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The diagnostic yield of ELR in patients with syncope, pre-syncope, or palpitation of unknown origin after routine workup was similar to implantable loop recorder (ILR) within the same timeframe, therefore, ELR could be considered for patients candidate for long-term ECG monitoring, stepwise before ILR.

Aims Pulmonary vein isolation (PVI) using cryoballoon ablation (CBA) is mainly reserved for patients with drug-refractory or drug-intolerant symptomatic atrial fibrillation. We evaluated a large cohort of patients treated in a real-world setting and examined the safety and efficacy profile of CBA when applied as a first-line treatment for atrial fibrillation. Methods In total, 249 patients (23% women; 56 ± 13 years; mean left atrial diameter 41 ± 7 mm; 73.5% paroxysmal atrial fibrillation; and 26.5% persistent atrial fibrillation) underwent an index PVI by CBA. Data were collected prospectively in the framework of the 1STOP ClinicalService project, involving 26 Italian cardiology centers. Results Median procedure and fluoroscopy times were 90.0 and 21.0 min, respectively. Acute procedural success was 99.8%. Acute/periprocedural complications were observed in seven patients (2.8%), including: four transient diaphragmatic paralyses, one pericardial effusion (not requiring any intervention), one transient ischemic attack, and one minor vascular complication. The Kaplan--Meier freedom from atrial fibrillation recurrence was 86.3% at 12 months and 76% at 24 months. Seventeen patients (6.8%) had a repeat catheter ablation procedure during the follow-up period. At last follow-up, 10% of patients were on an anticoagulation therapy, whereas 6.8% were on an antiarrhythmic drug. Conclusion In our multicenter real-world experience, PVI by CBA in a first-line atrial fibrillation patient population was well tolerated, effective, and promising. CBA with a PVI strategy can be used to treat patients with paroxysmal and persistent atrial fibrillation with good acute procedural success, short procedure times, and acceptable safety. Clinical Trial Registration clinicaltrials.gov (NCT01007474).

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Biventricular Pacing. Introduction: Biventricular pacing improves functional status in the majority of patients with drug-refractory heart failure, dilated cardiomyopathy, and interventricular conduction delay. The aim of this study was to analyze the baseline clinical and functional data of a cohort of patients implanted with a biventricular stimulation system in a single-center experience, to verify if the pathophysiologic characteristics of patients affect outcome, and to determine if preliminary identification of the right candidates for the new therapy is possible with noninvasive parameters.Methods and Results: Since March 1999, 52 patients with advanced heart failure (idiopathic cardiomyopathy 50%, ischemic cardiomyopathy 35 %, other etiology 15%) and left bundle branch block underwent cardiac resynchronization and were followed prospectively. Paired analysis over mean (± SD) follow-up of 348 ± 154 days showed an overall significant decrease of QRS width (baseline 194 ± 33.2 msec vs follow-up 159.6 ± 20.1 msec), New York Heart Association (NYHA) functional class (baseline 3.2 ± 0.5 vs follow-up 2.3 ± 0.5), quality-of-Iife score (baseline 54 ± 25 vs follow-up 25 ± 16), and increase of maximal VOz (baseline 12.6 ± 2.5 mLlkg/min vs follow-up 15.0 ± 3.3 mLlkg/min). There were 80% responders (documented, persistent decrease zel NYHA class) and 20% nonresponders (same NYHA class or decline of status; need for heart transplant; death due to progressive pump failure). No significant differences in baseline clinical and functional variables between the two subgroups were observed. In responders, there was a highly significant global improvement of all variables; in nonresponders, no parameters changed between baseline and follow-up.Conclusion: These data confirm the role of biventricular pacing in improving the functional status of the great majority of a selected patient population having advanced heart failure and left bundle branch block with wide QRS complex. Basal demographic, clinical, and functional characteristics are not helpful in preliminary selection of responders. Simple evaluation of NYHA class confirms favorable outcome (improvement of functional and hemodynamic status).

From 2020, many countries have adopted several restrictions to limit the COVID-19 pandemic. The forced containment impacted on healthcare organizations and the everyday life of patients with heart disease. We prospectively analyzed data recorded from implantable defibrillators and/or cardiac resynchronization devices of Italian patients during the lockdown (LDP), post-lockdown period (PLDP) and a control period (CP) of the previous year. We analyzed device data of the period 9 March 2019–31 May 2020 of remotely monitored patients from 34 Italian centers. Patients were also categorized according to areas with high/low infection prevalence. Among 696 patients, we observed a significant drop in median activity in LDP as compared to CP that significantly increased in the PLDP, but well below CP (all p < 0.0001). The median day heart rate and heart rate variability showed a similar trend. This behavior was associated during LDP with a significant increase in the burden of atrial arrhythmias (p = 0.0150 versus CP) and of ventricular arrhythmias [6.6 vs. 1.5 per 100 patient-weeks in CP; p = 0.0026]; the latter decreased in PLDP [0.3 per 100 patient-weeks; p = 0.0035 vs. LDP]. No modifications were recorded in thoracic fluid levels. The high/low prevalence of COVID-19 infection had no significant impact. We found an increase in the arrhythmic burden in LDP coupled with a decrease in physical activity and heart rate variability, without significant modifications of transthoracic impedance, independent from COVID-19 infection prevalence. These findings suggest a negative impact of the COVID-19 pandemic, probably related to lockdown restrictions.

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BackgroundThe presence of a persistent fibrous sheath in right-sided heart chambers after transvenous lead extraction has already been described in some studies as echocardiographic tubular mobile masses called ‘ghosts’. Their presence has been associated with cardiac device-related infective endocarditis or local device infection, but to the best of our knowledge, this is the first case where ‘ghosts’ have been reported among non-infected patients.Case summaryWe present a case of a 73-year-old woman hospitalized due to worsening dyspnoea and a significant pericardial effusion, relapsed after pericardiocentesis with removal of about 1500 mL of non-haemorrhagic fluid. The patient’s history revealed a previous dual-chamber pacemaker implantation due to symptomatic sick sinus syndrome. Transoesophageal echocardiography (TOE), essential to exclude endocarditis vegetations suggested an etiopathogenesis of mechanical irritation caused by the distal end of the passive fixation atrial lead on the right atrial appendage wall. Considering the echocardiographic report and the condition of reactive pericarditis with the early relapse of the significant pericardial effusion after pericardiocentesis, we opted for a lead removal procedure to eliminate the stimulus causing the irritation, with transoesophageal echocardiographic monitoring, thus the early detection of a ‘ghost’ was possible.DiscussionThis is the first clinical case describing the presence of fibrin ‘ghosts’ sometime after the implantation of a pacemaker, highlighting a non-exclusively infectious genesis, and emphasizing the importance of TOE for the early detection of this post-extraction complication and its monitoring.