Claudia Amellone

Efficacy of Low Interatrial Septum and Right Atrial Appendage Pacing for Prevention of Permanent Atrial Fibrillation in Patients with Sinus Node Disease: Results from the Electrophysiology-Guided Pacing Site Selection (EPASS) Study

Background— The role of pacing sites and atrial electrophysiology on the progression of atrial fibrillation (AF) to the permanent form in patients with sinus node dysfunction (SND) has never been investigated. The aim of the study was to investigate the relationship between atrial electrophysiology and the efficacy of atrial pacing at the low interatrial septum (IAS) or at the right atrial appendage (RAA) to prevent persistent/permanent AF in patients with SND. Methods and Results— The Electrophysiology-Guided Pacing Site Selection (EPASS) Study was a prospective, controlled, randomized study. Atrial refractoriness, basal and incremental conduction times from the RAA to the coronary sinus ostium were measured before implantation, and the difference (&Dgr;CTos) was calculated. Patients with &Dgr;CTos ≥50 ms (study group) and those with &Dgr;CTos <50 ms (control group) were randomly assigned to RAA or IAS with algorithms for continuous atrial stimulation “on.” The primary end point was time to development of permanent or persistent AF within a 2-year follow-up in the study group, IAS versus RAA. Data were analyzed by intention to treat. One hundred two patients (77±7 years, 44 mol/L) were enrolled, 69 (68%) in the study group and 33 (32%) in the control group. Of these, 97 ended the study, respectively, randomly assigned: 29 IAS versus 36 RAA and 18 IAS versus 14 RAA. After a mean follow-up of 15±7 (median, 17) months, 11 (16.6%) patients in the study group met the primary end point: 2 IAS versus 9 RAA (log rank=3.93, P=0.047). Conclusions— In patients with SND and intra-atrial conduction delay, low IAS pacing was superior to RAA pacing in preventing progression to persistent or permanent AF. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00239226.

Prognostic implications of detection of troponin I in patients with unstable angina pectoris.

In our study, troponin I was not a predictor of cardiac events and a negative troponin I test did not exclude the presence of severe coronary artery disease. A positive troponin I test in patients with unstable angina identified a subgroup with probable, more active coronary disease (with higher levels of C-reactive protein).

Optimization of cardiac resynchronization therapy: echocardiographic vs semiautomatic device algorithms.

Large evidence supports the importance of individualized optimization of cardiac resynchronization therapy in patients with congestive heart failure. The aim of this study was to compare a recently developed intracardiac electrogram (IEGM)-based method with the Doppler echocardiographic (ECHO)-based method to calculate optimal atrioventricular (AV) and interventricular (VV) delays. Ten male patients implanted with a St Jude Medical resynchronization device received AV and VV delay assessment with both the IEGM and the ECHO-based methods. Estimates of the optimal AV and VV delays assessed by the 2 tested methods proved highly comparable. No difference emerged between the IEGM (126.8+/-22.7) and the ECHO (127.3+/-19.8) AV delay values (P=.987). The VV delay suggested by ECHO was highly significantly correlated with the delays calculated by the IEGM method (35+/-27.6 vs 21.31+/-24.31; r(2)=0.78; P<.001). These preliminary data support the evidence that an IEGM based cardiac resynchronization optimization method may be as reliable as a complete ECHO assessment.

Hybrid right-left cardiac resynchronization therapy defibrillator implantation in persistent left superior vena cava.

Persistence of the left superior vena cava (PLSVC), observed in 0.3% of the general population as established by autopsy, is an anatomic variation particularly relevant when occurring in patients in need of a transvenous pacing. In this report, we describe a hybrid right-left cardiac resynchronization therapy defibrillator implantation approach in a patient with PLSVC. In our experience, the described approach proved feasible and safe, and may be considered an option in case of complex vein anatomy before referring for cardiac surgical implantation of a left ventricular lead.

'Sinus node' dysfunction associated with left atrial isomerism.

Introduction The eterotaxic syndromes encompass two main anatomic pictures: left and right atrial isomerism. They cause a distortion of the atria anatomy that may involve the conduction tissue. The prognosis is related to the severity of the intracardiac-associated defects. Case report We describe the case of a patient suffering from asymptomatic ‘sinus’ bradycardia since childhood, who was referred for pacemaker implantation, in which the diagnosis of left atrial isomerism was made. Conclusion The present paper may provide new insights on the clinical course of arrhythmic disorders, in particular among patients with congenital heart disease.

Twelve-year follow-up of catheter ablation for atrial fibrillation: A prospective, multicenter, randomized study

BACKGROUND Randomized and controlled studies have reported the effect of catheter ablation (CA) for atrial fibrillation (AF) over a follow-up of 12-24 months. OBJECTIVE We report on the effect of CA plus antiarrhythmic drugs in comparison with antiarrhythmic drugs alone on the maintenance of sinus rhythm over 12-year follow-up. METHODS We extended the follow-up duration of the 137 patients who were enrolled in the Catheter Ablation for the Cure of Atrial Fibrillation Study between February 1, 2002, and June 30, 2003, and randomized to antiarrhythmic drugs (control group) or antiarrhythmic drugs plus CA (ablation group). The primary end point was time to first symptomatic or asymptomatic recurrence of atrial arrhythmia lasting >30 seconds during follow-up. RESULTS During follow-up, 19 of 68 (27.9%; 95% confidence interval [CI] 18.7%-39.6%) ablation group patients and 3 of 69 (4.3%; 95% CI 1.49%-12.0%) control group patients did not experience any relapse of atrial tachyarrhythmia (P < .001). The Kaplan-Meier analysis performed to determine the probability of survival free from atrial arrhythmias showed a statistical difference in favor of the ablation group (log-rank, P < .001). The effect of CA was consistent in both patients with paroxysmal AF and those with persistent AF. In the multivariate Cox regression analysis, belonging to the control group (hazard ratio 2.95; 95% CI 1.896-4.726; P < .001) and longer time since first AF episode (hazard ratio 1.004; 95% CI 1.002-1.084; P = .041) were predictors of atrial tachyarrhythmia recurrence. CONCLUSION In patients with paroxysmal and persistent AF, CA significantly increased time to first recurrence of atrial arrhythmias during 12-year follow-up.

Economic impact of remote monitoring after implantable defibrillators implantation in heart failure patients: an analysis from the EFFECT study

Aims Heart failure (HF) patients with implantable cardioverter-defibrillators (ICD) require admissions for disease management and out-patient visits for disease management and assessment of device performance. These admissions place a significant burden on the National Health Service. Remote monitoring (RM) is an effective alternative to frequent hospital visits. The EFFECT study was a multicentre observational investigation aiming to evaluate the clinical effectiveness of RM compared with in-office visits standard management (SM). The present analysis is an economic evaluation of the results of the EFFECT trial. Methods and results The present analysis considered the direct consumption of healthcare resources over 12-month follow-up. Standard tariffs were applied to hospitalizations, in-office visits and remote device interrogations. Economic comparisons were also carried out by means of propensity score (PS) analysis to take into account the lack of randomization in the study design. The analysis involved 858 patients with ICD or CRT-D. Of these, 401 (47%) were followed up via an SM approach, while 457 (53%) were assigned to RM. The rate of hospitalizations was 0.27/year in the SM group and 0.16/year in the RM group (risk reduction =0.59; P = 0.0004). In the non-adjusted analysis, the annual cost for each patient was €817 in the SM group and €604 in the RM group (P = 0.014). Propensity score analysis, in which 292 RM patients were matched with 292 SM patients, confirmed the results of the non-adjusted analysis (€872 in the SM group vs. €757 in the RM group; P < 0.0001). Conclusion There is a reduction in direct healthcare costs of RM for HF patients with ICDs, particularly CRT-D, compared with standard monitoring. Clinical Trial Registration http://clinicaltrials.gov/Identifier, NCT01723865.

Intramural left atrial hematoma: A complication of primary coronary angioplasty inferior myocardial infarction

An intramyocardial dissecting hematoma following a myocardial infarction is a rare condition, and even more uncommon is a localization in the left atrium. There is uncertainty on the prognosis and most appropriate management of this complication, often a result of coronary artery perforation during percutaneous coronary intervention (PCI) (1). Although the dissecting hematoma usually forms almost exclusively in the myocardium adjacent to the culprit coronary lesion, in unique cases it can expand to other areas of the heart, compressing nearby structures and impeding blood flow. Therefore, we describe an intramural left atrial hematoma following a coronary perforation during PCI in a patient with inferior myocardial infarction.

Association between remote implantable cardioverter defibrillator monitoring and beta-blocker utilization: An analysis from the EFFECT study.

Introduction A substantial number of heart failure patients undergoing implantation of implantable cardioverter defibrillators (ICDs) fail to receive beta-blockers, or receive them at a suboptimal dose. Remote monitoring (RM) is becoming the standard means of following up recipients of ICDs. However, the impact of this shift toward remote ICD follow-up on the quality of drug therapy management in current clinical practice is unknown. The present analysis was aimed at investigating the impact of RM on the dose of beta-blockers achieved, and its association with clinical outcome at 12 months. Methods Altogether 987 consecutive patients were enrolled and followed up for at least 12 months in 25 Italian centres. RM was adopted by 499 patients. Results The number of patients receiving beta-blockers at any dose decreased after 12 months (from 403 (81%) to 370 (74%) for the remote arm and from 389 (80%) to 342 (70%) for the standard arm, both p < 0.02). Nonetheless, the number of patients on beta-blockers at the effective dose increased in both arms (from 60 (12%) to 82 (16%) for remote and from 63 (13%) to 98 (20%) for standard arms respectively, both p < 0.05). At multivariate analysis, RM was not associated with an effective dose of beta-blockers at the follow-up evaluation. However, the adoption of RM (p = 0.003) and the achievement of the effective dose of beta-blockers (p = 0.006) were independently and positively associated with an improved outcome. Discussion In a ‘real-world’ setting, we did not find an association between RM and the achieved dose of beta-blockers. However, we reported outcome benefits in achieving the effective dose of beta-blockers during follow-up and in adopting RM.

Remote Monitoring for Implantable Defibrillators: A Nationwide Survey in Italy

Background Remote monitoring (RM) permits home interrogation of implantable cardioverter defibrillator (ICD) and provides an alternative option to frequent in-person visits. Objective The Italia-RM survey aimed to investigate the current practice of ICD follow-up in Italy and to evaluate the adoption and routine use of RM. Methods An ad hoc questionnaire on RM adoption and resource use during in-clinic and remote follow-up sessions was completed in 206 Italian implanting centers. Results The frequency of routine in-clinic ICD visits was 2 per year in 158/206 (76.7%) centers, 3 per year in 37/206 (18.0%) centers, and 4 per year in 10/206 (4.9%) centers. Follow-up examinations were performed by a cardiologist in 203/206 (98.5%) centers, and by more than one health care worker in 184/206 (89.3%) centers. There were 137/206 (66.5%) responding centers that had already adopted an RM system, the proportion of ICD patients remotely monitored being 15% for single- and dual-chamber ICD and 20% for cardiac resynchronization therapy ICD. Remote ICD interrogations were scheduled every 3 months, and were performed by a cardiologist in 124/137 (90.5%) centers. After the adoption of RM, the mean time between in-clinic visits increased from 5 (SD 1) to 8 (SD 3) months (P<.001). Conclusions In current clinical practice, in-clinic ICD follow-up visits consume a large amount of health care resources. The results of this survey show that RM has only partially been adopted in Italy and, although many centers have begun to implement RM in their clinical practice, the majority of their patients continue to be routinely followed-up by means of in-clinic visits.