Danilo Ricciardi

Isolating the pulmonary veins as first-line therapy in patients with lone paroxysmal atrial fibrillation using the cryoballoon.

AIMS Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Nowadays, catheter-based ablative approaches are mainly reserved for drug-refractory patients. However, the value of an ablative therapy as a first-line alternative remains elusive. The aim of our study was to analyse the acute procedural success and clinical outcome of patients with lone paroxysmal AF undergoing cryoballoon ablation (CBA) as first-line treatment. METHODS AND RESULTS Eighteen individuals (mean age 44 ± 9 years, range 23-61 years, 15 males) with lone paroxysmal AF preferring a catheter-based treatment to drug treatment as first-line therapy were consecutively enrolled in our study. Mean left atrial size was 39 ± 4 mm and mean left ventricular ejection fraction 58 ± 3%. After a mean of 2.4 CBA (range 2-4) applications pulmonary vein (PV) isolation could be demonstrated in 70 (97%) PVs. Additional lesions with a focal ablation catheter were needed to isolate one right inferior pulmonary vein and one left superior pulmonary vein in two different patients. At the end of the procedure, all (100%) PVs were isolated. After a 2-month blanking period, 16 patients (89%) were free of symptomatic AF recurrence at a mean follow-up of 14 ± 9 months and without antiarrhythmic drugs (AADs). CONCLUSION Cryoballoon ablation in patients with lone paroxysmal AF yields a high acute efficacy rate with a great chance of being free of symptomatic AF recurrence without antiarrhythmic drugs on a mid-term follow-up period, when offered as a first-line treatment.

Pulmonary vein isolation during cryoballoon ablation using the novel Achieve inner lumen mapping catheter: a feasibility study.

AIMS Cryoballoon (CB) ablation has proven very effective in achieving pulmonary vein isolation (PVI). The Achieve catheter (AC) is a novel inner lumen catheter designed to be used in conjunction with the CB, which serves the double purpose of a guidewire and a mapping catheter. We aimed to evaluate the feasibility of CB ablation in conjunction with the novel AC, in terms of PVI and safety in a series of patients affected by drug resistant paroxysmal atrial fibrillation (AF). METHODS AND RESULTS Seventy patients (49 male) affected by paroxysmal AF were assigned to CB PVI using the AC as a mapping catheter. Patients underwent loop-Holter monitoring 1, 3 and 6 months after ablation. Isolation occurred in 98% of PVs with the CB-AC association without having switching to a regular guidewire. Pulmonary vein isolation could be documented by real-time (RT) recordings in 47% (132) of veins. Time to isolation was significantly longer in PVs exhibiting early left atrium-PV reconnection if compared with veins with sustained isolation (117 ± 25 s vs. 59 ± 25 s; P< 0,005). No serious complications occurred; four transient phrenic nerve palsies occurred all resolving completely before the end of the procedure. CONCLUSION Cryoballoon ablation in conjunction with the novel AC is feasible, safe, and most importantly affords PVI in nearly all veins without having to switch to a regular guidewire. However, RT recordings could be documented in only 47% of pulmonary veins.

Multipoint pacing via a quadripolar left-ventricular lead: preliminary results from the Italian registry on multipoint left-ventricular pacing in cardiac resynchronization therapy (IRON-MPP)

Abstract Aims This registry was created to describe the experience of 76 Italian centres with a large cohort of recipients of multipoint pacing (MPP) capable cardiac resynchronization therapy (CRT) devices. Methods and results A total of 507 patients in whom these devices had been successfully implanted were enrolled between August 2013 and May 2015. We analysed: (i) current clinical practices for the management of such patients, and (ii) the impact of MPP on heart failure clinical composite response and on the absolute change in ejection fraction (EF) at 6 months. Multipoint pacing was programmed to ‘ON’ in 46% of patients before discharge. Methods of optimizing MPP programming were most commonly based on either the greatest narrowing of the QRS complex (38%) or the electrical delays between the electrodes (34%). Clinical and echocardiographic follow-up data were evaluated in 232 patients. These patients were divided into two groups according to whether MPP was programmed to ‘ON’ (n = 94) or ‘OFF’ (n = 138) at the time of discharge. At 6 months, EF was significantly higher in the MPP group than in the biventricular-pacing group (39.1 ± 9.6 vs. 34.7 ± 7.6%; P < 0.001). Even after adjustments, early MPP activation remained an independent predictor of absolute increase in LVEF of ≥5% (odds ratio 2.5; P = 0.001). At 6 months, an improvement in clinical composite score was recorded in a greater proportion of patients with MPP-ON than in controls (56 vs. 38%; P = 0.009). On comparing optimal MPP and conventional vectors, QRS was also seen to have decreased significantly (P < 0.001). Conclusion This study provides information that is essential in order to deal with the expected increase in the number of patients receiving MPP devices in the coming years. The results revealed different practices among centres, and establishing the optimal programming that can maximize the benefit of MPP remains a challenging issue. Compared with conventional CRT, MPP improved clinical status and resulted in an additional increase in EF. Clinical Trial Registration http://www.clinicaltrial.gov/. Unique identifier: NCT02606071.

Prevalence, Clinical Characteristics and Management of Atrial Fibrillation in Patients With Brugada Syndrome

Atrial fibrillation (AF) can be the first manifestation of latent Brugada syndrome (BS). The aim of our study was to assess the prevalence of AF as the first clinical diagnosis in patients with BS and their demographic and clinical characteristics and diagnosis management in a large cohort of patients. The patient group consisted of 611 patients with BS. The data from those with a diagnosis of AF previous to the identification of BS were analyzed (n = 35). Eleven cases were unmasked after the initiation of a class I antiarrhythmic drug and one during the establishment of general anesthesia. In the remaining population, BS was diagnosed using an ajmaline test performed mainly because of younger age in patients with lone AF (n = 13), previous syncope or sudden cardiac death (n = 3), or a clinical history of sudden cardiac death in the family (n = 5). The mean patient age was 49 ± 15 years, 21 were male patients, 14 had a family history of sudden death, 15 had had previous syncope, and 4 had survived cardiac arrest. Concomitant electrical disorder was found in 13 patients. Remarkably, 21 patients had normal findings on the baseline electrocardiogram. In conclusion, AF could be one of the first clinical manifestations of latent BS in a considerable number of patients. This identification is crucial because the treatment of these patients is subject to relevant changes. The ajmaline test plays an essential role, mainly in young patients with a family history of sudden death, despite having normal findings on a baseline electrocardiogram.

Added value of transoesophageal echocardiography during transseptal puncture performed by inexperienced operators

AIMS Transseptal puncture (TP) appears to be safe in experienced hands; however, it can be associated with life-threatening complications. The aim of our study was to demonstrate the added value of routine use of transoesophageal echocardiography (TEE) for the correct positioning of the transseptal system in the fossa ovalis, thus potentially preventing complications during fluoroscopy-guided TP performed by inexperienced operators. METHODS AND RESULTS Two hundred and five patients undergoing pulmonary vein isolation procedure (PVI) for drug-resistant paroxysmal or persistent atrial fibrillation were prospectively included. When the operator (initially blinded to TEE) assumed that the transseptal system was in a correct position according to fluoroscopical landmarks, the latter was then checked with TEE unblinding the physician. If necessary, further refinement of the catheter position was performed. Refinement >10 mm, or in case of catheter pointing directly at the aortic root or posterior wall were considered as major repositioning. Thirty-four patients required major repositioning. Regression analysis revealed age (P: 0.0001, Wald: 12.9, 95% confidence interval: 1.04-1.16), left atrial diameter (P: 0.01, Wald: 6.6, 95% confidence interval: 1.04-1.34), previous PVI (P: 0.01, Wald: 6.3, 95% confidence interval: 1.31-8.76), and atrial septal thickness (P: 0.03, Wald: 4.5, 95% confidence interval: 1.05-3.4) as independent predictors of major revision with TEE. CONCLUSION Routine 2D TEE in addition to traditional fluoroscopic TP appears to be very useful to guide the TP assembly in a correct puncture position and thus, to avoid TP-related complications. However, further randomized prospective comparative studies are necessary to support these suggestions.

Value of electrocardiogram in the differentiation of hypertensive heart disease, hypertrophic cardiomyopathy, aortic stenosis, amyloidosis, and Fabry disease.

Left ventricular hypertrophy is 1 of the most frequent cardiac manifestations associated with an unfavorable prognosis. However, many different causes of left ventricular hypertrophy exist. The aim of the present study was to assess the diagnostic value of common electrocardiographic (ECG) parameters to differentiate Fabry disease (FD), amyloidosis, and nonobstructive hypertrophic cardiomyopathy (HC) from hypertensive heart disease (HHD) and aortic stenosis (AS). In 94 patients with newly diagnosed FD (n = 17), HHD (n = 20), amyloidosis (n = 17), AS (n = 20), and HC (n = 20), common ECG parameters were analyzed and tested for their diagnostic value. A stepwise approach including the Sokolow-Lyon index, corrected QT duration, and PQ interval minus P-wave duration in lead II to overcome P-wave abnormalities was applied. A corrected QT duration <440 ms in combination with a PQ interval minus P-wave duration in lead II <40 ms was 100% sensitive and 99% specific for the diagnosis of FD, whereas a corrected QT duration >440 ms and a Sokolow-Lyon index ≤1.5 mV were found to have a sensitivity and specificity of 85% and 100%, respectively, for the diagnosis of amyloidosis and differentiation from HC, AS, and HHD. Moreover, a novel index ([PQ interval minus P-wave duration in lead II multiplied by corrected QT duration]/Sokolow-Lyon index) proved to be highly diagnostic for the differentiation of amyloidosis (area under the curve 0.92) and FD (area under the curve 0.91) by receiver operator characteristic analysis. In conclusion, a combined analysis of PQ interval minus P-wave duration in lead II, corrected QT duration, and Sokolow-Lyon index proved highly sensitive and specific in the differentiation of FD, amyloidosis, and HC compared to HHD and AS. Analysis of these easy-to-assess ECG parameters may be of substantial help in the diagnostic workup of these 5 conditions.

Role of home monitoring in children with implantable cardioverter defibrillators for Brugada syndrome.

AIMS Implementation of remote home monitoring systems (HM) in clinical practice has become undoubtedly an added value for all patients with implantable cardiac devices. The aim of this study was to investigate the impact of HM in a population of children with Brugada syndrome (BS) who received an implantable cardioverter defibrillator (ICD). METHODS AND RESULTS Eleven children (age between 6 months and 18 years) implanted with an ICD were followed either by means of HM and with conventional in-hospital visits in our centre. Alerts and/or device-related clinical events were recorded, analysed, and subsequent clinical decisions were made if needed. During an average observation time of 26 months a total of 16 relevant alerts (13 pre-emptive alerts) were recorded in seven patients of our population. One patient experienced appropriate therapies for life-threatening ventricular arrhythmias. Three patients experienced inappropriate therapies due to supraventricular tachycardia and lead dislodgement. By means of HM two patients were discovered to have lead problems because of dislodgement or lead fracture. Mean anticipation of treatment based on the alerts was 76 ± 59 days. CONCLUSION Remote monitoring systems substantially improve the proper management of children with BS.

Cryoballoon ablation as index procedure for paroxysmal atrial fibrillation: long-term results from a single center early experience.

Aims Cryoballoon ablation (CRAB) as a modality for pulmonary vein isolation (PVI) is increasingly being accepted. We aim to study the long-term durability of CRAB in atrial fibrillation. Methods The first 51 consecutive patients with documented paroxysmal atrial fibrillation(PAF) who underwent CRAB at our institute were considered. Forty patients formed the study group. Successful PVI was achieved in all the patients. Patients were evaluated with Holter ECG recordings at 1, 3, 6 and 12 months and subsequent follow-up was biannual and based on the clinical status and physician discretion whether symptoms occurred. For the study purpose, a baseline ECG, a 24-h Holter and clinical evaluation were performed in all patients at final follow-up. Results A large 28-mm cryoballoon (CB) was used in 38 patients (95%), and the small 23-mm CB in the remaining two individuals (2%). The freedom from atrial fibrillation off-antiarrhythmic drug treatment (AAD) after a single procedure at a mean follow-up of 36.6 ± 4 months was 57.5% (23/40). Transient right phrenic nerve palsy was the most common complication. Conclusion Single balloon size CRAB provides a durable atrial fibrillation-free–AAD-free survival in drug-resistant PAF patients over long-term follow-up with a success rate of 57.5% with a single procedure.

A case of in vivo thrombogenicity of an externalized Riata ST lead

A 67-year-old man who had undergone implantation of a dual-chamber implantable cardioverter defibrillator (ICD) with a Riata lead, model #7020 (St Jude Medical) in 2007, 3 months ago presented with deterioration of heart failure. Interrogation of the ICD showed an …

A novel electrocardiographic index for the diagnosis of diastolic dysfunction

Background Although the assessment of diastolic dysfunction (DD) is an integral part of routine cardiologic examinations, little is known about associated electrocardiographic (ECG) changes. Our aim was to investigate a potential role of ECG indices for the recognition of patients with DD. Methods and Results ECG parameters correlating with echocardiographic findings of DD were retrospectively assessed in a derivation group of 172 individuals (83 controls with normal diastolic function, 89 patients with DD) and their diagnostic performance was tested in a validation group of 50 controls and 50 patients. The patient group with a DD Grade 1 and 2 showed longer QTc (422±24ms and 434±32ms vs. 409±25ms, p<0.0005) and shorter Tend–P and Tend–Q intervals, reflecting the electrical and mechanical diastole (240±78ms and 276±108ms vs. 373±110ms, p<0.0001; 409±85ms and 447±115ms vs. 526±119ms, p<0.0001). The PQ–interval was significantly longer in the patient group (169±28ms and 171±38ms vs. 153±22ms, p<0.005). After adjusting for possible confounders, a novel index (Tend–P/[PQxAge]) showed a high performance for the recognition of DD, stayed robust in the validation group (sensitivity 82%, specificity 93%, positive predictive value 93%, negative predictive value 82%, accuracy 88%) and proved a substantial added value when combined with the indexed left atrial volume (LAESVI, sensitivity 90%, specificity 92%, positive predictive value 95%, negative predictive value 86%, accuracy 91%). Conclusions A novel electrocardiographic index Tend–P/(PQxAge) demonstrates a high diagnostic accuracy for the diagnosis of DD and yields a substantial added value when combined with the LAESVI.