Mario Parlapiano

Endovascular repair for penetrating atherosclerotic ulcers of the descending thoracic aorta: early and mid-term results.

BACKGROUND Penetrating atherosclerotic ulcer is an acute aortic syndrome with a high incidence of complications and rupture. Until now, no generally accepted therapeutic regimen has been established because the natural history of penetrating atherosclerotic ulcers is extremely variable. We investigated the technical feasibility and the early and mid-term results of endovascular stent graft treatment in a consecutive series of patients who had penetrating ulcers. METHODS From July 1997 to December 2006, 19 patients (14 men and 5 women) with a mean age of 71.8 +/- 7.2 years were treated for penetrating ulcers. Seven patients presented with an acute and symptomatic penetrating atherosclerotic ulcer, and in 12 patients, the ulcerative process was chronic. Clinical and imaging follow-up was performed in all patients using computed tomography or magnetic resonance imaging. RESULTS Technical success (insertion and deployment of the stent graft) was achieved in 18 of 19 cases. Neither paraplegia nor other perioperative complications occurred. Two patients treated under emergency conditions in whom the aortic syndrome was recognized after the acute onset died in the hospital (11.1%) of multiorgan failure. Follow-up has been completed in all patients, with a median time of 22 months (range, 3 to 108 months). Endoleaks occurred in 3 patients: 1 had surgical repair (5.6%), 1 leak sealed spontaneously, and 1 sealed after a second endovascular procedure. Late death occurred in 4 patients from non-aortic causes. CONCLUSIONS Endovascular stent graft repair is a low-invasive, attractive, and rational treatment option in aortic ulcers that provides satisfactory perioperative and mid-term results.

Outcome of cardioverter–defibrillator implant in patients with arrhythmogenic right ventricular cardiomyopathy

The aim of the present study was to investigate outcomes of implantable cardioverter–defibrillator (ICD) treatment in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). We reviewed baseline/follow-up data of 15 consecutive ARVC patients (mean age 55 ± 15 years) and 30 randomly drawn patients with coronary artery disease (CAD) (mean age 60 ± 10 years) with matching durations of follow-up (all implanted with ICDs for primary/secondary prevention of sudden death). At implant, appropriate placement of the RV lead was more difficult in ARVC patients. During follow-up (median 41 months), appropriate interventions for any ventricular tachyarrhythmias occurred in 8 (53%) ARVC patients and 17 (57%) CAD patients, but the occurrence of high rate (>240 beats/min) ventricular tachyarrhythmias was higher in ARVC patients. Inappropriate ICD interventions occurred in 5 (33%) ARVC patients and 10 (33%) CAD patients. Lead-related adverse events requiring surgical revision occurred in 7 (47%) ARVC patients as compared with 4 (13%) CAD patients (P = 0.0004). While ICD implantation is highly effective for prevention of sudden death in ARVC, it does carry elevated burdens of long-term lead-related adverse events. These findings underline the need of careful follow-up in ARVC aimed at early recognition of complications that can impair ICD function.

Endovascular treatment for acute traumatic transection of the descending aorta: Focus on operative timing and left subclavian artery management

OBJECTIVE The operative timing and management of acute traumatic aortic rupture are matters of debate. We reviewed our experience with endovascular repair of acute traumatic aortic rupture, focusing on these topics. METHODS From 1998 to 2007, 31 patients were referred to our institute for acute traumatic rupture of the descending aorta. In 11 patients (group I) an early stent graft procedure was performed, whereas in 16 patients (group II) endovascular repair was delayed. The median time from trauma was 24 hours in group I and 1.5 months in group II. Eight (25.8%) patients had a short proximal neck (<5 mm from the left subclavian artery). Of these, 2 had the left subclavian artery totally covered by the endoprosthesis, and 2 had the left subclavian artery partially covered. Four patients with a posttraumatic pseudoaneurysm involving the left subclavian artery (3 patients) or the left common carotid artery (1 patient) underwent conventional open surgical intervention. RESULTS Technical success was obtained in all patients. There were neither intraoperative nor perioperative deaths. Cerebellar stroke was detected in 1 patient after the intentional closure of the left subclavian artery. Follow-up (32.7 +/- 27.5 months) was 100% complete. No late deaths, endoleaks, or complications occurred. CONCLUSION The endovascular approach was a safe and flexible procedure in traumatic aortic rupture and allowed us to fit the operative timing to every patients clinical and imaging findings. In the presence of an inadequate proximal landing zone, conventional open surgical intervention still remains a favorable option as an alternative to endovascular procedures if a surgical revascularization of the left subclavian artery, carotid artery, or both is necessary.

Peak Endocardial Acceleration Reflects Heart Contractility Also in Atrial Fibrillation

Previous studies demonstrated that peak endocardial acceleration (PEA) in sinus rhythm is related to LV dP/dtmax. Until now, PEA was never evaluated during R‐R interval variations in AF. The aim of this study was to establish the behavior of PEA in AF and the relationship of PEA versus LV dP/dtmax. Six sheep (65 ± 6 kg) were instrumented with a LV Millar catheter and with an accelerometer lead. AF was induced and PEA, LV dP/dtmax, and ECG were monitored. AF persisted for 5 ± 1.3 minutes. From sinus rhythm to AF, the heart rate went from 92 ± 3 to 130 ± 35 beats/mm (P < 0.05), LV dP/dtmax from 684 ± 18 to 956 ± 344 mmHg/s (P = NS) and PEA from 0.82 ± 0.06 to 0.94 ± 0.33 g (P = NS). The correlation between PEA and LV dP/dtmax was significative in sinus rhythm (r = 0.7, P < 0.05) and in AF (r = 0.8, P < 0.05). A positive relationship was found between the preceding interval and PEA (r = 0.4 ± 0,07, P < 0.05) and LV dP/dtmax (r = 0.61 ± 0.08, P < 0.05), while a negative one was found between the prepreceding interval and both PEA (r =− 0.39 ± O.11.P < 0.05) and LV dP/dtmax (r =− 0.64 ± 0.05, P < 0.05). At the onset of AF, LV dP/dtmax and PEA showed similar changes: beat‐to‐beat correlation between PEA and LV dP/dtmax was high. As for LV dP/dtmax, PEA is positively related to the preceding interval and negatively related to the prepreceding interval. These data confirm that PEA reflects heart contractility also during AF and hold promise for the use of this sensor in therapeutic implantable devices.

Effect of Right Ventricular Pacing on Cardiac Apex Rotation Assessed by a Gyroscopic Sensor

To quantify cardiac apex rotation (CAR), the authors recently proposed the use of a Coriolis force sensor (gyroscope) as an alternative to other complex techniques. The aim of this study was to evaluate the effects of right ventricular (RV) pacing on CAR. A sheep heart was initially paced from the right atrium to induce a normal activation sequence at a fixed heart rate (AAI mode) and then an atrioventricular pacing was performed (DOO mode, AV delay = 60 ms). A small gyroscope was epicardially glued on the cardiac apex to measure the angular velocity (Ang V). From AAI to DOO pacing mode, an increase (+9.2%, p < 0.05) of the maximum systolic twisting velocity (Ang VMAX) and a marked decrease (–19.9%, p < 0.05) of the maximum diastolic untwisting velocity (Ang VMIN) resulted. RV pacing had negligible effects (–3.1%, p = 0.09) on the maximum angle of CAR, obtained by integrating Ang V. The hemodynamic parameters of systolic (LVdP/dtMAX) and diastolic (LVdP/dtMIN) cardiac function showed slight variations (–3.8%, p < 0.05 and +3.9%, p < 0.05, respectively). Results suggest that cardiac dyssynchrony induced by RV pacing can alter the normal physiological ventricular twist patterns, particularly affecting diastolic untwisting velocity.

Multicenter clinical evaluation of a new SSIR pacemaker.

A multicenter clinical evaluation of Sorin Swing 100, a new SSIR pacemaker with a gravimetric sensor, was performed by seven different centers enrolling a total of 89 patients, 56 men and 33 women, mean age 73.1 years, for pacemaker implantion (73 patients) or pacemaker replacement (16 patients). Pacing mode was VVIR in 73 patients and AAIR in 16. The behavior of pacing rate was evaluated 3 months after the implant by performing a 24‐hour Holter monitor, an exercise stress test, and tests for the assessment of mechanical external interference (MEI). A physiological behavior of the paced rate was always observed during Holter monitoring. In 52 completely paced patients mean diurnal, nocturnal, and maximal heart rate were, respectively, 74.9 ± 5.7 ppm, 58.1 ± 5.8 ppm, and 113.4 ± 12.7 ppm; a paced rate exceeding 100 ppm was reached on the average 5.6 times/Holter monitor. In all but two patients the sleep rate (55 ppm) was reached during the night or long resting time. During exercise stress test a direct correlation between the increase in pacing rate and the increase in workload was observed; the mean maximal heart rate reached in 49 completely paced patients was, respectively, 102.8 ± 9 ppm in 17 patients who accomplished stage 1, 116.2 ± 13.6 ppm in 28 patients who accomplished stage 2, and 133 ± 6.7 ppm in 10 patients who accomplished stage 3 of the Bruce protocol. MEI testing never increased the pacing rate over the noise rate (10 ppm over the basic rate). In only seven patients the results obtained suggested to change the nominal set up of the pacemaker. Our experience clearly indicates that Swing 100 is an effective, reliable, and easy to use SSIR pacemaker. The availability of the sleep rate allows a more physiological pattern of pacing rate and can lead to significant energy saving.