Francesca Salghetti

A New Antiarrhythmic Drug in the Treatment of Recent-Onset Atrial Fibrillation: Vernakalant

Vernakalant is a new antiarrhythmic agent recently approved in Europe for the rapid cardioversion of recent-onset atrial fibrillation. It works by blocking early-activating K+ atrial channels and frequency-dependent atrial Na+ channels, prolonging atrial refractory periods and rate-dependent slowing atrial conduction, without promoting ventricular arrhythmia. Preclinical and clinical trials showed good toleration of this drug. The main purpose of our review is to describe all the trials that led to the incorporation of vernakalant into the current European atrial fibrillation guidelines.

Predicting the difficulty of a transvenous lead extraction procedure: Validation of the LED index: BONTEMPI et al .

A lead extraction difficulty (LED) score was proposed to predict the difficult transvenous lead extraction (TLE) procedures, defined by means of the fluoroscopy time. The aim of this study was to validate the estimation model based on the LED index above 10 on an independent data set of TLE cases.

Elastic Aortic Properties in Patients with X Syndrome

INTRODUCTION Elastic properties of the aorta represent an important determinant of left ventricular function and coronary blood flow but there are few data about aortic stiffness in patients with X syndrome. AIM To investigate the elastic aortic proprieties (aortic stiffness and distensibility) and arterial wall motion velocities as measured by tissue Doppler imaging (TDI) in patients with cardiac X syndrome. MATERIALS AND METHODS Fifteen patients with X syndrome (typical chest pain and angiographically normal coronary arteries associated with a positive exercise test) were enrolled in the study. The control group consisted of 15 healthy patients. The aortic elastic indexes, namely distensibility (cm(2) dyne(-1)) and stiffness index (β index) were calculated from M-mode echocardiographically-derived thoracic aortic diameters using accepted formulae, and TDI parameters were measured on the wall of the ascending aorta 3 cm above the aortic valve. Anterior wall aortic expansion velocity (S), early (E) and late (A) diastolic retraction velocity and peak systolic strain were determined. RESULTS Aortic elastic proprieties were more impaired in the syndrome X group than in the control group. Aortic distensibility was significantly lower in the syndrome X group (3.2 ± 1.3 vs. 7.95 ± 4 cm(2) dyne(-1), p<0.001), while stiffness index was higher (7.3 ± 2.1 vs. 4.1 ± 1.6, p<0.001) than in the control group. Peak systolic (S) and diastolic waves (E and A waves) of the aortic wall TDI were similar in patients and controls (S wave: 5.7 ± 1.6 cm/s vs. 5.8 ± 1.6 cm/s, E wave: -4.8 ± 2.0 vs. -4.1 ± 2.0 cm/s; A wave: -4.32 ± 2.1 vs. -4.76 ± 1.8 cm/s) while tissue strain of the aortic wall was lower in patients with X syndrome than controls (-12.80 ± 7% vs. -22.3 ± 5.9%, p<0.00001). CONCLUSION Deterioration in aortic elasticity properties in patients with cardiac syndrome X suggests that this disease may be a more generalised disturbance of the vasculature.

Characteristics and mid-term follow-up of a single-center population affected by Tako-Tsubo cardiomyopathy.

Introduction Tako-Tsubo cardiomyopathy (TTC) is an acute cardiomyopathy mimicking acute myocardial infarction. The aim of our study was to define clinical and instrumental features of an Italian population of patients with TTC and to report their short and mid-term outcome. Methods We retrospectively evaluated 42 patients admitted to our Department with diagnosis of TTC (100% women, age 67 ± 11 years) using Mayo Clinic-modified criteria. In this population, we analyzed the stressful event (if present), the clinical presentation, the ECG and echocardiogram at admission and the markers of myocardial cytonecrosis, such as troponin I, at admission and during the hospitalization. All the patients have been clinically evaluated after 6 months and 1 year of follow-up. Results In this population, a stressful event before TTC has been detected in 59% of patients. The most common clinical presentation was chest pain (81%) and the major sign was dyspnea (17%). ECG showed negative T waves and ST elevation, respectively, in 45 and 38%. Only 10% had a ST depression and 7% developed a newly acquired complete left bundle branch block. All of these abnormalities disappeared within 1.8 ± 0.9 days. The mean ejection fraction at admission was 35 ± 7% associated with apical (40%), mid-apical (56%) and mid-ventricular (4%) wall motion abnormalities. The recovery of these abnormalities occurred within 10 ± 3 days. At 6-month and 1-year follow-up, no patients had TTC recurrence, and 10 patients at 6 months and 20 patients at 1 year were re-hospitalized for a non-cardiac cause. Conclusion Our data describe the characteristics of TTC in a small Italian population, which are similarly described in Japanese and North American people. TTC was related to a very low mortality, both in the short and mid term, but the risk of acute heart failure in the acute phase could not be neglected.

Extraction of a coronary sinus lead: always so easy?

Lead extraction is a complex procedure associated with potential risks and requires considerable experience of the operator in the use of specific techniques and tools. With the exception of active fixation leads, the extraction procedure of coronary sinus leads is less complex and risky, in the absence of adhesions with other vascular leads. We report a difficult coronary sinus lead extraction, which required both superior (subclavian) and inferior (femoral) approaches and the use of multiple lead extraction tools. In order to perform a well tolerated and effective extraction procedure, well trained and experienced staff in a well equipped setting is, therefore, mandatory even for apparently simple cases.

Ranolazine therapy in drug-refractory ventricular arrhythmias

Aims Ranolazine is an antiischemic and antianginal agent, but experimental and preclinical data provided evidence of additional antiarrhythmic properties. The aim of this study was to evaluate the safety and efficacy of ranolazine in reducing episodes of ventricular arrhythmias in patients with recurrent antiarrhythmic drug-refractory ventricular arrhythmias or with chronic angina. Methods Seventeen implantable cardioverter defibrillator (ICD) recipients, who had experienced a worsening of their ventricular arrhythmia burden, and 12 ICD recipients with angina were enrolled. Patients were followed up for 6 months after the addition of ranolazine (postranolazine). Data were compared with before its administration (preranolazine). Results In the Arrhythmias group, a significant reduction was found in the median number of ventricular tachycardia episodes per patient (4 vs. 0, P = 0.01), and in ICD interventions in terms of both antitachycardia pacing (2 vs. 0, P = 0.04) and shock delivery (2 vs. 0, P = 0.02) after the addition of ranolazine. Moreover, fewer patients experienced episodes of nonsustained ventricular tachycardia (71 vs. 41%, P = 0.04), ventricular tachycardia (76 vs. 24%, P = 0.01), ICD antitachycardia pacing (47 vs. 18%, P = 0.02), and ICD shocks (47 vs. 6%, P = 0.03). In the Angina group, none of the patients developed major ventricular arrhythmias while on ranolazine treatment. No adverse effects were observed. Conclusion In this small study, ranolazine proved to be effective, well tolerated, and safe in reducing ventricular arrhythmia episodes and ICD interventions in patients with recurrent antiarrhythmic drug-refractory events. In addition, none of the patients with chronic angina developed major ventricular arrhythmias.

Can we implant left ventricle pacing lead in a patient with coronary sinus reducer

A 77-year-old man, who had a coronary sinus (CS) Reducer SystemTM (Neovasc, Canada) for refractory angina treatment implanted since 8 months, was referred for cardiac resynchronization therapy (CRT). The CS reducer is a stainless steel balloon-expandable hourglass-shaped stent, designed to create a focal narrowing leading to increased pressure in CS. The diameter of its mid portion is 3 mm (9F), and it can reach diameter of 7–13 mm (21–39F) at both ends. Recent studies have shown significant improvements in patients with refractory angina who were not candidates for revascularization [1, 2]. In order to position the left ventricular pacing lead, a CS angiography was performed showing the reducer system with a partial occlusion of the vessel lumen (Fig. 1A). A 5-Fr electrophysiology catheter was easily pushed through the reducer while the 9-Fr delivery sheath was stopped before the minimum diameter of the stent. A guidewire was inserted until the target postero-lateral vein and a 5-Fr quadripolar lead (QuartetTM LV, St Jude Medical, St Paul, MN, USA) was positioned using an over-the-wire approach (Fig. 1B). The CRT system implantation was completed successfully and a final angiography excluded the total occlusion of CS (Fig. 1C). To our knowledge, this is the first case of lead implantation in a patient with CS reducer, which could arise concerns considering the partial occlusion of the vessel. The procedure was feasible without any peculiar drawbacks as compared to a standard CRT implantation. No data are available on the long-term consequences of CS lead placement across this reducer system, including possibility of total occlusion or difficulty in lead extraction. Of note, in some anatomy of the CS branch, the insertion of the pacing lead may become more difficult due to lack of sufficient support from the sheath.

Endothelial dysfunction assessment by noninvasive peripheral arterial tonometry in patients with chronic obstructive pulmonary disease compared with healthy subjects

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of cardiovascular disease. The endothelial dysfunction likely plays a central role in increasing cardiovascular risk.

Thoracoscopic Implantation of an Array Electrode in the Pericardium Transverse Sinus to Reduce Defibrillation Threshold

Among the implantable cardioverter defibrillator recipients, there is still a subgroup of patients in whom the defibrillation threshold is too high and the maximal shock output of the implantable cardioverter defibrillator can fail to terminate a ventricular arrhythmia. We report a new thoracoscopic minimally invasive approach to place a standard array electrode in the transverse pericardial sinus of a patient implanted with a cardiac resynchronization and defibrillation therapy device with persistent high defibrillation threshold. This approach was developed to achieve very low shock impedance with a consequent increase in the current flow and reduction of defibrillation threshold.

Concomitant Brugada syndrome substrate ablation and epicardial abdominal cardioverter-defibrillator implantation in a child

Introduction Brugada syndrome (BrS) is a primary electrical disease of autosomal dominant inheritance, characterized by covedtype ST-segment elevation in the right precordial leads and increased risk of sudden cardiac death. Although the initial description included 3 children in a series of 8 patients, the prevalence of BrS in pediatric populations was extremely low (0.0098%) in subsequent studies compared to adults in the fourth or fifth decade of life (range 0.14%–0.7%). We report the case of a 3-year-old boy with highly symptomatic BrS, focusing on the feasibility and safety of combined epicardial substrate ablation of the right ventricular outflow tract (RVOT) and implantation of an epicardial implantable cardioverter-defibrillator (ICD).