Gianluca Rigatelli

A Feasible Approach for Direct His-Bundle Pacing Using a New Steerable Catheter to Facilitate Precise Lead Placement

Introduction: Much clinical evidence has shown that right ventricular (RV) apical pacing is detrimental to left ventricular function. Preservation of the use of the His‐Purkinje (H‐P) system may be ideal in heart block that is restricted to the AV node, but may be of no benefit when H‐P disease exists.

Permanent Right-to-Left Shunt Is the Key Factor in Managing Patent Foramen Ovale

OBJECTIVES We sought to prospectively evaluate risk of stroke and impact of transcatheter patent foramen ovale (PFO) closure in patients with permanent right-to left shunt compared with those with Valsalva maneuver-induced right-to-left shunt. BACKGROUND Pathophysiology and properly management of PFO still remain far from being fully clarified: in particular, the contribution of permanent right-to-left shunt remains unknown. METHODS Between March 2006 and October 2010, we enrolled 180 (mean age 44 ± 10.9 years, 98 women) of 320 consecutive patients referred to our center for transcatheter PFO closure, who had spontaneous permanent right-to-left shunt on transcranial Doppler and transthoracic/transesophageal echocardiography. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative transesophageal echocardiography and brain magnetic resonance imaging, with subsequent intracardiac echocardiographic-guided transcatheter PFO closure. We compared the clinical echocardiographic characteristics of these patients (Permanent Group) with the rest of 140 patients with right-to-left shunt only during Valsalva maneuver (Valsalva Group). RESULTS Compared with the Valsalva Group patients, patients of the Permanent Group had increased frequency of multiple ischemic brain lesions on magnetic resonance imaging, previous recurrent stroke, previous peripheral arteries embolism, migraine with aura, and-more frequently-atrial septal aneurysm and prominent Eustachian valve. The presence of permanent shunt confers the highest risk of recurrent stroke (odds ratio: 5.9, 95% confidence interval: 2.0 to 12, p < 0.001). No differences were recorded between the 2 groups with regard to recurrence of ischemic events after the closure procedure. CONCLUSIONS Despite its small-sample nature, our study suggests that patients with permanent right-to-left shunt have potentially a higher risk of paradoxical embolism compared with those without.

Persistent venous valves correlate with increased shunt and multiple preceding cryptogenic embolic events in patients with patent foramen ovale: an intracardiac echocardiographic study.

It has been suggested that prominent Eustachian valve (EV) and Chiaris network (CN) predispose to paradoxical embolism but their presence in patients with presumed paradoxical stroke is not always easily detectable by transesophageal echocardiography (TEE). We sought to prospectively assess the frequency of EV/CN as assessed by intracardiac echocardiography (ICE) in patients submitted to patent foramen ovale (PFO) transcatheter closure in order to investigate their role in determining shunt severity and risk of multiple paradoxical embolisms.

Primary Transcatheter Patent Foramen Ovale Closure Is Effective in Improving Migraine in Patients With High-Risk Anatomic and Functional Characteristics for Paradoxical Embolism

OBJECTIVES In the present study, we sought to assess the effectiveness of migraine treatment by means of primary patent foramen ovale (PFO) transcatheter closure in patients with anatomical and functional characteristics predisposing to paradoxical embolism without previous cerebral ischemia. BACKGROUND The exact role for transcatheter closure of PFO in migraine therapy has yet to be elucidated. METHODS We enrolled 86 patients (68 female, mean age 40.0 +/- 3.7 years) referred to our center over a 48-month period for a prospective study to evaluate severe, disabling, medication-refractory migraine and documented PFO. The Migraine Disability Assessment Score (MIDAS) was used to assess the incidence and severity of migraine. Criteria for intervention included all of the following: basal shunt and shower/curtain shunt pattern on transcranial Doppler and echocardiography, presence of interatrial septal aneurysm and Eustachian valve, 3 to 4 class MIDAS score, coagulation abnormalities, and medication-refractory migraine with or without aura. RESULTS On the basis of our inclusion criteria, we enrolled 40 patients (34 females, mean age 35.0 +/- 6.7 years, mean MIDAS 35.8 +/- 4.7) for transcatheter PFO closure; the remainder continued on previous medical therapy. Percutaneous closure was successful in all cases, with no peri-procedural or in-hospital complications. After a mean follow-up of 29.2 +/- 14.8 months (range 6 to 48 months), PFO closure was complete in 95%; all patients (100%) reported improved migraine symptomatology (mean MIDAS score 8.3 +/- 7.8, p < 0.03). Specifically, auras were eliminated in 100% of patients after closure. CONCLUSIONS Primary transcatheter PFO closure resulted in a very significant reduction in migraine in patients satisfying our criteria.

Validation of a Clinical-Significance-Based Classification of Coronary Artery Anomalies

The clinical significance and subsequent management of the various types of coronary artery anomalies (CAAs) are different, as is the relationship to sudden death, coronary artery disease, and myocardial ischemia. A practical global classification based on clinical significance has not yet been proposed. This retrospective study was aimed at evaluating the current clinical significance of CAAs and the effectiveness of a clinical-significance-based classification. In a single-center retrospective study at a public hospital, a review of the last 5,100 coronary angiographies was performed in order to select patients with CAAs. The CAAs were classified into 4 categories on the basis of a literature review according to angiographic appearance and clinical significance: benign (class I); relevant—associated with fixed myocardial ischemia (class II); severe—related to sudden death (class III); and critical—associated with superimposed coronary artery disease (CAD) (class IV). Clinical and instrumental records of the selected patients were reviewed as well as the occurrence of cardiovascular events from the date of diagnosis to July 2002. Sixty-two patients (1.2%, women/men 20/42, mean age 65.3 ±10.6 years) had CAA on coronary angiography. From the above-described classification, 40 patients were categorized in class I (64.5%), 9 in class II (14.5%), 7 in class III (11.3%), and 6 in class IV (9.7%). During the follow-up (mean duration 60.4 ±12.3 months) most cardiovascular events and death occurred in class III and IV patients (71.3% and 100% respectively). A high correlation was found between significance level and percentage of patients with cardiovascular events (r =0.99). Actuarial survival at 5 years was 82.9%. CAAs can be practically classified on the basis of clinical presentation and significance. This clinical classification may be useful in managing patients with CAA and personalizing their follow-up and therapeutic options according to their class and case histories.

Resolution of migraine by transcatheter patent foramen ovale closure with premere occlusion system in a preliminary series of patients with previous cerebral ischemia

Transcatheter closure of PFO with nitinol devices may be problematic in young patients with migraine due the risk of late erosions. Alternative devices with less amount of metal as the last generation devices may be preferable in such cases. We present the results of transcatheter closure of PFO with the last generation Premere Occlusion System device in a preliminary series of young adults with migraine and previous cerebral ischemia.

Patent oval foramen transcatheter closure: results of a strategy based on tailoring the device to the specific patient’s anatomy

BACKGROUND Usually the literature results for device-closure of patent oval foramen concern a single type of device or different devices implanted without anatomical preferences. We propose a strategy of device type and selection based on intra-cardiac echocardiography measurements of inter-atrial septum characteristics. METHODS We prospectively enrolled 100 consecutive patients with a mean age of 43 plus or minus 15.5 years, 68 females, who had been referred to our centre for catheter-based closure of inter-atrial shunts over a 48-month period. On the basis of intra-cardiac echocardiography findings the operators selected the Amplatzer Occluder family (AGA Medical Corporation) or the Premere Closure System (St Jude Medical Inc.). Determinants of the selection process were presence and extension of atrial septal aneurysm, tunnel length, rims length, and thickness, presence of additional fenestrations. RESULTS According on intra-cardiac echocardiography study, 26 patients have a long channel patent oval foramen, 44 patients had a large atrial septal aneurysm (more than four RL), 24 patients had a moderate atrial septal aneurysm (more than two RL but less than four right-to-left), and six patients had hypertrophic rims. Thus, the Amplatzer PFO Occluder was selected in 24 patients, the Amplatzer ASD Cribriform Occluder in 44 patients, and the Premere device in 32 cases. No aortic erosions, device thrombosis, or recurrent ischaemic cerebral events were observed. Pre-discharge and follow-up occlusion rates were 91% and 96%, respectively. CONCLUSIONS Our study suggested that such strategy driven from identification and measurements of the right atrium and inter-atrial septum components resulted in low complications and high-success rates, mandatory conditions when facing with otherwise healthy subjects, such as the patients with patent oval foramen.

The Association of Different Right Atrium Anatomical-Functional Characteristics Correlates with the Risk of Paradoxical Stroke: An Intracardiac Echocardiographic Study

BACKGROUND The contribution of different right atrium anatomical-functional characteristics to the risk of paradoxical stroke has not been extensively investigated, probably in part because of the limits of standard echocardiography. OBJECTIVE We sought to assess, using intracardiac echocardiography (ICE), the right atrium anatomical-functional characteristics and their role in the pathophysiology of paradoxical embolism in a sample of patent foramen ovale (PFO) patients undergoing transcatheter PFO closure. METHODS Over a 36-month period, we prospectively enrolled 114 consecutive patients (mean age 38+/- 10.5 years, 67 female) referred to our center for PFO catheter-based closure. On ICE study, all sensible characteristics other than PFO and mild ASA were recorded, including prominent EV or large CN, basal shunt without Valsalva maneuver, moderate to severe ASA, and multiperforated fossa ovalis. RESULTS After TEE and ICE study and measurements, a prominent EV or CN was diagnosed on ICE in 73%, a basal shunt was present in 48%, a moderate to severe ASA in 47%, and a multiperforated FO in 24% of patients. A tight correlation between number of concurrent factors and proportion of patients with curtain pattern on TC Doppler, larger right-to-left shunt, recurrent cerebral paradoxical embolism before closure, and migraine with aura was clearly evident (r > or = 0.97). Basal shunt and concurrent > or = 3 anatomical functional right atrium characteristics resulted as independent predictors of recurrent paradoxical embolisms. CONCLUSIONS Our data suggest that right atrium anatomical-functional characteristics other than PFO and mild ASA as assessed by ICE deeply affect the pathophysiology of paradoxical stroke.

Congenital heart diseases in aged patients: clinical features, diagnosis, and therapeutic indications based on the analysis of a twenty five-year Medline search.

Objectives: The increasing aging of the population make congenital heart disease more likely to be found in aged patients. No systematic data exist on epidemiology, diagnosis, and therapy in this complex class of patients. The purpose of this study was to provide specific clinical, diagnostic, and therapeutic information concerning patients over 65 with congenital heart disease (CHDs) and to identify the most frequent CHDs in such class of patients. Methods: A Medline search was performed to include articles related to congenital heart disease in patients over 65 in worldwide literature from January 1977 to January 2004. Follow-up studies of old, operated CHDs were excluded. The selected papers were divided and numbered on the basis of key words in the title and contents into general, diagnostic, and therapeutic topics. Results: One thousand ninety-five articles met the search criteria. Atrial septal abnormalities, coronary artery anomalies, bicuspid aorta and congenital aortic valve stenosis, and patent ductus arteriosus resulted in the most cited CHDs in the elderly. Clinical manifestations included syncope, supraventricular/ventricular arrhythmias, symptoms of chronic pulmonary hypertension, and congestive heart failure. Echocardiography for the most frequent CHDs and computed tomography and magnetic resonance for complex cases were the main diagnostic tools (277, 104, and 110 citations, respectively). Catheterization plays a marginal role (68 articles). Age is not considered a contraindication to interventions; surgical and endovascular therapy appeared to be similarly useful in managing the most frequent CHDs (88 and 63 citations, respectively), whereas medical treatments were selected for most complex CHDs (71 citations). Conclusions: Patients with CHDs, especially those with low mortality in childhood, are more frequently reaching old age. New imaging techniques and endovascular treatments seem useful in the challenging management of CHDs in aged patients.

Transcatheter Amplatzer duct occluder closure of direct right pulmonary to left atrium communication.

Although rare, a congenital direct communication between pulmonary artery and left atrium can present a paradoxical embolism in adults. In our case, diagnosis was first made on contrast transcranial Doppler with Valsalva maneuver and subsequently confirmed by intracardiac echocardiography and selective pulmonary angiography. Successful catheter‐based closure using Amplatzer duct occluder device resulted in definitive exclusion of the source of paradoxical embolism. Cathet Cardiovasc Intervent 2003;58:107–110.