Matteo Santamaria

Widespread Electroanatomic Alterations of Right Cardiac Chambers in Patients with Myotonic Dystrophy Type 1

Introduction: Conduction disturbances and arrhythmias characterize the cardiac feature of myotonic dystrophy type 1 (MD1); a myocardial involvement has been suggested as part of the cardiac disease. The aim of our study was to investigate the underlying myocardial alterations using electroanatomic mapping (CARTO) and their possible correlation with genetic and neurological findings.

Safety and Feasibility of Coronary Sinus Left Ventricular Leads Extraction: A Preliminary Report

Background: transvenous positioning of the left ventricular (LV) lead in a branch of the coronary sinus (CS) is generally the preferred implantation technique in biventricular pacing. Very few data are reported about removal of LV pacing leads positioned in a CS branch. Aim of the study was to describe our experience with percutaneous extraction of LV pacing leads in order to evaluate feasibility and safety of this procedure.Methods: we enrolled 392 patients who underwent a biventricular pacing implant. The indication for catheter removal was considered in case of definite diagnosis of infection and in some cases of lead dislodgement or diaphragmatic stimulation. LV lead extraction was first attempted by manual traction; in case of failure a locking stylet or locking stylet plus radiofrequency could be used.Results: twelve of 392 patients implanted needed LV lead removal. The leads had been in place for 13.9 ± 11.7 months. Extraction was indicated in 5 of them for LV lead dislodgement or diaphragmatic stimulation, and in 7 patients for lead infection. In all cases manual traction succeeded to remove the LV lead. In 7 cases of infection, the right atrial and ventricular leads were removed. The mean total procedure time was 69 ± 22 min. No complications were observed.Conclusions: our study suggests that CS leads could be easily and safely removed without any complication, also when placed in a CS branch, at least for relatively young catheters.

Device Longevity in a Contemporary Cohort of ICD/CRT-D Patients Undergoing Device Replacement.

The longevity of defibrillators (ICD) is extremely important from both a clinical and economic perspective. We studied the reasons for device replacement, the longevity of removed ICD, and the existence of possible factors associated with shorter service life.

Interlead anatomic and electrical distance predict outcome in CRT patients

BACKGROUNDnThe implantation strategy appears to play a pivotal role in determining response to cardiac resynchronization therapy (CRT).nnnOBJECTIVEnThe aim of our study was to determine the association between anatomic and electrical interlead distance and clinical outcome after CRT implantation.nnnMETHODSnWe included 216 first-time CRT recipients with left bundle branch block and sinus rhythm. On implantation, the electrical interlead distance (EID), defined as the time interval between spontaneous peak R waves detected at the right ventricular (RV) and left ventricular (LV) pacing sites, was measured. The anatomic distance between the RV and LV lead tips was determined on chest radiographs.nnnRESULTSnThe mean EID was 74 ± 41 ms, and the mean horizontal corrected interlead distance (HCID) was 125 ± 73 mm. After 12 months, 87 patients (40%) displayed an improvement in their clinical composite score. The cutoff values that best predicted an improved clinical status were as follows: 84 ms for EID (area under the curve 0.59; confidence interval [CI] 0.52-0.66; P = .026) and 90 mm for HCID (area under the curve 0.62; CI 0.55-0.69; P = .004). On multivariate analysis, only EID >84 ms (hazard ratio 0.36; CI 0.14-0.89; P = .028) and HCID >90 mm (hazard ratio 0.45; CI 0.23-0.90; P = .025) were significantly associated with the composite endpoint of death or cardiovascular hospitalization. In particular, the presence of both conditions (EID <84 ms and HCID <90 mm) was associated with the highest rate of events (log-rank test P = .002).nnnCONCLUSIONSnThe interlead anatomic and electrical distance are strongly and independently associated with patient outcome after CRT implantation. The 2 measures show an additive predictive value. (CRT MORE: Cardiac Resynchronization Therapy Modular Registry; www.clinicaltrials.gov, unique identifier: NCT01573091.)

1059G/C polymorphism within the exon 2 of the C-reactive protein gene: relationship to C-reactive protein levels and prognosis in unstable angina.

ObjectivePatients with unstable angina (UA) and high C-reactive protein (CRP) have increased cardiovascular risk. Whether genetic factors such as the synonymous 1059G/C polymorphism within the exon 2 of the human CRP gene determine CRP levels and outcome is unclear. MethodsIn 105 consecutive patients with UA, we assessed the CRP 1059G/C polymorphism, CRP plasma levels and interleukin-6 production after in-vitro stimulation of whole blood with lipopolysaccharide (1u2009ng/ml). Coronary events during a 24-month follow-up were recorded. ResultsCRP levels (median, range) were significantly lower among C-allele carriers (2.3u2009mg/l, 0.5–26.9) than among GG homozygotes (5.9u2009mg/l, 0.8–72.12, P=0.009). Interleukin-6 production was lower in C-allele carriers (1645u2009pg/ml, 832.0–9522) than in GG homozygotes (3929u2009pg/ml, 670.8–10u2009582), (P=0.085). At follow-up, 1059C-allele carriers experienced fewer coronary events than 1059GG homozygotes (13 vs. 47%, P=0.021). At multivariable analysis, a CRP level >3u2009mg/l, but not the 1059G/C polymorphism, was an independent predictor of coronary events (odds ratio 10.04, 95% confidence interval 2.84–35.44, P=0.0002). ConclusionThis study shows that the CRP synonymous 1059G/C polymorphism affects CRP levels. No independent association was, however, observed between this polymorphism and clinical outcome in UA.

Role of the CD14 C(-260)T promoter polymorphism in determining the first clinical manifestation of coronary artery disease.

Background Acute coronary syndromes (ACS) and chronic stable angina represent extremes of the clinical spectrum of coronary artery disease (CAD). It is unknown whether genetic determinants affect the first clinical manifestation of CAD. We evaluated the role of the C(−260)T polymorphism in the promoter of the CD14-receptor gene, an important mediator of the inflammatory response to lipopolysaccharide. Methods and results CD14 C(−260)T polymorphism was assessed in 100 patients with an acute presentation of CAD (group 1), 66 patients with stable presentation (group 2) and 88 healthy people (group 3); all patients were whites. In addition, baseline sCD14 plasma levels, and interleukin-6 production by circulating monocytes after in-vitro stimulation with lipopolysaccharide (1 ng/ml) were assessed. T/T homozygosis was more frequent in group 1 (36%, P < 0.001 versus others). Interleukin-6 production was higher in T/T homozygotes (median 4092.4; range 387–10 582 pg/ml) than in C/T heterozygotes (median 2442, range 40.5–9625 pg/ml, P < 0.001) and C/C homozygotes (median 3277.5; range 374.4–6250 pg/ml, P < 0.001). At multivariate analysis, T/T homozygosis and interleukin-6 production were independent predictors of acute presentation of CAD. Conclusion The present study shows that genetic factors that influence the reactivity of inflammatory cells may play a role in determining the first clinical presentation of CAD.

Radiofrequency catheter ablation guided by noncontact mapping of ventricular tachycardia originating from an idiopathic left ventricular aneurysm

Idiopathic left ventricular aneurysm and diverticulum is known to be an arrhythmogenic substrate associated to ventricular tachyarrhythmias, generally based on a reentry mechanism. A case of a young woman affected by a monomorphic ventricular tachycardia, refractory to medical treatment, originating from an aneurysm of the membranous interventricular septum is reported. The left ventricular aneurysm was well characterized by multislice computed tomography and left ventricular angiography. Because of the nonsustained and poorly tolerated nature of the target arrhythmia, a noncontact mapping system was used to guide radiofrequency catheter ablation, allowing the elaboration of a three-dimensional activation map of the left ventricle on the basis of a ventricular tachycardia single beat. The procedure was acutely successful, and the patient remained free of ventricular tachycardia recurrences without antiarrhythmic drugs during a subsequent 6-month follow-up period. This is the first report of a successful radiofrequency catheter ablation guided by noncontact mapping system of a ventricular tachycardia originating from an idiopathic left ventricular aneurysm. This nonfluoroscopic mapping method allows a reliable reconstruction of the spatial relationships between the left ventricular main cavity and the aneurysm and can be safely and effectively used to map the ventricular tachycardia and guide the ablation procedure, particularly when conventional mapping is not indicated or not effective because of nonsustained or not-tolerated characters of ventricular tachycardia.

High recurrence of device-related adverse events following transvenous lead extraction procedure in patients with cardiac resynchronization devices.

Little is known about the clinical outcome and recurring system‐related adverse events (SAE) in cardiac resynchronization therapy (CRT) patients after transvenous lead extraction (TLE).

Access to magnetic resonance imaging of patients with magnetic resonance-conditional pacemaker and implantable cardioverter-defibrillator systems: results from the Really ProMRI study

AimsnThe Really ProMRI study evaluates magnetic resonance imaging (MRI) access for patients with cardiac implantable electronic devices (CIEDs) as well as the performance of magnetic resonance (MR)-conditional leads when undergoing MRI.nnnMethods and resultsnPatients either with an MR-conditional pacemaker or implantable defibrillator (ICD) system or with at least a component (device or one or more leads) from an MR-conditional system, were asked to fill in a questionnaire when they were referred to a MR scan. The rate of prescription, denial, or execution of MR examinations was evaluated in a 1-year follow-up visit. In total, 555 patients [median age (interquartile range) 72.2 (62.2-78.6); 72% male] were enrolled, 49% (270) with a pacemaker, 51% (285) with an ICD system. Five-hundred and ten patients completed the follow-up period. A total of 37 MRI referrals were reported in 35 patients, with a consequent event rate of 7.0/100 patient-years (CI, 4.9-9.7). Fourteen were denied, while 23 [66%; (CI, 48-81%)] were performed. The number of patients with MR referrals was not statistically different between pacemaker and ICD groups (21 vs. 14; Pu2009=u20090.178). The rate of scans performed was higher in the pacemaker subjects (19/23 vs. 4/14, Pu2009=u20090.003), while it was similar between patients with or without a complete MR-conditional system (19/30 vs. 4/7, Pu2009=u20090.606).nnnConclusionnIn this study, we reported a 7.0/100 patient-years event rate of MR prescriptions in CIED patients. Many examinations were denied, despite MR-conditional systems, especially in ICD patients. Regulatory and cultural changes are needed to allow wider access to MR imaging in CIED patients with MR-conditional systems.

First clinical experience with the new four-pole standard connector for high-voltage ICD leads. Early results of a multicenter comparison with conventional implant outcomes

PurposeA new four-pole connector system (DF-4) for transvenous high-voltage implantable cardioverter defibrillators (ICD) is currently available in clinical practice. However, no clinical data demonstrating the safety and effectiveness of this complex electromechanical design is available. This study aims to test the safety and effectiveness of this newly designed system compared to the conventional DF-1 leads.MethodsDuring a 3-year period, 351 consecutive patients were implanted with DF-4 leads as part of an ICD or ICD-cardiac resynchronization therapy system. Patients were matched for age, sex, and follow-up with 154 patients implanted with a standard DF-1 lead. The primary outcome of the study was defibrillation lead failure, defined as the need for lead removal or capping. Operative, electrical, and safety data were obtained at implant and during postoperative follow-up.ResultsImplantation success rate in both groups was 100xa0%. A trend towards shorter procedure time was observed in the DF-4 group but the difference did not reach statistical significance. Handling characteristics of the DF-4 leads were graded better than those of DF-1 models. During a total follow-up of 8,130.5 lead-months, there were nine ICD-lead failures (four system erosion/infections and five electrical lead dysfunctions). The overall incidence of electrical lead failure was 0.64 vs. 0.97 per 100 lead-years, for DF-4 and DF-1 leads, respectively (Pu2009=u20090.2).ConclusionsThis multi-center experience provides strong evidence that the feasibility and safety of this novel technology compare favorably with those of the conventional DF-1 leads.