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Wörmann J, Strik M, Jurisic S, Stout K, Elrefai M, Becher N, Schaer B, van Stipdonk A, Srinivasan NT, Ploux S, Breitenstein A, Kron J, Roberts PR, Toennis T, Linz D, Dulai R, Hermes-Laufer J, Koneru J, Erküner Ö, Dittrich S, van den Bruck JH, Schipper JH, Sultan A, Rosenberger KD, Steven D, Lüker J. Incidence, implications, and management of sense-B-noise failure in subcutaneous cardioverter-defibrillator patients: insights from a large multicentre registry. Europace 2024; 26:euae161. [PMID: 38861398 PMCID: PMC11212320 DOI: 10.1093/europace/euae161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/07/2024] [Indexed: 06/13/2024] Open
Abstract
AIMS Subcutaneous implantable cardioverter-defibrillators (S-ICDs) offer potentially distinct advantages over transvenous defibrillator systems. Recent randomized trials showed significantly lower lead failure rates than transvenous ICD. Still, S-ICDs remain associated with the risk of inappropriate shocks (IAS). While previous studies have reported varying causes of IAS, this study explores a rare cause of IAS, referred to as 'sense-B-noise.' It was recently described in case series, but its incidence has not been studied in a large cohort of S-ICD patients. METHODS AND RESULTS We retrospectively reviewed data from patients implanted with S-ICD models 1010, A209, and A219 between October 2009 and July 2023 across nine centres in Europe and the USA. The analysis concentrated on determining the incidence and understanding the implications of sense-B-noise events. Sense-B-noise represents a rare manifestation of distinct electrogram abnormalities within the primary and alternate sensing vectors. Data were collected from medical records, device telemetry, and manufacturer reports for investigation. This registry is registered on clinicaltrials.gov (NCT05713708). Subcutaneous implantable cardioverter-defibrillator devices of the 1158 patients were analysed. The median follow-up time for all patients was 46 (IQR 23-64) months. In 107 patients (9.2%) ≥1 IAS was observed during follow-up. Sense-B-noise failure was diagnosed in six (0.5 and 5.6% of all IAS) patients, in all patients, the diagnosis was made after an IAS episode. Median lead dwell time in the affected patients was 23 (2-70) months. To resolve the sense-B-noise defect, in three patients reprogramming to the secondary vector was undertaken, and two patients underwent system removal with subsequent S-ICD reimplantation due to low amplitude in the secondary vector. In one patient, the secondary vector was initially programmed, and subsequently, an S-ICD system exchange was performed due to T-wave-oversensing IAS episodes. CONCLUSION This multicentre analysis' findings shed light on a rare but clinically highly significant adverse event in S-ICD therapy. To our knowledge, we provide the first systematic multicentre analysis investigating the incidence of sense-B-noise. Due to being difficult to diagnose and limited options for resolution, management of sense-B-noise is challenging. Complete system exchange may be the only option for some patients. Educating healthcare providers involved in S-ICD patient care is crucial for ensuring accurate diagnosis and effective management of sense-B-noise issues.
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Affiliation(s)
- Jonas Wörmann
- Department of Electrophysiology, Heart Center at the University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Marc Strik
- CHU de Bordeaux, service de Cardiologie-électrophysiologie et stimulation cardiaque, INSERM, U 1045, F-33000 Bordeaux, France
| | - Stjepan Jurisic
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Kara Stout
- Cardiology, VCU Health Pauley Heart Center, Richmond, VA, USA
| | - Mohamed Elrefai
- Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nina Becher
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Beat Schaer
- Cardiology, University Hospital Basel, Basel, Switzerland
| | - Antonius van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Neil T Srinivasan
- Department of Electrophysiology, The Essex Cardiothoracic Centre, Basildon, UK
- Circulatory Health Research Group, Medical Technology Research Centre, School of Medicine, Anglia Ruskin University, Chelmsford CM1 1SQ, UK
| | - Sylvain Ploux
- CHU de Bordeaux, service de Cardiologie-électrophysiologie et stimulation cardiaque, INSERM, U 1045, F-33000 Bordeaux, France
| | - Alexander Breitenstein
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Jordana Kron
- Cardiology, VCU Health Pauley Heart Center, Richmond, VA, USA
| | - Paul R Roberts
- Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tobias Toennis
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Rajdip Dulai
- Department of Electrophysiology, The Essex Cardiothoracic Centre, Basildon, UK
| | - Julia Hermes-Laufer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Jay Koneru
- Cardiology, VCU Health Pauley Heart Center, Richmond, VA, USA
| | - Ömer Erküner
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sebastian Dittrich
- Department of Electrophysiology, Heart Center at the University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jan-Hendrik van den Bruck
- Department of Electrophysiology, Heart Center at the University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jan-Hendrik Schipper
- Department of Electrophysiology, Heart Center at the University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Arian Sultan
- Department of Electrophysiology, Heart Center at the University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Kerstin D Rosenberger
- Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Daniel Steven
- Department of Electrophysiology, Heart Center at the University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jakob Lüker
- Department of Electrophysiology, Heart Center at the University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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Schiavone M, Gasperetti A, Vogler J, Compagnucci P, Laredo M, Breitenstein A, Gulletta S, Martinek M, Kaiser L, Tundo F, Palmisano P, Rovaris G, Curnis A, Kuschyk J, Biffi M, Tilz R, Di Biase L, Tondo C, Forleo GB. Sex differences among subcutaneous implantable cardioverter-defibrillator recipients: a propensity-matched, multicentre, international analysis from the i-SUSI project. Europace 2024; 26:euae115. [PMID: 38696701 PMCID: PMC11100525 DOI: 10.1093/europace/euae115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 05/04/2024] Open
Abstract
AIMS Women have been historically underrepresented in implantable cardioverter-defibrillator (ICD) trials. No data on sex differences regarding subcutaneous ICDs (S-ICD) carriers have been described. Aim of our study was to investigate sex-related differences among unselected S-ICD recipients. METHODS AND RESULTS Consecutive patients enrolled in the multicentre, international i-SUSI registry were analysed. Comparisons between sexes were performed using a 1:1 propensity matching adjusted analysis for age, body mass index (BMI), left ventricular function, and substrate. The primary outcome was the rate of appropriate shocks during follow-up. Inappropriate shocks and other device-related complications were deemed secondary outcomes. A total of 1698 patients were extracted from the i-SUSI registry; 399 (23.5%) were females. After propensity matching, two cohorts of 374 patients presenting similar baseline characteristics were analysed. Despite similar periprocedural characteristics and a matched BMI, women resulted at lower risk of conversion failure as per PRAETORIAN score (73.4% vs. 81.3%, P = 0.049). Over a median follow-up time of 26.5 [12.7-42.5] months, appropriate shocks were more common in the male cohort (rate/year 3.4% vs. 1.7%; log-rank P = 0.049), while no significant differences in device-related complications (rate/year: 6.3% vs. 5.8%; log-rank P = 0.595) and inappropriate shocks (rate/year: 4.3% vs. 3.1%; log-rank P = 0.375) were observed. After controlling for confounders, sex remained significantly associated with the primary outcome (aHR 1.648; CI 0.999-2.655, P = 0.048), while not resulting predictor of inappropriate shocks and device-related complications. CONCLUSION In a propensity-matched cohort of S-ICD recipients, women are less likely to experience appropriate ICD therapy, while not showing higher risk of device-related complications. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0473876.
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Affiliation(s)
- Marco Schiavone
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milan, Italy
| | | | - Julia Vogler
- Department of Rhythmology, University Heart Center Lübeck, Lubeck, Germany
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital ‘Ospedali Riuniti’, Ancona, Italy
| | - Mikael Laredo
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière and Sorbonne Université, Paris, France
| | | | - Simone Gulletta
- Arrhythmology and Electrophysiology Unit, San Raffaele Hospital, IRCCS, Milan, Italy
| | - Martin Martinek
- Department of Internal Medicine 2/Cardiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Lukas Kaiser
- Department of Cardiology and Critical Care Medicine, St. George Klinik Asklepios, Hamburg, Germany
| | - Fabrizio Tundo
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milan, Italy
| | | | - Giovanni Rovaris
- Cardiology Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Jürgen Kuschyk
- Cardiology Unit, University Medical Centre Mannheim, Manheim, Germany
| | - Mauro Biffi
- Cardiology Unit, IRCCS, Department of Experimental, Diagnostic and Specialty Medicine, Sant’Orsola Hospital, University of Bologna, Bologna, Italy
| | - Roland Tilz
- Department of Rhythmology, University Heart Center Lübeck, Lubeck, Germany
| | - Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology at Montefiore-Einstein Center, Bronx, New York, USA
| | - Claudio Tondo
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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3
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Malaty MM, Ray M, Ferreira D, Morris GM, Jackson N. Intra-Abdominal Hemorrhage Triggering Inappropriate Therapy From a Subcutaneous Defibrillator. JACC Case Rep 2024; 29:102167. [PMID: 38361550 PMCID: PMC10865138 DOI: 10.1016/j.jaccas.2023.102167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 02/17/2024]
Abstract
The SMART Pass filter (Boston Scientific) aims to reduce inappropriate shocks (IASs) from subcutaneous implantable cardioverter-defibrillators by filtering out low-frequency signals such as T waves. However, this filter is deactivated in the presence of diminished R-wave sensing. We describe a case of IAS in the setting of extensive intra-abdominal hemorrhage.
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Affiliation(s)
- Michael M. Malaty
- Department of Cardiology, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Max Ray
- Department of Cardiology, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - David Ferreira
- Department of Cardiology, John Hunter Hospital, New Lambton, New South Wales, Australia
- School of Medicine, University of Newcastle, New South Wales, Australia
| | - Gwilym M. Morris
- Department of Cardiology, John Hunter Hospital, New Lambton, New South Wales, Australia
- School of Medicine, University of Newcastle, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Nicholas Jackson
- Department of Cardiology, John Hunter Hospital, New Lambton, New South Wales, Australia
- School of Medicine, University of Newcastle, New South Wales, Australia
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Budrejko S, Zienciuk-Krajka A, Daniłowicz-Szymanowicz L, Kempa M. Comparison of Preoperative ECG Screening and Device-Based Vector Analysis in Patients Receiving a Subcutaneous Implantable Cardioverter-Defibrillator. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2186. [PMID: 38138289 PMCID: PMC10745078 DOI: 10.3390/medicina59122186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Subcutaneous implantable cardioverter-defibrillators (S-ICDs) provide protection against sudden cardiac death from outside the cardiovascular system. ECG screening is a prerequisite for implantation, but the reproducibility of its results post-operatively in the device is only partial. We aimed to compare the results of ECG screening with device-based sensing vector analysis. Materials and Methods: We screened the hospital records of all S-ICD recipients in our clinic. All of them had pre-operative ECG screening performed (primary, secondary, and alternate vectors). The results were compared with device-based vector analysis to determine the relation of the pre- and post-operative vector availability. Results: Complete ECG screening and device-based vector analysis were obtained for 103 patients. At least two acceptable vectors were found in 97.1% of the patients pre-operatively and in 96.1% post-operatively. When comparing vectors in terms of agreement (OK or FAIL) pre- and post-operatively, in 89.3% of the patients, the result for the primary vector was the same in both situations; for the secondary, it was in 84.5%, and for the alternate, it was in 74.8% of patients, respectively. In 55.3% of patients, all three vectors were labeled the same (OK or FAIL); in 37.9%, two vectors had the same result, and in 6.8%, only one vector had the same result pre- and post-operatively. The number of available vectors was the same pre- and post-operatively in 62.1% of patients, while in 15.5%, it was lower, and in 22.3% of patients, it was higher than observed during screening. Conclusions: Routine clinical pre-operative screening allowed for a good selection of candidates for S-ICD implantation. All patients had at least one vector available post-operatively. The final number of vectors available in the device-based analysis in most patients was at least the same (or higher) than during screening. The repeatability of the positive result for a single vector was high.
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Affiliation(s)
- Szymon Budrejko
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdansk, Smoluchowskiego 17, 80-214 Gdansk, Poland; (A.Z.-K.); (L.D.-S.); (M.K.)
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5
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Ghanta SN, Alotaibi B, Paydak H, Mounsey JP, Vallurupalli S, Devabhaktuni S. Inappropriate Subcutaneous Implantable Cardioverter-defibrillator Shocks-A Rare Case of Triple Counting. J Innov Card Rhythm Manag 2023; 14:5670-5674. [PMID: 38155720 PMCID: PMC10752427 DOI: 10.19102/icrm.2023.14121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/20/2023] [Indexed: 12/30/2023] Open
Abstract
Sudden cardiac death (SCD) caused by ventricular tachyarrhythmias is a significant contributor to cardiovascular deaths worldwide. Implantable cardioverter-defibrillators (ICDs) have shown efficacy in preventing and reducing mortality from SCD, but traditional transvenous ICDs have inherent challenges and drawbacks, such as lead fractures, lead-associated endocarditis, and lead failure. To address these issues, subcutaneous ICDs (S-ICDs) have been developed. S-ICDs lack pacing capacity but are a valid alternative for patients at high risk for infection or with difficult venous access. Pre-implantation screening can help prevent inappropriate device shocks. We present a case in which a patient received inappropriate S-ICD therapy, which was attributed to the triple counting of P-, R-, and T-waves in a patient with sinus rhythm. This is an unusual occurrence, and, to the best of our knowledge, there are only a limited number of case reports documenting inappropriate shocks due to the oversensing of P-waves and T-waves.
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Affiliation(s)
- Sai Nikhila Ghanta
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bader Alotaibi
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hakan Paydak
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - J. Paul Mounsey
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Srikanth Vallurupalli
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Subodh Devabhaktuni
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Migliore F, Biffi M, Viani S, Pittorru R, Francia P, Pieragnoli P, De Filippo P, Bisignani G, Nigro G, Dello Russo A, Pisanò E, Palmisano P, Rapacciuolo A, Silvetti MS, Lavalle C, Curcio A, Rordorf R, Lovecchio M, Valsecchi S, D’Onofrio A, Botto GL. Modern subcutaneous implantable defibrillator therapy in patients with cardiomyopathies and channelopathies: data from a large multicentre registry. Europace 2023; 25:euad239. [PMID: 37536671 PMCID: PMC10438213 DOI: 10.1093/europace/euad239] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS Patients with cardiomyopathies and channelopathies are usually younger and have a predominantly arrhythmia-related prognosis; they have nearly normal life expectancy thanks to the protection against sudden cardiac death provided by the implantable cardioverter defibrillator (ICD). The subcutaneous ICD (S-ICD) is an effective alternative to the transvenous ICD and has evolved over the years. This study aimed to evaluate the rate of inappropriate shocks (IS), appropriate therapies, and device-related complications in patients with cardiomyopathies and channelopathies who underwent modern S-ICD implantation. METHODS AND RESULTS We enrolled consecutive patients with cardiomyopathies and channelopathies who had undergone implantation of a modern S-ICD from January 2016 to December 2020 and who were followed up until December 2022. A total of 1338 S-ICD implantations were performed within the observation period. Of these patients, 628 had cardiomyopathies or channelopathies. The rate of IS at 12 months was 4.6% [95% confidence interval (CI): 2.8-6.9] in patients with cardiomyopathies and 1.1% (95% CI: 0.1-3.8) in patients with channelopathies (P = 0.032). No significant differences were noted over a median follow-up of 43 months [hazard ratio (HR): 0.76; 95% CI: 0.45-1.31; P = 0.351]. The rate of appropriate shocks at 12 months was 2.3% (95% CI: 1.1-4.1) in patients with cardiomyopathies and 2.1% (95% CI: 0.6-5.3) in patients with channelopathies (P = 1.0). The rate of device-related complications was 0.9% (95% CI: 0.3-2.3) and 3.2% (95% CI: 1.2-6.8), respectively (P = 0.074). No significant differences were noted over the entire follow-up. The need for pacing was low, occurring in 0.8% of patients. CONCLUSION Modern S-ICDs may be a valuable alternative to transvenous ICDs in patients with cardiomyopathies and channelopathies. Our findings suggest that modern S-ICD therapy carries a low rate of IS. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov/Identifier: NCT02275637.
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Affiliation(s)
- Federico Migliore
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Mauro Biffi
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Stefano Viani
- Second Cardiology Division, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Raimondo Pittorru
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Pietro Francia
- Cardiology, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, University Sapienza, Rome, Italy
| | - Paolo Pieragnoli
- Arrhythmic Disease Unit, University of Florence, Florence, Italy
| | - Paolo De Filippo
- Cardiac Electrophysiology and Pacing Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Gerardo Nigro
- Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Università Politecnica delle Marche, Ancona, Italy
| | - Ennio Pisanò
- Cardiology Unit, ‘Vito Fazzi’ Hospital, Lecce, Italy
| | | | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Massimo Stefano Silvetti
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Carlo Lavalle
- Cardiology Department, Policlinico Umberto I - La Sapienza University, Rome, Italy
| | - Antonio Curcio
- Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi Magna Graecia, Campus di Germaneto, Catanzaro, Italy
| | - Roberto Rordorf
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, IRCCS Fondazione Policlinico S. Matteo, Pavia, Italy
| | | | - Sergio Valsecchi
- Cardiac Rhythm Management Division, Boston Scientific, Milan, Italy
| | - Antonio D’Onofrio
- ‘Unità Operativa di Elettrofisiologia, Studio e Terapia delle Aritmie’, Monaldi Hospital, Naples, Italy
| | - Giovanni Luca Botto
- Department of Clinical cardiology and Electrophysiology ASST Rhodense, Rho and Garbagnate M.se, Milan, Italy
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