Matteo Bertini

Sex-based differences in ACS presentation and outcomes have been observed, but limited information is available on sex-specific electrocardiogram (ECG) features and their prevalence in this context. The aim of this study was to compare the prevalence of different ECG patterns between sexes and their prognostic roles for in-hospital mortality in ACS patients. This prospective single-center study (NCT02438085)° was conducted from June 2018 to December 2019, including 841 consecutive patients. Data on baseline characteristics, ECG findings, treatments, and outcomes were collected. Statistical analyses were performed to determine differences in the prevalence of various ECG patterns and identify independent predictors of in-hospital mortality. Males more frequently presented with ST-segment elevation (51% vs. 43%, p = 0.031) and hyperacute T waves (13% vs. 7%, p = 0.006) than females. Moreover, females more often had a normal ECG at admission (15% vs. 9%, p = 0.01). In female STEMI negative T waves (50% vs. 38%, p = 0.025) were more common than in males. Hyperacute T waves were linked to a higher risk of in-hospital death in female STEMI cases (OR=6.25, 95% CI: 1.0 −39.7, p = 0.048). Additionally the development of left bundle branch block during hospitalization (OR=14.4, 95% CI: 1.48–14 p = 0.02) was a significant predictor of in-hospital mortality in the female NSTEMI subgroup. No ECG features were found to predict in-hospital mortality in male patients. Compared to males, females with ACS often showed less frequent and less extensive ST-segment abnormalities and were more likely to have a normal initial ECG at admission. These differences could impact clinical evaluation and prognosis. Recognizing these sex-related ECG differences may help optimize the management of ACS patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT02438085

Background: Arrhythmogenic cardiomyopathy (ACM) and Brugada syndrome (BrS) are inherited arrhythmogenic disorders historically defined by their predisposition to ventricular arrhythmias and sudden cardiac death (SCD). Accumulating evidence indicates that both conditions also involve the atrial myocardium and are associated with a high prevalence of supraventricular tachyarrhythmias (SVT). A clearer understanding of their mechanisms and clinical impact is essential to optimize risk stratification and management. Methods: A systematic review was conducted in accordance with the PRISMA 2020 statement. PubMed and the Cochrane Library were searched up to December 2025 for studies reporting atrial fibrillation (AF), atrial flutter (AFL), atrioventricular nodal re-entrant tachycardia (AVNRT), or atrioventricular re-entrant tachycardia (AVRT) in patients with ACM or BrS. Of 487 records identified, 486 were screened after removal of one duplicate, and 30 studies met the inclusion criteria. Data on atrial substrate, SVT prevalence, mechanisms, and clinical outcomes were extracted. Results: SVT were consistently more frequent in both ACM and BrS than in age-matched general populations. AF was the most common arrhythmia, often arising at a young age and in structurally normal atria. Across studies, SVT were linked to inappropriate implantable cardioverter-defibrillator (ICD) shocks, heart failure progression, recurrence of ventricular arrhythmias, and an elevated thromboembolic risk that was frequently underestimated by the CHA₂DS₂-VASc score. Conclusions: SVT represent a clinically relevant manifestation of ACM and BrS and carry prognostic implications for arrhythmic monitoring, ICD programming, and thromboembolic risk assessment. Prospective studies are needed to refine risk-stratification tools and to clarify the mechanistic overlap between these inherited arrhythmogenic syndromes.

Atrial fibrillation (AF) and heart failure (HF) frequently coexist and mutually worsen prognosis, creating a complex clinical scenario in which treatment decisions are increasingly imaging driven. Catheter ablation has emerged as a pivotal rhythm control strategy in selected patients with HF, but careful phenotyping of the atrial and ventricular substrate is essential to balance potential benefits against procedural risk and the likelihood of durable sinus rhythm. In this narrative review, we summarize the role of multimodality imaging across the entire AF care pathway in patients with HF, from candidate selection to intraprocedural guidance and post-ablation follow-up. Ultrasound imaging remains the cornerstone of pre-procedural assessment. Cardiac computed tomography (CCT) refines anatomical characterization of the left atrium, pulmonary veins, and left atrial appendage. Cardiovascular magnetic resonance (CMR) offers comprehensive tissue characterization of atrial and ventricular fibrosis, allowing distinction between atrial primary and atrial secondary AF phenotypes and informing expectations of reverse remodelling. During ablation, intracardiac echocardiography and transesophageal echocardiography optimize transseptal access, catheter navigation, and complication monitoring, and they are particularly relevant with contemporary Pulsed Field Ablation systems. In follow-up, echocardiography, CCT, and CMR are pivotal for quantifying structural reverse remodelling and detecting rare but life-threatening complications such as atrio esophageal fistula and pulmonary vein stenosis. An integrated, multimodality, substrate-based imaging strategy is therefore crucial to personalize rhythm versus rate control decisions and to guide safe, effective ablation in patients with AF and HF.

Aims: Transoesophageal echocardiography (TOE) provides real-time soft-tissue anatomical information during pulsed field ablation (PFA) of atrial fibrillation. This focused technical report describes a standardized workflow in which TOE complements, rather than replaces, fluoroscopic, and angiographic guidance throughout the procedure. Technique: The workflow is organized into four consecutive phases: pre-procedural assessment, transseptal puncture, ablation–catheter configuration and positioning at the pulmonary vein ostia, and post-procedural assessment. Pre-procedural TOE focuses on exclusion of left atrial appendage thrombus, definition of pulmonary vein anatomy, assessment of the interatrial septum, and baseline evaluation for pericardial effusion. During transseptal access, orthogonal bicaval and short-axis views support puncture-site selection and continuous visualization of septal tenting, while fluoroscopy remains integral to guidewire and transseptal-system manipulation. During ablation, TOE complements fluoroscopic/angiographic guidance by depicting catheter configuration and its relationship with the pulmonary vein ostia and adjacent soft-tissue structures. At procedure completion, TOE is used to assess the iatrogenic interatrial septal defect and to exclude new pericardial effusion. Conclusion: TOE should be considered a complementary imaging modality during fluoroscopy- and angiography-guided PFA rather than a replacement for these techniques. Its principal contribution is real-time visualization of soft-tissue anatomy, transseptal puncture, catheter–tissue relationships, and immediate post-procedural complications. Prospective studies are required to quantify its incremental clinical value.

Aims: Atrial fibrillation (AF) is highly prevalent among cardiac amyloidosis (CA) patients and contributes significantly to their morbidity and mortality. Evidence regarding AF ablation efficacy and safety in CA patients remains limited. The aim of our study is to evaluate baseline characteristics, clinical course and outcomes of AF ablation in a series of patients with transthyretin (ATTR) or light-chain (AL) CA from a multicentre international registry. Methods and results: Patients with CA who underwent AF ablation were included. Co-primary endpoints were: (i) atrial arrhythmia (AA) recurrence; (ii) a composite endpoint of all-cause mortality and heart failure hospitalization (HFH). 109 patients (mean age 72.4 ± 7.4 years, females 17.4%, persistent AF 64.2%, ATTR 78%, AL 22%) were included. Radiofrequency, cryo-balloon and pulsed-field ablation were performed in 67%, 15% and 18% of patients, respectively; 49.5% received pulmonary vein isolation plus additional ablations. Low voltage zones were documented in 34 out of 44 patients undergoing electro-anatomical mapping (77.3%). During a median follow-up of 22.7 months, 63 patients (58.3%) experienced AA recurrence (32.4% persistent AF recurrence), with no significant differences between CA subtypes (ATTR 59.5% vs. AL 54.2%, log-rank P = 0.55). The composite endpoint of HFH and all-cause death occurred in 27 patients (25%). Recurrence of persistent AF was associated with three-fold higher risk (OR 2.9, P = 0.02) of the composite endpoint. Conclusion: CA patients undergoing AF ablation present high prevalence of persistent AF. Freedom from AA after AF ablation is achieved in 42% of patients after a two-year follow-up. Patients with persistent AF recurrence have a three-fold higher risk of HFH and death.

Background: Left bundle branch pacing (LBBP) restores physiological ventricular activation, yet its impact on left ventricular (LV) mechanical efficiency remains incompletely understood. Objective: To compare LV mechanical efficiency during spontaneous rhythm and LBBP using myocardial work (MW) indices, and to evaluate the influence of QRS transition type. Methods: In 115 patients enrolled in the prospective TREEBEARD study (NCT06324682), MW indices (i.e., global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE)) were measured before and after LBBP. Patients were classified according to QRS transition during decremental output as Left Bundle (LB) group (nonselective to selective LBB capture) or non‐LB group (nonselective capture to LV septal pacing). Results: Overall, LBBP achieved mechanical efficiency comparable to that observed during spontaneous rhythm. In the LB group, all MW indices showed strong correlations between spontaneous rhythm and LBBP. In the non‐LB group, GWI ( r = 0.685, p < 0.001) and GCW ( r = 0.750, p < 0.001) remained strongly correlated, whereas GWE ( r = 0.4224, p = 0.01) and GWW ( r = 0.395, p = 0.002) showed moderate and weak correlations, respectively. Conclusion: Based on our findings, LBBP appears to preserve LV mechanical efficiency to a degree comparable to spontaneous rhythm. Direct engagement of the conduction system, reflected by a nonselective to selective LBBP QRS transition, is associated with greater concordance of MW indices.

BACKGROUND: The role of atrial pacing support is unclear in patients receiving cardiac resynchronization therapy–defibrillator (CRT-D) without sinus node dysfunction. METHODS: We conducted a randomized, parallel-group, noninferiority trial to evaluate whether a 2-lead CRT-D capable of atrial sensing (but no pacing) by a floating dipole on the right ventricular lead (CRT-DX) is not inferior to a 3-lead CRT-D with a conventional atrial lead. Between October 17, 2018, and March 5, 2024, a total of 636 patients (68±10 years old, 28.6% women) with standard CRT-D indication, optimized medical therapy, and resting sinus rate ≥45 beats/min were randomized 1:1 to CRT-DX (atrial tracking without atrial pacing mode 35 beats/min) or CRT-D (atrial tracking with atrial pacing mode 50 beats/min) at 23 Italian sites. A centralized block-randomization procedure stratified by site was used, with patients and primary outcome assessors blinded to treatment assignment. The primary end point was a 1-year composite of all-cause mortality, cardiovascular hospitalization, and lead-related complications (loss of functionality not correctable by device reprogramming). Secondary end points included each individual component of the primary end point separately, echocardiographic reverse remodeling, and 6-minute walk test distance at 12 months. RESULTS: The primary end point occurred in 41 (13.1%) patients in the CRT-DX group and 47 (15.6%) patients in the CRT-D group, corresponding to a hazard ratio of 0.82 (95% CI, 0.54–1.25). This confirmed noninferiority (prespecified relative margin of 1.20) in both the per-protocol ( P =0.039) and intention-to-treat ( P =0.044) analyses. Individual components showed no significant differences, except for lead complications related to right atrial functionality (4 [1.3%] patients in the CRT-DX group versus 13 [4.2%] patients in the CRT-D group; P =0.040). Reverse remodeling responders were 203 (77.5% of 262) patients receiving CRT-DX and 190 (76.3% of 249) patients receiving CRT-D ( P =0.83). Walking distance did not differ between 2 study arms (404 versus 398 m; P =0.62). After a median follow-up of 2.4 years, only 1 patient receiving CRT-DX required implantation of a standard atrial lead. CONCLUSIONS: The 2-lead CRT-DX system without atrial pacing is noninferior to conventional 3-lead CRT-D, with fewer atrial lead–related complications. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03587064.