Background-The pulmonary veins (PVs) and surrounding ostial areas frequently house focal triggers or reentrant circuits critical to the genesis of atrial fibrillation (AF). We developed an anatomic approach aimed at isolating each PV from the left atrium (LA) by circumferential radiofrequency (RF) lesions around their ostia. Methods and Results-We selected 26 patients with resistant AF, either paroxysmal (nϭ14) or permanent (nϭ12). A nonfluoroscopic mapping system was used to generate 3D electroanatomic LA maps and deliver RF energy. Two maps were acquired during coronary sinus and right atrial pacing to validate the lateral and septal PV lesions, respectively. Patients were followed up closely for Ն6 months. Procedures lasted 290Ϯ58 minutes, including 80Ϯ22 minutes for acquisition of all maps, and 118Ϯ16 RF pulses were deployed. Among 14 patients in AF at the beginning of the procedure, 64% had sinus rhythm restoration during ablation. PV isolation was demonstrated in 76% of 104 PVs treated by low peak-to-peak electrogram amplitude (0.08Ϯ0.02 mV) inside the circular line and by disparity in activation times (58Ϯ11 ms) across the lesion. After 9Ϯ3 months, 22 patients (85%) were AF-free, including 62% not taking and 23% taking antiarrhythmic drugs, with no difference (PϭNS) between paroxysmal and permanent AF. No thromboembolic events or PV stenoses were observed by transesophageal echocardiography. Conclusions-Radiofrequency PV isolation with electroanatomic guidance is safe and effective in either paroxysmal or permanent AF.

Background-Circumferential radiofrequency ablation around pulmonary vein (PV) ostia has recently been described as a new anatomic approach for atrial fibrillation (AF). Methods and Results-We treated 251 consecutive patients with paroxysmal (nϭ179) or permanent (nϭ72) AF. Circular PV lesions were deployed transseptally during sinus rhythm (nϭ124) or AF (nϭ127) using 3D electroanatomic guidance. Procedures lasted 148Ϯ26 minutes. Among 980 lesions surrounding individual PVs (nϭ956) or 2 ipsilateral veins with close openings or common ostium (nϭ24), 75% were defined as complete by a bipolar electrogram amplitude Ͻ0.1 mV inside the lesion and a delay Ͼ30 ms across the line. The amount of low-voltage encircled area was 3594Ϯ449 mm 2 , which accounted for 23Ϯ9% of the total left atrial (LA) map surface. Major complications (cardiac tamponade) occurred in 2 patients (0.8%). No PV stenoses were detected by transesophageal echocardiography. After 10.4Ϯ4.5 months, 152 patients with paroxysmal AF (85%) and 49 with permanent AF (68%) were AF-free. Patients with and without AF recurrence did not differ in age, AF duration, prevalence of heart disease, or ejection fraction, but the LA diameter was significantly higher (PϽ0.001) in permanent AF patients with recurrence. The proportion of PVs with complete lesions was similar between patients with and without recurrence, but the latter had larger low-voltage encircled areas after radiofrequency (expressed as percent of LA surface area; PϽ0.001). Conclusions-Circumferential PV ablation is a safe and effective treatment for AF. Its success is likely due to both PV trigger isolation and electroanatomic remodeling of the area encompassing the PV ostia.

S-ICD screening failure is low in HCM, provided that patients with severe hypertrophy are carefully evaluated. Exercise test should be performed and right parasternal leads tested. Pacemaker patients display lower eligibility rate.

Background: Cardiac resynchronization therapy (CRT) has been introduced to treat drug refractory chronic heart failure (CHF). Apelin, the endogenous ligand of the APJ receptor, is under evaluation for its potential role in human CHF pathophysiology. This study aims to assess whether biventricular pacing affects plasma apelin levels in patients with severe CHF. Methods and results: Fourteen patients (9 men, 5 women, mean age 68 ± 13 years) undergoing biventricular pace-maker/ICD implantation were studied. Patients underwent baseline clinical and echocardiographic evaluation, and assessment of plasma apelin and NT-proBNP levels. The evaluation was repeated 48 h and 9 ± 2 months after device implantation to assess the acute and chronic effects of CRT on apelin and NT-proBNP levels. Eight healthy age-and sex-matched subjects served as controls.In CHF patients, baseline apelin levels were reduced and NT-proBNP increased compared to control subjects (apelin: 0.47 ± 0.2 vs. 0.97 ± 0.3 ng/mL, p < 0.001; NT-proBNP: 2007 ± 114 vs. 229 ± 72 pmol/L, p < 0.001). Short-term evaluation did not reveal any effect of CRT on apelin or NT-proBNP levels. By contrast, at 9 ± 2 months follow-up, CRT responders showed left ventricular reverse remodelling and an increase in ejection fraction, together with a significant increase in plasma apelin levels (0.99 ± 0.1 vs. 0.47 ± 0.2 ng/mL, p < 0.001) and decrease in NT-proBNP (938 ± 591 vs. 2007 ± 114 pmol/L, p < 0.05). Conclusions: Long-term CRT increases plasma levels of the endogenous inotrope apelin in patients with CHF.