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Background Epicardial placement of the left ventricular (LV) lead via a video‐assisted thoracoscopic (VAT) approach is an alternative to the standard transvenous technique. Hypothesis Long‐term safety and efficacy of VAT and transvenous LV lead implantation are comparable. To test it, we reviewed our experience and we compared the outcomes of patients who underwent implantation with the two techniques. Methods The VAT procedure is performed under general anesthesia, with oro‐tracheal intubation and right‐sided ventilation, and requires two 5 mm and one 15 mm thoracoscopic ports. After pericardiotomy at the spot of the epicardial target area, pacing measurements are taken and a spiral screw electrode is anchored at the final pacing site. The electrode is then tunneled to the pectoral pocket and connected to the device. Results 105 patients were referred to our center for epicardial LV lead implantation. After pre‐operative assessment, 5 patients were excluded because of concomitant conditions precluding surgery. The remaining 100 underwent the procedure. LV lead implantation was successful in all patients (median pacing threshold 0.8 ± 0.5 V, no phrenic nerve stimulation) and cardiac resynchronization therapy was established in all but one patient. The median procedure time was 75 min. During a median follow‐up of 24 months, there were no differences in terms of death, cardiovascular hospitalizations or device‐related complications vs the group of 100 patients who had undergone transvenous implantation. Patients of both groups displayed similar improvements in terms of ventricular reverse remodeling and functional status. Conclusions Our VAT approach proved safe and effective, and is a viable alternative in the case of failed transvenous LV implantation.

An analysis of the high-density activation maps allows greater precision in the identification of reconnection gaps in PV, which results in lower radiofrequency time for the new isolation.

No studies have investigated whether optimizing implantable cardiac monitors (ICM) programming can reduce false-positive (FP) alerts. We identified patients implanted with an ICM (BIOMONITOR III) who had more than 10 FP alerts in a 1-month retrospective period. Uniform adjustments of settings were performed based on the mechanism of FP triggers and assessed at 1 month. Eight patients (mean age 57.5 ± 23.2 years; 37% female) were enrolled. In 4 patients, FPs were caused by undersensing of low-amplitude premature ventricular contractions (PVCs). No further false bradycardia was observed with a more aggressive decay of the dynamic sensing threshold. Furthermore, false atrial fibrillation (AF) alerts decreased in 2 of 3 patients. Two patients had undersensing of R waves after high-amplitude PVCs; false bradycardia episodes disappeared or were significantly reduced by limiting the initial value of the sensing threshold. Finally, the presence of atrial ectopic activity or irregular sinus rhythm generated false alerts of AF in 2 patients that were reduced by increasing the R-R variability limit and the confirmation time. In conclusion, adjustments to nominal settings can reduce the number of FP episodes in ICM patients. More research is needed to provide practical recommendations and assess the value of extended ICM programmability.

Background: Data on transcatheter aortic valve replacement (TAVR) long-term clinical outcomes and hemodynamic performance of the self-expandable CoreValve (CV) and the balloon-expandable Edwards SAPIEN XT (ES) (Edwards Lifesciences, Irvine, California, USA) transcatheter heart valves (THV) are limited. Therefore, this study aimed to compare long-term clinical outcome data and hemodynamic performance of TAVR with either CV or ES. Results: Out of 171 patients treated with TAVR at our Institution, 87 received a CV and 84 an ES THV.Mean age was 81 [78][79][80][81][82][83][84][85] years, and mean Society of Thoracic Surgeons (STS) score was 7.5% (4.5-13.9%).Hemodynamic success by Valve Academic Research Consortium (VARC) definition was 97.1%. Mean trans-prosthetic gradient remained low and stable during follow-up in both groups (at 5-year 9.2±6.4 versus 12.7±5.1 mmHg, P=0.10). Late prosthesis failure occurred in 4 cases (2.4%). Thirty-day mortality was 4.7%, and estimated survival rates by Kaplan-Meyer after 1, 5 and 8 years were 87.6%, 44.9%, and 24.5%, respectively, without difference between THV groups. Rates of cardiovascular death, stroke, myocardial infarction (MI) and congestive heart failure (CHF) were also similar with CV and ES at long-term followup. History of CHF, pre-existent severe mitral regurgitation, paravalvular leak grade ≥2+, and chronic obstructive pulmonary disease were independent predictors of late mortality at multivariable analysis.Conclusions: Clinical and hemodynamic outcomes of patients treated by self-expandable CV or balloonexpandable ES THV were favorable and similar throughout long-term follow-up, with a rate of prosthesis failure of less than 3%.

Purpose. 3D nonfluoroscopic mapping systems (NMSs) are generally used in the catheter ablation (CA) of complex ventricular and atrial arrhythmias. The aim of this study was to evaluate the efficacy, safety, and long-term effect of the extended, routine use of NMSs for CA. Methods. Our study involved 1028 patients who underwent CA procedures from 2007 to 2016. Initially, CA procedures were performed mainly with the aid of fluoroscopy. From October 2008, NMSs were used for all procedures. Results. The median fluoroscopy time of the overall CA procedures fell by 71%: from 29.2 min in 2007 to 8.4 min in 2016. Over the same period, total X-ray exposure decreased by 65%: from 58.18 Gy⁎cm2 to 20.19 Gy⁎cm2. This reduction was achieved without prolonging the total procedure time. In AF CA procedures, the median fluoroscopy time fell by 85%, with an 86% reduction in total X-ray exposure. In SVT CA procedures, the median fluoroscopy time fell by 93%, with a 92% reduction in total X-ray exposure. At the end of the follow-up period, the estimated probability of disease-free survival was 67.7% at 12 months for AF CA procedures and 97.2% at 3 months for SVT CA, without any statistically significant difference between years. Conclusions. Our study shows the feasibility of using NMSs as the main imaging modality to guide CA. The extended, routine use of NMSs dramatically reduces radiation exposure, with only slight fluctuations due to the process of acquiring experience on the part of untrained operators, without affecting disease-free survival.

Mitral regurgitation secondary to accessory mitral valve (MV) chordae of the left atrium is an extremely rare congenital disease. A 85-year-old female (NYHA I-II) was hospitalized for investigations. An echocardiogram showed calcification of the MV with mild stenosis and moderate regurgitation. Transesophageal three-dimensional echocardiogram revealed a band-like structure extending from the distal third of the anterior wall of the left atrium to the MV. This accessory chordae determined severe systolic regurgitation and mild mitral stenosis. The patient was referred for consideration of cardiac surgery but was refused for comorbidities and anatomy. Usually aberrant chordae determinant valvulopathies are detected and treated at a much younger age. The delay of the symptoms could be explained in our case with the progressive growth and dilatation of the left atrium causing traction of the aberrant chord resulting in an increase in the leaflet prolapse and regurgitation.