Lorenza Inama

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.

The novel active fixation coronary sinus lead: efficacy and safety of transvenous extraction procedure.

AIMS Benefits of cardiac resynchronization therapy (CRT) are well known for heart failure; however, some patients might experience complications related to the coronary sinus (CS) lead (high pacing threshold, phrenic nerve stimulation, and dislodgment) with unfavourable impact on quality of life, costs, and management. Lead stability is one of the most common unmet needs for CRT procedures. METHODS AND RESULTS Recently, new model Medtronic 20066 Attain Stability(®) (Maastricht, The Netherlands) active fixation LV lead has been released, to overcome this issue. The lead has a small side helix of 0.20 mm (0.008 in.) that allows for secure placement of the lead within the vein at the desired location. We report our first experience with the extraction of this novel active fixation left ventricular lead. CONCLUSION In our case, to our knowledge the first reported in humans, the extraction of this new model of active fixation lead was proved to be a safe and effective procedure at 8 months after implantation. Indeed, under angiographic and fluoroscopic check, there was no documented dissection or damage to the CS during and after removal of the lead. The rotation manoeuvre was effective when combined with moderate traction of the lead itself.

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.

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.

Unexpected challenging case of coronary sinus lead extraction

An 84-year-old woman implanted with cardiac resynchronization therapy defibrillator underwent transvenous lead extraction 4 mo after the implant due to pocket infection. Atrial and right ventricular leads were easily extracted, while the attempt to remove the coronary sinus (CS) lead was unsuccessful. A few weeks later a new extraction procedure was performed in our center. A stepwise approach was used. Firstly, manual traction was unsuccessfully attempted, even with proper-sized locking stylet. Secondly, mechanical dilatation was used with a single inner sheath placed close to the CS ostium. Finally, a modified sub-selector sheath was successfully advanced over the electrode until it was free of the binding tissue. The post-extraction lead examination showed an unexpected fibrosis around the tip. No complications occurred during the postoperative course. Fibrous adhesions could be found in CS leads recently implanted requiring non-standard techniques for its transvenous extraction.

Sudden unexpected cardiac death as the first symptom in young people: Some useful clinical information from a systematic standardized anatomical study

The unexplained sudden cardiac death (SCD) of an adolescent or young adult is always a tragic event for the family, the society, the medical professional and the media. Such events demand an explanation, which is often unsatisfactory. The study by Vassalini et al. offers a useful clinical contribution to the analysis of similar cases of juvenile SCD, as it was based on a standardized technical method, implemented during a detailed investigation of cardiac conduction system (CCS) abnormalities in patients aged between 1 and 40 years with no previous history of heart disease before the fatal event. Moreover, the study excluded individuals in whom the cause of death was non-cardiac, such as drug or alcohol abuse (excluded by toxicological examination). As it did not consider individuals aged less than 1 year, it did not deal with the problem of sudden infant death syndrome (SIDS).

Leadless Cardiac Pacemaker – Feasibility of a ‘Heavy’ Case

T he conventional pacing systems consist of a small size-battery, an electronic circuit and leads. Despite improvements in diagnostic and therapeutic features, transvenous leads remain the weakest link of the pacing system. Nowadays, two types of leadless cardiac pacemaker (LCP) exist leading stimulation from the right ventricle (RV) apex or low septum at the desired lower rate, with rate responsive algorithms. We report our experience with an LCP implant in a severely obese patient and demonstrate the feasibility of the procedure and the excellent telemetric (conductive) communication between the LCP and the programmer despite the critical mass of the patient.

Hybrid Approach to Atrial Fibrillation Ablation

Percutaneous transluminal coronary angioplasty (PTCA) was introduced in the late 1970s as an alternative to coronary artery bypass graft surgery for coronary revascularization; since then, it has been accepted as a safe, reliable, and effective treatment for coronary artery disease, and its use has spread worldwide.Hyperlipidemia is a major cause of cardiovascular disease despite the availability of first-line cholesterol lowering agents such as statins. Although statin therapy is very efficient to reduce cholesterol, nearly 10-20% of individuals on statins, experience side effects, such myopathy, which hinder the drugs ability to achieve target low-density lipoprotein (LDL) cholesterol (LDL-C) levels. Statin-intolerant patients require more effective therapies for lowering LDL-C. As proprotein convertase subtilisin kexin type 9 (PCSK9) promotes the degradation of the LDL receptor (LDLR) and prevents it from recycling to the membrane, a new therapeutic approach to lowering LDL-C acts by blocking LDL-receptor degradation by serum PCSK9. Humanized monoclonal antibodies which target PCSK9 and its interaction with the LDL receptor (REGN727/SAR23653, AMG145, and RN316), as well as agents that inhibit PCSK9 synthesis, such as ALN-PCS, are now in clinical trials. The latter is a small interfering RNA (siRNA) that directs sequence-specific messenger RNA for PCSK9 leading to reduced hepatocyte-specific synthesis of PCSK9. Ongoing phase III trials’ results are awaited with great interest in order to define these agents’ long-term safety, tolerability and efficacy for reducing cardiovascular events.Sequential surgical thoracoscopic and electrophysiological (EP) ablation is gaining popularity as a novel approach for the treatment of patients with stand-alone, persistent and long standing persistent atrial fibrillation (AF).The measurement of fractional flow reserve (FFR) has been proven useful in evaluating whether or not to perform percutaneous coronary intervention (PCI), especially in the case of “intermediate” stenosis. Nowadays, the indication of its usefulness has been expanded. While coronary angiography remains the cornerstone for assessment of epicardial coronary artery lesions in the catheterization laboratory, FFR-guided coronary treatment has established its usefulness especially after FAME 1 & 2 trials.Atrial Fibrillation (AF) is associated with increased morbidity and mortality and a more severe impairment in quality of life compared with patients with congestive heart failure or myocardial infarction. Left atrial myocardial extensions, known as “myocardial sleeves”, are present in almost all pulmonary veins (PVs), and have been recognized as the main source of triggers that initiate and perpetuate AF.