Riccardo Cappato

Radiofrequency Catheter Ablation of Atrial Fibrillation in Athletes Referred for Disabling Symptoms Preventing Usual Training Schedule and Sport Competition

Introduction: Atrial fibrillation (AF) may occasionally affect athletes by impairing their ability to compete, and leading to noneligibility at prequalification screening. The impact of catheter ablation (CA) in restoring full competitive activity of athletes affected by AF is not known. The aim of our study was to investigate the effectiveness of CA of idiopathic AF in athletes with palpitations impairing physical performance and compromising eligibility for competitive activities.

Mapping of the Coronary Sinus and Great Cardiac Vein Using a 2-French Electrode Catheter and a Right Femoral Approach

Coronary Sinus Mapping. Introduction: Local electrogranis recorded from the coronary sinus and great cardiac vein provide important information for the diagnosis of various arrhythmias and identification of target sites for ablation of left‐sided accessory pathways. One limitation of present techniques is the inability, in many cases, to probe the great cardiac vein at the anterior mitral annulus. We tested the feasibility of a new technique for catheterization of the coronary sinus and great cardiac vein by means of a small‐diameter electrode catheter advanced via a right femoral approach through an angiography catheter.

Inappropriate sinus tachycardia after radiofrequency ablation of para-Hisian accessory pathways.

Inappropriate Sinus Tachycardia After Catheter Ablation. Introduction: Inappropriate sinus tachycardia (IST) has been observed following radiofrequency ablation (RFA) of the AV nodal fast pathway. This study was aimed to prospectively analyze the incidence and clinical significance of IST following RFA of para‐Hisian accessory pathways (APs).

Microvolt T‐Wave Alternans as Predictor of Electrophysiological Testing Results in Professional Competitive Athletes

Background: Several studies have confirmed the equivalence of the microvolt T‐wave alternans (mTWA) and the electrophysiology (EPS) tests in cardiac disease. No data are available in populations of competitive athletes with arrhythmias that might jeopardize the pursuit of their professional career.

Arrhythmia detection in single- and dual-chamber implantable cardioverter defibrillators: the more leads, the better?

The implantable cardioverter defibrillator (ICD) offers life‐saving therapies for primary and secondary prevention of sudden cardiac death in high‐risk patients. However, ICD detection algorithms consistently misclassify a substantial proportion of supraventricular rhythms, thus carrying the risk for inappropriate therapies. Although single‐chamber ICD (Sc‐ICD) discrimination tools have been reported to provide high specificity in rejecting sinus tachycardia and atrial fibrillation with a relatively low ventricular rate, accurate recognition of atrial fibrillation with faster ventricular rates, atrial tachycardias, atrial flutter, and some reentrant tachycardias is still an issue. Dual‐chamber ICDs (Dc‐ICDs) are supposed to overcome specificity issues by enhancing detection algorithms with information derived from the atrial and ventricular timing relationship. The initial promise of Dc‐ICDs was to improve detection specificity without compromising sensitivity, and to translate this advantage over Sc‐ICDs in a more selective use of aggressive therapies. Despite this solid background, superiority of Dc‐ over Sc‐ICDs has never been convincingly demonstrated. The present review focuses on the efficacy of contemporary ICD arrhythmia discrimination tools and appraises the so far reported evidence supporting the superiority of Dc‐ICDs in preventing inappropriate therapies.

CLINICAL RECURRENCES AFTER SUCCESSFUL ACCESSORY PATHWAY ABLATION : THE ROLE OF DORMANT ACCESSORY PATHWAYS

Dormant Accessory Pathways. Introduction: Recurrence of clinical symptoms after radiofrequency catheter ablation of an accessory atrioventricular pathway (AP) may be due to the late manifestation of an additional AP that was not detected during the initial ablation session. It was the purpose of this study to elucidate the phenomenon of these “dormant” APs.

Searching for Left Atrial Thrombi Prior to Catheter Ablation of Atrial Fibrillation: Are There Patients Who Can Safely Avoid Preablation Transesophageal Echocardiography?

Stroke and systemic embolism are potentially catastrophic complications of atrial fibrillation (AF). It has been estimated that the annual risk of stroke in patients with nonvalvular AF approximates 5%1-4 among 6.5 million people affected by this arrhythmia in the United States and Europe.5 Patients with AF account for 1 of every 6 strokes in the general population.6 While aging is known to carry an independent risk that increases with time, factors such as previous stroke, diabetes, history of hypertension and heart failure also contribute independently to the risk of thromboembolism (TE). According to a recently introduced risk stratification scheme, CHADS2,7,8 individual yearly stroke rates can be predicted from the CHADS2 score calculated from the combination of different risk criteria found in each individual patient. Patients with a CHADS2 score of 3 or greater have an annual risk of stroke of 6% or greater. Strategies for potentially limiting the risk of TE are based on the capacity to convert AF to stable sinus rhythm and on the use of appropriate antithrombotic therapy. There is evidence that maintenance of stable sinus rhythm protects against death and TE risk.9 Antiarrhythmic drugs, alone or in combination with electrical cardioversion,10 have long represented the cornerstone of the therapeutic armamentarium for achieving stable rhythm control in patients with AF, although recent data suggest that these agents may cause significant adverse events, including death, if sinus rhythm is not achieved during treatment.9 The efficacy and safety of antithrombotic therapy for prevention of TE in patients with AF has been well characterized.11 There is consensus that patients with an annual stroke risk of 6% or greater derive substantial benefit from oral anticoagulants, while consensus is less strong for patients with lower yearly risk rates. Still, patients at high risk are not fully protected from stroke and their yearly risk can be estimated in the range between 2 and 3%. Criteria to calculate the general TE risk of patients with AF do not apply during clinical phases requiring interventional treatment, such as in preparation to electrical cardioversion. In these patients, the TE risk in the 6 months following cardioversion ranges between 0.5 and 2.0%,12,13 and use of TEE has been proven effec-

Silent Cerebral Embolism and New Technologies for Catheter Ablation of Atrial Fibrillation: Time to Take a Deep Breath

Silent Cerebral Embolism and New Technologies for Catheter Ablation of Atrial Fibrillation: Time to Take a Deep Breath ANTONIO SORGENTE, M.D., Ph.D.,∗ ANTONIA CECCARELLI, M.D., Ph.D.,¶ and RICCARDO CAPPATO, M.D.∗ From the ∗Arrhythmia and Electrophysiology Center, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy; and ¶Department of Neurology, Brigham and Women’s Hospital, Laboratory for Neuroimaging Research, Partners MS Center, Harvard Medical School, Boston, Massachusetts, USA

Mechanical Block of a Manifested Accessory Pathway: What Is the Preexcitation Variant?

A 22-year-old male athlete with asymptomatic ventricular pre-excitation, persistent during a maximal exercise test, was referred to our center for electrophysiological evaluation. His 12-lead ECG showed minimal delta waves and a normal PR interval. An electrophysiological study was performed, and multipolar diagnostic catheters were positioned at the level of His bundle region and the coronary sinus. A comprehensive study established the presence of a fasciculoventricular pathway, showing a fixed degree of pre-excitation during multisite atrial pacing and at different pacing cycle lengths.