Mauro Carraro

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.

Correlation and prognostic role of neutrophil to lymphocyte ratio and SYNTAX score in patients with acute myocardial infarction treated with percutaneous coronary intervention: A six-year experience

BACKGROUND/PURPOSEnThe neutrophil/lymphocyte ratio (NLR) has been proposed as a prognostic marker in acute myocardial infarction (AMI). The aim of our study is to demonstrates the correlation between SYNTAX score (SXs) and NLR and its association with 1-year cardiovascular (CV) mortality in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention (PCI).nnnMETHODS/MATERIALSnOver 6 consecutive years, (1st January 2010 and 1st January 2016) 6560 patients (4841 males and 1719 females, mean age 64.36±11.77years) were admitted for AMI and treated with PCI within 24-h. The study population was divided into tertiles based on the SXs.nnnRESULTSnBoth in STEMI and NSTEMI groups, neutrophils and the SXs were significantly higher (p<0.0001) in upper versus lower among NLR tertiles and a significant correlation was found between the NLR and SXs (r=0.617, p<0.0001 and r=0.252, p<0.0001 for STEMI and NSTEMI groups, respectively). One-year CV mortality significantly raised up among the NLR tertiles in both STEMI and NSTEMI patients (p<0.0001). Multivariate analysis revealed that, after adjusting SXs and PAD, an NLR (≥3.9 and ≥2.7 for STEMI and NTEMI patients, respectively) was an independent significant predictor of 1-year CV mortality (OR 2.85, 95% CI 1.54-5.26, p=0.001 and OR 2.57, 95% CI 1.62-4.07, p<0.0001 for STEMI and NSTEMI respectively.) CONCLUSIONS: NLR significantly correlates with SXs and is associated with 1-year CV mortality in patients with STEMI or NSTEMI treated with PCI within 24-h.

ECG parameters predict left ventricular conduction delay in patients with left ventricular dysfunction

BACKGROUNDnEstimating left ventricular electrical delay (Q-LV) from a 12-lead ECG may be important in evaluating cardiac resynchronization therapy (CRT).nnnOBJECTIVEnThe purpose of this study was to assess the impact of Q-LV interval on ECG configuration.nnnMETHODSnOne hundred ninety-two consecutive patients undergoing CRT implantation were divided electrocardiographically into 3 groups: left bundle branch block (LBBB), right bundle branch block (RBBB), and nonspecific intraventricular conduction delay (IVCD). The IVCD group was further subdivided into 81 patients with left (L)-IVCD and 15 patients with right (R)-IVCD (resembling RBBB, but without S wave in leads I and aVL). The Q-LV interval in the different groups and the relationship between ECG parameters and the maximum Q-LV interval were analyzed.nnnRESULTSnPatients with LBBB presented a long Q-LV interval (147.7 ± 14.6 ms, all exceeding cutoff value of 110 ms), whereas RBBB patients presented a very short Q-LV interval (75.2 ± 16.3 ms, all <110 ms). Patients with an IVCD displayed a wide range of Q-LV intervals. In L-IVCD, mid-QRS notching/slurring showed the strongest correlation with a longer Q-LV interval, followed, in decreasing order, by QRS duration >150 ms and intrinsicoid deflection >60 ms. Isolated mid-QRS notching/slurring predicted Q-LV interval >110 ms in 68% of patients. The R-IVCD group presented an unexpectedly longer Q-LV interval (127.0 ± 12.5 ms; 13/15 patients had Q-LV >110 ms).nnnCONCLUSIONnPatients with LBBB have a very prolonged Q-LV interval. Mid-QRS notching in lateral leads strongly predicts a longer Q-LV interval in L-IVCD patients. Patients with R-IVCD constitute a subgroup of patients with a long Q-LV interval.

Prognostic role of a new risk index for the prediction of 30-day cardiovascular mortality in patients with acute pulmonary embolism: the Age-Mean Arterial Pressure Index (AMAPI)

Acute pulmonary embolism (PE) is the third cause of cardiovascular (CV) mortality. We evaluated a new risk index, named Age-Mean Arterial Pressure Index (AMAPI), to predict 30-day CV mortality in patients with acute PE. Data of 209 patients (44.0% male and 56.0% female, mean age 70.58xa0±xa014.14xa0years) with confirmed acute PE were retrospectively analysed. AMAPI was calculated as the ratio between age and mean arterial pressure (MAP), which was defined as [systolic blood pressurexa0+xa0(2xa0×xa0diastolic blood pressure)]/3. To test AMAPI accuracy, a comparison with shock index (SI) and simplified pulmonary embolism severity index (sPESI) was performed. Patients were divided in two groups according their hemodynamic stability, or not, at admission. 30-day mortality rate, in all cases for CV events, was 10.5% (nxa0=xa022). Hemodynamically unstable patients had a higher AMAPI compare to those without hypotension at admission (1.28xa0±xa00.39 vs 0.78xa0±xa00.27, pxa0<xa00.0001). Receiving operative curve analyses (ROC) found the optimal cut-off for AMAPI in hemodynamically stable and unstable patients ≥0.9 and ≥0.92, respectively. In both groups, patients with an AMAPI over the cut-off were significantly older, hypotensive (both systolic and diastolic blood pressure), with a higher SI and lower MAP. In hemodynamically stable patients, 30-day CV mortality risk prediction was improved adding AMAPI ≥0.9 to both SI and sPESI (net reclassification improvement—NRI—of 14.2%, pxa0=xa00.0006 and 11.5%, pxa0=xa00.0002, respectively). In hemodynamically unstable patients NRI was 19.2%, pxa0=xa00.006. Mantel–Cox analysis revealed a statistical significant difference in the distribution of survival between hemodynamically stable patients with an AMAPI index ≥0.9 compared to those with an AMAPI <0.89 [log rank (Mantel–Cox) pxa0<xa00.0001] and in hemodynamically unstable patients with an AMAPI ≥0.92 [log rank (Mantel–Cox) pxa0=xa00.001]. AMAPI ≥0.90 and ≥0.92 predict 30-day CV mortality in hemodynamically stable and unstable patients with acute PE.

Antiplatelet therapy in patients with glucose-6-phosphate dehydrogenases deficiency after percutaneous coronary intervention: A reappraisal for clinical and interventional cardiologists

Glucose-6-phosphate dehydrogenase (G6PD) deficiency represents one of the most common erythrocyte enzymopathy. In the era of drug-eluting stents (DESs), the use of prolonged dual antiplatelet therapy (DAPT) with aspirin (ASA) and thienopyridine (clopidogrel or ticlopidine) has become mandatory in the treatment of patients with acute coronary syndromes (ACS) and/or after percutaneous coronary intervention (PCI). However, the use of ASA, and more in general of antiplatelet drugs in patients with G6PD deficiency remains controversial, also for the absence of specific guidelines and scientific evidences. In the present manuscript, we reviewed the few cases available in medical literature, regarding patients with G6PD deficiency treated with percutaneous coronary artery intervention (PCI) and DAPT, with the aim to discuss and clarify the optimal treatment in these patients.

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.

The Effects on Morbidity and Mortality of CRT in Heart Failure

Cardiac resynchronization therapy (CRT) has become one of the main therapeutic alternatives for advanced congestive heart failure (CHF), but the effects on morbidity and mortality are still unclear.nnAim of the Study was to analyze hospitalization rate and mortality - total mortality (TM) and cardiac mortality (CM) - in a wide patient population implanted in our institution in the last six years.nnMethods since 1999, 187 pts (158 male) underwent CRT for severe CHF (EF 26.3% ± 6.9). In 82 pts a backup ICD was associated. The mean age was 71.1 ± 8.8 years (range 36 to 92); 103 pts (53%) had ischemic heart disease (IHD) while 84 were non ischemic (NIHD); 36 pts were in atrial fibrillation at the time of implant; 46 were previously paced via the right ventricular apex; 16 were candidates for heart transplantation. All the pts were evaluated in our clinic and the follow-up was scheduled every three month for the first year and then twice a year.nnResults the implant success rate was 98.9%. The mean follow-up was 29±16 months (range 1 – 74 months). Compared to the year before CRT, a significant decrease in hospitalization rate was observed during the first year of follow-up (2.38±1.6 vs. 0.56±0.7, p<.001). TM was 10.7%, CM was 8.0 %. The ICD group shows a reduction of TM compared to the group without: 7.3% vs. 13.3%: - 46 %.nnTM was also evaluated at implant, 6 months and steps of 1 year as follow: ![Graphic][1] nnIn the group of IHD vs. NIHD, TM was 11.6% % vs. 9.5% and CM was 10.7% vs. 4.7% respectively. The main causes of death in IHD were heart failure (8 pts) and sudden death (3 pts). In NIHD 3 pts died from cancer and 1 due to acute abdomen.nnConclusions 1) the benefit of CRT is similar in IHD and NIHD; 2) IHD seems to have a worse prognosis than NIHD in term of TM and CM; 3) CRT decreases the hospitalization rate and increases survival; 4) the association with a back-up ICD strongly reduces the mortality in this population.nn [1]: /embed/graphic-1.gif