The association between thrombosis, cancer and inflammation is well-established. Platelets play a major role in atherosclerosis, inflammation and immune response. Furthermore, growing evidence sugg...

Rhythm control of non-paroxysmal atrial fibrillation (AF) is significantly more challenging, as a result of arrhythmia perpetuation promoting atrial substrate changes and AF maintenance. We describe a tailored ablation strategy targeting multiple left atrial (LA) sites via a pentaspline pulsed field ablation (PFA) catheter in persistent AF sustained beyond 6 months (PerAF > 6 m) and long-standing persistent AF (LSPAF). The ablation protocol included the following stages: pulmonary vein antral and posterior wall isolation plus anterior roof line ablation (Stage 1); electrogram-guided substrate ablation (Stage 2); atrial tachyarrhythmia regionalization and ablation (Stage 3). Seventy-two [age:68 ± 10years, 61.1%males; AF history: 25 (18–45) months] patients with PerAF > 6 m (52.8%) and LSPAF (47.2%) underwent their first PFA via the Farapulse^TM system. LA substrate ablation (Stage 1 and 2) led to AF termination in 95.8% of patients. AF organized into a left-sided atrial flutter (AFlu) in 46 (74.2%) patients. The PFA catheter was used to identify LA sites showing diastolic, low-voltage electrograms and entrainment from its splines was performed to confirm the pacing site was inside the AFlu circuit. Left AFlu termination was achieved in all cases via PFA delivery. Total procedural and LA dwell times were 112 ± 25 min and 59 ± 22 min, respectively. Major complications occurred in 2 (2.8%) patients. Single-procedure success rate was 74.6% after 14.9 ± 2.7 months of follow-up; AF-free survival was 89.2%. In our cohort, PFA-based AF substrate ablation led to AF termination in 95.8% of cases. Very favourable clinical outcomes were observed during >1 year of follow-up.

Introduction: Ultrasound (US)‐guided axillary vein puncture is a safe and effective approach for cardiac implantable electronic device (CIED) implantation, and it is highly recommended by the current consensus document. However, only reports on small populations are available in the current literature regarding the comparison of this technique with other traditional approaches (subclavian vein blind puncture and cephalic vein surgical cutdown).Purpose: We aimed to assess the effectiveness and safety of US‐ guided axillary vein puncture using a microintroducer kit for CIED implantation as compared to the aforementioned traditional approaches.Methods: All consecutive patients with an indication to CIED implantation were prospectively enrolled in our observational study from March 2021 to July 2023. Patients were divided into three groups based on venous access route, according to the operator's preference: cephalic vein surgical cutdown (G1), US‐guided axillary vein puncture (G2), and subclavian vein blind puncture (G3). Clinical and procedural characteristics, success and complication rates were considered for analysis.Results: A total of 1000 patients (65.2% male, mean age 75.5 ± 10.8 years) were enrolled. Cephalic vein surgical cutdown was chosen in 172 (G1, 17.2%), US‐guided axillary access in 433 patients (G2, 43.3%), and subclavian vein in 395 (G3, 39.5%). Success rate was 77.6% in G1, 96.3% in G2, and 97.2% in G3 (G2 vs. G3, p = 0.5; G1 vs. G2, p < 0.0001; G1 vs. G2. vs. G3, p < 0.0001). Compared to subclavian and cephalic groups, in the US‐guided axillary group, a successful access was obtained with a reduced mean number of puncture attempts (G2 vs. G3: 1.3 ± 0.9 vs. 1.8 ± 1, p < 0.0001) and needed reduced times to get access (G2 vs. G3: 15 s [10–30 s] vs. 40 [20–65 s]; p < 0.0001, G1 vs. G2: 210 s [180–247 s] vs. 15 s [10–30 s]; p < 0.0001) and to reach the superior vena cava, without differences in total procedural times (72.9 ± 30.4 vs. 75.7 ± 34.8 min, p = 0.24). Bailout fluoroscopy times [1 (0–8) s vs. 20 (10–58) s, p < 0.0001] and usage of vein angiography (11.9% vs. 51.3%, p < 0.0001) were lower in G2 as compared to G3. Complication rate did not differ among the three study groups (early complications: 2.9% in G1, 2.5% in G2, and 2.5% in G3, p = 0.96; late complications: 2.9% in G1, 1.6% in G2, and 0.8% in G3, p = 0.15).Conclusions: US‐guided axillary vein puncture for CIED implantation using a microintroducer kit is a safe technique with a very high success rate. Compared to other traditional approaches, it allows to get access with a lower number of puncture attempts and with reduced times, without prolonging the total procedural time. Moreover, x‐ray use and need for contrast medium are very rare in US‐guided axillary approach. Hence, it should be considered the strategy of choice for most patients undergoing CIED implantation.

A 61-year-old man without comorbidities was admitted to a local hospital in Rome for fever and worsening dyspnoea. Two rhinopharyngeal swabs resulted positive for SARS-CoV2, chest X-ray demonstrated bilateral ground-glass opacities, and he was diagnosed with COVID-19 pneumonia. After intubation for respiratory deterioration, he was transferred to the intensive care unit (ICU) of our university hospital. At ICU admission, blood tests showed lymphopenia (0.3 × 10⁹/L), increased C-reactive protein (310 mg/L), normal procalcitonin, and a PaO₂/FiO₂ ratio of 143. Ventilator was set on volume-controlled ventilation with FiO₂ of 70%, positive end-expiratory pressure (PEEP) of 15 cmH₂O, tidal volume of 420 mL (6.0 mL/kg), and respiratory rate of 30 cycles/min. Resulting plateau pressure was 27 cmH₂O. A few hours later, neck and chest subcutaneous emphysema was noted. Chest computed tomography scan showed ground-glass opacities and consolidations in both lungs, with pneumopericardium, pneumomediastinum, and left pneumothorax, without large-airway lesions. No invasive cardiac procedure was performed because of patient’s stable haemodynamics, and chest X-rays showed progressive, spontaneous resolution of the pneumopericardium. After two prone-positioning sessions over the first 3 days of ICU admission, respiratory conditions progressively improved and patient was switched to spontaneous ventilation on Day 5 and, after tracheostomy on Day 14, was gradually taken off ventilatory support 1 month later.

Background and Aims: Transvenous lead extraction (TLE) has become a pivotal part of a comprehensive lead management strategy, dealing with a continuously increasing demand. Nonetheless, the literature about the long‐term impact of TLE on survivals is still lacking. Given these knowledge gaps, the aim of our study was to analyse very long‐term mortality in patients undergoing TLE in public health perspective.Methods: This prospective, single‐centre, observational study enrolled consecutive patients with cardiac implantable electronic device (CIED) who underwent TLE, from January 2005 to January 2021. The main goal was to establish the independent predictors of very long‐term mortality after TLE. We also aimed at assessing procedural and hospitalization‐related costs.Results: We enrolled 435 patients (mean age 70 ± 12 years, with mean lead dwelling time 6.8 ± 16.7 years), with prevalent infective indication to TLE (92%). Initial success of TLE was achieved in 98% of population. After a median follow‐up of 4.5 years (range: 1 month–15.5 years), 150 of the 435 enrolled patients (34%) died. At multivariate analysis, death was predicted by: age (≥77 years, OR: 2.55, CI: 1.8–3.6, p < 0.001), chronic kidney disease (CKD) defined as severe reduction of estimated glomerular filtration rate (eGFR <30 mL/min/1.73 m², OR: 1.75, CI: 1.24–2.4, p = 0.001) and systolic dysfunction assessed before TLE defined as left ventricular ejection fraction (LVEF) <40%, OR: 1.78, CI 1.26–2.5, p = 0.001. Mean extraction cost was €5011 per patient without reimplantation and €6336 per patient with reimplantation respectively.Conclusions: Our study identified three predictors of long‐term mortality in a high‐risk cohort of patients with a cardiac device infection, undergoing successful TLE. The future development of a mortality risk score before might impact on public health strategy.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with substantial morbidity and mortality due to increased risks of stroke, heart failure, and death. Catheter ablation is now firmly established as a first-line or early rhythm control strategy in selected patients with paroxysmal AF and as a Class I indication in symptomatic patients with persistent AF refractory to antiarrhythmic drug therapy. However, outcomes remain more variable in persistent and long-standing persistent AF, reflecting greater atrial substrate complexity, procedural challenges, and ongoing uncertainty regarding optimal ablation strategies. This review provides a structured, evidence-based overview of contemporary catheter ablation approaches for AF, with particular emphasis on persistent disease. We discuss the anatomical and mechanistic rationale underlying pulmonary vein isolation and adjunctive lesion sets, summarize current clinical evidence supporting various strategies, and highlight differences in efficacy, safety, and reproducibility. In addition, we address the importance of patient selection, shared decision making, procedural expertise, and comprehensive risk factor modification as integral components of successful long-term rhythm control. By integrating guideline recommendations with mechanistic insights and clinical trial data, this review aims to clarify the current best practices and identify remaining knowledge gaps in the catheter ablation of atrial fibrillation.