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We present the case of a 60-year-old woman with Brugada syndrome, permanent type 1 electrocardiographic pattern, who had previously received an implantable cardioverter-defibrillator. She suffered frequent syncopal episodes and multiple appropriate shocks (around five per month) due to polymorphic ventricular tachycardia/ventricular fibrillation, refractory to quinidine therapy. Combined epicardial and endocardial electroanatomical mapping was performed with a view to substrate ablation. An area of abnormal fractionated electrograms, lasting up to 370 ms and up to 216 ms after the end of the surface QRS, was identified in the epicardium in the lower anterior part of the right ventricular outflow tract. Extensive epicardial ablation of this area, which eliminated the fractionated electrograms, led to the disappearance of the Brugada electrocardiographic pattern six weeks after ablation. Despite discontinuation of quinidine, no further ventricular arrhythmias occurred during follow-up, which is still of short duration.

Background Despite the reduction in mortality and hospitalization rates, resynchronization therapy still has 30-40% of non-responders. Several studies are ongoing to evaluate if novel programming techniques such as multipoint pacing (MPP) increase the conversion rate of non-responder to responder to CRT. However, there is still lack of information about conversion to super-responders and the impact in quality of life of MPP. Purpose To evaluate the impact of MPP in conversion to super-responders and its impact in the quality of life of patients. Methods Randomized clinical trial of non-AF patients with indication for CRT and who implanted the Quartet™ quadripolar left ventricle (LV) lead. After implant, CRTs were programmed on biventricular pacing according to the latest activated area for 6 months. After a 6-month follow-up, patients were randomized in a 1:1 fashion to MPP ON or MPP OFF. MPP was programmed with the two widest spaced LV electrodes and with a LV1-LV2 to LV2-RV delay of 5ms. Patients were followed-up for 12 months with a 6-month evaluation of NTproBNP, echocardiographic remodeling criteria (LV end systolic volume (ESV) and LV ejection fraction), and quality of life (QoL) evaluated by EQ-5D, Minnesota Living with Heart Failure (MLWHF) questionnaire and 6-minute walk test (6MWT). Results  76 patients were included in this trial, 62 with a completed 12-month follow-up (average age 67.2 ± 10.2 years old, 32.3% female gender, dilated cardiomyopathy in 77.4%). Among these patients, 24 were randomized to MPP ON, 28 to MPP OFF. Six patients died and 4 were lost to follow-up. Baseline clinical and echocardiographic characteristics were similar between groups (p = NS). At 6 months, the overall response rate (reduction in ESV≥15%) was 75%. At twelve months, patients randomized to MPP ON had a super-response rate (reduction in ESV≥30%) higher than patients with MPP OFF (75% vs 39.3%, p = 0.01). Between 6-12 months, patients assigned to MPP ON had a higher reduction in ESV (93.4 ± 52.3mL to 82.1 ± 40.5mL, p = 0.04) and an improvement in LVEF (38.3 ± 9.8% to 45.1 ± 11.1%, p < 0.01) compared to patients with MPP OFF (92.2 ± 47.3mL to 95.4 ± 47.5mL, p = NS; 37.1 ± 12.0% to 40.2 ± 9.2%, p = NS). Additionally, QoL of patients with MPP ON improved during follow up (EQ-5D 78.3% to 86.3%, p < 0.01; MLWHF 12.1 to 6.6, p = 0.03, 6MWT 316m to 239m, p = NS; NTproBNP 1608 ± 2450pg/mL to 775 ± 914pg/mL, p = NS) and was unchanged in MPP OFF patients (76.6% to 74.2%; MLWHF 12.7 to 12.7; 6MWT 338m to 299m, NTproBNP 1112 ± 1442pg/mL to 1383 ± 2118pg/mL, for all p = NS). Conclusion In our population, patients with CRT programmed with MPP ON, when compared to MPP OFF, had an improvement in the super-response rate and in quality of life. These results may be consequence from a more favorable reverse remodeling due to MPP, with a higher reduction in the LV end systolic volume. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Introduction Discharge after overnight hospital stay is standard procedure in patients submitted to elective atrial fibrillation (AF) ablation. Taking into consideration the low rate of cryoablation procedure complications could the same day discharge be an option? Purpose To access the safety of same day discharge of patients submitted to AF cryoablation. Methods Single-center retrospective study of consecutive pts admitted to elective AF cryoablation in a tertiary center between February 2017 and November 2020. Patients were divided into two groups: same day discharge and next day discharge. Only patients submitted to ablation until 4 p.m. were included. Complication rates were obtained up to six months after the procedure. Complications were defined as death, pericardial tamponade, hematoma requiring evaluation and/or intervention, major bleeding requiring transfusion, hospital admission related to the procedure. Results One hundred fifty-four pts were included, with a mean age of 61 ± 10.9 years, 66.2% were males, 18.2% with diabetes, 65.6% with dyslipidemia, 77.9% with hypertension, 10.4% with chronic kidney disease KDIGO stage 3 or more. Median follow-up of 436 (IQ 178 – 729) days. Most of the pts had paroxysmal (73.4%) and persistent short duration AF (23.4%). Sixty-two pts (40.3%) were early discharged and there were no differences between the two groups regarding epidemiological and clinical characteristics (p = NS). A very low rate of complications in both groups was observed, occurring in 6.5% of pts with early discharge and in 8.7% of pts in overnight stay, without statistical significance between the two groups (p = 0.61). The most frequent complications were local hematoma (5 pts, 2 in early discharged group), pericardial effusion (3 pts, all in overnight stay), femoral pseudo-aneurism (2 pts, 1 in each group) and arteriovenous fistula (1 pt in overnight stay group). The type of complications did not differ between the two groups (p = 0.51). Two pts died during the follow up, unrelated with the procedure. In addition, no difference in success rate and arrhythmic recurrence was observed between the two groups. (p = NS) Conclusion Our study suggests that is safe to early discharge pts submitted to AF ablation, reducing the hospital stay length in selected pts. Larger studies are needed to confirm this data before routine implementation of this strategy.

Central venous obstruction following pacemaker implantation is not uncommon, and can prove challenging in the case of system upgrade. We report a case of DDDR to CRT-P (with multi-site pacing) upgrade, where a subclavian occlusion was overcome resorting to an atrial lead extraction (using only a locking stylet). This allowed regaining of the venous access with subsequent implantation of not just one, but two new leads and subsequent successful upgrade.