On site cardiac surgery for structural heart interventions: a fence to mend?

Current evidence supports device-based transcatheter interventions for the management of patients with structural heart disease, proving well their safety and efficacy; transcatheter aortic valve implantation (TAVI), transcatheter edge-to-edge repair (TEER) of mitral or tricuspid valves, and left atrial appendage occlusion (LAAO) are expanding their role in contemporary practice. Currently, guidelines recommend performing TAVI in 'Heart Valve Center' with interventional cardiology and institutional on-site cardiac surgery (iOSCS), while no site limitation has been defined for TEER and LAAO. The growing number of candidates for transcatheter interventions generates long waiting times with negative consequences on mortality, morbidity, hospitalization, and functional deterioration. Therefore, a debate on the feasibility of TAVI in centres without iOSCS has been set up. Data from randomized controlled trials and registries failed to document any difference in outcomes and in conversion rate to emergent surgical bailout in centres with or without iOSCS; on the other hand, a direct relationship with TAVI complications has been clearly documented for learning curve and centre volume. Therefore, the role of iOSCS for TAVI, as well as for other transcatheter interventions, should be carefully explored.

In-vitro investigation of cardiac implantable electronic device malfunction during and after direct photon exposure: A three-centres experience.

PURPOSE: Radiotherapy may cause malfunction of implantable cardioverter-defibrillators (ICDs) and pacemakers (PMs). We carried-out a multicentre randomized in-vitro study on 65 ICDs and 145 PMs to evaluate malfunctions during and after direct irradiation to doses up to 10 Gy. METHODS: Three centres equipped with different linear accelerator and treatment-planning systems participated in the study. Computed Tomography (CT) acquisitions were performed to build the treatment plans. All devices were exposed to dose of 2, 5, or 10 Gy (6 MV). All devices underwent a baseline examination and 64 wireless real-time telemetry-transmissions (47 ICDs and 17 PMs) were monitored during photon exposures. All devices were interrogated after exposure and once monthly for six subsequent months. RESULTS: Fifty-four of the 64 wireless-enabled CIEDs (84.4%) recorded noise-related interferences during exposure. In detail, 40/47 ICDs (85.1%) reported interference, of which 16 ICDs (34%) reported potentially clinically relevant pacing inhibition and inappropriate detections. Following exposure, a soft reset occurred in 1/145 PM (0.7%) while 7/145 PMs (4.8%) reported battery issues. During the six-month follow-up, 1/145 PM (0.7%) reported a soft reset, while 12/145 more PMs (8.3%) and 1/64 ICD (1.5%) showed abnormal battery depletion. All reported issues occurred independently of exposure dose. Finally, irreversible effects on software and battery life occurred in only non-MRI-compatible devices. CONCLUSION: ICDs mostly featured real-time transient sensing issues, while PMs mostly experienced long-term battery or software issues that were observed immediately following radiation exposure and during follow-up. Irreversible effects on battery life and software occurred in only non-MRI-compatible devices.

Is Occult Genetic Substrate the Missing Link Between Arrhythmic Mitral Annular Disjunction Syndrome and Sudden Cardiac Death?

We present the case of a 28-year-old man with a history of unexplained syncope, frequent ventricular arrhythmias, familial LMNA-related dilated cardiomyopathy (DCM), and mitral annular disjunction (MAD). We provide the first association of a novel truncating LMNA variant serving as a potential vulnerable substrate for arrhythmogenic MAD syndrome. This could suggest a possible synergistic role between concealed genetic variants (resulting in fibrosis as a "substrate" for arrhythmogenesis) and the presence of mitral annular disjunction (the "trigger" with mechanical stretch initiating ventricular arrhythmias), which may provide a link between mitral valve prolapse and sudden cardiac death.

Selection of the Optimal Candidate to MitraClip for Secondary Mitral Regurgitation: Beyond Mitral Valve Morphology.

Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.

A randomized in vitro evaluation of transient and permanent cardiac implantable electronic device malfunctions following direct exposure up to 10 Gy.

BACKGROUND AND PURPOSE: High-dose 6­MV radiotherapy may cause cardiac implantable electronic devices (CIEDs) to malfunction. To assess CIED malfunctions resulting from direct exposure up to 10 Gy, 100 pacemakers (PMs) and 40 implantable cardioverter-defibrillators (ICDs) were evaluated. MATERIALS AND METHODS: CIEDs underwent baseline interrogation. In ICDs, antitachycardia therapies were disabled via the programmer while the detection windows were left enabled. A computed tomography (CT) scan was performed to build the corresponding treatment plan. CIEDs were "blinded" and randomized to receive single doses of either 2, 5, or, 10 Gy via a 6-MV linear accelerator (linac) in a water phantom. Twenty-two wireless telemetry-enabled CIEDs underwent a real-time session, and their function was recorded by the video camera in the bunker. The CIEDs were interrogated after exposure and once monthly for 6 months. RESULTS: During exposure, regardless of dose, 90.9% of the CIEDs recorded electromagnetic interference, with 6 ICDs (27.3%) reporting pacing inhibition and inappropriate arrhythmia detections. After exposure, a backup reset was observed in 1 PM (0.7% overall, 1% among PMs), while 7 PMs (5% overall, 7% among PMs) reported battery issues (overall immediate malfunction rate was 5.7%). During follow-up, 4 PMs (2.9% overall; 4% among PMs) and 1 ICD (0.7% overall; 2.5% among ICDs) reported abnormal battery depletion, and 1 PM (0.7% overall; 1% among PMs) reported a backup reset (overall late malfunction rate was 4.3%). CONCLUSION: Apart from transient electromagnetic interference, last-generation CIEDs withstood direct 6­MV exposure up to 10 Gy. Permanent battery or software errors occurred immediately or later only in less recent CIEDs.

The 'dreaded PFO': anatomical and functional features of high risk for stroke.

Patent foramen ovale (PFO) has a high prevalence in general population and can be implicated in cryptogenic stroke among young people. Recent trials have shown that transcatheter PFO closure is superior to medical treatment in the secondary prevention of ischaemic stroke. The benefit in the reduction of stroke recurrence is particularly evident in patients who have documentation of a PFO with high-risk characteristics. Therefore, after the assessment of a clear causal relationship with the event, a thoughtful documentation of anatomic (height, length, presence of an aneurysmatic or a floppy atrial septum, a prominent Eustachian valve or Chiari's network, an acute angle with the inferior vena cava) and functional high-risk characteristics is mandatory.

Cardiac resynchronization therapy with multipoint pacing via quadripolar lead versus traditional biventricular pacing: A systematic review and meta-analysis of clinical studies on hemodynamic, clinical, and prognostic parameters.

BACKGROUND: Cardiac resynchronization therapy (CRT) is one of the cornerstones of heart failure (HF) therapy, as it has reduced mortality and morbidity and has shown improvement in functional capacity. Multipoint pacing (MPP) is a way of configuring CRT with the aim to improve the percentage of patients who respond to CRT. OBJECTIVE: To demonstrate the effectiveness of the MPP compared to traditional biventricular pacing (BiV). METHODS: We performed a systematic review and meta-analysis according to PRISMA guidelines of studies in which MPP vs BiV strategy were compared. RESULTS: MPP use is associated with a higher rate of patients experiencing functional improvement (odds ratio: 2.51, 95% confidence interval [CI], 1.56-4.06; P = .0002) and with higher delta LV dP/dtmax (mean difference, 1.82; 95% CI, 0.24-3.39; P = .0240) with respect to BiV. MPP and BiV have no significantly different effect on left ventricular end-systolic volume (LVESV) (mean difference, 0.39; 95% CI, -11.12 to 11.89; P = .9475); moreover, there is no significant difference between the 2 treatments regarding hospitalization for HF (odds ratio, 0.70; 95% CI, 0.32 to 1.54; P = .3816) and all-cause death (odds ratio, 0.81; 95% CI, 0.40 to 1.62; P = .5460). MPP is associated with a significantly lower projected battery longevity (mean difference -8.66 months; 95% CI, -13.67 to -3.66; P = .00007) with respect to BiV. CONCLUSION: MPP significantly improves functional class and acute hemodynamic parameters with respect to BiV. Prognostic indices and LVESV are not significantly influenced by MPP. MPP is associated with a significant reduction in projected battery longevity.

Successful treatment with rivaroxaban of an extended deep vein thrombosis complicated by pulmonary embolism in a patient with familial antithrombin III deficiency: a case report.

BACKGROUND: Patients with low levels of antithrombin III (AT III) are at an increased risk of developing arteriovenous thromboembolic disease. CASE SUMMARY: We report a case of a 28-year-old woman who presented with a 1-week history of spontaneous right calf pain and swelling. A heterozygous AT III deficiency, phenotypically expressed as deep vein thrombosis, was reported in the patient's mother and sister. Blood workup revealed residual AT III activity at 58% with normal protein C and protein S levels. Computed tomographic angiography (CTA) revealed subsegmental bilateral pulmonary embolism (PE) and deep vein thrombosis in the right leg extending into the inferior vena cava up to the confluence of the left renal vein. Placement of an inferior vena cava filter was not considered. Given the patient's haemodynamic stability, anticoagulant therapy with 15 mg of rivaroxaban twice a day was initiated instead. Echocardiography after 10 days of treatment revealed complete resolution of the thrombus located in the inferior vena cava, while CTA revealed complete resolution of the PE. DISCUSSION: Patients with AT III deficiency are likely to be heparin-resistant and will require higher heparin doses or the administration of AT III replacement therapy for the treatment of thrombosis, both of which are associated with an increased risk for haemorrhagic complications. Direct factor Xa inhibition by rivaroxaban provided an alternative mechanism for anticoagulation, which was found to be particularly useful in this patient with familial AT III deficiency, deep vein thrombosis, and PE.

Is shock impedance value alone to be considered a good predictor for shock efficacy in subcutaneous implantable cardioverter defibrillator?

Subcutaneous implantable cardioverter defibrillator (S-ICD) is easy to implant, with poor risks of the patient. However, fat is a poor current conductor and increases defibrillation threshold. As shock impedance alone should not be considered a good efficacy predictor of an S-ICD system, an X-ray latero-lateral view for lead position should be achieved.

[Nitrates in cardiology: current role and areas of uncertainty]. / I nitroderivati in cardiologia: attualità e incertezze.

Nitrates have been commonly used in the therapy of cardiovascular disease for more than 150 years. In spite of this longevity and the popularity of their use, it appears somewhat paradoxical that their use is not consistent among cardiologists, both as to their indications and as to their mode of administration. In part this results from their contradictory pharmacodynamics: when given acutely, their effectiveness is indisputable; however, their long-term efficacy is substantially limited by the development of tolerance and the induction of endothelial dysfunction, which may have negative prognostic implications. This review, reporting the most recent biochemical and pathophysiological acquisitions, re-examines the role of nitrates in cardiovascular medicine, reporting, comparing and commenting international guidelines.