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Aims: Catheter ablation (CA) of idiopathic ventricular arrhythmias (VAs) from the epicardial left ventricular summit is challenging. The endocardial approach targets two sites: the endocardial closest site (ECS) to the epicardial earliest activation site (epi-EAS) and the endocardial earliest activation site (endo-EAS). We aimed to differentiate between cases where CA at the ECS was effective and where CA at the endo-EAS yielded success.

Methods and results: Fifty-eight patients (47 men; age 60 ± 13 years) were analysed with VAs in which the EAS was observed in the coronary venous system (CVS). Overall, VAs were successfully eliminated in 42 (72%) patients: 8 in the CVS, 8 where the ECS matched with the endo-EAS, 11 at the ECS, and 15 at the endo-EAS. A successful ECS ablation was associated with a shorter epi-EAS-ECS distance (10.2 ± 4.7 vs. 18.8 ± 5.3 mm; P < 0.001) and shorter epi-EAS-left main coronary trunk (LMT) ostial distance (20.3 ± 7.6 vs. 30.3 ± 8.4 mm; P = 0.005), with optimal cut-off values of ≤12.6 and ≤24.0 mm, respectively. A successful endo-EAS ablation was associated with an earlier electrogram at the endo-EAS [23 (8, 36) vs. 15 (0, 19) ms preceding the QRS; P < 0.001] and shorter epi-EAS-endo-EAS interval [6 (1, 8) vs. 22 (12, 25) ms; P < 0.001], with optimal cut-off values of ≥18 and ≤9 ms, respectively.

Conclusion: Shorter anatomical distances between the epi-EAS and ECS, and between the epi-EAS and LMT ostium, predict a successful ECS ablation. The prematurity of the endo-EAS electrogram and a shorter interval between the epi-EAS and endo-EAS predicted a successful endo-EAS ablation.

Carotid sinus massage (CSM) as integral part of cardiovascular autonomic testing is indicated in all patients > 40 years with syncope of unknown origin and suspected reflex mechanism. However, large practice variation exists in performing CSM that inevitably affects the positivity rate of the test and may result in an inaccurate diagnosis in patients with unexplained syncope. Even though CSM was introduced into medical practice more than 100 years ago, the method of performing CSM is still largely operator- and centre-dependent, while in many places, the test has been entirely abandoned. Here, we describe a standardized protocol on how to perform CSM, which basic monitoring equipment is necessary and why CSM is a safe procedure to perform. Our aim is to create a uniform approach to perform CSM. The new proposed algorithm, the Six-Step-Method, includes: (i) check history for exclusion CSM; (ii) turn head slightly contralaterally and posterior (see also explanatory video and poster provided as Supplementary material; (iii) palpation to identify carotid sinus location; (iv) massage for 10 s; (v) monitoring of blood pressure and heart rate to assess of the haemodynamic response type; and (vi) include time intervals between subsequent massages. Carotid sinus massage should be performed on both the left and right and in the supine and upright position. The recommended equipment to perform CSM consists of: (i) a tilt table in order to perform CSM in supine and standing position, (ii) a continuous blood pressure monitor or cardiac monitor, and (iii) at least two persons.

Heart rhythm management is a continuously evolving sub-speciality of cardiology. Every year, many physicians and allied professionals (APs) start and complete their training in cardiac implantable electronic devices (CIEDs) or electrophysiology (EP) across the European Heart Rhythm Association (EHRA) member countries. While this training ideally ends with an EHRA certification, the description of the learning pathway (what, how, when, and where) through an EHRA core curriculum is also a prerequisite for a successful training. The first EHRA core curriculum for physicians was published in 2009. Due to the huge developments in the field of EP and device therapy, this document needed updating. In addition, a certification process for APs has been introduced, as well as a recertification process and accreditation of EHRA recognized training centres. Learning pathways are more individualized now, with Objective Structured Assessment of Technical Skills (OSATS) to monitor learning progression of trainees. The 2024 updated EHRA core curriculum for physicians and APs describes, for both CIED and EP, the syllabus, OSATS, training programme and certification, and recertification for physicians and APs and stresses the importance of continued medical education after certification. In addition, requirements for accreditation of training centres and trainers are given. Finally, suggested reading lists for CIED and EP are attached as online supplements.

Aims: Despite increasing evidence demonstrating the safety of magnetic resonance imaging (MRI) in patients with cardiac implantable electronic devices (CIEDs), this procedure is often neglected in this population. This Spanish registry aimed to determine the proportion of MRI referrals and performance among patients with pacemakers (PMs) or implantable cardioverter defibrillators (ICDs).

Methods and results: This prospective, multicentre, open-label registry involved 21 Spanish centres. Data were collected upon implant of PMs or ICDs from BIOTRONIK and one year after, and included the number of MRIs and computed tomography scans prescribed, performed and denied, and reasons for denial. Data from 1105 patients (mean age: 74.2 years) were analysed and 982 completed the follow-up. Of them, 82.2% had a PM and 17.8% an ICD. A total of 351 imaging tests were prescribed in 220 patients (19.9%), including 52 MRIs in 39 patients (3.5%) and 299 computed tomography scans in 196 patients (17.8%). Among the MRIs, 44 (84.6%) were performed, five (9.6%) were not performed, and three (5.8%) were replaced by an alternative test. Most of the indicated computed tomography scans were performed (97.7%). The proportion of patients with an MRI scan referral was 4.6% during the pre-COVID-19 period and 2.6% during the COVID-19 period. No MRI-related arrhythmic ventricular event was reported.

Conclusion: This registry revealed that only 3.5% of patients with CIEDs had an MRI referral over the study, with rates decreasing to 2.6% during the COVID-19 period. These rates contrast with the 85 MRIs conducted per 1000 inhabitants in Spain in 2020.

Aims: Atrial fibrillation (AF) is the most common sustained arrhythmia among patients with hypertrophic cardiomyopathy (HCM), increasing symptom burden and stroke risk. We aimed to construct a plasma proteomics-based model to predict new-onset AF in patients with HCM and determine dysregulated signalling pathways.

Methods and results: In this prospective, multi-centre cohort study, we conducted plasma proteomics profiling of 4986 proteins at enrolment. We developed a proteomics-based machine learning model to predict new-onset AF using samples from one institution (training set) and tested its predictive ability using independent samples from another institution (test set). We performed a survival analysis to compare the risk of new-onset AF among high- and low-risk groups in the test set. We performed pathway analysis of proteins significantly (univariable P < 0.05) associated with new-onset AF using a false discovery rate (FDR) threshold of 0.001. The study included 284 patients with HCM (training set: 193, test set: 91). Thirty-seven (13%) patients developed AF during median follow-up of 3.2 years [25-75 percentile: 1.8-5.2]. Using the proteomics-based prediction model developed in the training set, the area under the receiver operating characteristic curve was 0.89 (95% confidence interval 0.78-0.99) in the test set. In the test set, patients categorized as high risk had a higher rate of developing new-onset AF (log-rank P = 0.002). The Ras-MAPK pathway was dysregulated in patients who developed incident AF during follow-up (FDR < 1.0 × 10-6).

Conclusion: This is the first study to demonstrate the ability of plasma proteomics to predict new-onset AF in HCM and identify dysregulated signalling pathways.

Aims: The third-generation laser balloon (LB3) is an established ablation device for pulmonary vein isolation (PVI) that allows direct visualization of the anatomical target. Equipped with an automatic circumferential laser delivery modality, it aims at continuous circumferential PVI, improving both acute and clinical outcomes. We sought to evaluate the clinical efficacy of LB3 ablation using an anatomical-based approach without verifying electrical isolation.

Methods and results: Among 257 paroxysmal AF patients undergoing LB3 ablation across four Italian centres, 204 (72% male, mean age 60.4 ± 11.1 years) were included. The primary endpoint was freedom from any atrial tachyarrhythmia (ATa) recurrence after the blanking period (BP), assessed with implantable cardiac monitors (ICMs). All pulmonary veins (PVs) were targeted using the LB3, with the RAPID mode used on an average of 96 ± 8, 86 ± 19, 98 ± 11, and 84 ± 15% for the left superior, left inferior, right superior, right inferior PV, and left common ostium, respectively. Freedom from arrhythmia recurrences was 84.8% at 1, 80.4% at 2, and 76.0% at 3 years. An ATa burden ≥ 5% was documented in 2.5, 4.4, and 5.4% at 1, 2, and 3 years, respectively. Relapses during the BP [hazard ratio (HR) = 2.182, P = 0.032] and left atrial dilation (HR = 1.964, P = 0.048) were independent predictors of recurrences.

Conclusion: Anatomical-guided LB3 ablation for paroxysmal AF is a safe and effective approach, providing excellent clinical outcomes as assessed by ICM over nearly 3 years of follow-up.

The co-ordinated electrical activity of ∼2 billion cardiac cells ensures stability of the heartbeat. Indeed, the remarkably low incidence (<1%) of ventricular arrhythmias in the healthy heart is only possible when the electrical event across this syncytium is closely controlled. In contrast, the diseased myocardium is associated with increased electrophysiological heterogeneity, unstable rhythm, and increased incidence of lethal arrhythmias. But what is the link between cellular and tissue level heterogeneity? Recent research has shown the existence of considerable cellular heterogeneity even in the healthy heart, suggesting that cell-to-cell variability in electrical (e.g. action potential duration) and mechanical performance (e.g. twitch amplitude) is a normal property. This observation has been previously unappreciated because the aggregated function in the form of QT-interval and cardiac output varies <1% on a beat-to-beat basis. This article describes the underlying cellular variability that is tolerated-and perhaps needed-by different regions of the heart for normal function and indicates why this variability is not apparent in function at the chamber and organ level. Thus, in contrast to the current dominant view, this article postulates that heterogeneity is normal and potentially endows various functional benefits. This new view of how the component parts of the heart come together to function also suggests novel mechanisms for cardiac pathologies, namely that dysfunction may emerge from changes in the extent and/or nature of heterogeneity. Once understood, restoring normal forms of heterogeneity could be a novel approach to treatment.

Aims: Structural and fibrotic remodelling is a well-known contributor to the atrial fibrillation (AF) substrate. Epicardial adipose tissue (EAT) is increasingly recognized as a contributor through electrical remodelling in the atria. We aimed to assess the association of LA fibrosis and EAT with LA strain and function using cardiac magnetic resonance (CMR) imaging in patients with AF.

Methods and results: LA fibrosis was assessed using late gadolinium enhancement CMR, LA EAT was assessed using the fat-water separation Dixon sequence, and feature tracking was applied to assess global longitudinal strain in its three components [reservoir (GLRS), conduit (GLCdS), and contractile (GLCtS)]. LA emptying fraction and LA volume were measured using the cine sequences. All CMR images were acquired in sinus rhythm. One hundred one AF patients underwent pre-ablation CMR (39% female, average age 62 years). LA fibrosis was negatively associated with the three components of global longitudinal strain (GLRS: R = -0.35, P < 0.001; GLCdS: R = -0.24, P = 0.015; GLCtS: R = -0.2, P = 0.046). Out of the different sections of the LA, fibrosis in the posterior and lateral walls was most negatively correlated with GLRS (R = -0.32, P = 0.001, and R = -0.33, P = 0.001, respectively). LA EAT was negatively correlated with GLCdS (R = -0.453, P < 0.001). LA fibrosis was negatively correlated with LA emptying fraction but LA EAT was not (R = -0.27, P = 0.007, and R = -0.22, P = 0.1, respectively). LA EAT and fibrosis were both positively correlated with LA volume (R = 0.38, P = 0.003, and R = 0.24, P = 0.016, respectively).

Conclusion: LA fibrosis, a major component of the AF substrate, and EAT, an important contributor, are associated with a worsening LA function through strain analysis by CMR.