Superiority of Simulator-Based Training Compared With Conventional Training Methodologies in the Performance of Transseptal Catheterization

ObjectivesThis study aims to compare the performance of electrophysiology fellows in transseptal catheterization (TSP-C) after conventional (Conv-T) or simulator training (Sim-T).BackgroundCurrent training for TSP-C, an increasingly used procedure, relies on performance on patients with supervision by an experienced operator. Virtual reality, a new training option, could improve post-training performance.MethodsFellows inexperienced in TSP-C were enrolled and randomly assigned to Conv-T or Sim-T. The post-training performance of each fellow was evaluated and scored in 3 consecutive patient-based procedures by an experienced operator blinded to the fellow's training assignment.ResultsFourteen fellows were randomized to Conv-T (n = 7) or to Sim-T (n = 7) and, after training, performed 42 TSP-Cs independently. Training time was significantly longer for Conv-T than for Sim-T (median 30 days vs. 4 days; p = 0.0175). The Conv-T fellows had significantly lower post-training performance scores (median 68 vs. 95; p = 0.0001) and a higher number of recurrent errors (median 3 vs. 0; p = 0.0006) when compared with Sim-T fellows.ConclusionsThe TSP-C training with virtual reality results in shorter training times and superior post-training performance

The effects of gender on electrical therapies for the heart: procedural considerations, results and complications: A report from the XII Congress of the Italian Association on Arrhythmology and Cardiostimulation (AIAC)

Use of cardiac implantable devices and catheter ablation is steadily increasing in Western countries following the positive results of clinical trials. Despite the advances in scientific knowledge, tools development, and techniques improvement we still have some grey area in the field of electrical therapies for the heart. In particular, several reports highlighted differences both in medical behaviour and procedural outcomes between female and male candidates. Women are referred later for catheter ablation of supraventricular arrhythmias, especially atrial fibrillation, leading to suboptimal results. On the opposite females present greater response to cardiac resynchronization, while the benefit of implantable defibrillator in primary prevention seems to be less pronounced. Differences on aetiology, clinical profile, and development of myocardial scarring are the more plausible causes. This review will discuss all these aspects together with gender-related differences in terms of acute/late complications. We will also provide useful hints on plausible mechanisms and practical procedural aspects

Procedural Feasibility and Long-Term Efficacy of Catheter Ablation of Atypical Atrial Flutters in a Wide Spectrum of Heart Diseases: An Updated Clinical Overview

Atypical atrial flutters (AAFL) are difficult-to-manage atrial arrhythmias, yet potentially amenable to effective radiofrequency catheter ablation (CA). However, data on CA feasibility are only sparingly reported in the literature in different clinical settings, such as AAFL related to surgical correction of congenital heart disease. The aim of this review was to provide an overview of the clinical settings in which AAFL may occur to help the cardiac electrophysiologist in the prediction of the tachycardia circuit location before CA. Moreover, the role and proper implementation of cutting-edge technologies in this setting were investigated as well as which procedural and clinical factors are associated with long-term failure to maintain sinus rhythm (SR) to find out which patients may, or may not, benefit from this procedure. Not only different surgical and non-surgical scenarios are associated with peculiar anatomical location of AAFL, but we also found that CA of AAFL is generally feasible. The success rate may be as low as 50% in surgically corrected congenital heart disease (CHD) patients but up to about 90% on average after pulmonary vein isolation (PVI) or in patients without structural heart disease. Over the years, the progressive implementation of three-dimensional mapping systems and high-density mapping tools has also proved helpful for ablation of these macro-reentrant circuits. However, the long-term maintenance of SR may still be suboptimal due to the progressive electroanatomic atrial remodeling occurring after cardiac surgery or other interventional procedures, thus limiting the likelihood of successful ablation in specific clinical settings

Cryoablation of para-Hisian and mid-septal accessory pathways: long-term outcomes of a specific stepwise cryoablation protocol

Background: Although cryoablation (CA) of septally located accessory pathways (APs) is an established treatment for Wolff-Parkinson-White syndrome, its major limitation is the lack of data regarding long-term follow-up (FU). The present study sought to investigate long-term outcomes of a specific CA protocol targeting para-Hisian (P-H) and mid-septal (M-S) APs. Methods: 26 patients who previously underwent CA of PH or MS APs from 2004 to 2014, were prospectively considered to receive a follow-up (FU) during 2021. All subjects received an outpatient control visit, performing an exercise stress test and a 24-h ECG Holter monitoring. Results: Acute success was achieved in 22 patients (85%). One case of recurrence was reported at short-term FU. Long-term FU, performed after a mean time of 150 ± 37 months, did not show ventricular preexcitation recurrences, with a success rate of 81%, and without late adverse events. Symptoms reduction (12% vs. 96%, p<.001) and lower rates of antiarrhythmic drug use (12% vs. 62%, p<.001) were observed at long term-FU with respect to baseline. This clinical outcome was detected also among patients who underwent unsuccessful CA at baseline. Conclusions: Our CA protocol confirmed remarkable safety and efficacy throughout a longterm FU. Significant clinical improvement in terms of antiarrhythmic therapy discontinuation and symptoms reduction was also shown among patients who experienced acute failure of CA

Asymptomatic ventricular pre-excitation: which path to take?

The management of asymptomatic patients with ventricular pre-excitation diagnosed occasionally is controversial. In fact, the lack of clinical arrhythmias does not necessarily define a benign condition: it could be possibly due to poor conduction over the accessory pathway or, conversely, to peculiar and individual conditions, which, even if the accessory pathway is capable of fast conduction, can prevent the onset of arrhythmias. These can occur unexpectedly during follow-up and may include malignant ventricular arrhythmias, although sudden death is very rare in this clinical scenario. An aggressive strategy aiming at extensive ablation in all cases with asymptomatic ventricular pre-excitation is not justified, as well as the "wait-and-see" approach. Clinically, it is important to accurately define the individual risk of any arrhythmia related to the accessory pathway, which may require treatment. For decades, the management of asymptomatic ventricular pre-excitation has been quite inhomogeneous among centers and in some cases it is still very different. Recently, a consensus document proposed the combined use of non-invasive and invasive diagnostic tools for accurate screening of these patients. If non-invasive methodologies are unable to demonstrate poor conduction over the accessory pathway, then an invasive approach is justified for arrhythmia risk definition and, if necessary, adequate therapy

Transplantation of bone marrow stromal mesenchymal cells in the treatment of acute myocardial infarction

Introduction: Aim of the study to investigate the efficacy of bone marrow stromal mesenchymal cells (BMSCs) in the early stages of acute myocardial infarction (AMI) in a rat model. Material and methods: Bone marrow was collected from lower limbs of male Wistar rats. Cells were prepared and cultured. Myocardial infarction was induced in female Wistar rats by coronary occlusion. After 30 min, rats received an intramyocardial injection of BMSCs (n = 9) or culture medium (control, n = 11). Echocardiography was performed at baseline and 30 days later, before heart excision. RT-PCR was performed and presence of chromosome Y, NKX2.5, troponin I, GATA4, VEGF-\u3b1, VEGF-R1, and KDR was investigated in lesion areas and in the posterior wall. Results: At day 30, a significant decrease in ejection fraction (LVEF) (46.6 \ub116.2% vs. 35.6 \ub116.0%, p = 0.035) and a marked increase in end-diastolic (LVEDd) (6.74 \ub10.75 mm vs. 8.92 \ub11.59 mm, p = 0.012) and end-systolic (LVESd) diameters (5.32 \ub10.99 mm vs. 7.47 \ub11.68 mm, p = 0.012) were evident in the control group. Bone marrow stromal mesenchymal cells-treated rats showed no difference in LVEF (36.8 \ub112.1% vs. 44.8 \ub112.3%, p = 0.262), LVEDd (7.92 \ub10.89 mm vs. 7.76 \ub11.34 mm, p = 0.671), or LVESd (6.65 \ub11.15 mm vs. 6.21 \ub11.42 mm, p = 0.624). Chromosome Y was detected only in lesion areas of BMSC-treated hearts. Expression of NKX2.5, troponin I, GATA4, VEGF-\u3b1, VEGF-R1, and KDR was significantly higher in lesion areas of treated hearts. Conclusions: Cell therapy with BMSCs seems effective in the early stages of AMI, preventing LVEF worsening and remodelling. Injected cells give origin to muscular and endothelial cells. It is necessary to clarify whether new cells directly derive from injected cells, or originate from resident or circulating cells by stimulation or chemotaxis. Copyright \ua9 2009 Termedia & Banach

Optimization of catheter/tissue contact during pulmonary vein isolation: the impact of atrial rhythm

Aims. During pulmonary vein isolation (PVI), even if operators are aware of the contact force (CF), its values may greatly vary and the impact of cardiac rhythm has not been thoroughly investigated yet. This study aims at assessing the actual values of CF, the applications with suboptimal CF, and the impact of cardiac rhythm on CF during PVI. Methods. Twenty patients undergoing point-by-point PVI with a CF-sensing catheter were considered. CF target was between 6-40 g. The mean CF per application (mCF) was evaluated and considered suboptimal if 645 g. The real-time graphic of CF was also evaluated and classified as pulsatile if regular variations synchronous with the atrial rate were seen; otherwise it was irregular. Results. To achieve PVI, 1458 applications were delivered; 287 (19.68%) had suboptimal mCF. A great variability of mCF was seen according to anatomy, operators and patients. Compared to applications in atrial fibrillation (AF), those in sinus rhythm (SR) showed a higher median value of mCF (11 vs.9 g; p=0.0099) and a lower percentage of suboptimal mCF (17.95 vs. 25.15%; p=0.0051). Compared to the irregular, the pulsatile pattern, almost exclusively observed in SR, was associated with higher mCF (14.69\ub18.77 vs. 10.79\ub17.89 g; p<0.0001) and fewer suboptimal applications (8.02 vs. 27.73%; p<0.0001). Conclusion. During PVI, several factors influence CF, which, despite optimisation attempts, can be suboptimal in about 20% of the applications. However, CF is higher in SR than in AF and this is strictly associated with a pulsatile pattern of instant CF values

Efficacy and safety of cryoablation of para-Hisian and mid-septal accessory pathways using a specific protocol: single-center experience in consecutive patients

Purpose: Radiofrequency (RF) catheter ablation of para-Hisian (P-H) and mid-septal (M-S) accessory pathways (APs) is a potentially harmful procedure due to their close location to the A-V node. Conversely, cryoablation (CA) appears safer in this setting. The aim of this study was to assess the efficacy and safety of CA of these APs using a specific protocol. Methods: Fifty-three patients undergoing CA for P-H (45) or M-S (8) APs were included. CA was performed with a 4-mm catheter at 12 75&nbsp;\ub0C for 480&nbsp;s in the site where conduction block over the AP was obtained by a specific cryomapping protocol. Optimal catheter-tissue contact was achieved by inferior or superior vena cava approach. In case of failure, a 6-mm catheter and/or trans-septal catheterization (TSC) were considered. Normal AV conduction was monitored throughout CA, which was interrupted in case of its inadvertent modifications. Results: In 46 patients (87%), CA was successful. Reasons for failure were as follows: lack of AP interruption (3 patients), intraprocedure AP conduction resumption (3), or transient A-H interval prolongation (1). Failure was associated with more aggressive approach including multiple procedures, greater use of 6-mm catheters, TSC, and longer CA applications. No major complications were observed. Three out of 46 patients (6.5%) experienced relapse of AP conduction during follow-up and were successfully re-treated by CA. Conclusions: CA of P-H and M-S APs is highly safe and effective and a specific protocol for cryomapping and CA could lead to a low recurrence rate at follow-up