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BACKGROUND The benefit of an anterior mitral line (AML) in pa-tients with persistent atrial fibrillation (AF) and anterior atrial scar undergoing ablation has never been investigated. OBJECTIVE The purpose of this study was to evaluate the outcomes of AML in addition to standard treatment compared to standard treatment alone (no AML) in this subset of patients.METHODS Patients with persistent AF and anterior low-voltage zone (LVZ) treated with AML in 3 centers were retrospectively enrolled. The patients were matched in 1:1 fashion with patients having persistent AF and anterior LVZ who underwent conventional ablation in the same centers. Matching parameters were age, LVZ burden, and repeated ablation. Primary endpoint was AF/atrial tachycardia (AT) recurrence.RESULTS One hundred eight-six patients (age 66 +/- 9 years; 34% women) were selected and divided into 2 matched groups. Bidirec-tional conduction block was achieved in 95% of AML. After median follow-up of 2 years, AF/AT recurrence occurred in 29% of the patients in the AML group vs 48% in the no AML group (log-rank P = .024). On Cox regression multivariate analysis, left atrial vol-ume (hazard ratio [HR] 1.03; P = .006) and AML (HR 0.46; P = .003) were significantly associated with the primary endpoint. On univariate logistic regression, lower body mass index, older age, extensive anterior LVZ, and position of the left atrial activation breakthrough away from the AML were associated with first-pass AML block. CONCLUSION In this retrospective matched analysis of patients with persistent AF and anterior scar, AML in addition to standard treatment was associated with improved AF/AT-free survival compared to standard treatment alone.

IntroductionThe assessment of the ventricular myocardial substrate critically depends on the size of mapping electrodes, their orientation with respect to wavefront propagation, and interelectrode distance. We conducted a dual-center study to evaluate the impact of microelectrode mapping in patients undergoing catheter ablation (CA) of ventricular tachycardia (VT). MethodsWe included 21 consecutive patients (median age, 68 [12], 95% male) with structural heart disease undergoing CA for electrical storm (n = 14) or recurrent VT (n = 7) using the QDOT Micro catheter and a multipolar catheter (PentaRay, n = 9). The associations of peak-to-peak maximum standard bipolar (BVc) and minibipolar (PentaRay, BVp) with microbipolar (BV mu Max) voltages were respectively tested in sinus rhythm with mixed effect models. Furthermore, we compared the features of standard bipolar (BE) and microbipolar (mu BE) electrograms in sinus rhythm at sites of termination with radiofrequency energy. ResultsBV(mu Max) was moderately associated with both BVc (beta = .85, p < .01) and BVp (beta = .56, p < .01). BV mu Max was 0.98 (95% CI: 0.93-1.04, p < .01) mV larger than corresponding BVc, and 0.27 (95% CI: 0.16-0.37, p < .01) mV larger than matching BVp in sinus rhythm, with higher percentage differences in low voltage regions, leading to smaller endocardial dense scar (2.3 [2.7] vs. 12.1 [17] cm(2), p < .01) and border zone (3.2 [7.4] vs. 4.8 [20.1] cm(2), p = .03) regions in microbipolar maps compared to standard bipolar maps. Late potentials areas were nonsignificantly greater in microelectrode maps, compared to standard electrode maps. At sites of VT termination (n = 14), mu BE were of higher amplitude (0.9 [0.8] vs. 0.4 [0.2] mV, p < .01), longer duration (117 [66] vs. 74 [38] ms, p < .01), and with greater number of peaks (4 [2] vs. 2 [1], p < .01) in sinus rhythm compared to BE. Conclusionmicroelectrode mapping is more sensitive than standard bipolar mapping in the identification of viable myocytes in SR, and may facilitate recognition of targets for CA.

Objectives This study aimed to assess the long-term outcomes of minimally fluoroscopic approach (MFA) compared with conventional fluoroscopic ablation (ConvA) in terms of recurrences of arrhythmia and long-term complications. Background Catheter ablation (CA) of supraventricular tachycardia (SVT) with an MFA, under the guidance of electroanatomic mapping (EAM) systems, results in a significant reduction in exposure to ionizing radiations without impairing acute procedural success and complication rate. However, data regarding long-term outcomes of MFA compared with ConvA are lacking. Methods This is a retrospective observational study. All patients undergoing MFA CA of SVT (atrioventricular nodal re-entrant tachycardia and atrioventricular re-entrant tachycardia) between 2010 and 2015 were enrolled and were compared with matched subjects (1 MFA: 2 ConvA) undergoing ConvA during the same period. The 2 co-primary outcomes were recurrence of arrhythmias and long-term complications. Results A total of 618 patients (mean age 38 ± 15 years, 60% female) were enrolled. MFA included 206 patients, whereas 412 were treated with ConvA. Acute success (99% vs. 97%; p = 0.10) and acute complications (2.4% vs. 5.3%; p = 0.14) were similar in the 2 groups. During a median follow-up of 4.4 years, 5.9% of patients experienced recurrence of arrhythmias. At multivariate analysis, ConvA (hazard ratio [HR]: 3.03) and procedural success (HR: 0.10) were independently associated with recurrence of arrhythmias. Late complications (i.e., advance atrioventricular block and need for pacemaker implantation) occurred more frequently in ConvA (3.4% vs. 0.5%; p = 0.03) compared with MFA. Conclusions CA guided by EAM systems with MFA provided better long-term results and reduced risk of complications compared with ConvA.

Interest in endomyocardial biopsy (EMB) has progressively grown during the past decade. Still, its use remains limited to highly specialized centers, mostly because it is considered an invasive procedure with poor diagnostic yield and inherent complications. Indeed, the diagnostic performance of EMB is strictly linked to the sample of myocardium we can obtain. If we can precisely localize areas of diseased myocardium, sampling error or inadequate withdrawals are minimized. In this state-of-the-art review, we provide guidance on how to technically and practically perform EMB guided by electroanatomic voltage mapping and intracardiac echocardiography, and review the evidence supporting this combined approach.

Differential diagnosis of wide complex tachycardia in patients taking anti-arrhythmic can be challenging. Conventional ECG diagnostic criteria are poorly specific and should be applied with caution. Patients who develop life-threatening arrhythmias after flecainide infusion should be screened for Brugada Syndrome, especially if concomitant sinus node dysfunction is present. (Level of Difficulty: Intermediate.), Central Illustration

ST-segment elevation in patients sedated with propofol may be a sign of imminent malignant arrhythmias. Although propofol infusion syndrome-electrocardiographic abnormalities are usually described as Brugada-pattern, in unique cases nearly ubiquitous and extensive J-point and ST-segment elevation may be observed. These patients should undergo an ajmaline test following recovery. (Level of Difficulty: Beginner.), Central Illustration

Etiologic factors and long-term outcomes of catheter ablation of atrial fibrillation (AF) in young patients have not been well characterized. This study aimed to analyze the etiologic factors and outcomes of pulmonary vein isolation (PVI) in patients with young-onset AF (young-AF, defined as having first documented episode = 45 years (n = 554) was included. The most frequent risk factors in young-AF were intensive exercise (25%), moderate-to-heavy alcohol consumption (23%), and familial AF (22%). Compared with patients with AF onset >= 45-year, patients with young-AF were more often men (82% vs 66%, p < 0.001), had more frequently paroxysmal AF (81% vs 60%, p < 0.001), had less left atrial dilatation (40.9 +/- 6.2 mm vs 44.2 +/- 7.2 mm, p < 0.001), and had lower 4-year recurrence rate after last PVI procedure (22% vs 45%, p < 0.001). In young-AF, structural heart disease (SHD) was the only independent predictor of recurrence. Patients with young-AF selected to undergo cryoballoon (CB) ablation were younger (35.0 +/- 7.7 vs 36.6 +/- 6.7 years, p = 0.035) and had less persistent AF (6% vs 24%, p = 0.004) and coronary artery disease (2% vs 7%, p = 0.02) compared with radiofrequency ablation. After excluding patients with persistent AF and SHD, there was no difference in single procedural success between radiofrequency or CB PVI (27% vs 17%, p = 0.11). In conclusion, patients with young-AF have diverse etiologies and high single and multiprocedural PVI successes. SHD is the only independent predictor of recurrence. In patients with young-AF, there is a selection bias for CB ablation. (C) 2021 Elsevier Inc. All rights reserved.

Background Haemoptysis is usually caused by pulmonary and infectious diseases. In few cases, it has a cardiac cause, such as pulmonary embolism or mitral valve stenosis. Haemoptysis may be an uncommon symptom of prosthetic valve dysfunction, being related to elevated right heart pressures. Case summary A 22-year-old woman from sub-Saharan Africa known for a triple valve replacement was hospitalized for dyspnoea and haemoptysis. A careful clinical evaluation excluded the most common causes of haemoptysis. Transthoracic echocardiogram showed normal biventricular function, normally functioning mechanical prosthetic aortic and mitral valves, and the biological tricuspid prosthesis showed an increased transvalvular gradient. Contrast chest computed tomography scan excluded pulmonary embolism and mechanical valve obstruction, but revealed marked systemic venous hypertension. Right heart catheterization confirmed increased right heart pressures and severe bioprosthetic tricuspid valve stenosis. The patient underwent a successful percutaneous tricuspid valve-in-valve replacement, with complete resolution of symptoms. Discussion The increase in venous pressures due to bioprosthetic tricuspid stenosis caused veno-venous shunts: blood from the lower body was drained into the superior vena cava via the azygos vein. Increased pressure in the latter affected pressure in bronchial veins and arteries, leading to haemoptysis. Cardiac surgical reinterventions are associated with worse outcomes and higher mortality rates. Management of a degenerated prosthetic tricuspid valve is challenging and requires a multidisciplinary assessment. Transcatheter tricuspid valve replacement is becoming a feasible option in patients with prosthetic dysfunction. Based on evidence to date, tricuspid valve-in-valve replacement appears to be a safe, feasible, and effective alternative in selected young patients.

Background Endomyocardial biopsy (EMB) is part of 2010 Task Force Criteria (TFC) for arrhythmogenic right ventricular cardiomyopathy (ARVC). However, its usage has been curtailed because of its low presumed diagnostic yield, and it is now a poorly used tool. This study aims to analyze the contribution of EMB to the final diagnosis of ARVC. Methods and Results We included 104 consecutive patients evaluated for a suspicion of ARVC, who were referred for EMB. Patients with suspected left dominant pattern were excluded from the primary analysis. Subjects were initially stratified according to TFC without considering EMB. After EMB, patients were reclassified accordingly, and the reclassification rate was calculated. EMB yielded a diagnostic finding in 92 patients (85.5%). After including EMB evaluation, 20 (43%) more patients “at risk” received a definite diagnosis of ARVC. Overall, 59 patients received a definite diagnosis of ARVC, 34% only after EMB. EMB appeared to be the better‐performing exam with respect to the final diagnosis (β, 2.2; area uder the curve, 0.73; P P Conclusions Electroanatomic voltage mapping–guided EMB was safe and yielded an optimal diagnostic yield. It allowed upgrading of the diagnosis of nearly one‐third of the patients considered “at risk.” Classical TFC without EMB performed poorly in patients with the left dominant form of ARVC.

Multiple studies have addressed the importance of anteroseptal scar in patients with nonischemic cardiomyopathy. However, this pattern has never been fully evaluated in patients with prior myocarditis.The purpose of this study was to evaluate whether anteroseptal scar is associated with worse outcome in patients with prior myocarditis and how it affects the efficacy of catheter ablation (CA).This was a retrospective study of consecutive patients with prior myocarditis and arrhythmic presentation. Cardiac magnetic resonance and electroanatomic voltage mapping were used to identify the scar pattern. Patients were referred for either CA or escalated antiarrhythmic drug (AAD) therapy. The main outcome was ventricular arrhythmia (VA)-free survival according to the presence of anteroseptal scar.A total of 144 consecutive patients with prior myocarditis were included. Mean age was 42.1 ± 14.9 years, and 58% were men. Ejection fraction was normal in 73% of patients. Anteroseptal scar was present in 44% of cases. Sixty-one patients (42%) underwent CA. Overall, at 2-year follow-up, VA-free survival was 77% in the CA group. After CA, the mean number of AADs taken by each patient decreased from 1.8 to 0.9 per day (p0.001). The presence of anteroseptal scar was found to be an independent predictor of VA relapse both in patients treated with CA (hazard ratio [HR] 3.6; 95% confidence interval [CI] 1.1-11.4; P = .03) and in the overall population (HR 2.0; 95% CI 1.2-3.5; P = .02) .In patients with prior myocarditis and VA, the presence of anteroseptal scar negatively predicts outcomes irrespective of treatment strategy.

This study aimed to assess the long-term outcomes of minimally fluoroscopic approach (MFA) compared with conventional fluoroscopic ablation (ConvA) in terms of recurrences of arrhythmia and long-term complications.Catheter ablation (CA) of supraventricular tachycardia (SVT) with an MFA, under the guidance of electroanatomic mapping (EAM) systems, results in a significant reduction in exposure to ionizing radiations without impairing acute procedural success and complication rate. However, data regarding long-term outcomes of MFA compared with ConvA are lacking.This is a retrospective observational study. All patients undergoing MFA CA of SVT (atrioventricular nodal re-entrant tachycardia and atrioventricular re-entrant tachycardia) between 2010 and 2015 were enrolled and were compared with matched subjects (1 MFA: 2 ConvA) undergoing ConvA during the same period. The 2 co-primary outcomes were recurrence of arrhythmias and long-term complications.A total of 618 patients (mean age 38 ± 15 years, 60% female) were enrolled. MFA included 206 patients, whereas 412 were treated with ConvA. Acute success (99% vs. 97%; p = 0.10) and acute complications (2.4% vs. 5.3%; p = 0.14) were similar in the 2 groups. During a median follow-up of 4.4 years, 5.9% of patients experienced recurrence of arrhythmias. At multivariate analysis, ConvA (hazard ratio [HR]: 3.03) and procedural success (HR: 0.10) were independently associated with recurrence of arrhythmias. Late complications (i.e., advance atrioventricular block and need for pacemaker implantation) occurred more frequently in ConvA (3.4% vs. 0.5%; p = 0.03) compared with MFA.CA guided by EAM systems with MFA provided better long-term results and reduced risk of complications compared with ConvA.

Background:Arrhythmogenic left ventricular cardiomyopathy (ALVC) is an under-characterized phenotype of arrhythmogenic cardiomyopathy involving the LV ab initio. ALVC was not included in the 2010 International Task Force Criteria for arrhythmogenic right ventricular cardiomyopathy diagnosis and data regarding this phenotype are scarce.Methods:Clinical characteristics were reported from all consecutive patients diagnosed with ALVC, defined as a LV isolated late gadolinium enhancement and fibro-fatty replacement at cardiac magnetic resonance plus genetic variants associated with arrhythmogenic right ventricular cardiomyopathy and of an endomyocardial biopsy showing fibro-fatty replacement complying with the 2010 International Task Force Criteria in the LV.Results:Twenty-five patients ALVC (53 [48–59] years, 60% male) were enrolled. T wave inversion in infero-lateral and left precordial leads were the most common ECG abnormalities. Overall arrhythmic burden at study inclusion was 56%. Cardiac magnetic resonance showed LV late gadolinium enhancement in the LV lateral and posterior basal segments in all patients. In 72% of the patients an invasive evaluation was performed, in which electroanatomical voltage mapping and electroanatomical voltage mapping-guided endomyocardial biopsy showed low endocardial voltages and fibro-fatty replacement in areas of late gadolinium enhancement presence. Genetic variants in desmosomal genes (desmoplakin and desmoglein-2) were identified in 12/25 of the cohort presenting pathogenic/likely pathogenic variants. A definite/borderline 2010 International Task Force Criteria arrhythmogenic right ventricular cardiomyopathy diagnosis was reached only in 11/25 patients.Conclusions:ALVC presents with a preferential involvement of the lateral and postero-lateral basal LV and is associated mostly with variants in desmoplakin and desmoglein-2 genes. An amendment to the current International Task Force Criteria is reasonable to better diagnose patients with ALVC.

A radiofrequency energy lesion transmurality marker incorporating power, contact force, and time (Ablation Index, AI) was shown to be associated with outcomes of catheter ablation (CA) of multiple arrhythmias, but was never systematically assessed in the CA of focal atrial tachycardias (AT). We aimed to evaluate the role of AI as a predictor of outcomes in focal AT CA, and therefore, retrospectively included 45 consecutive patients undergoing CA for focal AT in four referral electrophysiology laboratories. Clinical and procedural information were collected. For each patient, maximum and mean (by averaging maximum AI values for each radiofrequency ablation lesion) AI were measured. The primary outcome was focal AT-free survival, and was systematically assessed with periodical Holter monitors or cardiac implantable electronic devices. CA was acutely effective in each case; however, 20% (n = 9) of the study population experienced a focal AT recurrence over a median follow-up of 288 days. Both maximum and mean AI values were significantly higher among patients without AT recurrences (maximum AI = 568 ± 91, mean AI = 426 ± 105) than in patients with AT relapses (maximum AI = 447 ± 142, mean AI = 352 ± 76, p = 0.036, and p = 0.028, respectively). The optimal cutoffs associated with freedom from recurrences were 461 for maximum AI (sensitivity, 0.89; specificity, 0.56) and 301 for mean AI (sensitivity, 0.97; specificity, 0.44). In a time-to-event analysis, maximum AI was significantly associated with survival free from AT recurrence (p = 0.001), whereas mean AI was not (p = 0.08). In summary, maximum AI is the best procedural parameter associated with the outcomes of CA for focal AT, and may help standardize the procedural approach.

Background A myocardial substrate assessment through percutaneous endomyocardial biopsy (EMB) represents an important additional diagnostic test for cardiomyopathies when uncertainties remain after non-invasive evaluation. Yet, extensive application of EMB has been limited by the low sensitivity of biopsies. Electroanatomic voltage mapping (EVM) is a promising modality for guiding Endomyocardial biopsies (EMB). Aim The aim of our study is to evaluate the diagnostic yield of EVM-guided EMB and the role of histological analysis in the diagnosis of patients with suspected cardiomyopathies and arrhythmic presentation. Methods One-hundred and sixty-two consecutive patients undergoing EMB at our Institution from 2010 to 2019 were included. Demographics, clinical data, CMR data and peri-procedural complications were retrospectively retrieved. All procedures were guided by endo-cavitary EVM. According to non-invasive data collected before proceeding with EMB a suspected clinical diagnosis was expressed and compared to histological diagnosis Results One-hundred and sixty-two patients were included in the study. Mean age of the cohort resulted 40.9±14.7 years, with 26.5% of the included patients being females. ECG alterations were present in 51.3% of the population, with the most common abnormality being T wave inversion. Sustained or non-sustained ventricular tachycardia was registered in 51 (31.5%) of the patients, while 44 (27.2%) patients were referred for frequent isolated premature ventricular complex (PVC), and 19 (11.7%) after an episode of an arrhythmogenic syncope or resuscitated cardiac arrest. Suspected ARVC (41.6%) together with acute/chronic myocarditis (28.0%) were the main clinical diagnosis leading to an invasive approach. The sampling site was the right ventricle in 116 (72.5%), the left ventricle in 31 (19.4%), and both ventricles in 13 (8.1%) patients. Biopsy samplings were judged appropriate for histological analysis in 141 (87.0%) patients. Among the analyzed samples, a diagnosis was reached in 120 patients (74.1%). In the remaining 21 cases (25.9%), the analysis yielded nonspecific histologic findings, inconclusive results, or sampling error. The biopsy allowed to confirm the clinical diagnosis in 72 (60.0%) patients, while a different diagnosis was reached in 48 (39.0%) cases (Reclassification are showed Figure 1).In particular of 67 (41.6%) patients suspected for ARVC, only 32 (22.7) reached a confirmation. Conversely, the number of patients with acute/chronic myocarditis augmented from 45 (28.0%) to 47 (33.3%). Conclusion EMB guided by EVM reached a diagnostic yield as high as 74.1%. EMB proved to be a useful tool in the clinical management of patients, as it allowed to correctly reclassify a significant number of patients who would have been misdiagnosed based only on non-invasive assessment. Sankey Diagram Funding Acknowledgement Type of funding source: None

Background Electroanatomic voltage mapping (EVM) is a promising modality for guiding Endomyocardial biopsies (EMB). Previous experiences on this techniques have reported safety and feasibility of this approach. These reports however, resulted limited by sample size or imperfect designs, preventing reliable comparisons of the effectiveness of this new methods with a conventional or a cardiac magnetic resonance (CMR) imaging guided approach. Aim We now report the largest cohort of patients undergoing EVM-guided EMB in order to show its diagnostic yield and comparing it with a cardiac magnetic resonance (CMR) guided approach. Methods One-hundred and sixty-two consecutive patients undergoing EMB at our Institution from 2010 to 2019 were included. Pathological areas identified at EVM and CMR underwent EMB. According to EMB results, CMR and EVM sensitivity and specificity regarding the identification of pathological substrates of myocardium were evaluated. Results A gadolinium-enhanced CMR had been performed in 143 (88.9%) of the population and yielded pathological findings in 121 (85.8%) of such cases. Late gadolinium enhancement (LGE) was present in 94 (70%) of the patients, while EVM identified areas of low voltages in 61%. Right (73%), left (19%) or both ventricles (8%) underwent sampling. EVM proved to have similar sensitivity to CMR (74% vs. 77%; P=0.479), with non-significantly higher specificity (70% vs. 47% P=0.738). In 12 patients with EMB-proven cardiomyopathy, EVM identified pathological areas, which had been undetected at CMR evaluation (concordance rate 53.8%; k = 0.26). Sensitivity of pooled EVM and CMR was as high as 95%. Five cases (3,8%) of cardiomyopathies were undetected by both CMR and EVM. Complications rate was low (4,9%), mostly vascular access related, with no patients requiring urgent management. Conclusion EVM proved to be a promising tool for targeted-EMB due to its sensitivity and specificity in identifying myocardial pathological substrates. EVM demonstrated to have an accuracy similar to CMR. EVM and CMR together conferred EMB a positive predictive value of 89%. Funding Acknowledgement Type of funding source: None

Background Current arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnostic criteria are mostly based on ventricle function and dimension. Previous studies have reported a significant overlap between ARVC and chronic myocarditis, at non-invasive assessment. Purpose Tto compare biopsy-proven ARVC and myocarditis patients, in order to identify clinical, imaging and invasive electroanatomic voltage mapping (EVM) differences between the two groups. Methods Patients with borderline diagnosis of ARVC or suspected myocarditis underwent compete assessment with cardiac magnetic resonance (CMR). All patients underwent endomyocardial biopsy (EMB) with targeted tissue sampling guided by EVM. All patients with an histological diagnosis of myocarditis or ARVC were included. Results 83 patients were included, divided into 35 (42.2%) ARVC and 48 (57.8%) myocarditis. Among ARVC patients, 25 (71.4%) had right dominant ARVC, 5 (14.3%) left dominant patter and 5 (14.3%) bi-ventricular involvement. Nine patients (23.1%) with suspected clinic diagnosis of ARVC before EMB, received and histological diagnosis of myocarditis. Two (5.7%) patients with suspected myocarditis were proven to have ARVC. When comparing patients with ARVC and patients with myocarditis, univariate analysis showed that age, sex, family history, arrhythmic disorders at presentation and ECG abnormalities were similar between the two groups (P>0.05 for all the variables). There was also no significant difference with regards to bi-ventricular function and dimension at CMR evaluation. More patients with myocarditis resulted positive at late gadolinium enhancement (LGE) evaluation, although non-significantly (P=0.082). Oedema was more frequently present in patients with myocarditis (P=0.01), while adipose tissue infiltration and segmental wall motion abnormalities were more often observed in patients with ARVC (P=0.002 and P Conclusion(s) A significant number of patients who received a clinical diagnosis of Myocarditis or ARVC according to current guidelines, were subsequently reclassified after histological analysis. Patients with ARVC and myocarditis were not distinguishable on the basis of clinical features and ventricular function and dimensions. Conversely, tissue analysis with CMR demonstrated how patient with ARVC had less oedema, more adipose tissue infiltration and had more extensive scar at EVM evaluation. Funding Acknowledgement Type of funding source: None

Introduction Myocarditis is a complex inflammatory disease, usually secondary to viral infections or immune system dysregulation, with extremely heterogeneous clinical manifestations. Among them, potentially life-threatening ventricular arrhythmias (VA) may present at any stage of the disease as an expression of myocardial electrical instability. Purpose Our aim was to evaluate the efficacy of radiofrequency catheter ablation (RFCA) of VA in our large cohort of myocarditis, trying to understand the predictors of RFCA success. Methods and results 144 patients (61 men; age 43 [29–54] years) with history of myocarditis with arrhythmic presentation (118 biopsy-proven, 82%) composed our population. At presentation, 26% of patients suffered of ventricular tachycardia (VT) while in 17% cardiac arrest occurred: overall 49 patients (35%) were implanted with an ICD. The median left ventricular ejection fraction (LVEF) was 58% (48–61%). An intensive non-invasive and invasive work-up was performed: 104 patients underwent cardiac magnetic resonance (CMR) that showed late gadolinium enhancement (LGE) in 67 of them (63%). In 37 patients LGE was found in the anteroseptal portion of the left ventricle: this pattern showed association with major arrhythmic relapse (VT and ventricular fibrillation) during follow up (Fig. 1; OR 4.0, CI 95% 1.14–14.1, p=0.03). 95 patients underwent endocardial RFCA, using contact electroanatomic mapping. Interestingly, in patients with anteroseptal LGE RCFA didn't affect significantly the arrhythmic relapse (OR 5, CI 95% 0.9–33, p=0.06). Otherwise RFCA prevent arrhythmic relapse in patients that showed LGE in ventricular portion other than the anteroseptal one (OR 0.027, IC 95% 0.002–0.40, p Conclusions In myocarditis patients with VA, LGE pattern predicts arrhythmic relapse during follow-up. RFCA success rate is strictly linked to scar location, being significantly higher in patients with non-anteroseptal LGE. Figure 1 Funding Acknowledgement Type of funding source: None

Background:Electroanatomic voltage mapping (EVM) is a promising modality for guiding endomyocardial biopsies (EMBs). However, few data support its feasibility and safety. We now report the largest cohort of patients undergoing EVM-guided EMBs to show its diagnostic yield and to compare it with a cardiac magnetic resonance (CMR)–guided approach.Methods:We included 162 consecutive patients undergoing EMB at our institution from 2010 to 2019. EMB was performed in pathological areas identified at EVM and CMR. CMR and EVM sensitivity and specificity regarding the identification of pathological substrates of myocardium were evaluated according to EMB results.Results:Preoperative CMR showed late gadolinium enhancement in 70% of the patients, whereas EVM identified areas of low voltage in 61%. Right (73%), left (19%), or both ventricles (8%) underwent sampling. EVM proved to have sensitivity similar to CMR (74% versus 77%), with specificity being 70% and 47%, respectively. In 12 patients with EMB-proven cardiomyopathy, EVM identified pathological areas that had been undetected at CMR evaluation. Sensitivity of pooled EVM and CMR was as high as 95%. EMB analysis allowed us to reach a new diagnosis, different from the suspected clinical diagnosis, in 39% of patients. The complications rate was low, mostly related to vascular access, with no patients requiring urgent management.Conclusions:EVM proved to be a promising tool for targeted EMB because of its sensitivity and specificity for identification of myocardial pathological substrates. EVM was demonstrated to have accuracy similar to CMR. EVM and CMR together conferred a positive predictive value of 89% on EMB.

Purpose Our purpose is to analyze the outcomes of endovascular aneurysm repair (EVAR) in patients treated with Excluder endograft (W.L. Gore and Associate, Flagstaff, AZ), comparing second generation, featuring SIM-PULL delivery system (ExSP) and third generation, featuring C3 (ExC3), concerning intraprocedural data and long-term outcomes. Methods In our single-center, comparative study, we retrospectively analyzed all patients undergoing elective EVAR with Excluder from May 2008 to December 2015. This cohort was firstly divided according to the design of the endograft used, and then, two subgroups of complex procedures were identified according to International Standards. Preliminary end points were early- and mid-term outcomes. Primary end point was procedural data (i.e., procedural and fluoroscopy time, radiation dose (DAP), and contrast medium amount). Results The study included 64 patients (24 ExSP and 40 ExC3) with a mean follow-up of 31.6 ± 22.9 months. Patients in ExC3 group had significantly more risk factors (past or present history of smoking, P = 0.019), comorbidities (chronic heart failure and chronic kidney disease, both P = 0.032), as well as a more unfavorable anatomy (neck angulation, P = 0.035). Concerning preliminary outcome, no significant between-group difference was noted. As for intraoperative data, procedure duration was significantly shorter: 120 vs. 151 min ( P = 0.002) in the overall population and 129 vs. 173 min ( P = 0.004) in complex cases. A significant reduction was also found in fluoroscopy time and radiation exposure: 24,084 vs. 32,548 cGy/cm 2 ( P = 0.020) in the overall population and 26,770 vs. 41,104 cGy/cm 2 ( P = 0.003) in complex cases. No significant difference was found for contrast volume. Conclusions The study shows that new C3 excluder enables to reduce radiation exposure and procedural time compared to the previous device. C3 excluder results are comparable to those of the previous device in spite of more comorbidities and complex anatomy of the treated patients. Further studies are needed to assess device performance on longer-term follow-up.

Background Percutaneous atrial septal defect (ASD) closure carries a not negligible burden of complications, such as the erosion of cardiac structures surrounding the device. Complications related to erosion are rare and often occur during the first 6 months after implantation. Case summary A 40-year-old female patient underwent percutaneous ASD closure in 2006. After 12 years of uneventful follow-up, in March 2018, a device dislodgement causing atrial shunting was incidentally discovered and was attributed to device-induced atrial septal erosion. The patient successfully underwent surgical removal of the device and correction of the interatrial defect. Discussion Our purpose is to underline the importance of staged long-term imaging follow-up, even many years after a successful procedure and to highlight the possible risk factors leading to this worrisome condition. In addition, we sought to underline the possible risks associated with deficient aortic rim and explain pros and cons of different approaches.

A 73-year-old man was referred to our clinic because of increasing fatigue, shortness of breath, and new-onset pulmonary hypertension (pulmonary artery pressure 73 mm Hg). Echocardiography and thoracic computed tomography scan showed a 75 × 67-mm mediastinal blood thickening with diffuse luminal