[Role of antiarrhythmic therapy for atrial fibrillation]. / Il ruolo dei farmaci antiaritmici nella fibrillazione atriale.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and is associated with a significantly increased risk of thromboembolic events and mortality. From the age of 50 years, prevalence of AF doubles every 10 years, being more common in males and reaching 5.9% in patients 65 years and older. The treatment of AF has as first objective the restoration and maintenance of sinus rhythm. The drugs used to date present several limitations in terms of side and pro-arrhythmic effects, associated with a limited antiarrhythmic effect. Recent European guidelines for the management of AF have pointed out that the pharmacological antiarrhythmic therapy to maintain sinus rhythm is helpful for symptoms related to the arrhythmia. Amiodarone is the drug with the greatest potential for maintenance of sinus rhythm in the older population as well. Other drugs currently in use are flecainide, propafenone, sotalol, and more recently introduced dronedarone and vernakalant. To date, there is no consensus among scientific societies on the management of AF: for elderly patients, who account for the majority of patients with AF, a strictly individualized evaluation is mandatory.

Hybrid Therapy for Atrial Fibrillation: where the Knife meets the Catheter.

During the past decades there has been a consistent evolution of both surgical and catheter-based techniques for the treatment of stand-alone atrial fibrillation, as alternatives or in combination with anti-arrhythmic drugs. Transcatheter ablation has significantly improved outcomes, despite often requiring multiple procedures and with limited success rates especially in presence of persistent atrial fibrillation. Surgical procedures have dramatically evolved from the original cut-and-sew Maze operation, allowing nowadays for closed-chest epicardial ablations on the beating heart. Recently, the concept of a close collaboration between the cardiac surgeon and the electrophysiologist has emerged as an intriguing option in order to overcome the drawbacks and suboptimal results of both techniques; therefore, the hybrid approach has been proposed as a potentially more successful strategy, allowing for a patient-tailored therapeutical approach. We reviewed the recent advancements either from the transcatheter and surgical standpoint, with a peculiar focus on the current option to merge both techniques along with an up-to-date review of the preliminary clinical experiences with the hybrid, surgical-transcatheter treatment of stand-alone atrial fibrillation.

Jugular pacing lead extraction with laser sheath: a case report.

Over the past 20 years, the number of patients with pacemakers (PM) or implantable cardioverter defibrillators has risen markedly; consequently, an increasing number of lead-removal procedures have become necessary. A 64-year-old woman presenting with an infected device pocket and positive bacterial cultures (Staphylococcus aureus) was admitted to our department for lead removal; in 1991, she underwent VVI PM implantation for atrioventricular II degree Mobitz 1 block, and a unipolar lead was introduced via the left jugular vein. The procedure was performed in our Electrophysiology Lab with a cardiac surgeon on standby, using an excimer laser system emitting the energy at the tip of a flexible, fibre-optic 12 F sheath, developed by Spectranetics, Inc., Colorado Springs, CO, USA.

[Infective complications in patients with implantable cardiac devices: catheter extraction]. / Complicanze infettive nel paziente portatore di dispositivi: l'estrazione di elettrocateteri.

Complications related to device implantation, such as infections and malfunction, play a major role when considering the increasing rate of implant procedures. It is widely accepted in the scientific literature that the most effective way to eradicate device-related infections or complications resulting from malfunctioning involves the complete removal of the pacing system. The techniques of transvenous lead extraction include manual traction, mechanical dilation, powered sheaths (excimer laser system) using the femoral, jugular/subclavian or hybrid approach. The possibility of using different approaches, even in combination, has broadened the therapeutic armamentarium, allowing to revise the indications for removal of the system. Further clinical studies relating, specifically, to the different extraction techniques may contribute to develop common protocols by also evaluating the cost-effectiveness of the methods available.