Fabrizio Gimigliano

Patent foramen ovale and cryptogenic stroke. A critical review.

The underlying causes of ischemic stroke in young patients are often difficult to find, despite systematic investigations concerning heart, coagulation system or any other type of vascular disease, thus the definition of ‘cryptogenic’. In patients with cryptogenic stroke, the prevalence of a patent foramen ovale is about 45%, versus 25% of the general healthy population, leading to many speculations about a potential role of intracardiac right-to-left shunts in determining ischemic cerebral disease. Since a possible mechanism has been thought to be paradoxical embolism, percutaneous closure of the foramen ovale is currently discussed, at least until the appearance of data from the ongoing randomized trials. However, recurrent paradoxical embolism in patients with an aneurysmal atrial septum and a patent foramen ovale is currently the only unequivocal indication for percutaneous closure. Professional divers may benefit from the procedure as well, whereas migraine is still not considered an indication. In the pediatric population, closure of the patent foramen ovale seems to be safe and effective to prevent recurrent stroke. As the complication rate for device implantation decreases, the threshold for percutaneous closure is likely to decline.

Ventricular pre-excitation: symptomatic and asymptomatic children have the same potential risk of sudden cardiac death

AIMS Children and adolescents with ventricular pre-excitation (VPE) are at increased risk for sudden cardiac death (SCD). Although antiarrhythmic therapy and catheter ablation are well established temporary or definitive treatments for patients with Wolff-Parkinson-White (WPW) syndrome, the optimal management of children with asymptomatic VPE remains to be clearly defined. On the basis of the most recent guidelines and recommendations, the aim of this study was to determine the electrophysiological characteristics of young patients with VPE and WPW syndrome to assess and compare their potential risk of SCD. METHODS AND RESULTS We retrospectively investigated 124 consecutive young patients with VPE (51 with WPW syndrome and 73 asymptomatic) who underwent transoesophageal electrophysiological study. At baseline, atrioventricular reentrant tachycardia (AVRT) was induced in 13 WPW vs. 10 asymptomatic patients (25.5 vs. 13.7%, P = NS). Atrial fibrillation (AF) was induced in 13 WPW vs. 15 asymptomatic patients (25.5 vs. 20.5%, P = NS). A shortest pre-excited R-R interval (SPERRI) ≤250 ms during AF was found in four WPW vs. six asymptomatic patients (30.8 vs. 40%, P = NS). During isoproterenol infusion or stress testing, AVRT was induced in 31 of 44 WPW vs. 33 of 69 asymptomatic patients (70.4 vs. 47.8%, P = 0.018). Atrial fibrillation was induced in 12 of 44 WPW vs. 21 of 69 asymptomatic patients (27.3 vs. 30.4%, P = NS). A SPERRI ≤ 210 ms was found in 6 of 12 WPW vs. 10 of 21 asymptomatic patients (50 vs. 47.6%, P = NS). No statistically significant correlation was observed between accessory pathway location and symptoms, AVRT/AF inducibility, or mean APERP/SPERRI values. CONCLUSION Children and adolescents with WPW syndrome have a higher rate of AVRT inducibility than asymptomatic patients. However, no differences between the two groups were found in atrial vulnerability and parameters related to the risk of SCD.

Blood Pressure and Left Ventricular Characteristics in Young Patients with Classical Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency

High steroid doses are often necessary in congenital adrenal hyperplasia (CAH) to suppress androgens and may increase blood pressure (BP). We evaluated 24-hour BP profile (ambBP), BP during exercise (excBP), and echocardiography in 20 young CAH patients. Systolic and diastolic BP during ambBP and excBP was normal in all patients. None presented myocardial hypertrophy. Nocturnal diastolic BP was affected by testosterone (: .016, 95% CI: 0.002 to 0.021, = 0.01). Left ventricular mass (LVM ) was affected by height SDS (: .007, 95% CI: 2.67 to 14.17, = 8.42), age (: , 95% CI: 2.12 to 5.82, = 3.97), and testosterone (: .008, 95% CI: 0.01 to 0.09, = 0.053). Left ventricular mass index (LVMI) correlated with BMI SDS (: .044, 95% CI: 0.09 to 6.17, = 3.13) and testosterone (: .031, 95% CI: 0.002 to 0.035, = 0.018). Hydrocortisone dose did not influence ambBP, excBP, or myocardial hypertrophy.

Miniaturized Implantable Loop Recorder in Small Patients: An Effective Approach to the Evaluation of Subjects at Risk of Sudden Death

The etiological diagnosis of syncope and/or palpitations in children is often challenging. However, when noninvasive conventional examinations are inconclusive, the subcutaneous miniaturized implantable loop recorder (ILR) is recommended. The aim of our study was to evaluate the efficacy of miniaturized cardiac implantable devices in the early diagnosis of arrhythmias in children ≤6 years.

Dysfunctional Behaviors in Children and Adolescents with NeurocardiogenicSyncope

Objective: We evaluate a large sample of children and adolescent with suspected neurocardiogenic syncope (NCS) and we compared the results with a healthy sample, with the aim to reveal a possible correlation between syncopal events and dysfunctional behaviors. Methods: A total number of ninety two patients with NCS (median age 14.7 years) were evaluated with Head-Up Tilt Test (HUTT) and psychological assessment at the same time. The results of the ninety two patients who underwent HUTT and completed psychological tests were compared with a normative group. The risk of psychosocial dysfunctions was assessed by using the standardized Italian version of the Child Behavior Checklist in Youth Self Report (YSR). Results: Compared with normative group, patients with NCS reported worse scores to the internalizing and total problem scales and to the syndrome scales of anxiety problems, depressive withdrawal problems, somatic complaints, social problems and thought problems. Conclusions: Patients with NCS present major emotional and behavioral dysfunctions than healthy sample. Our findings call for additional investigations on the possible pathophysiological association between psychosocial problems and the reflex mechanism that produces syncope. Furthermore, future clinical studies are necessary to plan an interventional strategy and optimize the clinical management.

Use of a Pediatric Syncope Unit Improves Diagnosis and Lowers Costs: A Hospital-Based Experience

Objectives To assess the effect of a dedicated pediatric syncope unit on the diagnostic and therapeutic management of children with suspected syncope. We also evaluated the effectiveness of the pediatric syncope unit model in decreasing unnecessary tests and hospitalizations, minimizing social costs, and improving diagnostic yield. Study design This single‐center cohort observational, prospective study enrolled 2278 consecutive children referred to Bambino Gesù Childrens Hospital from 2012 to 2017. Characteristics of the study population, number and type of admission examinations, and diagnostic findings before the pediatric syncope unit was implemented (2012‐2013) and after the pediatric syncope unit was implemented (2014‐2015 and 2016‐2017) were compared. Results The proportion of undefined syncope, number of unnecessary diagnostic tests performed, and number of hospital stay days decreased significantly (P < .0001), with an overall decrease in costs. A multivariable logistic regression analysis, adjusted for confounding variables (age, sex, number of diagnostic tests), the period after pediatric syncope unit (2016‐2017) resulted as the best independent predictor of effectiveness for a defined diagnosis of syncope (P < .0001). Conclusions Pediatric syncope unit organization with fast‐tracking access more appropriate diagnostic tests is effective in terms of accuracy of diagnostic yield and reduction of costs.

SYMPTOMATIC AND ASYMPTOMATIC CHILDREN WITH VENTRICULAR PREEXCITATION: SAME RISK FOR SUDDEN DEATH

Very recently, PACES/HRS Expert Consensus Statement on the Management of the Asymptomatic Young Patient with a WPW Electrocardiographic Pattern has been claimed that utilization of invasive risk stratification to assess the shortest preexcited R-R interval (SPERRI) in is reasonable in young patients