Fabrizio Guarracini

Early diagnosis of left ventricular diastolic dysfunction in diabetic patients: a possible role for natriuretic peptides

BackgroundThe aim of the present study was to verify whether BNP might detect pre-clinical diastolic dysfunction (LVDD) in type-2 diabetic patients.MethodsOne-hundred and twenty-seven consecutive outpatients with type-2 diabetes mellitus were enrolled into the study. Subjects with overt heart failure or NYHA class > 1, history of coronary artery disease, severe valvulopathy or chronic atrial fibrillation were excluded from the study. All patients underwent clinical evaluation, laboratory assessment of brain natriuretic peptide (BNP) and echocardiographic examination.ResultsNo patients showed systolic impairment of left ventricular function, whereas diastolic dysfunction was detected in 53 (42%) cases (all impaired relaxation). Median BNP was 27 pg/ml without any significant difference between 76 patients with normal left ventricular function and 53 with diastolic dysfunction; in 54 (43%) patients showing HBA1C≥8 (uncontrolled diabetes) normal function was found in 32 and diastolic dysfunction in 22, with a significant difference of BNP at multivariate analysis (OR = 1.02, 95%CI = 1.05-1.09, p = 0.003). In uncontrolled diabetic cohort, BNP was a strong predictor for LVDD (OR = 2.7, 95%CI = 1.3-5.6, p = 0.006) along with the duration of diabetes (OR = 1.6, 95%CI = 1.1-2.9, p = 0.046). BNP > 25 pg/ml was a cut-off value with high accuracy to detect a LVDD.DiscussionEarly screening of high-risk patients for diabetic cardiomyopathy development might be useful to better control glycemic profile in order to reduce heart disease progression or even to reverse itConclusionsBNP could be a cheap, easy and useful tool to screen those ones with preclinical ventricular diastolic dysfunction in a subset of patients particularly prone to develop cardiovascular complications, like uncontrolled diabetic patients.

Radiation dose among different cardiac and vascular invasive procedures: The RODEO study

BACKGROUNDnInterventional radiology and cardiology procedures contribute significantly to the collective dose of radiation exposure from medical interventions. Recent and dedicated studies comparing directly these procedures in term of patient radiation exposure are lacking. Our aim was to compare radiation exposure among different interventional procedures performed under fluoroscopic guidance.nnnMETHODSnThe RODEO study (NCT: 02972736) is an international observational retrospective multicenter study enrolling all patients undergoing diagnostic or interventional procedures performed by different interventional operators (i.e. radiologists, interventional cardiologists or electrophysiologists) in 6 centers, without exclusion criteria. The primary end-point of the study was the comparison of dose area product (DAP) among interventional cardiology, electrophysiology or interventional radiology procedures.nnnRESULTSnA total of 17,711 procedures were included in the study: 13,522 interventional cardiology, 2352 electrophysiology and 1864 interventional radiology procedures. The highest DAP values were observed for interventional radiology procedures (74Gy∗cm2 [Interquartile range 27-178Gy∗cm2]), followed by interventional cardiology (40Gy∗cm2 [22-78Gy∗cm2]) and electrophysiology procedures (13Gy∗cm2 [4-44Gy∗cm2], p<0.0001). In term of specific procedures, the highest DAP values were observed in structural or valvular cardiac procedures (134Gy∗cm2 [51-260Gy∗cm2]) whereas the lowest DAP values in pacemaker insertion (11Gy∗cm2 [4-28Gy∗cm2]).nnnCONCLUSIONnIn this large multicenter study, the highest radiation exposure was observed in procedures performed by interventional radiologists. However, among specific procedures, structural or valvular cardiac procedures were associated with the highest radiation exposure.

A Cost-Effective Analysis of Systematically Using Mapping Systems During Catheter Ablation Procedures in Children and Teenagers

The aim of this study is to evaluate the cost-effectiveness of an extended use of 3D non-fluoroscopic mapping systems (NMSs) during paediatric catheter ablation (CA) in an adult EP Lab. This study includes 58 consecutive patients (aged between 8 and 18) who underwent CA from March 2005 to February 2015. We compare the fluoroscopy data of two groups: group I, patients who underwent CA from 2005 to 2008 using only fluoroscopy, and group II, patients who underwent CA from 2008 to 2015 performed also using NMSs. Two cost-effectiveness analyses were carried out: the first method was based on the alpha value (AV), and the second one was based on the value of a statistical life (VSL). For both methods, a children’s correction factor was also considered. The reduction cost estimated from all these methods was compared to the real additional cost of using NMSs. The use of an NMS during a CA procedure has led to an effective dose reduction (ΔE) of 2.8 milli-Sievert. All presented methods are based on parameters with a wide range of values. The use of an NMS, applying directly AV values or VSL values, is not cost-effective for most countries. Only considering the children’s correction factor, the CA procedure using an NMS seems to be cost-effective. The cost-effectiveness of a systematic use of NMSs during CA procedures in children and teenagers remains a challenging task. A positive result depends on which value of AV or VSL is considered and if the children’s correction factor is applied or not.

Minimally Invasive Thoracoscopic Technique for LV Lead Implantation in CRT Patients

Background: Epicardial placement of the left ventricular (LV) lead is an alternative approach to the standard cardiac resynchronization therapy (CRT) procedure. In our center we developed a minimally invasive thoracoscopic technique. We reviewed our experience to evaluate the long-term safety and effectiveness of the technique. Methods: The procedure is performed under general anesthesia with oro-tracheal intubation and right-sided ventilation, and requires 3 thoracoscopic ports (two 5-mm and one 15-mm). We analyzed 94 consecutive patients referred to our center for epicardial LV lead implantation. Results: Five patients were excluded because of concomitant conditions precluding surgery or lack of indication for CRT. The remaining 89 patients underwent the procedure. Of these, 57 had undergone previous unsuccessful LV lead implantation (Group 1). In the remaining 32 patients, effective CRT was discontinued owing to LV lead dislodgment (Group 2). LV lead implantation was successful in all patients (median pacing threshold 0.8V, IQR: 0.6-1.2, at 0.5 ms, no phrenic nerve stimulation) and CRT was successfully established in all but one patient. No complications were reported, except for 2 cases of transitory peri-electrode bleeding and 3 cases of ventricular fibrillation induced during the procedure (no sequelae). The median procedure time was 75 min (IQR: 55-95). During a median follow-up of 24 [IQR: 13-39] months, 21 patients died and 4 additional device-related complications were reported (comparable rates between groups). Conclusions: Our thoracoscopic approach proved to be safe and effective. It is a viable alternative to the standard transvenous approach in the case of failed de novo implantation and in those patients who positively respond to CRT but experience LV lead dislodgment.

A late presentation of congenital cardiac anomaly: Accessory chordae from the left atrium causing severe mitral regurgitation

Mitral regurgitation secondary to accessory mitral valve (MV) chordae of the left atrium is an extremely rare congenital disease. A 85‐year‐old female (NYHA I–II) was hospitalized for investigations. An echocardiogram showed calcification of the MV with mild stenosis and moderate regurgitation. Transesophageal three‐dimensional echocardiogram revealed a band‐like structure extending from the distal third of the anterior wall of the left atrium to the MV. This accessory chordae determined severe systolic regurgitation and mild mitral stenosis. The patient was referred for consideration of cardiac surgery but was refused for comorbidities and anatomy. Usually aberrant chordae determinant valvulopathies are detected and treated at a much younger age. The delay of the symptoms could be explained in our case with the progressive growth and dilatation of the left atrium causing traction of the aberrant chord resulting in an increase in the leaflet prolapse and regurgitation.

Transcatheter Ablation in Athletes

The natural history of arrhythmias has suffered an epochal change after the advent of transcatheter ablation. It is a minimally invasive procedure that enables the elimination of additional electric circuits or foci that are responsible for supraventricular and ventricular arrhythmias. In most cases it is carried out under local anesthesia, for which the patient, who is perfectly conscious or possibly mildly sedated, follows the operations and cooperates actively in the procedure and can at any moment communicate with the medical team. The catheters are inserted through venous and/or, more rarely, arterial vascular access points and are moved painlessly and under radioscopic guidance towards the heart. All the material used is completely sterile and for single use. The electrocatheters are positioned in certain anatomically defined areas of the heart, and the electric signals corresponding to cardiac activity are registered.

Electrophysiological Studies in Athletes

Electrophysiological studies are instrumental methods enabling the registration of electric endocavitary cardiac signals relative to the various phases of the cardiac cycle. Registration is carried out through unipolar or bipolar electrocatheters, which also allow electrical stimulation of the heart. Stimulation of the cardiac chambers is an extremely useful method for accurately measuring intervals and/or pauses and for reproducing in the laboratory arrhythmias that patients may experience clinically (arrhythmic inducibility test). Electrophysiological evaluations can be performed via the transesophageal or endocavitary pathways. All the material used both for endocavitary and transesophageal electrophysiological studies is sterile and for single use.

L’ablazione transcatetere negli atleti

L’ablazione transcatetere e una procedura che si esegue in anestesia locale, minimamente invasiva e che permette di eliminare i circuiti elettrici accessori o i foci responsabili delle aritmie sopraventricolari e ventricolari.

Lo studio elettrofisiologico negli atleti

Lo studio elettrofisiologico e una metodica strumentale che permette la registrazione dei segnali elettrici endocavitari cardiaci relativi alle varie fasi del ciclo cardiaco. La valutazione elettrofisiologica puo essere effettuata per via transesofagea o endocavitaria. La prima presenta dei limiti che consistono nella esiguita di informazioni elettriche (registrazione solo di segnali atriali) rispetto a uno studio endocavitario completo durante il quale e possibile stimolare sia le camere ventricolari che atriali ed eseguire contestualmente una procedura ablativa.