cycles in the network, resembling the main propagation pattern of AFL. The method was tested on two subjects in sinus rhythm, six in an experimental model of in-silico simulations, and 10 subjects diagnosed with AFL who underwent a catheter ablation. The algorithm correctly detected the electrical propagation of both sinus rhythm cases and in-silico simulations. Regarding the AFL cases, arrhythmia mechanisms were either totally or partially identified in most of the cases (8 out of 10), i.e., cycles around the mitral valve, tricuspid valve and figure-of-eight reentries. The other two cases presented a poor mapping quality or a major complexity related to previous ablations, large areas of fibrotic tissue, etc. Directed network mapping represents an innovative tool that showed promising results in identifying AFL mechanisms in an automatic fashion. Further investigations are needed to assess the reliability of the method in different clinical scenarios.

The Web of Things (WoT) standard recently promoted by the W3C constitutes a promising approach to devise interoperable IoT systems able to cope with the heterogeneity of software platforms and devices. The WoT architecture envisages interconnected IoT scenarios characterized by a multitude of Web Things (WTs) that interact according to well-defined software interfaces; at the same time, it assumes static allocations of WTs to hosting devices, and it does not cope with the intrinsic dynamicity of IoT environments in terms of time-varying network and computational loads. In this paper, we extend the WoT paradigm for cloud-edge continuum deployments, hence supporting dynamic orchestration and mobility of WTs among the available computational resources. Differently from state-of-art Mobile Edge Computing (MEC) approaches, we heavily exploit the W3C WoT, and specifically its capability to standardize the software interfaces of the WTs, in order to propose the concept of a Migratable WoT (M-WoT), in which WTs are seamlessly allocated to hosts according to their dynamic interactions. Three main contributions are proposed in this paper. First, we describe the architecture of the M-WoT framework, by focusing on the stateful migration of WTs and on the management of the WT handoff process. Second, we rigorously formulate the WT allocation as a multi-objective optimization problem, and propose a graph-based heuristic. Third, we describe a container-based implementation of M-WoT and a twofold evaluation, through which we assess the performance of the proposed migration policy in a distributed edge computing setup and in a real-world IoT monitoring scenario.

Abstract The number of patients with nonischemic cardiomyopathy (NICM) undergoing catheter ablation of ventricular tachycardia (VT) has increased by the years, however, there are no randomized studies of VT ablation in this population. Many studies have reported more mixed or inferior outcome after the ablation in patients with NICM as compared to in those with ischemic cardiomyopathy (ICM)—likely because of the heterogeneous VT substrates in each etiology. While, various ablation strategies for substrate modification in the setting of ICM, including low voltage area ablation, late potential abolition, and local abnormal ventricular activity elimination, have been well established, it is still unknown which ablation strategy is effective for prevention of recurrence VTs in NICM patients. Therefore, this review will highlight the recent progress made in VT ablation in patients with NICM.