A wide QRS with left bundle branch block pattern is usually required for cardiac resynchronization therapy (CRT) in patients with dilated cardiomyopathy. However, ∼30% of patients do not benefit from CRT. We evaluated whether a detailed analysis of QRS complex can improve prediction of CRT success. We studied 51 patients (67.3 + 9.5 years, 36 males) with classical indication to CRT. Twelve-lead electrocardiogram (ECG) (50 mm/s, 0.05 mV/mm) was obtained before and 3 months after CRT. The following ECG intervals were measured in leads V1 and V6: (i) total QRS duration; (ii) QRS onset–R wave peak; (iii) R wave peak–S wave peak (RS-V1 and RS-V6); (iv) S wave peak–QRS end; and (v) difference between QR in V6 and in V1. Patients were considered as responder when left ventricular ejection fraction (LVEF) increased by ≥5% and New York Heart Association class by ≥1 after 3 months of CRT. Of ECG intervals, only basal RS-V1 was longer in responders (n = 36) compared with non-responders (52.9 ± 11.8 vs. 44.0 ± 12.6 ms, P = 0.021). Among patients with RS-V1 ≥45 ms 83% responded to CRT vs. 33% of those with RS-V1 < 45 ms (P < 0.001). RS-V1 ≥ 45 ms was independently associated with response to CRT in multivariable analysis (odds ratio 9.8; P = 0.002). A reduction of RS-V1 ≥ 10 ms by CRT also significantly predicted clinical response. RS-V1 shortening correlated with improvement in LVEF (r = −0.45; P < 0.001) and in MS (r = 0.46; P < 0.001). Our data point out that RS-V1 interval and its changes with CRT may help to identify patients who are most likely to benefit from CRT.

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.

Cardiac implantable electronic devices (CIEDs) offer the benefit of remote monitoring and decision making and find particular applications in special populations such as the elderly. Less transportation, reduced costs, prompt diagnosis, a sense of security, and continuous real-time monitoring are the main advantages. On the other hand, less physician–patient interactions and the technology barrier in the elderly pose specific problems in remote monitoring. CIEDs nowadays are abundant and are mostly represented by rhythm control/monitoring devices, whereas hemodynamic remote monitoring devices are gaining popularity and are evolving and becoming refined. Future directions include the involvement of artificial intelligence, yet disparities of availability, lack of follow-up data, and insufficient patient education are still areas to be improved. This review aims to describe the role of CIED in the very elderly and highlight the merits and possible drawbacks.

Genetic background is a critical determinant of disease expression, arrhythmic vulnerability, and therapeutic response in inherited cardiomyopathies. Implantable cardioverter-defibrillators (ICD) remain the cornerstone for primary prevention of sudden cardiac death, yet conventional selection based on left ventricular ejection fraction does not adequately reflect the heterogeneity of genetic substrates. Increasing evidence demonstrates that pathogenic variants differ not only in prevalence across cardiomyopathy subtypes but also in prognostic impact. Truncating variants, particularly in genes encoding structural proteins, are often associated with severe remodeling, progressive dysfunction, and high arrhythmic risk, whereas missense variants may confer variable expressivity, ranging from aggressive arrhythmogenic phenotypes to milder or late-onset disease. This variability underscores the importance of distinguishing variant classes in clinical decision-making. Integrating genetic information with advanced imaging markers, such as late gadolinium enhancement, allows refinement of arrhythmic risk stratification beyond static thresholds and supports more tailored ICD allocation. Nevertheless, translation into routine practice is limited by challenges in variant interpretation, phenotypic overlap between cardiomyopathy subtypes, and the lack of prospective validation of genotype-based models. In the precision medicine era, evolving strategies should move toward dynamic, multimodal approaches that combine genotype, phenotype, and imaging biomarkers, enabling more accurate prediction of arrhythmic risk and more cost-effective use of ICD therapy.

Background. Adults with congenital heart disease (ACHD) are often affected by cardiac arrhythmias requiring catheter ablation. Catheter ablation in this setting represents the treatment of choice but is flawed by frequent recurrencies. Predictors of arrhythmia relapse have been identified, but the role of cardiac fibrosis in this setting has not been investigated. The aim of this study was to determine the role of the extension of cardiac fibrosis, detected by electroanatomical mapping, in predicting arrhythmia recurrencies after ablation in ACHD. Materials and Methods. Consecutive patients with congenital heart disease and atrial or ventricular arrhythmias undergoing catheter ablation were enrolled. An electroanatomical bipolar voltage map was performed during sinus rhythm in each patient and bipolar scar was assessed according to the current literature data. During follow-up, arrhythmia recurrences were recorded. The relationship between the extent of myocardial fibrosis and arrhythmia recurrence was assessed. Results. Twenty patients underwent successful catheter ablation of atrial (14) or ventricular (6) arrhythmias, with no inducible arrhythmia at the end of the procedure. During a median follow-up period of 207 weeks (IQR 80 weeks), eight patients (40%; five atrial and three ventricular arrhythmias) had arrhythmia recurrence. Of the five patients undergoing a second ablation, four showed a new reentrant circuit, while one patient had a conduction gap across a previous ablation line. The extension of the bipolar scar area (HR 1.049, CI 1.011–1.089, p = 0.011) and the presence of a bipolar scar area >20 cm² (HR 6.101, CI 1.147–32.442, p = 0.034) were identified as predictors of arrhythmia relapse. Conclusion. The extension of the bipolar scar area and the presence of a bipolar scar area >20 cm² can predict arrhythmia relapse in ACHD undergoing catheter ablation of atrial and ventricular arrhythmias. Recurrent arrhythmias are often caused by circuits other than those previously ablated.

Permanent pacemaker implantation (PPI) represents a frequent complication after transcatheter aortic valve implantation (TAVI) due to atrio-ventricular (AV) node injury. Predictors of early AV function recovery were investigated. We analyzed 50 consecutive patients (82 ± 6 years, 58% males, EuroSCORE: 7.8 ± 3.3%, STS mortality score: 5 ± 2.8%). Pacemaker interrogations within 4–6 weeks from PPI were performed to collect data on AV conduction. The most common indication of PPI was persistent third-degree (44%)/high-degree (20%) AV block/atrial fibrillation (AF) with slow ventricular conduction (16%) after TAVI. At follow-up, 13 patients (26%) recovered AV conduction (i.e., sinus rhythm with stable 1:1 AV conduction/AF with a mean ventricular response >50 bpm, associated with a long-term ventricular pacing percentage < 5%). At multivariate analysis, complete atrio-ventricular block independently predicted pacemaker dependency at follow-up (p = 0.019). Patients with persistent AV dysfunction showed a significant AV conduction time prolongation after TAVI (PR interval from 207 ± 50 to 230 ± 51, p = 0.02; QRS interval from 124 ± 23 to 147 ± 16, p < 0.01) compared to patients with recovery, in whom AV conduction parameters remained unchanged. Several patients receiving PPI after TAVI have recovery of AV conduction within a few weeks. Longer observation periods prior to PPI might be justified, and algorithms to minimize ventricular pacing should be utilized whenever possible.