Vascular Accesses in Cardiac Stimulation and Electrophysiology: An Italian Survey Promoted by AIAC (Italian Association of Arrhythmias and Cardiac Pacing).

Cardiac implantable electronic device (CIED) implants and electrophysiological procedures share a common step: vascular access. On behalf of the AIAC Ricerca Investigators' Network, we conducted a survey to outline Italian common practice regarding vascular access in EP-lab. All Italian physicians with experience in CIED implantation and electrophysiology were invited to answer an online questionnaire (from May 2020 to November 2020) featuring 20 questions. In total, 103 cardiologists (from 92 Italian hospitals) answered the survey. Vascular access during CIED implants was considered the most complex step following lead placement by 54 (52.4%) respondents and the most complex for 35 (33.9%). In total, 54 (52.4%) and 49 (47.6%) respondents considered the cephalic and subclavian vein the first option, respectively (intrathoracic and extrathoracic subclavian/axillary vein by 22 and 27, respectively). In total, 45 (43.7%) respondents performed close arterial femoral accesses manually; only 12 (11.7%) respondents made extensive use of vascular closure devices. A total of 46 out of 103 respondents had experience in ultrasound-guided vascular accesses, but only 10 (22%) used it for more than 50% of the accesses. In total, 81 (78.6%) respondents wanted to increase their ultrasound-guided vascular access skills. Reducing complications is a goal to reach in cardiac stimulation and electrophysiological procedures. Our survey shows the heterogeneity of the vascular approaches used in Italian centres. Some vascular accesses were proved to be superior to others in terms of complications, with ultrasound-guided puncture as an emerging technique. More effort to produce the standardization of vascular accesses could be made by scientific societies.

The role of atrial sensing for new-onset atrial arrhythmias diagnosis and management in single-chamber implantable cardioverter-defibrillator recipients: Results from the THINGS registry.

INTRODUCTION: Atrial tachycardia/fibrillation (AT/AF) episodes are common in implantable cardioverter-defibrillator (ICD) recipients and can be undetected by standard single-chamber devices. This study aims to explore whether a single-lead ICD with an atrial dipole (ICD DX; BIOTRONIK SE & Co, Berlin, Germany) could improve the AT/AF diagnosis and management as compared to standard ICD (ICD VR). METHODS AND RESULTS: We selected patients without AT/AF history from the THINGS registry which included consecutive patients implanted with ICD for standard indications. The ICD VR and the ICD DX groups included 236 (62.8%) and 140 (37.2%) patients, respectively, and had no significant differences in baseline characteristics. During a median follow-up of 27 months, there were 7 AT/AF diagnoses in the ICD VR and 18 in the ICD DX group. The 2-year incidence of AT/AF diagnosis was 3.6% (95% confidence interval [CI]: 1.6%-9.6%) for the ICD VR and 11.4% (95% CI: 6.8%-18.9%) for the ICD DX group (adjusted hazard ratio [HR]: 3.85 [95% CI: 1.58-9.41]; P = .003). Initiation of oral anticoagulation (OAC) due to AT/AF diagnosis was reported in 15 patients. The 2-year incidence of OAC onset was 3.6% (95% CI: 1.6%-7.8%) for the ICD VR and 6.3% (95% CI: 3.0%-12.7%) for ICD DX group (adjusted HR: 1.99 [95% CI: 0.72-5.56]; P = .184). CONCLUSION: We observed that atrial sensing capability in single-chamber ICD patients without evidence of atrial arrhythmias at implant is associated with a greater likelihood of detecting AT/AF episodes. The management of these diagnosed arrhythmias often led to clinical interventions, mainly represented by initiation of OAC therapy.

Internal Jugular Vein Complete Thrombosis After Dual Chamber Pacemaker Implant.

Venous thrombosis after pacemaker implant is a known, although often underrecognized condition that can challenge system revision or upgrading, leading occasionally to thromboembolic complications. Several factors are considered to promote thrombus formation. Among them, alteration of blood flow mechanics due to the presence of catheters in the vessel lumen may itself play a pivotal role. Hereby we present the case of a 65-year old men who underwent a dual-chamber pacemaker implant in another institute for sick sinus syndrome by means of left cephalic venous access. About two months later he started experiencing neck swelling, pain and dysphagia. Six months later, ultrasonography and CT-scan revealed complete jugular vein thrombosis caused by a lead loop at the level of the left subclavian vein. Of note, thrombosis occurred despite proper oral anticoagulation with warfarin undertaken for coexisting atrial fibrillation. It's important to keep in mind this possible complication of pacemaker implant to allow for early diagnosis and better treatment chances. This case report is an example of how proximal catheter displacement may promote thrombus formation, probably by affecting blood flow mechanics, even in spite of proper oral anticoagulation.

[ST-segment elevation myocardial infarction in a patient with thrombophilia taking new oral anticoagulants]. / Infarto miocardico acuto in corso di terapia con nuovo anticoagulante orale in paziente con trombofilia.

We report the case of a 65--year-old woman admitted for inferior ST-segment elevation myocardial infarction complicated by complete atrioventricular block. The patient was under treatment with a novel oral anticoagulant (NOAC, rivaroxaban) because of a history of recurrent idiopathic pulmonary embolism. Emergency angiography showed complete acute thrombotic occlusion of the right coronary artery. After manual thrombectomy, there was no angiographic evidence of underlying atherosclerosis, therefore no further percutaneous coronary intervention was performed. Subsequent clinical course was uneventful. Laboratory tests demonstrated the presence of a heterozygous mutation of the factor II gene (G20210A), confirming the clinical evidence of a thrombophilic state. As rivaroxaban seemed to be ineffective in preventing spontaneous coronary thrombosis in this patient, antithrombotic therapy was shifted to warfarin plus low-dose aspirin. No further ischemic events occurred during the 1-year follow-up. It can be hypothesized that factor Xa inhibition by NOACs, such as rivaroxaban, could be insufficient in case of a thrombophilic state due to thrombin mutation. A brief review of the current literature on use of NOACs in acute coronary syndromes is also reported.

Anabolic androgenic steroid-induced Takotsubo cardiomyopathy.

Anabolic steroid abuse, aimed at increasing muscle mass, has been growing in recent years. We describe a case of a 25-year-old bodybuilder who, after taking nandrolone and stanozolol, presented with Takotsubo syndrome. The angiography showed a normal coronary anatomy with the absence of stenosis. The left ventricular function was completely normalised after 1 week.

Congenitally corrected transposition of the great arteries in an 83-year-old asymptomatic patient: description and literature review.

We describe the case of an 83-year-old asymptomatic man followed in our centre. Transoesophageal echocardiography disclosed congenitally corrected transposition of great arteries (CCTGA) with no associated anomalies and only mild aortic regurgitation. Cardiac MR confirmed the diagnosis and revealed preserved systemic ventricle systolic function with a normal perfusional pathway. This report is a demonstration that CCTGA without associated anomalies can reach older life in an asymptomatic condition. This is the oldest asymptomatic living patient with CCTGA ever described.

Pericardial, pleural and diaphragmatic endometriosis in association with pelvic peritoneal and bowel endometriosis: a case report and review of the literature.

Diaphragmatic endometriosis is a rare entity, often asymptomatic, which has been described only in small series. It is almost always associated with severe pelvic involvement. The most plausible theory about this condition is based on retrograde menstruation and subsequent transportation of viable cells in peritoneal fluid from the pelvis up the right gutter to the right hemidiaphragm, thus demonstrating its asymmetric distribution on the diaphragm. Pre-operative diagnosis is poorly supported by imaging techniques. In most cases, it is an incidental finding because the lesions may hide behind the right hepatic lobe. In that case it cannot be easily demonstrated with a laparoscope from an umbilical port. Symptomatic diaphragmatic endometriosis is associated with deep lesions which can involve the entire thickness of the diaphragm. In these cases, treatment is more difficult with possible incomplete pain relief and a considerable possibility of recurrence. In this subset, abdominal surgery is recommended. Surgical treatment must be individualized on the basis of the patient's age, fertility desires, type and location of disease and symptoms. We report the surgical treatment of a patient with synchronous pericardial, pleural and diaphragmatic endometriosis associated with pelvic peritoneal and bowel involvement. A review of the literature regarding pericardial and diaphragmatic endometriosis focusing on anatomical and surgical aspects of its management is undertaken.

Papillary fibroelastoma of the mitral valve in an 8-month-old infant.

Papillary fibroelastomas, the third most common primary cardiac tumor in adults, are extremely rare in children. These tumors grow slowly and are histologically benign but with high potential for life-threatening complications. We report an 8-month-old asymptomatic female infant with papillary fibroelastoma of the mitral valve, discovered by echocardiograph examination.

Percutaneous treatment of the left main coronary artery ostial obstruction following aortic valve replacement.

Iatrogenic left main coronary artery ostial stenosis is a rare and late life-threatening complication of aortic valve replacement. The exact causes of this critical condition, despite being still nowadays elusive, are possibly related to the insertion of perfusion catheters into the left coronary system for cardioplegia delivery. We describe the case of a 69-year-old man, with normal coronary arteries documented by preoperative coronary angiography before surgery, who developed 1 year after aortic valve replacement worsening effort angina. A second coronary angiography revealed a severe left main ostial stem stenosis, which was successfully treated by sirolimus-eluting stent deployment. This case demonstrates a new percutaneous approach of this poorly understood, yet potentially fatal complication following aortic valve replacement.