Flecainide in Structural Heart Diseases: A Contemporary Reappraisal Beyond the CAST Trial.

Flecainide has been contraindicated in patients with structural heart disease (SHD) since the 1991 Cardiac Arrhythmia Suppression Trial (CAST) showed increased mortality in post-myocardial infarction patients. This review argues that the CAST findings were overgeneralized, resulting in the underutilization of a valuable antiarrhythmic medication. Emerging observational evidence suggests that flecainide may be safe and effective in specific SHD populations, including those with stable coronary artery disease without active ischemia and preserved ventricular function.

Personalized pulmonary vein isolation guided by left atrial wall thickness for persistent atrial fibrillation ablation: the PeAF-by-LAWT randomized trial.

Background: A personalized pulmonary vein isolation(PVI) approach aimed at ablation index(AI)titration according to MDCT-derived left atrial wall thickness(LAWT) maps reported high effectiveness and efficiency outcomes for persistent atrial fibrillation(PeAF) ablation. To date, no randomized trials have compared this approach with the standard CLOSE protocol.

Objectives: This non-inferiority randomized controlled trial sought to compare a LAWT-guided PVI with CLOSE protocol-based for PeAF(NCT05396534).

The use of cardiac imaging in patients undergoing atrial fibrillation ablation.

Cardiac imaging (CI), including echocardiography, multidetector computed tomography (MDCT), and cardiac magnetic resonance (CMR), is gaining increasing interest to aid atrial fibrillation (AF) ablation procedures, from pre-procedural planning to intra-procedural guidance. Transthoracic echocardiography is widely used for imaging, especially for preprocedural assessment, while transesophageal and intracardiac echocardiography (ICE) are used for intraprocedural guidance during transseptal puncture. Cardiac MDCT, leveraging its high spatial resolution, offers a detailed anatomical visualization of cardiac chambers and adjacent structures; moreover, left atrial wall thickness assessed by MDCT may guide radiofrequency energy titration to enhance procedural safety and efficiency.

Subcutaneous Implantable Defibrillator Therapy in Patients With Brugada Syndrome: Data From a Large Multicenter Registry.

Background: The implantable cardioverter-defibrillator (ICD) is recognized as the most effective life-saving therapy in patients with Brugada syndrome (BrS). However, transvenous ICD is associated with a notable rate of complications over time. The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as a promising alternative to the transvenous ICD.

Outcomes of ventricular tachycardia ablation facilitated by pre-procedural cardiac imaging-derived scar characterization: a prospective multi-centre international registry.

Aims: Pre-procedural imaging can facilitate scar-related ventricular tachycardia (VT) ablation, although only limited data have been reported. This prospective registry aimed to analyse procedural data and outcomes in a multi-centre setting of a pre-defined VT ablation strategy facilitated by the integration of pre-procedural imaging into the navigation system.

Methods And Results: Consecutive patients referred for scar-related left-sided VT ablation were prospectively enrolled at five European tertiary hospitals.

Arrhythmic Stratification of Cardiac Amyloidosis: State of the Art.

Cardiac amyloidosis is an infiltrative myocardial disease whose prevalence significantly increased in recent years. Its clinical history is changing due to the advent of novel therapies, and careful risk stratification has become impelling. Arrhythmias, frequently found during the course of the disease, include conduction system disease, atrial fibrillation (AF), and ventricular arrhythmias (VAs).

Substrates of Sudden Cardiac Death in Hypertrophic Cardiomyopathy.

Sudden cardiac death (SCD), the most devastating complication of hypertrophic cardiomyopathy (HCM), is primarily triggered by ventricular tachycardia or fibrillation. Despite advances in knowledge, the mechanisms driving ventricular arrhythmia in HCM remain incompletely understood, stemming from an interplay of multiple pro-arrhythmic factors. Myocyte disarray and myocardial fibrosis form a structural substrate favorable to re-entrant arrhythmias by altering myocardial electrophysiological properties, while cellular abnormalities predominate in patients without evident structural remodeling.

Subcutaneous Implantable Defibrillators in Young Patients: Arrhythmias, Complications, and Physical Activity.

Background: The safety of subcutaneous implantable cardioverter defibrillator (S-ICD) recipients who lead active lifestyles and engage in recreational sports is unknown. We aimed to evaluate the association between lifestyle and recreational sports and the occurrence of arrhythmia- and device-related complications, appropriate and inappropriate shocks in S-ICD recipients.

Methods: We assessed a cohort of young-adult (15-65 years) S-ICD patients, evaluated their physical activity with IPAQ (International Physical Activity Questionnaire), and assessed the association between lifestyle and recreational sports on S-ICD safety and shocks.

Cardioneuroablation: a new treatment for vasovagal syncope.

Cardioneuroablation (CNA) is emerging as an appealing therapeutic option for patients with vasovagal reflex syncope. This review examines key aspects of CNA, including patient selection, procedural aspects and mid-term effects. We critically evaluate procedural results from recent studies and address ongoing challenges, such as the need for standardized procedural protocols and harmonized postprocedural data collection.

Left atrial intramyocardial fat at pulmonary vein reconnection sites during atrial fibrillation redo ablation.

Aims: Electrical reconnections between pulmonary veins (PVs) and the left atrium (LA) are frequently responsible for atrial fibrillation (AF) recurrences after pulmonary vein isolation (PVI). Multidetector computed tomography (MDCT)-derived images can be post-processed to detect intramyocardial fat (inFAT) by signal radiodensity thresholding. The role of inFAT on PV-LA reconnections remains unknown.

The risk of failure of subcutaneous implantable cardioverter defibrillator therapy: from PRAETORIAN score to clinical practice.

Aims: The subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to traditional ICDs. The PRAETORIAN score, based on chest radiographs, has been validated to predict the probability of successful S-ICD defibrillation testing by assessing factors like fat thickness between the coil and sternum and generator placement. This study evaluated the correlation between the PRAETORIAN score and clinical characteristics, as well as implantation variables.

Differential and synergistic effects of right and left atrial ganglionated plexi ablation in patients undergoing cardioneuroablation: results from the ELEGANCE multicenter study.

Background: Cardioneuroablation (CNA) treats reflex syncope by ablating ganglionated plexi (GPs) either confined to the right (RA) or left atrium (LA), or accessible from both. We assessed whether GP ablation in one atrium affects parasympathetic modulation in the other and how ablation sequence (RA then LA, or vice-versa) impacts efficacy.

Methods: Two propensity-matched groups of patients with reflex syncope or functional bradycardia were analyzed.

Transcatheter Ablation of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy: A Multicenter Propensity Score-Based Analysis.

Background: The prognostic impact of catheter ablation (CA) of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients has not yet been satisfactorily elucidated.

Objectives: The aim of the study was to assess the impact of CA of AF on clinical outcomes in a large cohort of HCM patients.

Methods: In this retrospective multicenter study, 555 HCM patients with AF were enrolled, 140 undergoing CA and 415 receiving medical therapy.

Personalized pulmonary vein isolation with very high-power short-duration lesions guided by left atrial wall thickness: the QDOT-by-LAWT randomized trial.

Aims: Pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) using very high-power short-duration (vHPSD) radiofrequency (RF) ablation proved to be safe and effective. However, vHPSD applications result in shallower lesions that might not be always transmural. Multidetector computed tomography-derived left atrial wall thickness (LAWT) maps could enable a thickness-guided switching from vHPSD to the standard-power ablation mode.

Scar architecture affects the electrophysiological characteristics of induced ventricular arrhythmias in hypertrophic cardiomyopathy.

Aims: Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) detects myocardial scarring, a risk factor for ventricular arrhythmias (VAs) in hypertrophic cardiomyopathy (HCM). The LGE-CMR distinguishes core, borderzone (BZ) fibrosis, and BZ channels, crucial components of re-entry circuits. We studied how scar architecture affects inducibility and electrophysiological traits of VA in HCM.

Clinical characteristics and outcome of end stage hypertrophic cardiomyopathy: Role of age and heart failure phenotypes.

Background: A minority of patients with hypertrophic cardiomyopathy (HCM) presents advanced heart failure (HF) during their clinical course, in the context of left ventricular (LV) remodeling with reduced LV ejection fraction (LVEF), or of severe diastolic dysfunction without impaired LVEF. Aim of this study was to describe a multicentric end stage (ES) HCM population and analyze clinical course and outcome among its different phenotypes.

Methods: Data of all HCM patients from 7 Italian referral centres were retrospectively evaluated.

Long-term clinical outcomes of patients with drug-induced type 1 Brugada electrocardiographic pattern: A nationwide cohort registry study.

Background: There are limited real-world data on the extended prognosis of patients with drug-induced type 1 Brugada electrocardiogram (ECG).

Objective: We assessed the clinical outcomes and predictors of life-threatening arrhythmias in patients with drug-induced type 1 Brugada ECG.

Methods: This multicenter retrospective study, conducted at 21 Italian and Swiss hospitals from July 1997 to May 2021, included consecutive patients with drug-induced type 1 ECG.

Assessing left atrial intramyocardial fat infiltration from computerized tomography angiography in patients with atrial fibrillation.

Aims: Epicardial adipose tissue might promote atrial fibrillation (AF) in several ways, including infiltrating the underlying atrial myocardium. However, the role of this potential mechanism has been poorly investigated. The aim of this study is to evaluate the presence of left atrial (LA) infiltrated adipose tissue (inFAT) by analysing multi-detector computer tomography (MDCT)-derived three-dimensional (3D) fat infiltration maps and to compare the extent of LA inFAT between patients without AF history, with paroxysmal, and with persistent AF.

Clinical course of hypertrophic cardiomyopathy patients implanted with a transvenous or subcutaneous defibrillator.

Aims: The implantable cardioverter-defibrillator (ICD) is a life-saving therapy in patients with hypertrophic cardiomyopathy (HCM) at risk of sudden cardiac death. Implantable cardioverter-defibrillator complications are of concern. The subcutaneous ICD (S-ICD) does not use transvenous leads and is expected to reduce complications.

Modern subcutaneous implantable defibrillator therapy in patients with cardiomyopathies and channelopathies: data from a large multicentre registry.

Aims: Patients with cardiomyopathies and channelopathies are usually younger and have a predominantly arrhythmia-related prognosis; they have nearly normal life expectancy thanks to the protection against sudden cardiac death provided by the implantable cardioverter defibrillator (ICD). The subcutaneous ICD (S-ICD) is an effective alternative to the transvenous ICD and has evolved over the years. This study aimed to evaluate the rate of inappropriate shocks (IS), appropriate therapies, and device-related complications in patients with cardiomyopathies and channelopathies who underwent modern S-ICD implantation.

Procedure, management, and outcome of subcutaneous implantable cardioverter-defibrillator extraction in clinical practice.

Aims: Subcutaneous implantable cardioverter-defibrillator (S-ICD) therapy is expanding rapidly. However, there are few data on the S-ICD extraction procedure and subsequent patient management. The aim of this analysis was to describe the procedure, management, and outcome of S-ICD extractions in clinical practice.