Anna Degiovanni

Long-term follow-up of DDDR closed-loop cardiac pacing for the prevention of recurrent vasovagal syncope.

Aims Vasovagal syncope (VVS) is a common disorder characterized by a drop in blood pressure accompanied with bradycardia; although it is generally considered a benign condition, some patients may be highly symptomatic despite general counselling and/or pharmacological therapy. Closed-loop stimulation (CLS), responding to myocardial contraction dynamics, demonstrated effectiveness in short-term prevention of recurrent VVS. The aim of this study was to evaluate CLS pacing in a long-term follow-up. Methods The study involved 35 patients (mean age 59 ± 15 years) with 3 years’ follow-up (mean 61 ± 35 months). We compared syncopal events and presyncopes before and after CLS implantation. Mean number of syncopes for patients was six (range 1–24; 212 syncopal spells registered) before pacemaker implantation. Results At follow-up, 29 of 35 patients (83%) were asymptomatic; one patient experienced recurrent loss of consciousness but reported an improvement in the quality of life (one syncope or presyncope per month after CLS, vs. one syncope per week and daily presyncopes before CLS). Five patients experienced syncopal recurrences after CLS (range: 1–7, with a total of 15 episodes); in all the cases, the number of post-CLS syncopes was significantly lower. Conclusion Our study seems to confirm previous results of short-term trials: DDDR-CLS pacing is an extremely useful tool in the prevention of recurring VVS, even in long-term follow-up.

Inappropriate Asystole Detection in Early Postoperative Phase after Loop Recorder Implantation

The implantable loop recorder is a useful diagnostic tool for patients with unexplained syncope. The capability to automatically detect and store arrhythmic events, implemented in the last generations of these devices, can further improve the diagnostic yield, but this feature can be compromised by inappropriate detection of false arrhythmias. We herein report the case of a patient in which several inappropriate activations of long-lasting asystole occurred in the two days following the implant, probably because of an intermittently loose contact between the device and subcutaneous tissue for a small pocket haematoma.

Prevalence of ventricular arrhythmias in patients with cardiac resynchronization therapy without back-up ICD: a single-center experience.

Aims Current guidelines recommend cardiac resynchronization therapy (CRT) in selected heart failure patients, but do not precisely clarify when a back-up implantable cardioverter defibrillator (ICD) should be associated (CRT-D). In this study we evaluate the occurrence of ventricular arrhythmias in a population of patients implanted with biventricular pacemaker without a back-up ICD (CRT-P). Methods We performed a retrospective analysis on 84 patients (55 men, mean age 74 ± 7 years), implanted with a CRT-P since April 2000. Patients had in 31% an underlying coronary artery disease, in 56% an idiopatic dilated cardiomyopathy and in 13% a valvular disease. An upgrade to CRT-P was performed from previous conventional pacemakers in 36% of cases. Baseline New York Heart Association (NYHA) functional class was II in 25%, III in 63% and IV in 12%. Mean left ventricular ejection fraction was 29.8 ± 8.8% with two-dimensional echo. During follow-up, occurrence of ventricular arrhythmias was assessed clinically and through the pacemaker stored data at the scheduled check-up. Results During a mean follow-up of 29 months (range 2–127 months), telemetry interrogation revealed unsustained ventricular tachyarrhythmias in 11 of 84 patients (13.1%). Only one patient experienced an episode of sustained ventricular tachycardia. An upgrading to a CRT-D was performed in two patients; one of these patients died suddenly 15 months after the upgrade. Death occurred in 20 of 84 patients (23.8%): 15 for refractory heart failure and five for noncardiac causes. Conclusion Our data show that CRT-P may be well tolerated in selected patients even during a long-term follow-up; and that an upgrade to CRT-D may not be enough to prevent sudden death.

Left atrium function in patients with coronary artery disease.

Purpose of reviewThe left atrial cavity has recently been identified as a potential biomarker for cardiac and cerebrovascular accidents. This review examines the potential of left atrial size and function in predicting cardiovascular disease in the general population and outcomes in coronary artery disease (CAD) patients. Recent findingsThe atrium is perfused primarily by branches of the proximal left circumflex coronary artery (LCx), and depression of the cavity mechanical performance has been demonstrated in experimental studies during LCx occlusion. Thus, left atrial volume and function assessment may have prognostic relevance, particularly in CAD patients. Such a line of thinking, however, is challenged by the widespread notion that the contribution by left atrial chamber morphology and functional quantitation to the risk stratification process after a first cardiovascular event is not adequately considered. However, a number of studies have shown that left atrial volume predicts survival and major adverse events after an acute myocardial infarction. Left atrial remodeling also provides an important overall prognostic information and correlates with brain natriuretic peptide after primary percutaneous coronary interventions. SummaryEvaluation of left atrial size and function is currently of great interest and it will be more so in the very near future, given its potential for insights into the pathophysiology of the ischemic heart, which makes it an important clinical risk identifier in CAD patients.

Machine Learning Analysis of Left Ventricular Function to Characterize Heart Failure With Preserved Ejection Fraction

Background: Current diagnosis of heart failure with preserved ejection fraction (HFpEF) is suboptimal. We tested the hypothesis that comprehensive machine learning (ML) of left ventricular function at rest and exercise objectively captures differences between HFpEF and healthy subjects. Methods and Results: One hundred fifty-six subjects aged >60 years (72 HFpEF+33 healthy for the initial analyses; 24 hypertensive+27 breathless for independent evaluation) underwent stress echocardiography, in the MEDIA study (Metabolic Road to Diastolic Heart Failure). Left ventricular long-axis myocardial velocity patterns were analyzed using an unsupervised ML algorithm that orders subjects according to their similarity, allowing exploration of the main trends in velocity patterns. ML identified a continuum from health to disease, including a transition zone associated to an uncertain diagnosis. Clinical validation was performed (1) to characterize the main trends in the patterns for each zone, which corresponded to known characteristics and new features of HFpEF; the ML-diagnostic zones differed for age, body mass index, 6-minute walk distance, B-type natriuretic peptide, and left ventricular mass index (P<0.05) and (2) to evaluate the consistency of the proposed groupings against diagnosis by current clinical criteria; correlation with diagnosis was good (&kgr;, 72.6%; 95% confidence interval, 58.1–87.0); ML identified 6% of healthy controls as HFpEF. Blinded reinterpretation of imaging from subjects with discordant clinical and ML diagnoses revealed abnormalities not included in diagnostic criteria. The algorithm was applied independently to another 51 subjects, classifying 33% of hypertensive and 67% of breathless controls as mild-HFpEF. Conclusions: The analysis of left ventricular long-axis function on exercise by interpretable ML may improve the diagnosis and understanding of HFpEF.

Non-invasively estimated left atrial stiffness is associated with short-term recurrence of atrial fibrillation after electrical cardioversion

BACKGROUND As atrial stiffness (Kla) is an important determinant of cardiac pump function, better mechanical characterization of left atrial (LA) cavity would be clinically relevant. Pulmonary venous ablation is an option for atrial fibrillation (AF) treatment that offers a powerful context for improving our understanding of LA mechanical function. We hypothesized that a relation could be detected between invasive estimation of Kla and new non-invasive deformation parameters and traditional LA and left ventricular (LV) function descriptors, so that Kla can be estimated non-invasively. We also hypothesized that a non-invasive surrogate of Kla would be useful in predicting AF recurrence after cardioversion. METHODS In 20 patients undergoing AF ablation, LA pressure-volume curves were derived from invasive pressure and echocardiographic images; Kla was calculated during ascending limb of V-loop as ΔLA pressure/ΔLA volume. 2D-speckle-tracking echocardiographic LA and LV longitudinal strains and volumes, ejection fraction (EF) and ventricular stiffness (Klv), as obtained from mitral deceleration time, were tested as non-invasive Kla predictors. In 128 sinus rhythm patients 1 month after electrical cardioversion for persistent AF, non-invasively estimated Kla (computed-Kla) was tested as predictor of recurrence at 6 months. RESULTS Tertiles of mean LA pressure correlated with increasing Kla (trend, p=0.06) and decreasing LA peak strain, LVEF, and LV longitudinal strain (p=0.029, p=0.019, and p=0.024). There were no differences in LA and LV volumes and Klv across groups. Multiple regression analysis identified LV longitudinal strain as the only independent predictor of Kla (p=0.014). Patients in highest quartile of computed-Kla (estimated as [log]=0.735+0.051×LV strain) tended to have highest AF recurrence rate (25%) as compared with remaining 3 quartiles (9%, 9%, 3%, p=0.09). CONCLUSION Kla can be assessed invasively in patients undergoing AF ablation and it can be estimated non-invasively using LV strain. AF recurrence after cardioversion tends to be highest in highest quartile of computed-Kla.

[Giant aneurysm of the right coronary artery: an unusual treatment].

Coronary artery aneurysm (CAA) is an uncommon disease observed in only 0.15-4.9% of patients undergoing coronary angiography. CAA are defined as dilated coronary artery sections exceeding by 1.5 times the diameter of normal adjacent segments or of the patients largest coronary vessel. Occasionally, CAA enlarge enough to be called giant CAA. We report the case of a 78-year-old man, with known chronic ischemic cardiomyopathy and a history of prior coronary artery bypass surgery (with a left internal mammary artery graft to the left anterior descending coronary artery and saphenous venous graft to the obtuse marginal branch), who was referred to our cardiology department for progressive dyspnea. Echocardiography showed severe mitral regurgitation suggesting replacement; coronary angiography revealed three-vessel coronary artery disease, left internal mammary artery patency, saphenous vein graft occlusion and an aneurysm of the mid right coronary artery. Cardiac magnetic resonance confirmed this finding, showing a giant CAA (65 x 75 mm) with a large endoluminal thrombus. Treatment is not standardized and may include medical therapy, percutaneous treatment and surgical intervention; our patient underwent percutaneous coil embolization. One-month angiographic follow-up showed successful obliteration. The patient underwent surgical mitral valve replacement without any complications. At 9-month clinical follow-up, he was asymptomatic; transthoracic echocardiography showed an ejection fraction of 44% without prosthetic mitral regurgitation.

Persistence of ICD indication at the time of replacement in patients with initial implant for primary prevention indication: Effect on subsequent ICD therapies

Background Indication to implantable cardioverter defibrillator (ICD) for primary prevention of sudden death relies on left ventricular ejection fraction (LVEF). We measured the proportion of patients in whom indication to ICD persisted at the time of generator replacement (GR) and searched for predictors of appropriate therapies after GR. Methods We identified all consecutive patients who had received an ICD at our hospital, for LVEF ≤35% and no previous arrhythmias or unexplained syncope. Then, we included the 166 patients who outlived their first device and underwent GR. Results At the time of GR (mean follow-up 59 ± 20 months), ICD indication (i.e. LVEF ≤35% or previously treated ventricular arrhythmias) persisted in 114 (69%) patients. After GR, appropriate ICD therapies were delivered in 30 (26%) patients with persistent ICD indication and in 12 (23%) of the remaining patients (p = 0.656). Nonetheless, the annual rate of therapies was higher in the first group (1.08 versus 0.53 events/year; p < 0.001), as well as the rate of inappropriate therapies (0.03 versus 0 events/year; p = 0.031). The only independent predictor of appropriate ICD therapies after GR was the rate of shocks received before replacement (Hazard Ratio: 1.41; 95% confidence interval: 1.01–1.96; p = 0.041). Conclusion In heart failure with reduced LVEF, ICD indication persisted at the time of GR in 69% of patients. However, even in the absence of persistent ICD indication at GR, the risk of recurrence of arrhythmic events was not null.

Ranolazine : Effects on Ischemic Heart

Coronary artery disease is the major cause of mortality and morbidity in the industrialized countries; in the United States of America and in Europe, it is responsible for one of every six deaths per year. In the setting of ischemic heart disease, angina pectoris and chest pain, in particular, are the major causes of emergency department accesses. Angina pectoris is a clinical syndrome characterized by discomfort typically in the chest, neck, chin and left arm induced by physical exertion, emotional stress and cold and is relieved by rest or by taking of nitrates. The main targets of treatment of angina pectoris are to improve quality of life by reducing the frequency and the severity of symptoms, to increase functional capacity and to improve prognosis. Ranolazine is a recent antianginal drug with unique methods of action. It was approved by the US Food and Drug Administration in 2006 as add-on therapy in patients symptomatic for stable angina. With the inhibition of the late sodium current, Ranolazine protects against ion deregulation, prevents cellular calcium overload and the subsequent increase in diastolic tension without impacting heart rate and blood pressure. Short term clinical trials and patent research show that add on therapy with Ranolazine in patients with chronic stable angina significantly improves exercise duration, exercise time to angina and reduces the use of nitro glycerine. Long term clinical trials showed no significant differences in the rate of cardiovascular death and myocardial infarction in patients with non-ST segment elevation acute coronary syndromes but a reduction in terms of recurrent ischemia. Ranolazine is generally well tolerated and even if it increases the duration of QTc interval it is not associated with atrial and ventricular arrhythmias. Therefore Ranolazine represents a good therapeutic approach in patients with chronic stable angina still symptomatic, while on optimal anti-ischemic therapy, or intolerant to traditional anti-ischemic drugs.

Feasibility of cathodic-anodal left ventricular stimulation for alternative multisite pacing: DELL'ERA et al.

Simultaneous cathodic‐anodal capture by a bipole of a cardiac resynchronization therapy (CRT) left‐ventricular (LV) catheter may depolarize a larger LV area than conventional multipoint pacing. We evaluated the feasibility of cathodic‐anodal LV stimulation.