Publications by authors named "Federico Ferraris"

43 Publications

The end of "very low risk" in localized prostate cancer?

Prostate 2021 Jul 19;81(10):615-617. Epub 2021 May 19.

Instituto de Investigaciones Médicas Dr. Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina.

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http://dx.doi.org/10.1002/pros.24168DOI Listing
July 2021

Comparison of posterior indirect adhesive restorations (PIAR) with different preparation designs according to the adhesthetics classification. Part 1: Effects on the fracture resistance.

Int J Esthet Dent 2021 May;16(2):144-167

Aim: To investigate whether: 1) in the adhesive era, a full-crown restoration in a molar tooth is more resistant compared with an overlay-type restoration; b) a posterior indirect adhesive restoration (PIAR) is similar to a sound tooth from a mechanical point of view.

Materials And Methods: Seventy extracted molars were divided into five groups (1. Butt Joint; 2. Full Bevel; 3. Shoulder; 4. Full Crown; 5. Sound Tooth (control); N = 14) and prepared with four different PIAR overlay design types (according to an adhesthetics classification). Seven expert dentists performed all the preparation and cementation phases with codified protocols. A CAD/CAM workflow was used to realize the 56 monolithic lithium disilicate restorations. The samples were tested with thermomechanical aging (margin quality data will be given in Part 2 of this article series), and the resistance to fracture was then tested and analyzed.

Results And Conclusions: In terms of fracture resistance in a situation of overload and within the limitations of the present study, it is possible to conclude that the Full Bevel group showed higher fracture strength than all the other groups. All PIAR restorations performed equally or better than the natural control tooth in the Sound Tooth group. The Full Crown group did not perform better than partial overlay PIAR. The fracture types were limited to the crown in 50% or more of the samples; the rest involved the cervical part of the root. The preparation design that involved the root the least was the Full Crown group (14%).
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May 2021

Minimal fluoroscopy approach for right-sided supraventricular tachycardia ablation with a novel ablation technology: Insights from the multicenter CHARISMA clinical registry.

J Cardiovasc Electrophysiol 2021 May 14;32(5):1296-1304. Epub 2021 Apr 14.

Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Turin, Turin, Italy.

Background: No data exist on the ability of the novel Rhythmia 3-D mapping system to minimize fluoroscopy exposure during transcatheter ablation of arrhythmias. We report data on the feasibility and safety of a minimal fluoroscopic approach using this system in supraventricular tachycardia (SVT) procedures.

Methods: Consecutive patients were enrolled in the CHARISMA registry at 12 centers. All right-sided procedures performed with the Rhythmia mapping system were analyzed. The acquired electroanatomic information was used to reconstruct 3-D cardiac geometry; fluoroscopic confirmation was used whenever deemed necessary.

Results: Three hundred twenty-five patients (mean age = 56 ± 17 years, 57% male) were included: 152 atrioventricular nodal reentrant tachycardia, 116 atrial flutter, 41 and 16 right-sided accessory pathway and atrial tachycardia, respectively. Overall, 27 481 s of fluoroscopy were used (84.6 ± 224 s per procedure, equivalent effective dose = 1.1 ± 3.7 mSv per patient). One hundred ninety-two procedures (59.1%) were completed without the use of fluoroscopy (zero fluoroscopy, ZF). In multivariate analysis, the presence of a fellow in training (OR = 0.15, 95% CI: 0.05-0.46; p = .0008), radiofrequency application (0.99, 0.99-1.00; p = .0002), and mapping times (0.99, 0.99-1.00; p = .042) were all inversely associated with ZF approach. Acute procedural success was achieved in 97.8% of the cases (98.4 vs. 97% in the ZF vs. non-ZF group; p = .4503). During a mean of 290.7 ± 169.6 days follow-up, no major adverse events were reported, and recurrence of the primary arrhythmia was 2.5% (2.1 vs. 3% in the ZF vs. non-ZF group; p = .7206).

Conclusions: The Rhythmia mapping system permits transcatheter ablation of right-sided SVT with minimal fluoroscopy exposure. Even more, in most cases, the system enables a ZF approach, without affecting safety and efficacy.
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http://dx.doi.org/10.1111/jce.15023DOI Listing
May 2021

Interatrial electrical dissociation with concealed atypical atrial flutter during catheter ablation.

Europace 2021 Jan 4. Epub 2021 Jan 4.

Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Corso Bramante 88/90, 10126 Turin, Italy.

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http://dx.doi.org/10.1093/europace/euaa381DOI Listing
January 2021

Safety, efficacy, and reproducibility of cavotricuspid isthmus ablation guided by the ablation index: acute results of the FLAI study.

Europace 2021 Feb;23(2):264-270

San Francesco Hospital, Via Mannironi 1, 08100 Nuoro, Italy.

Aims: Ablation index (AI) is a marker of lesion quality during catheter ablation that incorporates contact force, time, and power in a weighted formula. This index was originally developed for pulmonary vein isolation as well as other left atrial procedures. The aim of our study is to evaluate the feasibility and efficacy of the AI for the ablation of the cavotricuspid isthmus (CTI) in patients presenting with typical atrial flutter (AFL).

Methods And Results: This prospective multicentre non-randomized study enrolled 412 consecutive patients with typical AFL undergoing AI-guided cavotricuspid isthmus ablation. The procedure was performed targeting an AI of 500 and an inter-lesion distance measurement of ≤6 mm. The primary endpoints were CTI 'first-pass' block and persistent block after a 20-min waiting time. Secondary endpoints included procedural and radiofrequency duration and fluoroscopic time. A total of 412 consecutive patients were enrolled in 31 centres (mean age 64.9 ± 9.8; 72.1% males and 27.7% with structural heart disease). The CTI bidirectional 'first-pass' block was reached in 355 patients (88.3%), whereas CTI block at the end of the waiting time was achieved in 405 patients (98.3%). Mean procedural, radiofrequency, and fluoroscopic time were 56.5 ± 28.1, 7.8 ± 4.8, and 1.9 ± 4.8 min, respectively. There were no major procedural complications. There was no significant inter-operator variability in the ability to achieve any of the primary endpoints.

Conclusion: AI-guided ablation with an inter-lesion distance ≤6 mm represents an effective, safe, and highly reproducible strategy to achieve bidirectional block in the treatment of typical AFL.
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http://dx.doi.org/10.1093/europace/euaa215DOI Listing
February 2021

Editorial: Meet our authors and discover more.

Int J Esthet Dent 2020;15(3):237-238

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October 2020

Zero-fluoroscopy atrial fibrillation ablation in the presence of a patent foramen ovale: a multicentre experience.

J Cardiovasc Med (Hagerstown) 2020 Apr;21(4):292-298

Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin.

Introduction: Atrial fibrillation ablation has historically been guided by fluoroscopy, with the related enhanced risk deriving from radiation. Fluoroscopy exposure may be confined to guide the transseptal puncture. Small sample size study presented a new methodology to perform a totally fluoroless atrial fibrillation ablation in the case of a patent foramen ovale (PFO). We evaluated this methodology in a large sample size of patients and a multicentre experience.

Methods And Results: Two hundred and fifty paroxysmal atrial fibrillation patients referred for first atrial fibrillation ablation with a CARTO3 electroanatomic mapping system were enrolled. In 58 out of 250 patients, a PFO allowed crossing of the interatrial septum, and a completely fluoroless ablation was performed applying the new method (Group A). In the remaining patients, a standard transseptal puncture was performed (Group B). Pulmonary vein isolation was achieved in all patients with comparable procedural and clinical outcomes at short- and long-term follow-up.

Conclusion: The presence of a PFO may allow a completely fluoroless well tolerated and effective atrial fibrillation ablation. Probing the fossa ovalis looking for the PFO during the procedure is desirable, as it is not time-consuming and can potentially be done in every patient undergoing atrial fibrillation ablation.
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http://dx.doi.org/10.2459/JCM.0000000000000943DOI Listing
April 2020

Is the mid-diastolic isthmus always the best ablation target for re-entrant atrial tachycardias?

J Cardiovasc Med (Hagerstown) 2020 Feb;21(2):113-122

Clinica Universidad de Navarra, Pamplona, Spain.

Aims: We evaluated the ability of an ultrahigh mapping system to identify the most convenient Rhythmia ablation target (RAT) in intra-atrial re-entrant tachycardias (IART) in terms of the narrowest area to transect to interrupt the re-entry.

Methods: A total of 24 consecutive patients were enrolled with a total of 26 IARTs. The Rhythmia mapping system was used to identify the RAT in all IARTs.

Results: In 18 cases the RAT matched the mid-diastolic phase of the re-entry whereas in 8 cases the RAT differed. In these patients, the mid-diastolic tissue in the active circuit never represented the area with the slowest conduction velocity of the re-entry. The mean conduction velocity at the mid-diastolic site was significantly slower in the group of patients in which the RAT matched the mid-diastolic site (P = 0.0173) and that of the remaining circuit was significantly slower in the group in which the RAT did not match (P = 0.0068). The mean conduction velocity at the RAT was comparable between the two groups (P = 0.66).

Conclusion: Identifying the RAT in challenging IARTs by means of high-density representation of the wavefront propagation of the tachycardia seems feasible and effective. In one-third of cases this approach identifies an area that differs from the mid-diastolic corridor.
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http://dx.doi.org/10.2459/JCM.0000000000000923DOI Listing
February 2020

Atrial fibrillation ablation in a patient with a peculiar common postero-inferior pulmonary vein trunk.

Eur Heart J Case Rep 2019 Mar 9;3(1):yty157. Epub 2019 Jan 9.

Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza di Torino' Hospital, University of Turin, Corso Bramante 88, Turin, Italy.

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http://dx.doi.org/10.1093/ehjcr/yty157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439357PMC
March 2019

Concentrated pineapple juice for visualisation of the oesophagus during magnetic resonance angiography before atrial fibrillation radiofrequency catheter ablation.

Eur Radiol Exp 2018 Nov 21;2(1):39. Epub 2018 Nov 21.

Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy.

The purpose of this study was to compare in vitro pineapple juice and a solution of concentrated pineapple juice with a paramagnetic contrast agent in order to determine the feasibility of using the solution of concentrated pineapple juice in vivo for oesophagus visualisation at magnetic resonance angiography (MRA) before the radiofrequency catheter ablation procedure for atrial fibrillation. The pineapple juice was concentrated by a microwave heating evaporation process performed in a domestic microwave oven. Five grams of modified potato starch for every 40 mL of concentrated pineapple juice were added to the concentrated pineapple juice in order to thicken the solution. The solution resulted visually and quantitatively as hyperintense as the contrast agent in vitro (ratio = 1.02). in vivo, no technical difficulties were encountered during the MRA acquisition and a complete enhanced oesophagus was obtained in 37/38 patients (97.4%). The volumetric analysis and the three-dimensional reconstruction were feasible; the quality was rated as diagnostic in every patient. The intensified oesophagus was successfully merged into the electro-anatomical maps in all the patients. In summary, we demonstrated that this technique allows a feasible and safe oesophagus visualisation during MRA.
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http://dx.doi.org/10.1186/s41747-018-0067-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6246758PMC
November 2018

Update on the 'index technique' in worn dentition: a no-prep restorative approach with a digital workflow.

Int J Esthet Dent 2018 ;13(4):516-537

Following the guidelines of the 'index technique' that were published in this journal in 2015, this article presents the 'digital index technique,' an updated no-prep restorative approach to the management of worn dentition. Patients with minimal, moderate, and severe hard tissue wear can be treated based on the application of minimally invasive or noninvasive adhesive composite restorations on posterior and anterior worn dentition. The technique allows for a purely additive treatment without sacrificing healthy hard tooth tissue. It follows the principles of biodentistry (maximum conservation of healthy tissue), and the reinforcing of residual dental structure. Depending on the severity of the enamel and dentin wear, the number of caries, and the size of the existing restorations, different treatment options can be applied to each tooth: direct and indirect partial restorations or full crowns. It is essential to diagnose and treat tooth surface loss in order to properly restore biomechanics, function, and esthetics by means of adhesive restorations. This article proposes that the update of the index technique through the digital workflow is a fast and conservative approach for the planning and management of a full-mouth adhesive restoration in all cases of light, moderate, and severe worn dentition. The technique is based on a 'copy-and-paste' guided approach, stamping composite resin directly onto the tooth surface by means of a transparent index created from a full-mouth digital restorative wax-up, following an initially planned increase in occlusal vertical dimension (OVD) through an esthetic and functional analysis.
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June 2019

Cryoballoon vs. radiofrequency contact force ablation for paroxysmal atrial fibrillation: a propensity score analysis.

J Cardiovasc Med (Hagerstown) 2018 04;19(4):141-147

Cardiology Division, Department of Medical Sciences, University of Turin, Turin.

Background: Radiofrequency and cryoballoon pulmonary vein isolation are common approaches for paroxysmal atrial fibrillation treatment, showing similar results in recent multicenter studies, including heterogeneous tools and protocols. The aim of this study is to compare prospectively in a single, high-volume center the outcome of paroxysmal atrial fibrillation ablation performed specifically by second-generation cryoballoon or contact force radiofrequency ablation.

Methods: Consecutive patients scheduled for paroxysmal atrial fibrillation transcatheter ablation have been included and prospectively followed up. Aiming to reduce potential bias deriving from baseline characteristics, a propensity score matching analysis has been performed to analyze safety and efficacy outcomes.

Results: Out of consecutive patients undergoing atrial fibrillation transcatheter ablation between January 2015 and December 2016, 46 patients approached by cryoablation were matched 1 : 1 by propensity score to a similar population treated by last-generation radiofrequency ablation. Freedom from atrial fibrillation after 12 months (76 vs. 78%, P = 0.804) and incidence of complications (4 vs. 6%, P = 0.168) did not differ between the two groups. Radiological exposure was higher for the cryoballoon group (11 vs. 4 min, P < 0.001), whereas procedural duration did not differ (P = 0.174). Aiming to assess the potential impact of a learning curve in patients undergoing cryoablation, the first-third of patients (n = 15) were compared with the remaining, reporting longer radiological exposure (P < 0.001), but similar safety and efficacy.

Conclusion: In this propensity score analysis, last-generation cryoballoon and radiofrequency catheters for atrial fibrillation ablation present similar efficacy and safety. Cryoablation requires longer fluoroscopy exposure compared with radiofrequency, although this is reduced by increased experience.
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http://dx.doi.org/10.2459/JCM.0000000000000633DOI Listing
April 2018

Hypnosis as an effective and inexpensive option to control pain in transcatheter ablation of cardiac arrhythmias.

J Cardiovasc Med (Hagerstown) 2018 Jan;19(1):18-21

Division of Cardiology, Cardio-Thoracic Department.

: Supportive care for pain relief and back discomfort during electrophysiology interventions is usually needed in the electrophysiology lab, especially in long-lasting procedures like atrial fibrillation ablation. Although this is usually achieved with conventional pharmacologic anesthesia, hypnosis has recently aroused interest as a reliable tool to complement and possibly enhance conscious sedation. We collected five case of percutaneous arrhythmia ablation in which, after informed consent, hypnosis was performed by nurse anesthetists in the cath lab. In each case at the end of the intervention, the patients described complete alterations of perception or memory of the pain or of the length of the study. No anesthetic drug was needed. While waiting for more robust data, we suggest hypnosis could be a reliable, inexpensive and well tolerated tool to obtain complete pain control and comfort during arrhythmia ablation.
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http://dx.doi.org/10.2459/JCM.0000000000000605DOI Listing
January 2018

Posterior indirect adhesive restorations (PIAR): preparation designs and adhesthetics clinical protocol.

Int J Esthet Dent 2017;12(4):482-502

Posterior indirect adhesive restorations (PIAR) are very common nowadays in clinical practice. The indirect approach is often indicated by a need for cuspal coverage (one or more cusps). With the adhesthetics protocol, the first step is to perform a cavity analysis evaluating the resistance of the tooth after restoration. The structures to be evaluated are, in sequence, the interaxial dentin, ridges, roof of the pulp chamber, and cusps. To improve the strength, the cusps should be covered, when required. The build-up for PIAR is performed with an adhesive technique, and, if possible, with low-shrinkage materials. The use of an adhesive post is not required, but not contraindicated if performed with a conservative approach on the root canal. Different preparation designs can be chosen. The butt joint, the most common with an adhesive technique, is used to protect the cusp when it is evaluated to be too fragile. A variant of the butt joint, the bevel, is useful for esthetic purposes or for providing more space or more enamel surface on the peripheral part of the preparation. The shoulder is useful if a cervical grasp is required, but is usually indicated when a previous cusp fracture needs to be restored. The veneerlay combines an overlay design with a buccal veneer when there are specific esthetic needs. In the interproximal areas, the preparation designs can be classified as: slot - the most common; bevel - useful in some cases to restore the ridge with a more conservative approach; ridge up - useful to preserve the ridge (a very important structure to maintain the resistance of the tooth) even when cuspal coverage is required. Ridge up can have two variants: ridge preservation and ridge coverage. More than one preparation design is used in many cases in the same preparation, taking into consideration the specific situation of the tooth and its different areas, in order to balance the prognosis with a conservative approach.
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December 2017

The "index cutback technique": a three-dimensional guided layering approach in direct class IV composite restorations.

Int J Esthet Dent 2017;12(4):450-466

One of the main difficulties encountered with conventional class IV direct composite restorations is the layering management in terms of three-dimensionality and shape control. The major concern is the predictability of the esthetic outcome, which is closely linked to the clinician's skills. This article presents a predictable approach to treat class IV direct composite restorations. The technique allows for the shape and thickness of different composite layers to be guided through transparent indexes that have been carried out previously on a planned wax-up. The final goal is to achieve a good esthetic outcome in an easy and fast way through a copy-and-paste approach. The "index cutback technique" is a complementary variant of the "index technique" for class IV direct restorations. After the casts have been generated, the technician creates a full wax-up of the tooth to be restored. A transparent silicone key of the full wax-up provides the full enamel index that is then cut with a blade along the incisal edge to achieve two enamel indexes, one palatal and one buccal. Then, the required amount of wax is removed from the full wax-up through a cutback step. The aim of this step is to remove a suitable amount of wax to leave a predetermined space for the composite enamel layers, both on the palatal and buccal surfaces. A second transparent silicone key is built on the cutback wax-up to achieve the cutback dentin index, which is then used to press the composite dentin onto the prepared tooth.
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December 2017

Anticoagulant cessation following atrial fibrillation ablation: limits of the ECG-guided approach.

Expert Rev Cardiovasc Ther 2017 Jun 29;15(6):473-479. Epub 2017 May 29.

a Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital , University of Turin , Turin , Italy.

Introduction: Long-term cessation of oral anticoagulation (OAC) following successful catheter or surgical ablation of atrial fibrillation (AF) is debated. Usually, in the presence of sinus rhythm at serial ECG recordings, the CHADS2, CHA2DS2VASc, and HAS-BLED scores are adopted to guide decision regarding OAC management. Areas covered: The safety of OAC cessation in patients without recurrent AF but with historically elevated risk for thromboembolism remains largely unknown. Taking the cue from two clinical cases, we provide an updated summary of the latest evidence regarding how to manage OAC after a successful atrial fibrillation ablation. Expert commentary: The present clinical perspective suggests that, at least within patients with severely enlarged left atrium, previous cardiac surgery and catheter or surgical AF ablation, especially if repeated, assessment of atrial contractility by transthoracic echocardiography should be performed before discontinuing OAC in patients who maintain sinus rhythm, confirmed by serial ECG or Holter monitorings.
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http://dx.doi.org/10.1080/14779072.2017.1332993DOI Listing
June 2017

Conduction recovery following catheter ablation in patients with recurrent atrial fibrillation and heart failure.

Int J Cardiol 2017 Aug 22;240:240-245. Epub 2017 Feb 22.

Cardiology Division, Department of Medical Sciences, University of Turin, Turin, Italy. Electronic address:

Background: Atrial fibrillation (AF) catheter ablation is increasingly proposed for patients suffering from AF and concomitant heart failure (HF). However, the optimal ablation strategy remains controversial. We performed this study to assess the prevalence of pulmonary vein (PV) or linear lesion reconnection in HF patients undergoing repeated procedures.

Methods And Results: At seven high-volume centres, 165 patients with HF underwent a repeat procedure after a first AF ablation including PV isolation alone (47 patients, group A) or PV isolation plus left atrial lines (118 patients, group B). Group A patients presented more often paroxysmal AF (p<0.001), less enlarged left atrium (p<0.001) and less left ventricular systolic dysfunction (p=0.031) compared to Group B, that more commonly had atypical atrial flutter (p<0.001). Forty-one (87%) patients in Group A and 69 (58%) in Group B presented at least one reconnected PV (p<0.001). Sixty-one (52%) patients in Group B presented at least one reconnected atrial line (left isthmus or roof). Patients without any reconnected PV (n=54, 33%) more frequently experienced persistent AF (p<0.001), had longer AF duration (p=0.047) and larger left atrial volume (p<0.001). Twenty-five patients (15%) with no PV and/or line reconnection did not significantly differ, concerning baseline characteristics, compared to those with at least one reconnected ablation site.

Conclusion: As in the general AF population undergoing catheter ablation, PV reconnection is frequent in patients with HF and symptomatic recurrence. However, one third of patients presented arrhythmic recurrences even in the absence of PV reconnection, highlighting the importance of the underlying atrial substrate.
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http://dx.doi.org/10.1016/j.ijcard.2017.02.067DOI Listing
August 2017

Cooling dynamics: a new predictor of long-term efficacy of atrioventricular nodal reentrant tachycardia cryoablation.

J Interv Card Electrophysiol 2017 Apr 10;48(3):333-341. Epub 2016 Dec 10.

Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy.

Purpose: Catheter ablation of the slow pathway is the most effective treatment for atrioventricular nodal reentrant tachycardia (AVNRT). Cryoenergy, compared to radiofrequency, relates to lower heart block risk but higher incidence of AVNRT recurrences. The aims of this study are to confirm the safety and efficacy of AVNRT cryoablation and to identify predictors of long-term recurrences.

Methods: Among 241 patients undergoing AVNRT cryoablation, 239 (99.2%) experienced acute effective cryoablation of the slow pathway, and no procedure-related complications were reported.

Results: After a follow-up of 44.9 ± 31.7 months, 28 (11.7%) patients presented AVNRT recurrences. A shorter preablation (p = 0.05) and postablation anterograde Wenckebach cycle length (p < 0.01), a shorter postablation atrioventricular node refractory period (p = 0.04), and persistence of the crossover sign (p = 0.03) were associated with higher incidence of long-term recurrences. Considering cooling dynamics, a longer time to reach temperature ≤-70 °C (p = 0.03) and a higher minimal temperature during ablation (p = 0.04) were related to recurrences. Patients without residual markers of dual AV node physiology (AH jump, single atrial echo beat, crossover) reported a lower recurrence rate (p = 0.05) compared to those without. At multivariate analysis, a longer time to -70 °C was the strongest independent predictor of long-term recurrence (OR 1.75, 95% CI 1.01-3.03, p = 0.04).

Conclusions: AVNRT cryoablation is safe and effective. Long-term recurrence rate was 11.7%. An ablation approach directed to the complete elimination of dual AV node physiology, along with assessment of the tissue's cooling dynamics, holds the potential to improve long-term AVNRT cryoablation efficacy.
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http://dx.doi.org/10.1007/s10840-016-0208-4DOI Listing
April 2017

Anatomic relationship between left coronary artery and left atrium in patients undergoing atrial fibrillation ablation.

J Cardiovasc Med (Hagerstown) 2017 Jul;18(7):528-533

aDivision of Cardiology, Department of Medical Sciences, University of Torino, 'Città della Salute e della Scienza' Hospital, Turin bDepartment of Cardiovascular and Neurological Sciences, University of Cagliari, Cagliari cDivision of Cardiology, Policlinico Casilino, ASL, Rome, Italy.

Background: Atrial fibrillation transcatheter ablation (TCA) is, within available atrial fibrillation rhythm control strategies, one of the most effective. To potentially improve ablation outcome in case of recurrent atrial fibrillation after a first procedure or in presence of structural myocardial disease, isolation of the pulmonary veins may be associated with extensive lesions within the left atrium. To avoid rare, but potentially life-threatening, complications, thorough knowledge and assessment of left atrium anatomy and its relation to structures in close proximity are, therefore, mandatory. Aim of the present study is to describe, by cardiac computed tomography, the anatomic relationship between aortic root, left coronary artery and left atrium in patients undergoing atrial fibrillation TCA.

Methods And Results: The cardiac computed tomography scan of 21 patients affected by atrial fibrillation was elaborated to segment left atrium, aortic root and left coronary artery from the surrounding structures and the following distances measured: left atrium and aortic root; left atrium roof and aortic root; left main coronary artery and left atrium; circumflex artery and left atrium appendage; and circumflex artery and mitral valve annulus. Above all, the median distance between left atrium and aortic root (1.9, 1.5-2.1 mm), and between circumflex artery and left atrium appendage ostium (3.0, 2.1-3.4 mm) were minimal (≤3 mm). None of measured distances significantly varied between patients presenting paroxysmal versus persistent atrial fibrillation.

Conclusion: The anatomic relationship between left atrium and coronary arteries is extremely relevant when performing atrial fibrillation TCA by extensive lesions. Therefore, at least in the latter case, preablation imaging should be recommended to avoid rare, but potentially life-threatening, complications with the aim of an as well tolerated as possible procedure.
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http://dx.doi.org/10.2459/JCM.0000000000000484DOI Listing
July 2017

Starfix lead extraction: Clinical experience and technical issues.

J Cardiol Cases 2016 Jan 14;13(1):25-30. Epub 2015 Nov 14.

Division of Cardiology, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy.

Transvenous lead extraction (TLE) of the Starfix coronary sinus (CS) active-fixation lead may be challenging, due to undeployment of fixation lobes and venous occlusion. We report our experience in Starfix TLE, in comparison with previous data. A 78-year-old male, implanted in 2009 with Starfix lead, was referred to our institution for TLE, due to infective endocarditis with lead-associated vegetations. The tip of Starfix lead was located in distant, anterior position, in the great cardiac vein, close to patent left internal mammary artery-to-left anterior descending artery anastomosis, and first-choice surgical removal had a prohibitive operative risk. Conventional dilatation beyond CS ostium, as well as the use of a standard delivery catheter, was ineffective. An off-label modification of the delivery, by cutting the distal soft tip, was successful. However, the tip of the lead fragmented and was trapped in the innominate vein. Then a gooseneck snare grasped the fragment, allowing complete retrieval. TLE of Starfix leads may be particularly challenging, especially when its tip is located in a distant anterior location. In these cases, important help may be obtained by dilatation within the CS, by means of conventional or modified delivery catheters. Only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads. < TLE of Starfix leads may be challenging, particularly when the tip is located in a distant anterior position. Dilatation with conventional tools may be precluded. In these cases modifications of the delivery catheters may be useful. Surgery should be avoided as first-choice procedure; only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads.>.
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http://dx.doi.org/10.1016/j.jccase.2015.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281896PMC
January 2016

Left persistent superior vena cava as a source of focal atrial arrhythmias: A late arrhythmia recurrence due to a latent proximal focus.

Int J Cardiol 2016 Jan 2;203:523-4. Epub 2015 Nov 2.

Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Italy.

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http://dx.doi.org/10.1016/j.ijcard.2015.10.241DOI Listing
January 2016

Do left atrial appendage morphology and function help predict thromboembolic risk in atrial fibrillation?

J Cardiovasc Med (Hagerstown) 2016 Mar;17(3):169-76

Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy.

Clinical scores (i.e. CHA2DS2-VASc) are the mainstay of thromboembolic risk management in nonvalvular atrial fibrillation. Nonetheless, they bear some limitations to precisely define risk-benefit ratio of oral anticoagulation (OAC), both with vitamin K antagonists and with novel direct oral anticoagulants, especially in patients with low-intermediate scores. Cardiovascular imaging, allowing directly visualization of those pathophysiological alterations, which may lead to the formation of intracardiac thrombi, offers itself as a unique tool helping to refine thromboembolic risk stratification. Many parameters have been tested, focusing primarily on functional and morphological variables of the left atrium and left atrial appendage (LAA). Left atrium volume and LAA peak flow velocity have, for a longtime, been associated with increased thromboembolic risk, whereas some new parameters, such as left atrium fibrosis assessed by late-gadolinium enhanced (LGE) MRI, left atrium and LAA strain and LAA morphology have more recently shown some ability in predicting embolic events in atrial fibrillation patients. Overall, however, these parameters have seen, to date, scarce clinical implementation, especially because of the inconsistency of validated cutoffs and/or strong clinical evidence driven by technical limitations, such as expensiveness of the technologies (i.e. MRI or computed tomography), invasiveness (i.e. transesophageal echocardiography) or limited reproducibility (i.e. LGE MRI). In conclusion, to date, cardiovascular imaging plays a limited role; however, validation and diffusion of the new techniques hereby systematically presented hold the potential to refine thromboembolic risk stratification in nonvalvular atrial fibrillation.
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http://dx.doi.org/10.2459/JCM.0000000000000305DOI Listing
March 2016

Left Atrial Function After Radiofrequency Catheter Ablation of Atrial Fibrillation--Can Pre-Ablation Function Predict Contractile Improvement During Follow-up?

Circ J 2015 8;79(12):2576-83. Epub 2015 Oct 8.

Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza" Hospital and Department of Medical Sciences, University of Turin.

Background: Data are lacking on the effect of radiofrequency catheter ablation (RFCA) on atrial function. The aim of this study was to determine a cut-off of pre-ablation left atrial (LA) function in order to predict atrial functional recovery after RFCA.

Methods and results: A total of 64 atrial fibrillation (AF) patients who underwent RFCA were enrolled (age, 59.05±12.09 years; 36% persistent AF; LA volume 37.8±13.6 ml/m(2)). LA emptying fraction (LAEF), LA active fraction (LAAEF), LA passive emptying fraction (LAPEF) and LA expansion index (LAEI) were evaluated in sinus rhythm before and 48 h, 15 days, 1, 2, 3 and 9 months after ablation. LA function improvement was defined as any positive increase in LAEF compared with baseline. On univariate and multivariate analysis only baseline atrial function proved to be an independent predictor of LA function improvement after ablation (P=0.002; OR=0.001; 95% CI: 0.000-0.099). On receiver operating characteristic analysis (AUC=0.70), cut-off for baseline LAEF was 40%. At 9 months, patients with LAEF <40% had significant improvement in atrial performance (LAEF, P=0.01; LAAEF, P=0.036; LAEI, P=0.004); a significant negative correlation between baseline LAEF and LA function improvement was observed (r=-0.62; 95% CI: -0.83 to -0.26; P(r=0)<0.002).

Conclusions: Baseline LAEF is an independent predictor of LA function recovery after RFCA. The beneficial effect of AF ablation is most evident in patients with LAEF<40%.
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http://dx.doi.org/10.1253/circj.CJ-15-0184DOI Listing
September 2016

Long-term events following atrial fibrillation rate control or transcatheter ablation: a multicenter observational study.

J Cardiovasc Med (Hagerstown) 2016 Mar;17(3):187-93

aDivision of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, TurinbDivision of Cardiology, Department of Internal Medicine, Cardinal Massaia Hospital, AsticDivision of Cardiology, Mauriziano Umberto I Hospital, Turin, Italy.

Background: Atrial fibrillation increases thromboembolic risk. Oral anticoagulation with antivitamin K (AVK) reduces thromboembolic event rate, but increases hemorrhagic risk.

Objective: The aim of the present study was to describe long-term cerebral thromboembolic/hemorrhagic event rates in atrial fibrillation patients managed by rhythm control, pursued by atrial fibrillation transcatheter ablation (AFTCA), and rate control strategy.

Methods And Results: One thousand and five hundred consecutive patients referring to three medical care centers for atrial fibrillation were retrospectively divided into three groups: AFTCA maintaining AVK (group A); AFTCA discontinuing AVK (group B); and rate control strategy and AVK (group C). Thromboembolic and hemorrhagic events were recorded in 60 ± 28 months of follow-up. Thromboembolic events did not differ between the groups (5/500, 1% group A; 7/500, 1.4% group B; 11/500, 2.2% group C; P = 0.45), and hemorrhagic events were greater in group A (9/500, 1.8%) and C (12/500, 2.4%) than in group B (no events; P = 0.003). Among patients with CHA2DS2 VASc score 2 or less, thromboembolic events did not differ in the group discontinuing AVK (group B, 4/388, 1%) or not (group A, 1/319, 0.3%; P = 0.38), whereas hemorrhagic events were more common in patients on AVK (5/319, 1.5% group A and 3/175, 1.7% group C; P = 0.02) compared with those discontinuing AVK (0/388, group B). Following AFTCA (groups A and B), 299/1000 experienced atrial fibrillation relapses; all thromboembolic events (12/299, 4%) occurred within these patients (P < 0.001).

Conclusion: Considering this multicenter design study, AVK continuation following AFTCA, especially within patients with low-to-intermediate thromboembolic risk, confers a hemorrhagic risk greater to the thromboembolic protective effect. All thromboembolic events following AFTCA occur within patients experiencing atrial fibrillation relapses; therefore, in patients with high thromboembolic risk routine rhythm monitoring is essential after AVK discontinuation.
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http://dx.doi.org/10.2459/JCM.0000000000000311DOI Listing
March 2016

Left anterior descending coronary artery fistula to left ventricle: The revenge of a well treated myocardial infarction in the era of primary percutaneous angioplasty.

Int J Cardiol 2015 31;187:508-10. Epub 2015 Mar 31.

Cardiology Unit, Department of Internal Medicine, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2015.03.418DOI Listing
March 2016

Atrial fibrillation and female sex.

J Cardiovasc Med (Hagerstown) 2015 Dec;16(12):795-801

Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy.

Atrial fibrillation is the most common supraventricular arrhythmia. Its prevalence increases with age and preferentially affects male patients. Over 75 years of age, however, female patients being more prevalent, the absolute number of patients affected is similar between sexes. Despite this, few data are available in the literature concerning sex-related differences in atrial fibrillation patients. The present systematic review therefore considers comorbidities, referring symptoms, quality of life, pharmacological approaches and trans-catheter ablation in female rather than in male atrial fibrillation patients in search of parameters that may have an impact on the treatment outcome. In brief, female atrial fibrillation patients more commonly present comorbidities, leading to a higher prevalence of persistent atrial fibrillation; moreover, they refer to hospital care later and with a longer disease history. Atrial fibrillation symptoms relate to low quality of life in female patients; in fact, atrial fibrillation paroxysm usually presents higher heart rate, leading to preferentially adopt a rate rather than a rhythm-control strategy. Female atrial fibrillation patients present an increased risk of stroke, worsened by the lower oral anticoagulant prescription rate related to the concomitant higher haemorrhagic risk profile. Trans-catheter ablation is under-used in female patients and, on the contrary, they are more commonly affected by anti-arrhythmic drug side effects.
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http://dx.doi.org/10.2459/JCM.0000000000000239DOI Listing
December 2015

The "index technique" in worn dentition: a new and conservative approach.

Int J Esthet Dent 2015 ;10(1):68-99

The development and reliability of adhesive resin composite systems have offered clinicians a further option for the management of tooth-surface loss. Patients with minimum, moderate, and severe hard tissue wear can be treated based on the application of minimally invasive adhesive composite restorations for posterior and anterior worn dentition. This article presents the "index technique", a new and very conservative approach to the management of worn dentition. The technique allows for a purely additive treatment without sacrificing healthy hard tooth tissue. It follows the principles of bioeconomics (maximum conservation of healthy tissue) and the reinforcing of residual dental structure. Depending on the severity of enamel and dentin wear, the number of caries, and the size of existing restorations, different treatment options can be applied to each tooth: direct and indirect partial restorations or full crowns. It is essential to diagnose and treat tooth-surface loss in order to properly restore biomechanics, function, and esthetics by means of adhesive restorations. This article proposes that the index technique is a fast and conservative approach for the planning and management of a fullmouth adhesive treatment in all cases of worn dentition. The technique is based on stamping composite directly on the tooth surface by means of a transparent index created from the full-mouth wax-up following an initially planned increase in occlusal vertical dimension (OVD).
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December 2015

Influence of enamel composite thickness on value, chroma and translucency of a high and a nonhigh refractive index resin composite.

Int J Esthet Dent 2014 ;9(3):382-401

Objectives: To evaluate the influence of thickness on the optical properties of two enamel shade composites, one with a high refractive index and one traditional.

Methods: A medium value enamel shade was selected from the resin composites Enamel Plus HRi (UE2) and Enamel Plus HFO (GE2). Enamel Plus HRi is a high refractive index composite. Samples were fabricated in five different thicknesses: 0.3, 0.5, 1, 1.5 and 2 mm. Three specimens per material and thickness were fabricated. Three measurements per sample, over white, black and dentin composite background were generated with a spectrophotometer (Spectroshade Micro, MHT). Value, chroma, translucency and color differences (ΔE) of the specimens were calculated. RESULTS were analyzed by the Pearson correlation test, ANOVA and a post-hoc Tukey test.

Results: Increasing the thickness of the enamel layers decreased the translucency and the chroma of the substrate for both materials tested. For HRi the increase of the thickness resulted in an increase of the value, whereas for HFO it resulted in a reduction of the value. The two composites showed a significant difference in value for each thickness, but not in translucency and chroma. Color difference between them was perceptible in layers equal or higher than 0.5 mm.

Conclusions: The high refractive index enamel (HRi) composite exhibits different optical behavior compared to the traditional one (HFO). HRi enamel composite behaves more like natural enamel as by increasing the thickness of the enamel layer, the value also increases.
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September 2014

Pulmonary vein isolation with a new multipolar irrigated radiofrequency ablation catheter (nMARQ™): feasibility, acute and short-term efficacy, safety, and impact on postablation silent cerebral ischemia.

J Cardiovasc Electrophysiol 2014 Dec 14;25(12):1299-305. Epub 2014 Sep 14.

Cardiology Division, Cardinal Guglielmo Massaia Hospital, Asti, Italy.

Background: Simultaneous multipolar ablation catheters have been proposed to simplify pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (AF). Recently, a new multipolar irrigated radiofrequency (RF) ablation catheter (nMARQ™, Biosense Webster Inc., Diamond Bar, CA, USA) combining both 3-dimensional electroanatomic mapping and multipolar open-irrigated ablation capability has been developed. Aim of our study was to assess feasibility, acute and short-term success and safety of PVI by the use of this new technology with particular regard to the incidence of postablation silent cerebral ischemia (SCI).

Methods And Results: Twenty-five patients (76% males; age 57 ± 13 years) with paroxysmal AF underwent PVI using the nMARQ™ catheter. PVI, confirmed by Lasso catheter mapping, was achieved in 100 out of 102 pulmonary veins (98%) identified, and final PVI was obtained in 24 out of 25 (96%) patients. The overall concordance between Lasso and nMARQ™ signals in demonstrating PVI was 78%. No major procedural complications occurred and no patient suffered SCI, on the basis of cerebral magnetic resonance imaging performed before and after the procedure. Following a 6-month follow-up, 17/25 (68%) patients remained free from AF without antiarrhythmic drugs.

Conclusions: In our preliminary experience, PVI with nMARQ™ catheter appears to be feasible and safe, without incidence of SCI. Long-term clinical efficacy has to be evaluated in further studies.
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http://dx.doi.org/10.1111/jce.12500DOI Listing
December 2014

Left persistent superior vena cava and paroxysmal atrial fibrillation: the role of selective radio-frequency transcatheter ablation.

J Cardiovasc Med (Hagerstown) 2014 Aug;15(8):647-52

aDivision of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Torino, Turin, Italy bDivision of Cardiology, Cardinal Massaia Hospital, Asti, Italy.

Persistent left superior vena cava (LPSVC) is a rare congenital anomaly of the thoracic venous system that can trigger paroxysmal atrial fibrillation. The role of this venous anomaly must be carefully considered in patients undergoing conventional atrial fibrillation transcatheter ablation by pulmonary vein isolation to avoid unnecessary lesions, left atrium access and arrhythmia relapses. In fact, the present clinical perspective suggests sole LPSVC isolation is a well tolerated and effective approach in patients with paroxysmal atrial fibrillation and arrhythmic trigger originating from a LPSVC.
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http://dx.doi.org/10.2459/JCM.0000000000000144DOI Listing
August 2014