Luca Conte

Optimization of left ventricular pacing site plus multipoint pacing improves remodeling and clinical response to cardiac resynchronization therapy at 1 year

BACKGROUND Approximately one-third of the patients with heart failure (HF) treated with cardiac resynchronization therapy (CRT) fail to respond. Positioning the left ventricular (LV) pacing lead in the area of the latest electrical delay may improve the response to CRT. Multipoint pacing (MPP) of the LV has been shown to improve the acute hemodynamic response. OBJECTIVE The purpose of this study was to test the hypothesis that patients treated with MPP in whom LV pacing location is optimized have better long-term clinical outcomes than do patients treated with conventional CRT. METHODS We evaluated the echocardiographic and clinical response of 110 patients with HF treated for nearly 1 year with either conventional CRT (standard [STD] group, n = 54, 49%), CRT with hemodynamic and electrical optimization of the LV pacing site (optimized [OPT] group, n = 36, 33%), or OPT combined with MPP (OPT + MPP group, n = 20, 18%). Responders were classified in terms of reduction in end-systolic volume index ≥15%, reduction in New York Heart Association (NYHA) class ≥1, and Packer score variation (NYHA response with no HF-related hospitalization events or death). RESULTS In STD, OPT, and OPT + MPP groups, 56%, 72%, and 90% of patients, respectively, were end-systolic volume index responders (P = .004) and 67%, 78%, and 95% were NYHA class responders (P = .012); 59%, 67%, and 90% of patients exhibited a 1-year Packer score of 0 (P = .018). These trends remained significant after adjustment for confounding factors by multivariate logistic analysis. CONCLUSION Combining MPP with optimal positioning of the LV lead on the basis of electrical delay and hemodynamics enhances reverse remodeling and improves clinical outcomes beyond the effect due to conventional CRT.

Air pollution and ST-elevation myocardial infarction treated with primary percutaneous coronary angioplasty: A direct correlation

PURPOSE The relationships between air pollutant concentration levels and admission for primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) have never been assessed. METHODS We retrospectively reviewed 4 consecutive years of medical and instrumental data (1st January 2012 to 1st March 2016) to identify patients admitted with STEMI and subsequently treated with primary PCI in our third referral center. Daily atmospheric pressure data (in hectopascal [hPa]) and air pollutant concentration levels were obtained from the regional meteorological service which had a monitoring site in our city (Rovigo, Italy). Pollutants investigated were nitrogen dioxide (NO2), particulate matter ≤10μm (PM10), ozone (O3), sulfur dioxide (SO2) and carbon monoxide (CO). Safety air concentration levels for the air pollutants were also considered. RESULTS PCI in STEMI patients was more frequent when AP was higher than 1013.15hPa (61.8% vs 38.2%, p<0.001). The incidences of STEMI patients when NO2, PM10 and O3 levels overcame the safe threshold were 83.1%, 52% and 8.5%, respectively. A positive correlation was found between the daily number of STEMI subsequently treated with primary PCI and the air pollutant levels of the same day for NO2 (r=0.205, p=0.001), PM10 (r=0.349, p<0.0001) and O3 (r=0.191, p=0.002). CONCLUSIONS A direct and significant correlation exists between the number of daily STEMI patients and the NO2, PM10 and O3 air concentration levels of the same day.

TIMI Risk Index as a Predictor of 30-Day Outcomes in Patients with Acute Pulmonary Embolism

BACKGROUND Available studies have already identified age, heart rate (HR) and systolic blood pressure (SBP) as strong predictors of early mortality in acute pulmonary embolism (PE). MATERIAL AND METHODS One-hundred-seventy patients, with acute PE confirmed on computed tomography angiography (CTA) were enrolled. Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) was calculated using the formula [heart rate (HR) x (AGE/102)/ systolic blood pressure (SBP)]. Study outcomes were 30-day mortality and/or clinical deterioration. RESULTS Receiver operating characteristics (ROC) curve revealed that a TRI ≥45 was highly specific for both outcomes (AUC 0.91, 95% CI 0.83-0.98, p<0.0001) with a positive predictive value (PPV) and negative predictive value (NPV) of 8.3 and 96% for 30-day mortality while PPV and NPV for 30-day mortality and/or clinical deterioration were 21.1 and 98.2%, respectively. Multivariate regression analysis showed that TRI ≥45 was an independent predictor of 30-day mortality (O.R. 22.24, 95% CI 2.54-194.10, p=0.005) independently from positive cTnI and RVD (O.R. 9.57, 95% CI 1.88-48.78, p=0.007; OR 24.99, 95% CI 2.84-219.48, p=0.004). Similarly, 30-day mortality and/or clinical deterioration was predicted by TRI ≥45 (O.R. 11.57, 95% CI 2.36-56.63, p=0.003) and thrombolysis (3.83, 95% CI 1.04-14.09, p=0.043), independently from age, RVD and positive cTnI. Cox regression analysis confirmed the role of TRI as independent predictor for both outcomes. Mantel-Cox analysis showed that after 30-day follow-up there was a statistically significant difference in the distribution of survival between patients with and without TRI ≥45 [log rank (Mantel-Cox) chi-square 17.04, p<0.0001]. CONCLUSIONS Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) predicted both 30-days mortality (all-causes) and/or clinical deterioration in patients with acute PE.

Modified balloon aortic valvuloplasty in fragile symptomatic patients unsuitable for both surgical and percutaneous valve replacement

BACKGROUND Balloon Aortic valvuloplasty (BAV) is considered as a bridge therapy to percutaneous valve implantation or a palliative treatment in patients with aortic valve stenosis (AVS). Potential risk of complications, in particular in fragile patients, is still not negligible. AIM To describe the technique and outcomes of modified BAV in fragile symptomatic patients unsuitable for other treatments using no-pacing and minimally invasive approach. METHODS Symptomatic fragile patients with severe aortic valve stenosis judged unsuitable by the heart team for surgical or percutaneous valve implantation from 1 September 2013 to 1 September 2017 were offered modified BAV. Simplified procedural protocol included a 4F right radial artery access for gradient check, a 8F compatible undersized balloons, two partial inflations-trial before a full inflation with no-pace maker back-up, final pressure gradient recording and aortography. RESULTS Thirty-four symptomatic fragile patients (mean age 80.9±4.9, range 73 to 91years, 100% Katz >6, mean Euroscore I 30.0±11.7%) underwent modified BAV in the last 5years with immediate success in all (100%). Mean aortic valve area increased from 0.58±0.2cm2 to 1.1±0.2cm2 (p<0.01) whereas mean peak gradient decreased from 75.6±11.3 to 35.8±11.2mmHg (p<0.01). Procedural complications were 14.7%. Thirty-day mortality was 11.8%. On a mean follow up of 38.4±4.6months four patients successfully repeated the procedure, while global mortality was 23.5% (8 patients). The other 22 patients maintained a NYHA class of 2.1±0.7. CONCLUSIONS No-pacing minimally invasive BAV seems to have acceptable outcomes in patients with severe AVS and no other treatment options.

Takotsubo Cardiomyopathy in an Elderly Woman with Alzheimer's Disease: A Rare Association. Case Report and Mini-Review of the Literature

An 89-year-old woman with asthenia and shortness of breath was admitted to the emergency department. Her medical history included permanent atrial fibrillation, diverticulosis, glaucoma, osteoporosis, and Basedow disease. Home medical treatment included digoxin, torsemide, lormetazepam, lysine-acetylate, and memantine 20 mg/d. A diagnosis of AD had been made 2 years earlier, when she had presented with visual hallucinations and delirium. Her last geriatric examination, performed 2 months before, showed severe cognitive (Mini-Mental State Examination score 16) and functional (activity of daily living scale score 2/6; instrumental activity of daily living scale score 0/6) impairment. At admission, cardiac examination revealed no systolic or diastolic murmurs and an arrhythmic pulse. No clinical signs of heart failure were present. Neurological assessment showed disorientation to time and space. Blood pressure was 110/60 mmHg, heart rate 77 beats/min, and oxygen saturation 99% with 4 L/min of oxygen administered through nasal prongs. Chest X-ray was negative. Electrocardiogram showed atrial fibrillation with ST-segment elevation in the anteroseptal leads. Troponin I level was 2.4 pg/mL (reference value <0.045 pg/mL), and N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) was greater than 35,000 ng/mL. Complete blood count, glycemic levels, liver enzymes, and serum creatinine were normal. An initial diagnosis of anteroseptal ST-segment elevation acute myocardial infarction was made, and she was pretreated with clopidogrel 300 mg orally, intravenous lysine-acetylsalicylate 250 mg, and low-molecular-weight heparin. Cardiac catheterization revealed no coronary artery disease, and left ventriculography showed anteroseptal akinesis and evidence of apical ballooning (Figure 1A, B). Calculated left ventricular ejection fraction was estimated as 22% on left ventriculography and 30% on transthoracic echocardiogram (TTE). A diagnosis of TTC was made according to the Mayo criteria. The woman was admitted to the intensive cardiac care unit for clinical medical therapy with beta-blockers, angiotensin-inhibiting enzyme inhibitors, and anti-mineralocorticoid. TTE performed on the second day of hospitalization confirmed left ventricular apical ballooning with LVEF of 30%. After 3 days, she was transferred to the cardiology ward, where her clinical course gradually improved, and troponin I and NT-proBNP levels slowly decreased until normalization. Follow-up TTE at 6 days showed normalization of left ventricular contractility, and she was discharged.

Basic Properties And Clinical Applications Of The Intracardiac

The electric signals detected by intracardiac electrodes provide information on the occurrence and timing of myocardial depolarization, but are not generally helpful to characterize the nature and origin of the sensed event. A novel recording technique referred to as intracardiac ECG (iECG) has overcome this limitation. The iECG is a multipolar signal, which combines the input from both atrial and ventricular electrodes of a dual-chamber pacing system in order to assess the global electric activity of the heart. The tracing resembles a surface ECG lead, featuring P, QRS and T waves. The time-course of the waveform representing ventricular depolarization (iQRS) does correspond to the time-course of the surface QRS with any ventricular activation modality. Morphological variants of the iQRS waveform are specifically associated with each activity pattern, which can therefore be diagnosed by evaluation of the iECG tracing. In the event of tachycardia, SVTs with narrow QRS can be distinguished from other arrhythmia forms based upon the preservation of the same iQRS waveform recorded in sinus rhythm. In ventricular capture surveillance, real pacing failure can be reliably discriminated from fusion beats by the analysis of the area delimited by the iQRS signal. Assessing the iQRS waveform correspondence with a reference template could be a way to check the effectiveness of biventricular pacing, and to discriminate myocardial capture alone from additional His bundle recruitment in para-Hisian stimulation. The iECG is not intended as an alternative to conventional intracavitary sensing, which remains the only tool suitable to drive the sensing function of a pacing device. Nevertheless, this new electric signal can add the benefits of morphological data processing, which might have important implications on the quality of the pacing therapy.

Acute Aortic Intimal Layer and Valvar Apparatus Prolapse Into the Left Ventricle

A 73-year-old hypertensive man was referred to our institution for urgent coronary angiography because of typical chest pain, slight increase in troponin level, and ECG signs of inferolateral subendocardial ischemia. An aortic systolic murmur was clearly audible, and pulses were present ubiquitously. The patient was referred for urgent coronary artery angiography, but because of an unsuccessful attempt to cannulate both coronary ostia, an aortogram …