Background/Objectives: Persistent high Premature Ventricular Contraction (PVC) burden (>10%) may result in PVC-induced cardiomyopathy. Current guidelines, supported by limited evidence, recommend flecainide for PVCs originating from the ventricular outflow tract (Class IIa). UNIFLECA is a prospective cohort study, aiming to assess the efficacy and safety of flecainide in PVC burden reduction in adults, irrespective of PVC origin, focusing secondarily on symptom relief and improvement of left ventricular ejection fraction (LVEF) in patients suffering from PVC-induced cardiomyopathy. Methods: Participants were adults with frequent PVCs, defined as PVC burden > 5%, confirmed by two 24 h Holter recordings taken at least one month apart, who denied catheter ablation treatment. Patients who were deemed ineligible for catheter ablation were also included. A total of 50 patients were screened and 35 were administered Flecainide, with dosage adjustment based on follow-up Holter results and QRS increases. Changes in PVC burden, LVEF, symptomatic status, along with treatment adherence, were evaluated. Results: In adults with frequent PVCs, flecainide led to a significant reduction in PVC burden, with a mean decrease of 76.2% in the first month, and 63.1% of patients achieving a PVC burden reduction greater than 80%. Conclusions: UNIFLECA contributes to the understanding of how personalized, non-interventional therapeutic modalities can be employed to manage PVCs, especially for patients unwilling to have or ineligible for ablation procedures.

Background: Flecainide, a class Ic antiarrhythmic agent, has long been contraindicated in structural heart disease (SHD) due to findings of the Cardiac Arrhythmia Suppression Trial (CAST). However, its proven efficacy in patients without structural abnormalities and emerging safety data in selected SHD populations have prompted reconsideration of its role. Aim: This mini review evaluates recent evidence on the safety and efficacy of flecainide in atrial fibrillation (AF) and premature ventricular contractions (PVCs), particularly in patients with stable coronary artery disease (CAD), and arrhythmogenic right ventricular cardiomyopathy (ARVC). Results: Modern imaging and improved risk stratification allow for more precise identification of patients who may safely receive flecainide, even in the presence of specific structural abnormalities. Observational studies have reported no mortality or ventricular arrhythmias incidence increase in stable CAD or ARVC when flecainide is administered under stringent criteria. While current guidelines remain cautious, clinical practice is beginning to reflect a more individualized approach. Conclusions: Flecainide use in selected SHD patients appears both feasible and safe when guided by comprehensive imaging and clinical judgment. The need for prospective randomized trials to confirm these findings and potentially inform future guideline updates is urgent and of utmost importance in the field of antiarrhythmic therapies.

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.

Background: Radiation exposure in the cardiac catheterization laboratory remains a critical occupational hazard for interventional cardiologists and staff, contributing to orthopedic injuries, cataracts, and malignancy. In parallel, procedural complexity continues to increase, demanding both precision and safety. Robotic-assisted percutaneous coronary intervention (R-PCI), alongside advanced shielding systems and imaging integration, has emerged as a transformative strategy to minimize radiation and enhance operator ergonomics. Objective: This state-of-the-art review synthesizes the current clinical evidence and technological advances that support a radiation-reduction paradigm in percutaneous coronary intervention (PCI), with a particular focus on the role of R-PCI platforms, procedural modifications, and emerging shielding technologies. Methods: We reviewed published clinical trials, registries, and experimental studies evaluating robotic PCI platforms, contrast and radiation dose metrics, ergonomic implications, procedural efficiency, and radiation shielding systems. Emphasis was given to the integration of CT-based imaging (coronary computed tomography angiography—CCTA, fractional flow reserve computed tomography—FFR-CT) and low-dose acquisition protocols. Results: R-PCI demonstrated technical success rates of 81–100% and clinical success rates up to 100% in both standard and complex lesions, with significant reductions in operator radiation exposure (up to 95%) and procedural ergonomic burden. Advanced shielding technologies offer radiation dose reductions ranging from 86% to nearly 100%, while integration of (CCTA), (FFR-CT), and Artificial Intelligence (AI) -assisted procedural mapping facilitates further fluoroscopy minimization. Robotic workflows, however, remain limited by lack of device compatibility, absence of haptic feedback, and incomplete integration of physiology and imaging tools. Conclusions: R-PCI, in combination with shielding technologies and imaging integration, marks a shift towards safer, radiation-minimizing interventional strategies. This transition reflects not only a technical evolution but a philosophical redefinition of safety, precision, and sustainability in modern interventional cardiology.

Commentary: Coronary stent deformation induced by guide catheter extension

Background and Objectives: Atrial fibrillation (AF) is the most common cardiac arrhythmia, present in up to 14–20% of patients undergoing cardiac surgery, with the number of patients expected to double within the next decade. Despite a Class I recommendation for concomitant surgical ablation and a Class I-B recommendation for left atrial appendage (LAA) occlusion in patients with AF undergoing cardiac surgery (Class IIa for endoscopic or hybrid AF ablation), both procedures remain substantially underutilized in clinical practice. The design of the Mapping atrial fibrillation after Epicardial Surgical Ablation plus AtriClip to Guide Endocardial ablation (MESAGE) prospective study is presented. Materials and Methods: A narrative literature review was conducted using PubMed through March 2025. Randomized controlled trials, multicenter registries, meta-analyses and current clinical guidelines were prioritized. The MESAGE study protocol is presented in accordance with the SPIRIT recommendations. Results: Randomized evidence demonstrates that hybrid ablation achieves 32–48% greater arrhythmia freedom than catheter ablation (CA) alone in persistent and long-standing persistent AF, with comparable safety and significantly fewer interventions at two-year follow-up. Epicardial LAA occlusion with the AtriClip device achieves complete occlusion in all patients with an 87.5% relative reduction in ischemic stroke risk in anticoagulation-free follow-up. Continuous implantable loop recorder (ILR)-based monitoring reveals AF recurrence in substantially more patients than conventional monitoring, with AF burden emerging as a more meaningful endpoint than arrhythmia freedom. The MESAGE study enrolls 40 patients undergoing cardiac surgery who have pre-existing AF, pre-randomized 1:1 to pulmonary vein isolation (PVI) alone versus PVI-BOX, with mandatory pre-operative ILR implantation, intra-operative AtriClip LAA exclusion, and systematic Day-60 endocardial mapping and supplementary ablation using the Affera dual-energy system. Conclusions: Hybrid epicardial–endocardial ablation combined with LAA exclusion and continuous ILR monitoring represents a comprehensive, mechanistically rational and evidence-informed approach to AF management in patients undergoing cardiac surgery, although current evidence remains heterogeneous, and the benefits depend on the AF phenotype and monitoring strategy. The MESAGE pilot study will generate hypothesis-generating prospective comparative data on epicardial PVI versus PVI-BOX in the concomitant surgical setting, assessed through systematic post-surgical endocardial mapping and continuous rhythm monitoring.