Tako-Tsubo cardiomyopathy with coronary artery stenosis: a case-series challenging the original definition.

We report a case-series of seven patients with Tako-Tsubo cardiomyopathy (TTC) and at least one concomitant >or=50% coronary stenosis. Each case involves a female patient who presented symptoms and an electrocardiogram compatible with acute coronary syndrome, mild troponin I elevation, a ventriculogram showing left ventricle (LV) apical or midventricular ballooning (classical or variant TTC), an angiogram showing at least one >or=50% stenosis and a cardiac magnetic resonance showing no myocardial late Gadolinium enhancement. Full recovery of normal LV contractility after the event was required to confirm TTC. Our report presents the case for the opportunity to modify the TTC definition, removing the requirement for absence of coronary stenosis not to exclude patients with bystander coronary lesions, who are probably under diagnosed as per the original TTC definition.

MRI evaluation of myocardial viability.

Cardiac magnetic resonance imaging (MRI) has become an accurate noninvasive imaging procedure for the study of postischaemic residual cardiac function, thanks to the evolution of MRI machines, postprocessing software and, above all, sequences. After infarction, and in chronic myocardial ischaemia, the degree of contractile dysfunction is one of the main determinants of longterm survival. The identification and quantification of viable dysfunctional myocardium and the possibility of improving its contractility after revascularisation improves patient prognosis and quality of life. In current clinical practice, myocardial viability is evaluated with stress echocardiography and nuclear methods. Thanks to its intrinsic characteristics and to the delayed-enhancement technique (DE-MRI), MRI has recently emerged as the only noninvasive modality able to provide a three-dimensional (3D) evaluation of cardiac viability with a multiparametric approach.

Acute changes in circulating hormones in older patients with impaired ventricular function undergoing on-pump coronary artery bypass grafting.

OBJECTIVES: Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) causes an acute stress response characterized by changes in the levels of several hormones, which might play a role in the high complication rate experienced by older patients after CABG. Thus, the aim of the study was to investigate changes in the circulating levels of anabolic and catabolic hormones in old people undergoing CABG with CPB. DESIGN: Intervention case study. METHODS: 19 patients (12 males, 7 females) aged 70.1 +/- 6.1 yr (age range 62-80) with coronary artery disease and an ejection fraction <40% who underwent cardiac surgery. Cortisol (Cort), DHEA, DHEAS, LH, estradiol (E2), total testosterone (Te), SHBG, IGF-I were measured the day before, on the day of the procedure and 1, 2, 3, 4, and 30 days after CABG. RESULTS: After surgery, serum IGF-I levels decreased (p<0.001), while levels of Cort, DHEAS and E2 significantly increased in both men and women. Alterations in Te levels differed between the two sexes with a significant decline in men and a significant increment in women. CONCLUSION: CABG with CPB resulted in a dramatic drop in Te levels in old men and a significant decline in IGF-I in both sexes. Serum Cort levels also significantly increased in both sexes. These hormonal changes may, at least partially, explain why the elderly need prolonged rehabilitation after CABG.

Neurologic symptoms after great saphenous vein harvesting for coronary artery bypass grafting.

AIM: Incidence evaluation of cutaneous neurologic symptoms in the lower limbs as a new event after great saphenous vein (GSV) harvesting for coronary artery bypass grafting (CABG). Each day we harvest the GSV for CABG. Some authors have reported the onset of saphenous neuralgia complex as a new event of which we would evaluate the incidence. METHODS: From January 2000, until June 2001, 2,091 patients underwent cardiac surgery; 1,326 underwent CABG, 1,227 of them using the GSV as a conduit for almost one graft. These patients were prospectively reviewed; all were preoperatively examined to determine the presence of normal sensation in the lower limbs and elude the presence of saphenous neuralgia. Then, we evaluated sensations in the lower limbs at 5 days, 8 weeks, and 5 months after operation to determine the new onset of saphenous neuralgia. The areas of sensory loss were recorded each time and reported in a diagram to obtain 3 areas. RESULTS: Hyperaesthesia and pain were noted in a few patients, especially at 5 days and 8 weeks control, but at 5 months none of them complained of real pain. CONCLUSION: This study demonstrates that saphenous neuralgia after harvesting the GSV for CABG is a rare consequence. The main symptom is anaesthesia but its duration is generally no longer than 2 months. Hyperaesthesia and pain, for the early onset and the early disappearance, are considered as a normal consequence of surgical procedure.

Thoracic aortic stents: a combined solution for complex cases.

OBJECTIVES: The combination of endovascular and standard surgical techniques may facilitate the management of complex aortic disease although the long-term durability of this approach needs to be confirmed. DESIGN: A retrospective review of our experience in the treatment of patients with complex aortic pathology using a combined endovascular and surgical approach. MATERIALS AND METHODS: Between 1998 and 2001, 27 patients with thoracic aortic aneurysm underwent stent-graft implantation. Eight required combined endovascular and surgical procedure because of complex pathology. In 3 cases, combined repair was carried out for a concomitant abdominal aortic aneurysm or aorto-iliac-femoral occlusive disease. In the other 5 cases, vessel relocation was performed to obtain safe landing zones: left subclavian artery to left carotid artery translocation in 3 patients, celiac trunk to superior mesenteric artery translocation in one and aorto-celiac-mesenteric bypass grafting in one. RESULTS: One of the 8 patients died on 12th post-operative day of intestinal bleeding and bowel infarction. No neurological sequelae were reported. The other patients are currently well at 11 months mean follow-up time. CONCLUSIONS: Simultaneous surgical and endovascular procedure is a feasible and may be a valuable adjunct to the treatment of complex aortic and peripheral vessel anatomy.

[Anterior jugular-internal jugular bypass to salvage a dialysis arteriovenous fistula]. / Pontage jugulaire antérieure - jugulaire interne pour sauvetage de fistule artério-veineuse.

Thrombosis of the anonymous vein can compromise the arteriovenous fistula in chronic renal patients on hemodialysis. Clinical manifestations include edema of the arm, stasis acrocyanosis, tugor of the neck and shoulder veins, and severe headache. The fistula may have to be closed to achieve symptom relief, requiring a catheter for dialysis until an new arteriovenous fistula becomes functional. In case of stenosis or occlusion of the brachiocephalic venous axis, the goal is to preserve a functional fistula yet resolve symptoms. Self-expanding stents have been used but results have been less than satisfactory or short-lived. Different surgical bypass techniques have been proposed. We report an anterior jugular-internal jugular bypass used to salvage a dialysis arteriovenous fistula.

New perspectives for the treatment of thoracic aortic aneurysm with self-expanding endoprostheses. Preliminary experience.

We present our preliminary experience with the application of covered aortic stents to treat aneurysms and dissections of the thoracic artery, a technique that was developed in 1996. Seven selected patients were treated with World Medical Talent bare spring tip endoprostheses and followed up for a total of 67 months. All prostheses were implanted at the Parma General Hospital Cardiovascular Department. Seven patients, average age 57.8 years, range 44-73 years, were treated; a total of 11 prosthetic segments were implanted. Aortic pathologies included: 2 isthmic atherosclerotic aneurysms, 2 chronic dissections, 1 acute dissection, 1 thoracic aneurysm associated with an aneurysm of the abdominal aorta below the renal arteries. Dilation diameters ranged from 6-9 cm, lengths from 4-12 cm. All patients underwent computerized tomography and angiography before stent implantation. The procedure was carried out in an operating room with the patient under general anesthesia and in controlled hypotension. In 2 cases the common iliac artery, prepared for the extraperitoneal route by application of a No. 10 Dacron introducer sheath, was used as the insertion site; in 4 cases the common femoral artery was used, in the case of the double aneurysm the traditional surgical route was used to correct the abdominal aneurysm, and the thoracic aneurysm was repaired through the abdominal prosthesis. All patients were released in good condition; thrombosis of the aneurysm surrounding the graft was immediate in all cases except one which required the application of a second segment shortly after the initial procedure. There were no major complications; one case of iatrogenic dissection of the femoral artery used as the access site required a prosthetic bypass. No implant-related complications were observed during follow-up. Our initial experience has been favorable and demonstrates that stents can be utilized for aortic pathologies of varying etiologies; we had no mortality or major complications, and hospital stays were short. Long term results must be confirmed before the therapeutic potential of this technique can be fully evaluated.

Clinical evaluation of St Jude Medical Hemodynamic Plus versus standard aortic valve prostheses: The Italian multicenter, prospective, randomized study.

OBJECTIVE: Hemodynamic and clinical performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus aortic valves (St Jude Medical, Inc, St Paul, Minn) were compared with those of 21-mm and 23-mm St Jude Medical standard cuff aortic valves in the first such multicenter, prospective, randomized study. Hemodynamic Plus valves are mechanical, bileaflet prostheses suitable for the small aortic anulus. METHODS: Patients with 21-mm and 23-mm anulus diameters were randomized to receive either a Hemodynamic Plus or a standard cuff valve. Postoperatively and at 6 months after the operation, patients underwent 2-dimensional Doppler echocardiography. Ejection fraction, cardiac output, peak gradient, mean gradient, effective orifice area, effective area index, and performance index were calculated. Postoperative and 6-month echocardiographic measurements and their variations across observation times were analyzed statistically. RESULTS: Of the 140 patients enrolled, 5 died at operation and 1 died of aortic dissection during the follow-up period. Eight patients were lost to follow-up. A total of 125 patients completed the study. In 1 patient a sewing cuff escaped intraoperatively. At 6 months the 21-mm and 23-mm Hemodynamic Plus valves showed significantly lower peak gradients and mean gradients than those of the 21-mm and 23-mm standard cuff valves. The 21-mm Hemodynamic Plus valves had gradients similar to those of the 23-mm Hemodynamic Plus valves. The effective orifice area did not differ significantly between the Hemodynamic Plus and standard cuff valves at either measurement. No valve mismatch was found in the 4 groups of patients. A more enhanced decrease of peak gradients and mean gradients and a more enhanced increase of effective orifice areas, effective area indices, and performance indices were found across observation times for patients with Hemodynamic Plus valves compared with those with standard cuff valves. CONCLUSIONS: Clinical hemodynamic performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus valves correspond closely with those of standard cuff valves, and gradients are substantially better than those of standard cuff valves of the same diameter. Therefore, use of this valve may minimize the need for aortic anulus enlargement. Early follow-up results with the Hemodynamic Plus valves were excellent, although more time is required to confirm this outcome.

Surgical repair of thoracic aortic aneurysms: results and complications.

Between January 1990 and February 2001 a total of 323 patients underwent following operations at our Institution: respectively 256 on the ascending aorta, 13 on the transverse arch and 54 on thoracic descending aorta. Sixteen patients with thoracic aortic aneurysms underwent endovascular stent graft implantation. The overall in-hospital mortality was respectively: 7% for ascending aortic aneurysms, 7.7% in the aortic arch aneurysms group and 5.5% for descending aortic aneurysms. The mortality was greater in case of emergency surgery and in the subgroup of patients with acute type A dissection. Stroke with permanent dysfunction occurred in 1.5% of ascending aneurysms, 7.7% of arch aneurysms and in 3.7% of thoracic descending aneurysms. In the latter group, all the major neurological events were related to conventional surgical procedures only: really no mortality or neurological morbidity occurred with endovascular stent graft implantation. Even if modern physiologic monitoring devices and new surgical techniques have been developed in the last years, the treatment of thoracic aortic aneurysms remains challenging. Endoluminal placement of stent grafts has developed as an alternative procedure for the treatment of thoracic aortic aneurysms, even if longer term follow-up is still necessary to fully define the efficacy of this approach.

Three cases of cardiac hydatidosis: diagnosis, surgical treatment, and complications.

Three cases of cardiac hydatid disease from among the many cases of hydatidosis (>300) in various organs observed by the authors are reported. The sites of the cysts and the complications that arose are described. The first case developed hydatid pulmonary embolism caused by rupture into the right ventricular cavity, the second suffered peripheral hydatid embolism caused by rupture into the left ventricular cavity, and the third, whose diagnosis was fortuitous, had no complications. The first patient died shortly after admission. The other two underwent radical pericystectomy and partial pericystectomy with cardiopulmonary bypass. The best result was obtained in the third case where rupture had not occurred. The second patient recovered but developed hemiparesis. The various diagnostic tools available are discussed, as well as some technical aspects of pericystectomy, which has a high mortality rate. The importance of early diagnosis and treatment of this rare localization of Echinococcus granulosus is emphasized, and echocardiography is recommended even for nonspecific cardiac symptoms in areas where the parasite is endemic.

Radial artery in re-do coronary artery bypass grafting: our experience.

We evaluated our experience with the use of the radial artery as a key conduit in re-do coronary artery bypass surgery to determine the safety and efficacy and to compare this procedure to re-operations performed without the radial artery. Sixty-eight patients operated on re-do revascularization were studied: mean age was 67 years; 42 patients were in CCS III (62%) and 18 in CCS IV (26%); past myocardial infarction occurred in 12 patients (18%). We performed 116 anastomoses in all 68 patients (mean no. anastomoses/patient 1.7). Perioperative mortality was 4.4%. Three patients (4.4%) showed a transient postoperative low cardiac output syndrome; four (5.8%) had a respiratory failure and an acute renal failure occurred in 2 patients (2.9%). Four patients (5.8%) required re-operation for bleeding. The comparison of the radial re-do group (27 patients) with the non-radial re-do group (41 patients) showed a lower mortality and morbidity in the former, even if p value was not significant. We conclude that the use of the radial artery in re-do coronary operations is safe, effective, allowing an additional conduit choice and may avoid late vein graft failure.

Pericardial drainage for pericardial tamponade: surgical management criteria.

Aim of this study is the review of our experience in 82 patients treated by pericardial drainage for cardiac tamponade, to assess the efficacy and safety of different techniques and the related indications. The causes of pericardial effusion were: malignancy in 8 patients (9.7%), post-cardiac surgery in 12 (14.6%), while the others patients were admitted at our Institution with no identified preoperative diagnosis. Thirty-eight patients (46%) underwent subxiphoid pericardial drainage and 44 (54%) were operated on by catheter pericardiocentesis. There were no perioperative deaths. Two patients, who initially underwent pericardiocentesis, needed urgent sternotomy: the first patient developed a severe hypotension and bradicardia related to a vagal reaction and the other one because of accidental right ventricle puncture. Our experience indicates that subxiphoid pericardiocentesis provides expeditious, effective and durable treatment, with low morbidity, in case of pericardial effusions related to all causes. We believe that echocardiography is a powerful tool in the diagnosis and management of pericardial effusion. We conclude that pericardiocentesis seems to be the procedure of choice for patients with pericardial tamponade requiring an emergency treatment.

Ischaemic mitral valve regurgitation: a surgical approach.

UNLABELLED: The aim of this study IS to determine surgical results after surgical mitral valve repair in ischaemic mitral regurgitation. MATERIALS AND METHODS: Between January 1999 and June 2000, 64 patients (5.1% of overall patients) underwent myocardial revascularization and mitral valve surgery. A Cosgrove-Edwards mitral annuloplasty ring was used in 59 cases (92.2%). Average patient age was 64.3 +/- 12.4 years (38 males, 21 females). Average degree of mitral regurgitation was 2.8 +/- 0.6. Average NYHA class was 3.5 +/- 0.5. Average ejection fraction (EF) was 40 +/- 12.5 percent. RESULTS: Post-operative 30-day mortality was 3.4% (2 patients). The follow-up was complete for 95 percent (mean 20.4 +/- 4.8 months for patients) and data showed an improvement of NYHA class (mean value 1.8 +/- 0.2) (p = 0.01) and ejection fraction (mean value 51.7 +/- 10.2) (p = 0.05) with residual mitral regurgitation value of 0.6 +/- 0.7. CONCLUSIONS: Mitral valve repair in coronary artery disease improves left ventricular function, quality of life and survival rate with low operative risk. Perioperative transesophageal echocardiography has a central role in surgical decision making.

Outbreak of acute renal failure due to cefodizime-vancomycin association in a heart surgery unit.

OBJECTIVE: To describe an outbreak of acute renal failure (ARF) occurring in a group of patients undergoing open-heart surgery, simultaneously to a change in perioperative antibiotic prophylaxis. DESIGN: Case series. SETTING: A nine-bed heart surgery intensive care unit, serving a 1,300-bed University teaching hospital. PATIENTS: Thirty-two patients undergoing open-heart surgery during an 11-day period, when the preoperative surgical prophylaxis protocol had been changed from the usual antibiotic association of ceftriaxone + vancomycin to cefodizime + vancomycin. RESULTS: ARF occurred in 16 of the 32 (50%) patients exposed to the new antibiotic prophylaxis regimen; seven patients had oliguric ARF, and nine patients had an increase in serum creatinine (SCr) levels >50% over 24-48 h. In the seven patients with oliguric ARF, SCr increased from a median preoperative level of 88 micromol/l (80-115 micromol/l) to a peak value of 725 micromol/l (521-857 micromol/l) in 5 days (4-6). Eight patients out of the sixteen with ARF (50%) were diabetics, as opposed to none of the 16 patients not experiencing ARF. Renal biopsy (three patients) showed tubular dilation and necrosis, interstitial edema, and lymphomononuclear infiltrate of moderate degree. Only one patient required hemodialysis, and all recovered renal function. No other cases of unexplained ARF occurred in the unit after the original prophylaxis protocol was resumed. CONCLUSION: The simultaneous infusion of cefodizime and vancomycin may involve a high risk of substantial renal function derangement, especially in diabetics.

The radial artery: which place in coronary operation?

Previous long-term studies have shown unsatisfactory patency of saphenous vein grafts, compared with internal mammary artery grafts. Recently, the use of the radial artery as a coronary artery bypass graft has enjoyed a revival, on the basis of the belief that it will help improving long-term results of coronary operations. The recent report of encouraging 5-year patency rates, supports its continued use as a bypass graft. In this paper, we review the current knowledge about the radial artery as a bypass graft, with special emphasis on the clinical results.

[Total arterial myocardial revascularization: surgical technique and mid-term results]. / La rivascolarizzazione miocardica arteriosa totale: tecnica chirurgica e risultati a medio termine.

The purpose of this study is to evaluate perioperative and mid-term results of total arterial coronary revascularization in our experience and to establish its safety. One-hundred and ninety-one patients underwent total arterial coronary revascularization at our Institution from February 1997 to August 2000. The mean age was 60.1 years. Of the patients, 45% had three coronary vessels disease, 12% a left main coronary artery disease and 2.6% of them were classified urgent. Mean ejection fraction was 59.6%. Three hundred and thirty-four comprehensive anastomoses were performed; mean grafts per patient was 1.8. A Y or T graft with the left internal thoracic artery was used in 21 patients. The in-hospital mortality rate was 1% (2 patients). Complications included low cardiac output syndrome in 2.8% of patients, acute myocardial infarction in 0.9% and acute renal insufficiency in 3.1%. Intraaortic balloon pump was used in 1.8% of patients. At a mean follow-up of 899 days the first 81 patients contacted are all free of angina but two (one experienced an acute myocardial infarction and another one died for a pulmonary neoplasia). We conclude that total arterial coronary revascularization is a safe surgical technique, providing excellent perioperative and mid-term results.

[Endoluminal repair of aortic aneurysms. Our experience]. / Correzione endoluminale degli aneurismi aortici. Nostra esperienza.

From February 1998 and March 2000 fourteen patients underwent "custom made" aortic self-expanding endoprostheses implantation (World Medical Talent Sunrise): nine of them for dilative pathology of thoracic aorta and 5 for abdominal aortic aneurysm below renal arteries. The etiology was degenerative in 8 patients, false aneurysm in 2, chronic dissection in 2 cases, acute dissection in one patient and post traumatic in the last one. All patients underwent preoperative Computed Tomography and Substraction Angiography studies. Stent-graft implantation was successful in all cases but one who required the conversion of the endovascular procedure in traditional surgery for technical problems. There were no perioperative deaths or major complications. We registered 2 cases of dissection of the femoral artery used to introduce the stent-graft, and treated with an iliac-femoral prosthetic bypass. There were no cases of paraplegia or renal failure or bowel ischemia. With the exception of one patient, died for a car accident, the others are alive and continue their scheduled follow-up controls. Our experience shows that this procedure is safe, allowing favorable results, if compared to traditional surgery, even if it requires further long-term evaluations.

[Experimental results of the use of hyaluronic acid based materials (CV Seprafilm and CV Sepracoat) in postoperative pericardial adhesions]. / Risultati sperimentali sull'uso di materiale a base di acido ialuronico (CV Seprafilm e CV Sepracoat) nelle aderenze pericardiche post-chirurgiche.

Repeat cardiac surgical procedures are associated with increased technical difficulty and risk related to the presence of dense adhesions between the heart and the surrounding tissues. We examined the efficacy of a bioabsorbable membrane containing hyaluronic acid in the prevention of pericardial adhesions in 23 rabbits. After thoracotomy and pericardiotomy the animals were divided in three groups: Group 1 (9 animals) in which the epicardial surfaces were covered by Seprafilm membrane, Group 2 (9 animals) treated with both Seprafilm membrane and Sepracoat solution, and Group 3 (5 animals) as controls. The animals were reexplored at 10, 30 and 60 days: no intrapericardial adhesions were found in all the animals of Group 2. In 4 animals (44%) of Group 1 localized post-operative adhesions were detected, in absence of epicardial hyperplasia; in contrast, dense and diffuse adhesions were present in all the control animals. The use of the bioabsorbable membrane Seprafilm significantly reduces adhesion formation even if better results are possible with the previous intrapericardial administration of Sepracoat solution. Application of these biocompatible products could reduce the technical difficulty and risk of repeat surgical procedures.

Prospective clinical evaluation and follow-up of a cohort of consecutive VT/VF patients, using a staged-care protocol, including coronary arteriography, programmed electrical stimulation and cardiac surgery.

The prospective evaluation and follow-up of 39 consecutive subjects with VT/VF, 6 of whom, with cardiac arrest (CA), are reported. Patients were enrolled in a specific staged-care approach protocol, which included coronary arteriography (CAR) and ventriculography (VC), in order to exclude the need of cardiac surgery, including coronary artery bypass graft (CABG), with and without left ventricular aneurysmectomy (LVA). The protocol included inducibility of VT/VF, which was verified by programmed electrical stimulation (PES) in control conditions and after antiarrhythmic therapy (ADT), to assess persistent inducibility and mainly to verify the hemodynamic sequelae of VT. VT that showed poor hemodynamic tolerance was treated with ICD, while well-tolerated VT was treated by ADT or ablation when indicated. Furthermore, PES was obtained after surgical procedures. As a first step, the patients were assigned to receive amiodarone (AMIO) (200-400 mg/daily) in the presence of EF% < 30% or contraindication to sotalol, (Group A), or sotalol (SOT) (80-140 mg/daily) in the presence of EF > or = 31%. (Group C). Conversely, in case of recurrences, patients were assigned to receive AMIO (200-300 mg/daily) plus metoprolol (MET) (20-100 mg/daily), (Group B) or, in case of intolerance to beta-blockers, to AMIO plus mexiletine (MEX) (200 mg/daily) (Group D). The four groups were similar for the type of VA, with recurrent ventricular tachycardia (RVT) being the most frequent one. The most frequent underlying cardiac disease of VA in this study was post-AMI CAD, with a rate of over 60% in all four groups. Single- and two-vessel lesions were found at CAR in various patients in all four groups, in 5/13 (38%) in Group A, in 8/14 (57%) in Group B, in 5/7 (71%) in Group C, and in 3/5 (60%) in Group D. Cardiac surgery was performed in a similar and limited number of patients in all four groups, in 4/13 (30%) in Group A, in 4/14 (35%) in Group B, in 2/7 (28%) in Group C, and in 2/5 (40%) in Group D. In 8/39 (20.5%) of the patients who underwent CABG, there was no operative or late mortality; 4/39 (10.2%) received CABG and LVA, and two died. For the amiodarone plus metoprolol and sotalol patients only, PES showed a lower residual inducibility, in comparison to the amiodarone and amiodarone + mexiletine groups. In the entire group, 7 out of 26 (27%) were still inducibile at PES while in 19/26 (64%) of the patients, an apparently effective treatment could be found, documenting the relative usefulness of PES. Recurrence rate was the highest in the amiodarone + mexiletine group and in patients with previous CA. Our data show the potential utility and limitations of ADT, even using the most effective antiarrhythmic drugs and association of drugs, mainly because of the high recurrence rate of VT observed in the present study, even in non-inducible patients [14/39 (36%)]. In conclusion, in a prospective and staged-care approach protocol of management of VT/VF patients, only a few patients with VT/VF benefited from cardiac surgery. PES could still play a role in the evaluation of the most effective ADT. Amiodarone + metoprolol seems to be the most effective ADT in these patients. Nevertheless, a high recurrence rate was observed in this patient population, even with an aggressive protocol, in the short follow-up period of 12 +/- 8 months, confirming recent data on the superiority of ICD to ADT, in patients with frequent recurrences or hemodynamically poorly-tolerated VT. In these patients, ICD therapy should definitively be preferred to ADT.