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Funding Acknowledgements Type of funding sources: None. Background/Introduction Pulmonary vein (PV) reconnection is commonly associated with recurrence of atrial fibrillation (AF) after the initial catheter ablation procedure. Visualization and identification of PV reconnections are critical during repeat procedures. Purpose To examine the use of dynamic mapping (LiveView) in combination with a high-density mapping catheter (HD Grid) in the recognition of PV reconnections in redo AF ablation procedures. Methods Acute procedure data from 81 patients were prospectively collected. Mapping catheter selection and the use of LiveView was determined at the physician’s discretion. For cases where LiveView was used, the location and number of gaps from the previous procedure were identified using both standard mapping and dynamic mapping separately. Results Most of the patients included in the analysis were treated for paroxysmal AF (PAF: n=63/81, 77.8%). Dynamic mapping data was incorporated in 50 PAF cases and 15 persistent AF cases. Within these 65 cases, standard mapping identified a total of 120 PV gaps whereas LiveView identified a total of 138 PV gaps; gaps were most frequently identified on the right PVs, especially in the anterior region (Table1). A contact force-sensing ablation catheter was commonly (n=64/81, 79%) used by the operators. The right anterior region was ablated with an average contact force of 13.8±3.1g and Lesion index (LSI) of 5.2±0.7 at a power of 35.8±8.4W. Non-PV ablation was performed in 38 (46.9%) patients; the most common lesion sets were roofline, cavotricuspid isthmus (CTI) line, and mitral isthmus line. Acute PV isolation was achieved in all patients at the end of the procedure. Conclusion Data from this analysis suggest the incorporation of dynamic mapping data may help reveal more PV reconnections compared to standard mapping. Additional study is needed to assess the long-term clinical outcomes when regional dynamic mapping data is used to identify PV reconnections in repeat procedures.

Introduction Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). ESC guidelines state as class IIB indication left appendage exclusion in patients with contraindication to oral anticoagulation. Here we give our contribute to the issue of safety and efficacy of standalone totally thoracoscopic left appendage exclusion (TT-LAE) for stroke prevention in patients with contraindication to oral anticoagulant or at risk of life threatening hemorrhage on antiplatelet therapy: a large single Centre experience. Materials and methods 60 patients with non valvular AF and contraindication to oral anticoagulation (25 cerebral hemorrhages,8 GI bleeding, 18 non cerebral/Gi bleeding requiring multiple transfusions, 2 myelodysplastic syndrome, 7 anatomy unsuitable for percutaneous closure, 75%male, patients age ranged 53–87 years,mean CHAD-VASC 6.4,mean HASBLED range 4.7, type of AF permanent 76.6%, 23.4% longstanding persistent), underwent stand alone totally thoracoscopic appendage exclusion. All patinets enrolled after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography, spirometry and cerebrovascuar doppler ultrasound. Intraoperative appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit. Follow up (range 35–1 months) included outpatient visit and CT scan or TEE at 3–6-12 month in all patients to document LAA exclusion. Perioperative mortality and early and late morbidity in addition to freedom from neurological events at follow up were analyzed by chart evaluation and full outpatient neurological examination including including the Questionnaire for Verifying Stroke Free Status (QVSFS) as validated screening tool. Results Mean duration of surgery “skin to skin” was 52.4 minutes; all patients were extubated shortly after the procedure. There were no deaths nor need for blood transfusion or pulmonary procedure related morbidities, only three casea of pericarditis treated with colchicine till complete resolution was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with minimal residual stumps and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit and questionnaire filling. Conclusion Standalone totally thoracoscopic left appendage clipping is a safe and effective procedure for stroke prevention in patients with permanent and longstanding persistent atrial fibrillation with contraindication to oral anticoagulation. Longer follow up and an European registry are needed to, possibly, confirm this preliminary results. Funding Acknowledgement Type of funding source: None

Introduction The most appropriate treatment for stroke prevention in standalone atrial fibrillation patients with a high CHADS2VASC score contraindicated for oral anticoagulation (OAC) or novel OAC (NOAC) still needs to be defined. Percutaneous left atrial appendage (LAA) closure devices are available, but because of their endocardial positioning need a period of antiplatelet therapy (APT). This study aimed to evaluate the safety and efficacy of epicardial left atrial appendage clipping in patients contraindicated for (N)OAC and APT. Methods and results We describe a standalone totally thoracoscopic LAA clipping of forty-five consecutive patients with nonvalvular atrial fibrillation (NVAF; 32 males; age, 73.1 ± 7.4 years; CHADVASC, 6.5 ± 1.1; HAS-BLED 4.9 ± 0.9) with absolute contraindications to (N)OAC. The patients were selected by a multidisciplinary Heart Team. Sixty percent had a previous ischemic stroke and 51% a history of the hemorrhagic event and 22% both. All patients were implanted with an LAA epicardial clip, guided by preoperative computed tomography and intraoperative transesophageal echocardiography. The mean procedural duration was 52.3 ± 12.6 minutes with postprocedural extubation interval of 22.8 ± 14.6 minutes. No procedure-related complications occurred. Intraprocedural transesophageal echocardiography (TEE) showed complete LAA occlusion in all patients. At a mean follow-up of 16.4 ± 9.1 months (range, 2-34), with all patients off (N)OAC or APT, no ischemic stroke or hemorrhagic complications occurred. computed tomography or TEE at follow-up demonstrated a correct LAA occlusion in all with mean stumps of 3.3 ± 2.8 mm. Conclusion Thoracoscopic epicardial closure of the LAA with the AtriClip PRO2 device is a potentially safe and efficient treatment for stroke prevention in patients with NVAF contraindicated for anticoagulant therapy or APT.

Background The traditional technique for subcutaneous implantable cardioverter defibrillator (S-ICD) implantation, which involves three incisions and a subcutaneous pocket, is associated with possible complications, including inappropriate interventions. The aim of this prospective multicenter study was to evaluate the efficacy and safety of an alternative intermuscular two-incision technique for S-ICD implantation. Methods The study population included 36 consecutive patients (75% male, mean age 44 ± 12 years [range 20–69]) who underwent S-ICD implantation using the intermuscular two-incision technique. This technique avoids the superior parasternal incision for the lead placement and consists of creating an intermuscular pocket between the anterior surface of the serratus anterior and the posterior surface of the latissimus dorsi muscles instead of a subcutaneous pocket. Results All patients were successfully implanted in the absence of any procedure-related complications with a successful 65-J standard polarity defibrillation threshold testing, except in one, who received a second successful shock after pocket revision. During a mean follow-up of 10 months (range 3–30), no complications requiring surgical revision were observed. At device interrogation, stable sensing without interferences was observed in all patients. Two patients (5.5%) experienced appropriate and successful shock on ventricular fibrillation and in four patients (11%), a total of seven nonsustained self-terminated ventricular tachycardias were correctly detected. No inappropriate interventions were observed. Conclusions Our experience suggests that the two-incision intermuscular technique is a safe and efficacious alternative to the current technique for S-ICD implantation that may help reducing complications including inappropriate interventions and offer a better cosmetic outcome, especially in thin individuals.

Aims The effectiveness of atrial fibrillation (AF) ablation relies on detailed knowledge of the anatomy of the left atrium (LA) and pulmonary veins (PVs). It is common to combine computed tomography/magnetic resonance (CT/MR) with imaging by electroanatomical (EA) mapping systems. The aim of this study was to evaluate the accuracy of LA anatomical reconstruction by ‘One Model’ and ‘VeriSense’ tools (Ensite Velocity 3.0, St Jude Medical), compared with CT/MR imaging. Methods and results Seventy-two patients with AF underwent pre-procedural imaging (97% CT-scan, 3% MR imaging) and transcatheter ablation of PVs. Operators were blinded to CT/MR imaging. Electrical Coupling Index (ECI) was used to recognize venous structures when the circular catheter could not. The LA ‘One Model’ map was obtained without complications; all 124 main left PVs and 144 main right PVs were detected. Nine of 9 intermediate right PVs and 30 of 30 early branches were detected, whereas 1 of the 27 early branches on the right inferior PVs was missed. Comparison between LA intervein distances measured on the roof (RO) and the posterior wall (PW) showed a high correspondence between the EA model and CT/MR imaging (RO CT/MR imaging vs. EA: 32 ± 7 vs. 32 ± 7 mm; PW CT/MR imaging vs. EA: 36 ± 6 vs. 36 ± 7 mm). The EA model yielded slightly larger PV ostia diameters, owing to the distortion caused by catheter pressure. Conclusions Recent 3D mapping tools allow outstanding anatomical rendering and are key in complex ablation procedure set-up. This study shows that 3D anatomical reconstruction of LA, PVs, and their variable branches is not only safe and fast but also accurate and reliable.

Introduction The recently developed second‐generation subcutaneous implantable cardioverter defibrillator (S‐ICD) and the intermuscular two‐incision implantation technique demonstrate potential favorable features that reduce inappropriate shocks and complications. However, data concerning large patient populations are lacking. The aim of this multicentre prospective study was to evaluate the safety and outcome of second‐generation S‐ICD using the intermuscular two‐incision technique in a large population study. Methods and Results The study population included 101 consecutive patients (75% male; mean age, 45 ± 13 years) who received second‐generation S‐ICD (EMBLEM; Boston Scientific, Marlborough, MA) implantation using the intermuscular two‐incision technique as an alternative to the standard implantation technique. Twenty nine (29%) patients were implanted for secondary prevention. Twenty four (24%) patients had a previously implanted transvenous ICD. All patients were implanted without any procedure‐related complications. Defibrillation testing was performed in 80 (79%) patients, and ventricular tachycardia was successfully converted at less than or equal to 65 J in 98.75% (79/80) of patients without pulse generator adjustments. During a median follow‐up of 21 ± 10 months, no complications requiring surgical revision or local or systemic device‐related infections were observed. Ten patients (9.9%) received appropriate and successful shocks for ventricular arrhythmias. Three (2.9%) patients experienced inappropriate shocks due to oversensing the cardiac signal (n = 1), noncardiac signal (n = 1), and a combination of both cardiac and noncardiac signals (n = 1), with one patient requiring device explantation. No patients required device explantation due to antitachycardia pacing indications. Conclusions According to our multicentre study, second‐generation S‐ICD implanted with the intermuscular two‐incision technique is an available safe combination and appears to be associated with a low risk of complications, such as inappropriate shocks.

Slow pathway ablation in common AVNRT can be complicated by total AV block. When radiofrequency energy is delivered to the posterior aspect of the triangle of Koch, total AV block may be the consequence of the absence of anterograde conduction along the fast pathway or of inadvertent damage to a fast pathway abnormally located close to the slow pathway. To localize the anterogradely conducting fast pathway, the triangle of Koch was pacemapped in 72 patients who underwent the ablation of common AVNRT. In all cases, before ablation the St-H interval was calculated by stimulating the anteroseptal (AS), mid-septal (MS), and posteroseptal (PS) aspect of the triangle of Koch at a rate slightly faster than the sinus rate. In all patients, common AVNRT was induced. In 64 (89%) of 72 patients (group A) the shortest St-H interval was recorded on stimulating the AS region. In six (8%) patients (group B) the shortest St-H interval was recorded on stimulating the MS region. Finally, in two (3%) patients (group C) the shortest St-H interval was recorded stimulating in the PS region. In group C, AH interval, calculated on stimulating in the AS region, was significantly longer than in patients of groups A and B (200 +/- 99 ms vs 64 +/- 18 and 62 +/- 3, respectively). In group A, on stimulating in the AS, MS, and PS regions, the AH interval remained constant in all patients. In contrast, in groups B and C on stimulation in the MS and PS regions, AH interval shortened (in group B from 56 +/- 8 to 27 +/- 37 and 37 +/- 14, respectively; in group C from 200 +/- 99 to 170 +/- 100 and to 137 +/- 109, respectively). In groups A and B, a posteroseptal slow pathway, and in group C, an anteroseptal retrograde fast pathway were successfully ablated without AV block. Pacemapping of the triangle of Koch can help to recognize patients in whom the anterograde conducting fast pathway is abnormally located far from the anteroseptal region or in whom anterograde conduction of the fast pathway is absent. In these cases the risk of AV block can be reduced by performing slow pathway ablation in a site sufficiently far from the site of the anterograde fast pathway or ablating the retrogradely conducting fast pathway.

Pace Mapping of Koch's Triangle in AVNRT. Introduction: Slow pathway (SP) ablation of AV nodal reentrant tachycardia (AVNRT) can be complicated by second- to third-degree AV block. We assessed the usefulness of pace mapping of Koch's triangle in preventing this complication. Methods and Results: Nine hundred nine consecutive patients undergoing radiofrequency ablation of AVNRT were analyzed. Group 1 (n = 487) underwent conventional slow pathway ablation. Group 2 (n = 422) underwent ablation guided by pace mapping of Koch's triangle, which located the anterogradely conducting fast pathway (AFP) based on the shortest St-H interval obtained by stimulating the anteroseptal, midseptal, and posteroseptal aspects of Koch's triangle. In group 2, AFP was anteroseptal in 384 (91%), midseptal in 33 (7.8%), and posteroseptal or absent in 5 (1.2%). In 32 of 33 patients with midseptal AFP, slow pathway ablation was performed strictly in the posteroseptal area. In 4 of 5 patients with posteroseptal or no AFP, retrograde fast pathway was ablated. Two patients refused ablation. Persistent second- to third-degree AV block was induced in 7 (1.4%) of 487 group 1 patients versus 0 (0%) of 422 group 2 patients (P = 0.038). Ablation was successful in all patients in whom ablation was performed. Conclusion: Pace mapping of Koch's triangle identifies patients in whom the AFP is absent or is abnormally close to the slow pathway. In these cases, guiding ablation helps to avoid AV block.

Radiofrequency ablation of either the fast or the slow pathway in AV nodal reentrant tachycardia was introduced in the early 1990s [1–4]. Both methods have a high success rate and low complications. As the procedures require the delivery of energy close to the AVN and the bundle of His, a possible complication is second or third degree AV block.

It is commonly held that long-lasting atrial fibrillation (AF), especially if associated with marked enlargement of the left atrium, is a negative predictive factor for both the recovery and the maintenance of sinus rhythm. The aim of the present study was to identify the clinical features of patients who have a greater likelihood of success both in the acute phase and, especially, in the medium-long term.Since June 1997, we have performed low-energy internal cardioversion to 93 patients (66 males, 27 females, mean age 62 +/- 9 years, range 26-80 years) with a mean duration of AF of 922 +/- 1032 days. Seventy-four patients had heart disease and 19 isolated AF. External cardioversion had been previously performed in 79 patients to no avail. All patients underwent antiarrhythmic therapy and were followed for a period of 13 +/- 7 months.Low-energy internal cardioversion proved efficacious, restoring sinus rhythm, in 92% of patients (86/93) and inefficacious in 8% (7/93). In 24% (21/86) the procedure, although efficacious, was followed by early recurrence of AF which proved to be intractable in 52% (11/21). At the end of the session, 81% (75/93) of the patients maintained sinus rhythm. At the end of follow-up, 40% (38/93) maintained sinus rhythm. Of all the parameters considered in the two groups, the duration of AF was the only one which differed significantly between the group in sinus rhythm and that in AF, with regard to both the efficacy of the procedure in the acute phase (755 +/- 868 vs 1618 +/- 1359 days, p0.001) and the long-term outcome (655 +/- 5.8 vs 1107 +/- 1098 days, p0.05).AF lasting more than 2 years constitutes a negative predictive factor for both the recovery and the long-term maintenance of sinus rhythm.

Atrial fibrillation is the most common supraventricular arrhythmia in the clinical setting. Some patients present both atrial fibrillation and other supraventricular tachycardias such as focal atrial tachycardia, common and uncommon atrial flutter, atrioventricular reentrant tachycardia related to an overt or a concealed Kent bundle, or atrioventricular nodal reentrant tachycardia. E.N. Prystowsky [1] suggested that all the above mentioned forms of paroxysmal supraventricular tachycardia can trigger atrial fibrillation, a phenomenon he referred to as “tachycardia-induced tachycardia”. Potential factors affecting conversion of sustained atrial and nonatrial tachycardias to atrial fibrillation include tachycardia cycle length [2, 3], particular electrophysiological characteristics of the triggering arrhythmia [1] and contraction-excitation feed-back [4]. As to the latter phenomenon, it has been demonstrated that after the onset of some supraventricular tachycardias, a sudden dilatation of the atria can occur [1]. Subsequently, as changes in mechanical stress can alter cardiac membrane potential (contraction-excitation feedback), it is possible that sudden dilatation of the atria affects cardiac membrane potential and leads to atrial fibrillation.

Angiotensin-converting enzyme (ACE) inhibitors reduce mortality, the development of remodeling, left ventricular (LV) dysfunction, and ischemic events, both when administered alone as long-term treatment in patients with impaired LV function and/or heart failure (HF) and as short-term treatment, early after acute myocardial infarction (AMI) and/or HF. The few data available on the use of ACE inhibitors in the elderly after AMI are conflicting. Nothing is known about the effects of ACE inhibitors in elderly postinfarction patients with preserved LV function: these patients have a remarkable medium- to long-term mortality and HF incidence after infarction. The aim of this study is to evaluate, in patients with AMI agedor =65 years, the effects of Perindopril on the combined outcome of death, hospitalization for HF, and heart remodeling, considered to be aor =8% increase in LV end-diastolic volume (LVEDV). Secondary objectives include the same factors listed in the primary end points but considered separately. In addition, safety of the drug, ventricular remodeling, and adaptation are being evaluated. A total of 1100 patients with AMI (first episode or reinfarction), agedor =65 years, and preserved or only moderately depressed LV (LV ejection fractionor =40%), are to be enrolled and randomly assigned to treatment (8 mg for 12 months of Perindopril or placebo, in double-blind conditions). Clinical assessment is performed at fixed times, and periodic evaluations of (1) ventricular shape, dimensions, and function by quantitative 2-D echocardiography, and (2) heart rate variability and arrhythmias by ambulatory electrocardiographic monitoring are anticipated. The results and conclusions will be available by 2002 year.