Cryoballoon ablation of atrial fibrillation is effectively feasible without previous imaging of pulmonary vein anatomy: insights from the 1STOP project.

BACKGROUND: Pulmonary vein isolation by cryoablation (PVI-C) is a standard therapy for the treatment of atrial fibrillation (AF); however, PVI-C can become a challenging procedure due to the anatomy of the left atrium and pulmonary veins (PVs). Importantly, the utility of imaging before the procedure is still unknown regarding the long-term clinical outcomes following PVI-C. The aim of the analysis is to evaluate the impact of imaging before PVI-C on procedural data and AF recurrence. METHODS: Patients with paroxysmal AF underwent an index PVI-C. Data were collected prospectively in the framework of 1STOP ClinicalService® project. Patients were divided into two groups according to the utilization of pre-procedural imaging of PV anatomy (via CT or MRI) or the non-usage of pre-procedural imaging. RESULTS: Out of 912 patients, 461 (50.5%) were evaluated with CT or MRI before the PVI-C and denoted as the imaging group. Accordingly, 451 (49.5%) patients had no pre-procedural imaging and were categorized as the no imaging group. Patient baseline characteristics were comparable between the two cohorts, but the ablation centers that comprised the imaging group had fewer PVI-C cases per year than the no imaging group (p < 0.001). The procedure, fluoroscopy, and left atrial dwell times were significantly shorter in the no imaging cohort (p < 0.001). The rates of complications were significantly greater in the imaging group compared to the no imaging group (6.9% vs. 2.7%; p = 0.003); this difference was attributed to differences in transient diaphragmatic paralysis. The 12-month freedom from AF was 76.2% in the imaging group and 80.0% in the no imaging group (p = 0.390). CONCLUSIONS: In our analysis, PVI-C was effective regardless of the availability of imaging data on PV anatomy.

Effects of immune system status on long-term results of cardiac resynchronization therapy.

AIM: Cardiac resynchronization therapy (CRT) is an effective therapy for patients with reduced systolic function and enlarged QRS. Recently, some Authors have demonstrated that the presence of positive antinuclear antibodies (ANAs) may play a role in the development of heart failure in a population of patients implanted with PM. METHODS: We investigated the effect of positive ANAs in 90 patients (mean age 71±8 years) implanted with a CRT device in our Centre between May 2010 and June 2013. To assess for immunologic contribution to CRT outcome, patients were divided into positive and negative ANAs (ANA +, ANA -), considering as positive patients with an ANAs dilution > 1:80. The primary endpoint was constituted by a combined endpoint of death or first hospitalization for heart failure; secondary endpoints were constituted by: 1) incidence of first hospitalization for heart failure; and 2) total cause mortality. RESULTS: After a mean follow-up of 1200 days, primary endpoint occurred in 11 patients (30%) of ANA+ group and in 8 patients (15.1%) of ANA-group. The significant difference is due to difference in heart failure events (27% vs. 11.3%, P<0.05), whilst difference in total mortality did not reach statistical significance (10.8% vs. 3.8%). CONCLUSION: Immune status seems to play a role in patients with congestive heart failure. If this immunological alteration is a determinant or a consequence of heart failure remains unclear.

Efficacy of ranolazine in a patient with idiopathic dilated cardiomyopathy and electrical storm.

A case of idiopathic dilated cardiomyopathy with an arrhythmic storm refractory to the usual antiarrhythmic therapy will be reported. The idiopathic structural heart disease of the patient is a vulnerable anatomic substrate in itself, for electrical instability and reentry mechanism, because of heterogeneous areas of scarred myocardium and low left ventricle ejection fraction. In this case, the ranolazine administration was safe and effective for the prevention of further electrical storms.

The importance of reducing heart rate in cardiovascular diseases: effects of Ivabradine.

Heart rate is a major determinant of cardiac output, myocardial oxygen consumption and coronary blood flow under physiological and pathological conditions. Experimental and clinical data have demonstrated that heart rate reduction is the main mechanism for reducing ischemia, improving left ventricular function, decreasing the risk of plaque rupture and post myocardial infarction mortality. Nowadays betablockers are the best class of drugs that can lower heart rate in patients with cardiovascular diseases, but sometimes their use is limited by some contraindications. Ivabradine is a new drug that reduces the firing rate of pacemaker cells in the sinoatrial node through a different mechanism with respect to betablockers. The purpose of this review is to investigate the main trials that support Ivabradine adoption in clinical practice.

Mitral valve prolapse and conduction disturbances: the forgotten association.

Various cardiac arrhythmias and conduction defects have been described in patients with mitral valve prolapse. We describe a case of a young woman affected by a mitral valve prolapse, involving the posterior mitral leaflet, with mild mitral regurgitation and an episode of syncope due to asystolia. It is hoped that this short communication will once again focus attention on the as yet unexplained association between mitral valve prolapse and various cardiac conduction disorders.

Management of pacing system related complications in patients undergoing dynamic cardiomyoplasty.

Integrity of the electrical circuit is a necessary requirement for appropriate heart/wrapped skeletal muscle interaction to be achieved in cardiomyoplasty. This article describes the management of two different complications after a cardiomyoplasty procedure involving the electrical system (infection of the abdominal cardiomyostimulator pocket and intramuscular lead fracture). Minimal approaches were carried out, which ensured the successful treatment of the infective and of the mechanical insult, and represent useful strategy for solving such uncommon problems.

Antiarrhythmic benefits of dual chamber stimulation with rate-response in patients with paroxysmal atrial fibrillation and chronotropic incompetence: a prospective, multicentre study.

BACKGROUND: While the haemodynamic benefits of DDDR pacing compared with DDD pacing in patients with brady-tachy syndrome and chronotropic incompetence (CI) are well demonstrated, the antiarrhythmic advantage is controversial and so far not clearly demonstrated. AIM: We have performed a prospective, randomized, multicentre study to evaluate the efficacy of DDDR and DDD pacing modes in preventing paroxysmal atrial fibrillation (PAF) episodes in patients with brady-tachy syndrome and CI. METHODS AND RESULTS: Seventy-eight patients were included in the study. All patients had a dual chamber pacemaker implanted and were randomly programmed to DDD or DDDR with a cross over (DDD --> DDDR or vice versa) at 3 months. The final evaluation was performed at 6 months by means of two self-administered symptom questionnaires to evaluate activity. Symptoms of palpitations were analysed and scored. The patients were less symptomatic with the DDDR mode. The number of mode-switch activations compared with symptomatic episodes of PAF confirmed the high rate of asymptomatic PAF episodes in patients with brady-tachy syndrome. We conclude that in a small but well defined population of patients affected by sick sinus syndrome with CI and severely symptomatic PAF, DDDR pacing compared with DDD pacing may offer an additional antiarrhythmic benefit and should be considered the primary mode of pacing.

Cardiomyoplasty and implantable cardioverter defibrillator: efficacy and safety of concomitant device implantation: sudden death and cardiomyoplasty.

Sudden death represents a common event in the natural history of patients affected by chronic heart failure. Such an outcome also has been shown to characterize the follow-up of the cardiomyoplasty procedure. We report two cases of patients who had cardiomyoplasty and experienced witnessed episodes of ventricular arrhythmia at variable times after surgery (2 years and 2 months, respectively). In the first case, an implantable cardioverter defibrillator (ICD) was implanted subsequent to the arrhythmic episode, whereas the second patient had a combined cardiomyoplasty and ICD implantation procedure. In particular, this patient underwent a modified wrapping technique, herein described, because of a large left ventricular dilatation. In both cases, ventricular defibrillation did not affect the correct functioning of the implanted cardiomyostimulator. Our article confirms that ventricular arrhythmia is common in cardiomyoplasty patients. The combined use of a skeletal muscle stimulator and implantable defibrillator may therefore be effective in preventing arrhythmia-related sudden death without any concurrent effect on the correct functioning of the wrapped muscle/heart circuit, with likely benefit on long-term cardiomyoplasty patient survival.

[The electrotherapy of the arrhythmias in 3 cases of myotonic dystrophy (Steinert's disease)]. / Terapia elettrica delle aritmie in tre casi di distrofia miotonica (malattia di Steinert).

Myotonic dystrophy is a progressive multisystem disease with autosomal dominant inheritance. Cardiac involvement is an integral part of the disorder, the most prominent manifestations being various conduction defects and rhythm disturbances sometimes related to syncope or sudden cardiac death. We describe 3 cases admitted to our Centres. Two patients received a permanent pacemaker for atrioventricular block of different degree and in the third case an implantable cardioverter defibrillator with antibradycardia pacing was inserted for malignant ventricular tachyarrhythmias and advanced atrioventricular block during atrial flutter.

[Diagnosis and follow-up of 330 patients admitted for syncope in the Department of Cardiology and Neurology. How important is an interdisciplinary study?]. / Diagnosi e follow-up di 330 pazienti ricoverati per sincope in Cardiologia e Neurologia. Quanto è importante uno studio interdisciplinare?

Many mechanisms of different nature-hemodynamic, metabolic and reflex-may cause syncope. We have studied all patients referred for syncope to the Divisions of Cardiology and Neurology of our Hospital, focusing five end-points: standardize a diagnostic protocol; evaluate the diagnostic value of the different tools in the diagnosis of syncope; evaluate the causes of syncope in our patients; value the importance of systematic cardiological-neurological co-operation in these patients; observe the prognosis of patients with syncopal attacks. We have studied 330 patients referred to our Divisions for syncopal attacks (239 in Cardiology and 91 in Neurology) with a protocol organized in 4 steps of increasing levels of complexity: step 1: history, clinical examination, standard electrocardiogram, carotid sinus massage, chest radiography, neurological and cardiological examination; step 2: two-dimensional Doppler echocardiography, dynamic 24-72 hour ECG, standard electroencephalogram (EEG), head-up tilt-table test; step 3: EEG after sleep deprivation, computed tomography, Doppler evaluation of carotid flows, transesophageal electrophysiologic study (EPS); step 4: Oxford test for 24-hour evaluation of arterial blood pressure, intracavitary EPS. We have found in 165 patients (50%) a cardiac syncope, in 78 (23.6%) a reflex syncope, in 43 patients (13%) a syncope of different origin ("non cardiac-non reflex") and in 44 patients (13.4%) we have not been able to find a cause of patient's syncopal attacks. We have established a diagnosis in 148 patients (51.7% of diagnoses) with step 1 examinations, in 98 cases (34.2%) with step 2, in 33 (11.5%) with step 3 and in 7 (2.5%) with step 4 examinations. One hundred-twenty three patients - or relatives of died patients-(37.3%) have answered our follow-up questionnaire (mean follow-up 54.85 +/- 13.73 months, range 36-78 months). Among them, patients with cardiac syncope have had a mortality rate of 18.57%, those with reflex syncope of 7.69%, those with "non cardiac-non reflex" syncope of 7.14%. No patients with syncope of unknown origin died. Our study demonstrates that in the evaluation of patients with syncope, the simplest diagnostic tools are of great value: in fact we have obtained 86% of the diagnoses with the first 2 steps examinations. Furthermore, our study confirms that cardiac syncope has a higher mortality rate compared to other forms of syncope. Co-operation between our Divisions has not been very useful in increasing the number of diagnosed cases, but it has allowed to correctly and rapidly direct our attention toward one form of syncope so that we have been able to speed up the diagnostic process.

[Evaluation of the efficacy and tolerance of doxazosin vs. enalapril inaged patients with light to moderate arterial hypertension]. / Valutazione dell'efficacia e della tollerabilità del doxazosin vs enalapril in pazienti anziani affetti da ipertensione arteriosa lieve-moderata.

The above study was performed as a single blind trial in 70 elderly patients (average age 66 years) who were randomized into two groups of 36 and 34 subjects respectively. After clinical and laboratory evaluation without treatment for at least two weeks, the two groups were treated with enalapril 5-10 or 20 mg daily plus doxazosin at the dosage of 1-2-4- or 8 mg daily; they were observed for 24 weeks. During the trial, pressure values, both systolic and diastolic, were seen to diminish significantly in both groups. This effect was accompanied by minor, usually transient side effects. At echocardiography at the end of the treatment period, doxazosin was found to reduce some volumetric cardiac parameters, thus showing to be apt to counteract left ventricular hypertrophy. These findings go to counteract left ventricular hypertrophy. These findings go to show that alpha-1 inhibitors are a valid alternative in the "first step" of antihypertensive therapy, especially in patients at risk for cardiovascular complications.

Bacterial infection of cardiomyostimulator abdominal pocket following cardiomyoplasty procedure: an original approach to preserve synchronous muscle stimulation.

Dynamic cardiomyoplasty (DC) represents a new technique in therapy for refractory heart failure. So far, DC has been applied to more than 500 cases worldwide but reports on postoperative complications and related management are still lacking. We present the case of a patient suffering from refractory chronic heart failure for which the DC procedure was applied also accompanied by the complication of an infection process at the cardiomyostimulator pocket that began 2 weeks postoperatively. Following trials with several unsuccessful conservative approaches, an original procedure was developed to temporarily retain the implanted stimulation system, while at the same time maintain the synchronous contractions of the wrapped muscle. Finally, reimplantation of the pacing system was achieved with a low-risk procedure, effective cardiac assistance was preserved, and the infection process was arrested 3 years following DC.

Implantable defibrillation and thromboembolic events.

In ICD patients thromboembolic events (TEEs) are described as possible complications at implant or during the follow-up. We report four cases of TEEs (two peripheral and two cerebral; 6.5% of patients) that occurred in our series during a mean follow-up of 19.4 months. The patients had chronic postinfarction LV aneurysm (3) and idiopathic dilated cardiomyopathy (1). None had previous embolisms nor evidence of left atrial or LV clots at standard preoperative transthoracic echocardiography. No paroxysms of atrial fibrillation were documented prior or after ICD implant. We discuss the possible causes of embolization and the suitability of anticoagulant therapy in ICD patients.

Parapharyngeal space lesions syncope-syndrome. A newly proposed reflexogenic cardiovascular syndrome.

An intense vaso-vagal reaction characterizes those reflex cardiovascular syncopes in which the glossopharyngeal nerve constitutes the main afferent nerve pathway. In these syndromes, afferent fibres of the glossopharyngeal nerve project from the baroreceptorial area to the medullary cardiac and vasomotor centres, from which efferent fibres descend into the vagus. The most common reflex cardiovascular syndromes linked to the IX nerve are carotid sinus syndrome (CSS) and glossopharyngeal neuralgia-asystole syndrome (GNS). Eleven male patients (mean age 65.4 years) with recurrent and severe vaso-vagal attacks are described. The episodes were characterized by asthenia and general malaise, pallor, sudation, unrecordable or very low (40-60 mmHg) arterial blood pressure, mental disorientation and/or syncope. The admission diagnosis in these patients was CSS, but the clinical picture was quite different from classic CSS: triggering factors were not present, vasovagal episodes were longer, syncopes were more frequent and severe and VVI pacing was ineffective. Further investigation, including computerized tomography, showed in all patients a malignant or benign pathological growth occupying and compressing the parapharyngeal space. The authors think that the symptoms exhibited by their patients may be attributed to parapharyngeal space involvement. The pathogenetic mechanism of syncope in these cases could be similar to that occurring in GNS except for the absence of neuralgia itself. Surgical carotid sinus denervation or A-V sequential DDD pacing were ineffective in completely controlling symptoms. Intracranial section of the IX nerve appears to be the most effective mechanism for controlling the syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hypersensitivity and carotid sinus syndrome in patients with chronic atrial fibrillation]. / Ipersensibilità e sindrome del seno carotideo in pazienti con fibrillazione atriale cronica.

BACKGROUND: Carotid sinus hypersensitivity (CSH) has always been described in patients in sinus rhythm; we did not find reports of CSH in patients with chronic atrial fibrillation (AF). After the observation of bilateral CSH in a patient with chronic AF admitted to our Division for syncope, we began to systematically study patients with chronic AF and neurological disturbances to evaluate carotid sinus stimulation effects upon cardiac activity and arterial blood pressure in these subjects. METHODS: We studied 28 subjects with chronic AF (mean age 73.3 yrs.; range 60-89): 16 patients had dizziness, fainting or syncope, and formed the study group (A); 12 asymptomatic patients were considered the control group (B). After a careful clinical and instrumental evaluation, all the patients underwent a 24 hour ambulatory (Holter) ECG analysis and right and left carotid sinus massage (CSM). If the latter manoeuvre induced asystolia longer than 3 seconds, CSM was repeated during ventricular pacing to evaluate the vasal component of the carotid sinus reflex. RESULTS: In group A, 24-hour Holter monitoring showed a greater incidence (81.2%) of ventricular standstill (mean duration 2.67 seconds) in comparison to the control group. In group A we found CSH in 75% of the cases, more frequently right CSH (7 subjects with right, 1 with left and 4 with bilateral CSH) with prolonged ventricular asystolia (mean duration 5.3 +/- 1.9 sec. with right CSM; 7.8 +/- 1.4 sec. with left CSM); during CSM, we reproduced spontaneous symptomatology in 9 patients. In 12 patients in group A, diagnosis of carotid sinus syndrome was established; the cardioinhibitory forms were clearly prevalent (91.7%); only one patient presented a cardioinhibitory-vasodepressor form with a predominant vasodepressor component. CONCLUSIONS: The authors believe that CSH is frequent in patients with chronic AF; the vagal hyperactivity due to CSH can induce prolonged ventricular asystole that may be responsible for neurological disturbances such as dizziness, fainting or syncope, as observed in patients in sinus rhythm with carotid sinus syndrome. Abnormal sensitivity of the carotid sinus could thus be one of the causes of increased morbidity and mortality in patients with chronic AF. The majority of these patients may be expected to benefit from permanent pacemaker therapy.

[Anomalous origin of the left coronary artery from the pulmonary artery. A rare case diagnosed in adulthood]. / Origine anomala della coronaria sinistra dall'arteria polmonare. Un raro caso diagnosticato in età adulta.

Anomalous origin of the left coronary artery from the pulmonary artery (Bland-White-Garland syndrome) is a rare but often lethal congenital lesion. Clinical manifestations of this syndrome present, in the large majority of cases, in infancy. The authors describe a case of Bland-White-Garland syndrome diagnosed in adult age.

[Hemodynamic and neuroendocrine profile of 2 different cardiovascular responses in vasodepressor syncope induced by the head-up tilt test]. / Profilo emodinamico e neuroendocrino di due distinte risposte cardiovascolari nella sincope vasodepressiva indotta da head-up tilt test.

BACKGROUND: Syncope in apparently healthy subjects is usually attributed to a vasovagal reaction. However, a vagal cardio-inhibitory component is not always associated with a vasodepressor component in causing syncope: in fact, increases in heart rate, arterial pressure and plasmatic levels of catecholamines frequently precede loss of consciousness. METHODS: Prolonged 60 degrees head-up tilt table test (HUTT) was performed in 50 healthy subjects (27 male, 23 female - mean age 37.2 years) with recurrent syncope of vasodepressor or unknown origin. The upright-tilt test lasted 45 minutes: every minute of HUTT we measured heart rate (HR) and systolic (SBP) and diastolic blood pressure (DBP); at set intervals we took a blood sample to determine epinephrine (EP) and norepinephrine (NEP) levels. RESULTS: In patients with positive HUTT (42%) we observed a vaso-vagal response (10 patients) characterized by a sharp drop in SBP and DBP (> 50% of the basal values) and bradycardia (< 40 bpm) and/or sinus node arrests, and a hyperchronotropic-vasodepressor response (11 patients) characterized by a considerable increase in HR (> 60%) and simultaneous drop in SBP and DBP (> 30% of the basal values), and a large increase in plasmal EP (+881.9%). CONCLUSIONS: According to the Authors, vasovagal response is mainly due to a reflex reaction originating from the cardiac stretch-receptors, whereas hyperchronotropic-vasodepressor response is mainly due to psychic stress and anxiety provoked by prolonged and forced posture during HUTT. The high levels of adrenergic activity and plasmal EP cause the excessive chronotropic response and the vasal effects of the syndrome. Due to the induction of a state of anxiety and its postural effects, HUTT is a useful provocative tool for complete evaluation of young patients with syncope of vasodepressor origin. We treated the patients differently, depending on how they responded to HUTT. Those with a vaso-vagal response were treated with alpha-sympathomimetic agents (ethylephrine or mydodrine) and those with a hyperchronotropic-vasodepressor response received non-selective beta-blockers. None of our patients had syncope recurrences during a mean follow-up of 12.3 months. Only two patients complained of dizziness; in one of them, symptomatology was abolished by an alpha-sympathomimetic beta-blocker association.