Atrial tachycardia ablation through the sub-pulmonary ventricle in a patient with multiple malformations associated with congenitally corrected transposition of the great arteries and double-sided slow-pathway

A 46-year-old woman with congenitally corrected transposition of the great arteries (ccTGA) associated with dextrocardia, situs viscerus inversus, and left superior vena cava persistence presented with an incessant supraventricular tachycardia. Electrophysiological study was not conclusive in differential diagnosis of atrial tachycardia versus atypical atrioventricular (AV) nodal reentrant tachycardia, also due to the unconventional anatomy of the coronary sinus. By a comprehensive mapping of cardiac chambers, a double side slow-pathway was localized in both atrial chambers and subsequently ablated by radiofrequency delivery without tachycardia changes. Aortic root and cusps were devoid of electrical activity. The muscular part of the sub-pulmonary ventricle at the level of interatrial septum showed an earliest activation signal of -90 ms and ablation of this site was effective in abolish the tachycardia. This is the first case to report technical concerns of septal atrial tachycardia ablation in ccTGA associated with multiple anatomical malformations. Moreover, some peculiarities have been reported for the first time including the presence of double-side AV nodal slow-pathway and atypical localization of the tachycardia origin into the muscular part of the sub-pulmonary ventricle instead of posterior pulmonary cusp.

Mechanism of Charge Transport in Lithium Thiophosphate

Lithium ortho-thiophosphate (Li3PS4) has emerged as a promising candidate for solid-state electrolyte batteries, thanks to its highly conductive phases, cheap components, and large electrochemical stability range. Nonetheless, the microscopic mechanisms of Li-ion transport in Li3PS4 are far from being fully understood, the role of PS4 dynamics in charge transport still being controversial. In this work, we build machine learning potentials targeting state-of-the-art DFT references (PBEsol, r2SCAN, and PBE0) to tackle this problem in all known phases of Li3PS4 (α, β, and γ), for large system sizes and time scales. We discuss the physical origin of the observed superionic behavior of Li3PS4: the activation of PS4 flipping drives a structural transition to a highly conductive phase, characterized by an increase in Li-site availability and by a drastic reduction in the activation energy of Li-ion diffusion. We also rule out any paddle-wheel effects of PS4 tetrahedra in the superionic phases-previously claimed to enhance Li-ion diffusion-due to the orders-of-magnitude difference between the rate of PS4 flips and Li-ion hops at all temperatures below melting. We finally elucidate the role of interionic dynamical correlations in charge transport, by highlighting the failure of the Nernst-Einstein approximation to estimate the electrical conductivity. Our results show a strong dependence on the target DFT reference, with PBE0 yielding the best quantitative agreement with experimental measurements not only for the electronic band gap but also for the electrical conductivity of β- and α-Li3PS4.

The Fluoroless Future in Electrophysiology: A State-of-the-Art Review

Fluoroscopy has always been the cornerstone imaging method of interventional cardiology procedures. However, radiation exposure is linked to an increased risk of malignancies and multiorgan diseases. The medical team is even more exposed to X-rays, and a higher incidence of malignancies was reported in this professional group. In the last years, X-ray exposure has increased rapidly, involving, above all, the medical team and young patients and forcing alternative fluoroless imaging methods. In cardiac electrophysiology (EP) and pacing, the advent of 3D electroanatomic mapping systems with dedicated catheters has allowed real-time, high-density reconstruction of both heart anatomy and electrical activity, significantly reducing the use of fluoroscopy. In addition, the diffusion of intracardiac echocardiography has provided high anatomical resolution of moving cardiac structures, providing intraprocedural guidance for more complex catheter ablation procedures. These methods have largely demonstrated safety and effectiveness, allowing for a dramatic reduction in X-ray delivery in most arrhythmias' ablations. However, some technical concerns, as well as higher costs, currently do not allow their spread out in EP labs and limit their use to only procedures that are considered highly complex and time-consuming and in young patients. In this review, we aim to update the current employment of fluoroless imaging in different EP procedures, focusing on its strengths and weaknesses.

Arrhythmogenic Cardiomyopathy: Definition, Classification and Arrhythmic Risk Stratification

Arrhythmogenic cardiomyopathy (ACM) is a heart disease characterized by a fibrotic replacement of myocardial tissue and a consequent predisposition to ventricular arrhythmic events, especially in the young. Post-mortem studies and the subsequent diffusion of cardiac MRI have shown that left ventricular involvement in arrhythmogenic cardiomyopathy is common and often develops early. Regarding the arrhythmic risk stratification, the current scores underestimate the arrhythmic risk of patients with arrhythmogenic cardiomyopathy with left involvement. Indeed, the data on arrhythmic risk stratification in this group of patients are contradictory and not exhaustive, with the consequence of not correctly identifying patients at a high arrhythmic risk who deserve protection from arrhythmic death. We propose a literature review on arrhythmic risk stratification in patients with ACM and left involvement to identify the main features associated with an increased arrhythmic risk in this group of patients.

Fighting Cardiac Thromboembolism during Transcatheter Procedures: An Update on the Use of Cerebral Protection Devices in Cath Labs and EP Labs

Intraprocedural stroke is a well-documented and feared potential risk of cardiovascular transcatheter procedures (TPs). Moreover, subclinical neurological events or covert central nervous system infarctions are concerns related to the development of dementia, future stroke, cognitive decline, and increased risk of mortality. Cerebral protection devices (CPDs) were developed to mitigate the risk of cardioembolic embolism during TPs. They are mechanical barriers designed to cover the ostium of the supra-aortic branches in the aortic arch, but newer devices are able to protect the descending aorta. CPDs have been mainly designed and tested to provide cerebral protection during transcatheter aortic valve replacement (TAVR), but their use in both Catheterization and Electrophysiology laboratories is rapidly increasing. CPDs have allowed us to perform procedures that were previously contraindicated due to high thromboembolic risk, such as in cases of intracardiac thrombosis identified at preprocedural assessment. However, several concerns related to their employment have to be defined. The selection of patients at high risk of thromboembolism is still a subjective choice of each center. The aim of this review is to update the evidence on the use of CPDs in either Cath labs or EP labs, providing an overview of their structural characteristics. Future perspectives focusing on their possible future employment are also discussed.

Subcutaneous Implantable Cardioverter Defibrillator: A Contemporary Overview

The difference between subcutaneous implantable cardioverter defibrillators (S-ICDs) and transvenous ICDs (TV-ICDs) concerns a whole extra thoracic implantation, including a defibrillator coil and pulse generator, without endovascular components. The improved safety profile has allowed the S-ICD to be rapidly taken up, especially among younger patients. Reports of its role in different cardiac diseases at high risk of SCD such as hypertrophic and arrhythmic cardiomyopathies, as well as channelopathies, is increasing. S-ICDs show comparable efficacy, reliability, and safety outcomes compared to TV-ICD. However, some technical issues (i.e., the inability to perform anti-bradycardia pacing) strongly limit the employment of S-ICDs. Therefore, it still remains only an alternative to the traditional ICD thus far. This review aims to provide a contemporary overview of the role of S-ICDs compared to TV-ICDs in clinical practice, including technical aspects regarding device manufacture and implantation techniques. Newer outlooks and future perspectives of S-ICDs are also brought up to date.

Uric acid significantly correlates with the presence of low-voltage areas at the endocardial mapping in patients with non-valvular atrial fibrillation

BACKGROUND AND AIMS

Interest in the role of atrial substrate in maintaining Atrial Fibrillation (AF) is growing. Fibrosis is the culprit in the electrical derangement of the myocytes. Many cardiovascular risk factors are known to be linked to atrial scarring; among them Uric Acid (UA) is emerging. The purpose of our study is to find whether UA is associated with Left Atrium (LA) with pathological substrate.

METHODS AND RESULTS

81 patients who underwent radiofrequency transcatheter ablation for nonvalvular AF at the cardiological department of the Niguarda Hospital were enrolled in an observational, cross-sectional, single-center study. UA levels were analysed before the procedure. High density electroanatomic mapping of the LA was performed and patients were divided according to the presence or not of areas of pathological substrate (bipolar voltage <0.5 mV in sinus rhythm). 19 patients showed a LA with pathological substrate. These subjects showed a significant higher prevalence of persistent phenotype of AF (84.2 vs. 25.8%, p < 0.001). UA levels were significantly higher in the group of patients with LA with pathological substrate (6.8 ± 1.9 vs 5.3 ± 1.4 mg/dL, p < 0.001) as well as the prevalence of hyperuricemia (26.5 vs. 6.5%, p = 0.021). The association between uric acid LA with pathological substrate remains significant even after correction for confounding factors (age, left ventricular dysfunction, valvular disease, arrythmia phenotype and furosemide use) and also when the ratio UA/creatinine was evaluated.

CONCLUSIONS

In a population of patients who underwent AF ablation, higher UA levels were significantly associated with pathological LA substrate at electro-anatomical mapping.

Electrocardiogram Changes in the Postictal Phase of Epileptic Seizure: Results from a Prospective Study

BACKGROUND

The brain and heart are strictly linked and the electrical physiologies of these organs share common pathways and genes. Epilepsy patients have a higher prevalence of electrocardiogram (ECG) abnormalities compared to healthy people. Furthermore, the relationship between epilepsy, genetic arrhythmic diseases and sudden death is well known. The association between epilepsy and myocardial channelopathies, although already proposed, has not yet been fully demonstrated. The aim of this prospective observational study is to assess the role of the ECG after a seizure.

MATERIALS AND METHODS

From September 2018 to August 2019, all patients admitted to the emergency department of San Raffaele Hospital with a seizure were enrolled in the study; for each patient, neurological, cardiological and ECG data were collected. The ECG was performed at the time of the admission (post-ictal ECG) and 48 h later (basal ECG) and analyzed by two blinded expert cardiologists looking for abnormalities known to indicate channelopathies or arrhythmic cardiomyopathies. In all patients with abnormal post-ictal ECG, next generation sequencing (NGS) analysis was performed.

RESULTS

One hundred and seventeen patients were enrolled (females: 45, median age: 48 ± 12 years). There were 52 abnormal post-ictal ECGs and 28 abnormal basal ECGs. All patients with an abnormal basal ECG also had an abnormal post-ictal ECG. In abnormal post-ictal ECG, a Brugada ECG pattern (BEP) was found in eight patients (of which two had BEP type I) and confirmed in two basal ECGs (of which zero had BEP type I). An abnormal QTc interval was identified in 20 patients (17%), an early repolarization pattern was found in 4 patients (3%) and right precordial abnormalities were found in 5 patients (4%). Any kind modification of post-ictal ECG was significantly more pronounced in comparison with an ECG recorded far from the seizure (p = 0.003). A 10:1 higher prevalence of a BEP of any type (particularly in post-ictal ECG, p = 0.04) was found in our population compared to general population. In three patients with post-ictal ECG alterations diagnostic for myocardial channelopathy (BrS and ERP), not confirmed at basal ECG, a pathogenic gene variant was identified (KCNJ8, PKP2 and TRMP4).

CONCLUSION

The 12-lead ECG after an epileptic seizure may show disease-related alterations otherwise concealed in a population at a higher incidence of sudden death and channelopathies. Post-ictal BEP incidence was higher in cases of nocturnal seizure.

Left Atrial Appendage Occlusion in Patients with Failure of Antithrombotic Therapy: Good Vibes from Early Studies

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and predisposes patients to an increased risk of cardioembolic events (CE), such as ischemic stroke, TIA, or systemic embolism [...].

Direct anchoring technique for pacing and defibrillation leads inserted through cephalic vein: insight for a single high-volume center

BACKGROUND

Direct anchoring of PM and ICD leads over cephalic vein body is officially discouraged by manufactures due to a supposed risk of conductor fracture or insulation failure, however careful tightening of anchoring knots can probably prevent lead damage. Direct anchoring (DA) technique is routinely used in our center for all leads inserted by cephalic vein while standard anchoring sleeves are used to secure subclavian leads only. Aim of the study is to assess short- and long-term safety of cephalic direct anchoring technique.

METHODS

All patients undergoing PM and ICD implantation in our center from November 2014 to March 2016 were consecutively enrolled. Primary endpoints were acute lead fracture, lead dislodgement and chronic lead failure. Secondary endpoint was a composite of short-term surgical complications (pocket hematoma, pneumothorax, and pericardial effusion) plus device infections. Subclavian leads secured with sleeve anchoring (SA) were used as control.

RESULTS

A total of 550 leads were implanted in 310 consecutive patients. DA involved 323 leads (59%) while SA was used for 227 (41%). Median follow-up was 50 months (IQR 24-62 months). 17 lead malfunctions (3.1%) were observed during follow-up. No difference was observed between groups (10 DA vs. 7 SP, P=ns). Survival analysis found no difference between groups. Secondary endpoints were not statistically different between groups (5 vs. 1, P=0.08).

CONCLUSIONS

Direct anchoring technique of PM and ICD leads is a safe technique and does not increase lead malfunction risk.

Left Bundle Branch Area Pacing over His Bundle Pacing: How Far Have We Come?

Implantable cardiac pacemakers have greatly evolved during the few past years, focusing on newer modalities of physiologic cardiac pacing [...].

Clinical characteristics and outcomes of patients with ventricular arrhythmias after continous-flow left ventricular assist device implant

Background

Ventricular arrhythmias (VAs) are observed in 25%–50% of continuous‐flow left ventricular assist device (CF‐LVAD) recipients, but their role on mortality is debated.

Methods

Sixty‐nine consecutive patients with a CF‐LVAD were retrospectively analyzed. Study endpoints were death and occurrence of first episode of VAs post CF‐LVAD implantation. Early VAs were defined as VAs in the first month after CF‐LVAD implantation.

Results

During a median follow‐up of 29.0 months, 19 patients (27.5%) died and 18 patients (26.1%) experienced VAs. Three patients experienced early VAs, and one of them died. Patients with cardiac resynchronization therapy (CRT‐D) showed a trend toward more VAs (p = 0.076), compared to patients without CRT‐D; no significant difference in mortality was found between patients with and without CRT‐D (p = 0.63). Patients with biventricular (BiV) pacing ≥98% experienced more frequently VAs (p = 0.046), with no difference in mortality (p = 0.56), compared to patients experiencing BiV pacing <98%. There was no difference in mortality among patients with or without VAs after CF‐LVAD [5 patients (27.8%) vs. 14 patients (27.5%), p = 0.18)], and patients with or without previous history of VAs (p = 0.95). Also, there was no difference in mortality among patients with a different timing of implant of implantable cardioverter‐defibrillator (ICD), before and after CF‐LVAD (p = 0.11).

Conclusions

VAs in CF‐LVAD are a common clinical problem, but they do not impact mortality. Timing of ICD implantation does not have a significant impact on patients' survival. Patients with BiV pacing ≥98% experienced more frequently VAs.

State-of-the-Art of Endomyocardial Biopsy on Acute Myocarditis and Chronic Inflammatory Cardiomyopathy

Purpose of Review

Histologic evidence of myocardial inflammatory infiltrate not secondary to an ischemic injury is required by current diagnostic criteria to reach a definite diagnosis of myocarditis. Endomyocardial biopsy (EMB) is therefore often indicated for the diagnosis of myocarditis, although it may lack sufficient sensitivity considering the limited possibility of myocardial sampling. Improving the diagnostic yield and utility of EMB is of high priority in the fields of heart failure cardiology and myocarditis in particular. The aim of the present review is to highlight indications, strengths, and shortcomings of current EMB techniques, and discuss innovations currently being tested in ongoing clinical studies, especially in the setting of acute myocarditis and chronic inflammatory cardiomyopathy.

Recent Findings

EMB provides unique diagnostic elements and prognostic information which can effectively guide the treatment of myocarditis. Issues affecting the diagnostic performance in the setting of acute myocarditis and chronic inflammatory cardiomyopathies will be discussed in this review in the light of recent expert consensus documents on the management of these conditions and on indication to EMB. Recent innovations using electroanatomic mapping (EAM)-guided EMB and fluoroscopic-guided EMB during temporary mechanical circulatory support have improved the utility of the procedure.

Summary

EMB remains an important diagnostic test whose results need to be interpreted in the context of (1) clinical pre-test probability, (2) timing of sampling, (3) quality of sampling (4) site of sampling, (5) histologic type of myocarditis, and (6) analytic methods that are applied. Herein we will review these caveats as well as perspectives and innovations related to the use of this diagnostic tool.

[Leadless pacemakers: results of a survey from implanter centers in the Lombardy region]

BACKGROUND

Transvenous pacing is nowadays the cornerstone of interventional management of bradyarrhythmias. It is still associated, however, with significant complications, mostly related to indwelling transvenous leads or device pocket. In order to reduce these complications, leadless pacemakers have been recently introduced into clinical practice, but no guidelines are yet available to indicate who are those patients that might benefit the most and whether leadless pacing should be preferred in the old or young population. This survey aims to describe the use of leadless pacemaker devices in a real-world setting.

METHODS

Eleven arrhythmia centers in the Lombardy region (out of a total of 17 participating centers) responded to the proposed questionnaire regarding patient characteristics and indications to leadless pacing.

RESULTS

Out of a total of 411 patients undergoing leadless pacing during 4.2 ± 0.98 years, the median age was 77 years, with 0.18% of patients having less than 18 years, 29.9% 18-65 years, 34.3% 65-80 years and 35.6% >80 years. The most common indication was slow atrial fibrillation (49% of patients), followed by atrioventricular block and sinoatrial dysfunction. Two centers reported in-hospital complications.

CONCLUSIONS

Leadless pacemakers proved to be a safe pacing strategy actually destined mostly to elderly patients.

Seasonal evolution impact on Montepulciano grape ripening

In an environmental background characterized by climate change, the seasonal trend increasingly affects the qualitative and quantitative expression of the vineyards. The sugar concentration, titratable acidity, the ratio sugar/acids and yield were related with heat accumulation (growing degree days accumulation), calculated in different period of grapevine cycle. The 21.5 °Babo threshold has been reached by Montepulciano grapes in the various years (2007-2019) even with 40 days difference. Over a period of 13 years, the sugar of Montepulciano grapes was influenced by thermal evolution between March to July. The relationship with high coefficient determination (R2 0.74) was obtained between heat accumulation and titratable acidity. According to this forecasting model, increases in heat accumulation of 100 degree-days in the period from March to June correspond to a reduction of about 0.85 g/l of acidity of the must at the harvest associated with an increase of 0.75 degree-days in the ratio between sugars and acids. The thermal evolution between June and July was correlated with yield of Montepulciano, an increase of 100 degree-days is associated with a decrease of about 1.86 t/ha. The thermal evolution between March and July is crucial for yield and grape quality of Montepulciano.

Atrial Flutter Mechanism Detection Using Directed Network Mapping

Atrial flutter (AFL) is a common atrial arrhythmia typically characterized by electrical activity propagating around specific anatomical regions. It is usually treated with catheter ablation. However, the identification of rotational activities is not straightforward, and requires an intense effort during the first phase of the electrophysiological (EP) study, i.e., the mapping phase, in which an anatomical 3D model is built and electrograms (EGMs) are recorded. In this study, we modeled the electrical propagation pattern of AFL (measured during mapping) using network theory (NT), a well-known field of research from the computer science domain. The main advantage of NT is the large number of available algorithms that can efficiently analyze the network. Using directed network mapping, we employed a cycle-finding algorithm to detect all cycles in the network, resembling the main propagation pattern of AFL. The method was tested on two subjects in sinus rhythm, six in an experimental model of in-silico simulations, and 10 subjects diagnosed with AFL who underwent a catheter ablation. The algorithm correctly detected the electrical propagation of both sinus rhythm cases and in-silico simulations. Regarding the AFL cases, arrhythmia mechanisms were either totally or partially identified in most of the cases (8 out of 10), i.e., cycles around the mitral valve, tricuspid valve and figure-of-eight reentries. The other two cases presented a poor mapping quality or a major complexity related to previous ablations, large areas of fibrotic tissue, etc. Directed network mapping represents an innovative tool that showed promising results in identifying AFL mechanisms in an automatic fashion. Further investigations are needed to assess the reliability of the method in different clinical scenarios.

F/OH ratio in a rare fluorine-poor blue topaz from Padre Paraíso (Minas Gerais, Brazil) to unravel topaz's ambient of formation

Topaz [Al₂SiO₄(F,OH)₂] is one of the main fluorine-bearing silicates occurring in environments where variably acidic (F)/aqueous (OH) fluids saturate the silicate system. In this work we fully characterized blue topaz from Padre Paraíso (Minas Gerais, Brazil) by means of in situ synchrotron X-Ray and neutron powder diffraction measurements (temperature range 298-1273 K) combined with EDS microanalyses. Understanding the role of OH/F substitution in topaz is important in order to determine the hydrophilicity and the exchange reactions of fluorine by hydroxyl groups, and ultimately to characterize the environmental redox conditions (H₂O/F) required for mineral formation. The fluorine content estimated from neutron diffraction data is ~ 1.03 a.f.u (10.34 wt%), in agreement with the chemical data (on average 10.0 wt%). The X_OH [OH/(OH + F)] (0.484) is close to the maximum X_OH value (0.5), and represents the OH- richest topaz composition so far analysed in the Minas Gerais district. Topaz crystallinity and fluorine content sharply decrease at 1170 K, while mullite phase starts growing. On the basis of this behaviour, we suggest that this temperature may represent the potential initial topaz's crystallization temperature from supercritical fluids in a pegmatite system. The log(fH₂O/fHF^)fluid (1.27 (0.06)) is coherent with the fluorine activity calculated for hydrothermal fluids (pegmatitic stage) in equilibrium with the forming mineral (log(fH₂O/fHF)^fluid = 1.2-6.5) and clearly different from pure magmatic (granitic) residual melts [log(fH₂O/fHF)^fluid < 1]. The modelled H₂O saturated fluids with the F content not exceeding 1 wt% may represent an anomalous water-dominant / fluorine-poor pegmatite lens of the Padre Paraíso Pegmatite Field.

The folding and aggregation properties of a single KH-domain protein: Ribosome binding factor A (RbfA) from Pseudomonas aeruginosa

BACKGROUND

Ribosome-binding factor A from the pathogenic bacterium Pseudomonas aeruginosa (PaRbfA) is a small ribosome assembly factor, composed by a single KH domain, involved in the maturation of the 30S subunit. These domains are characterized by the ability to bind RNA or ssDNA and are often located in proteins involved in a variety of cellular functions. However, although the ability of proteins to fold properly, to misfold or to aggregate is of paramount importance for their cellular functions, limited information is available on these dynamic properties in the case of KH domains.

METHODS

PaRbfA thermodynamic stability and folding mechanism: Far-UV CD and fluorescence spectroscopy, stopped-flow kinetics and chevron plot analysis, site-directed mutagenesis. Fibrils characterization: FT-IR spectroscopy, Thioflavin T fluorescence, Transmission Electron Microscopy (TEM) and X-ray fibrils diffraction.

RESULTS

Quantitative analysis of the (un)folding kinetics of PaRbfA show that, in vitro, the protein folds via a 3-states mechanism involving a transiently populated folding intermediate. We also provide experimental evidences that PaRbfA can form ordered fibrils endowed with cross-β structure even in mild conditions.

CONCLUSION

These results lead to the hypothesis that the folding intermediate of PaRbfA may expose (some of) the predicted amyloidogenic regions, which could act as aggregation nuclei in the fibrillogenesis.

GENERAL SIGNIFICANCE

The methodological approach presented herein could be readily adapted to verify the ability of other KH domain proteins to form cross-β structured fibrils and to transiently populate a folding intermediate.

Long-Term Outcome After Ventricular Tachycardia Ablation in Nonischemic Cardiomyopathy: Late Potential Abolition and VT Noninducibility

BACKGROUND

In patients with an ischemic cardiomyopathy (ICM), the combination of late potential (LP) abolition and postprocedural ventricular tachycardia (VT) noninducibility is known to be the desirable end point for a successful long-term outcome after VT ablation. We investigated whether LP abolition and VT noninducibilty have a similar impact on the outcomes of patients with non-ICMs (NICM) undergoing VT ablation.

METHODS

A total of 403 patients with NICM (523 procedures) who underwent a VT ablation from 2010 to 2016 were included. The procedure end points were the LP abolition (if the LPs were absent, other ablation strategies were undertaken) and the VT noninducibilty.

RESULTS

The underlying structural heart disease consisted of dilated cardiomyopathy (DCM, 49%), arrhythmogenic right ventricular dysplasia (ARVD, 17%), postmyocarditis (14%), valvular heart disease (8%), congenital heart disease (2%), hypertrophic cardiomyopathy (2%), and others (5%). The epicardial access was performed in 57% of the patients. At baseline, the LPs were present in 60% of the patients and a VT was either inducible or sustained/incessant in 85% of the cases. At the end of the procedure, the LP abolition was achieved in 79% of the cases and VT noninducibility in 80%. After a multivariable analysis, the combination of LP abolition and VT noninducibilty was independently associated with free survival from VT (hazard ratio, 0.45 [95% CI, 0.29-0.69], P=0.0002) and cardiac death (hazard ratio, 0.38 [95% CI, 0.18-0.74], P=0.005). The benefit of the LP abolition on preventing the VT recurrence in patients with ARVD and postmyocarditis appeared superior to that observed for those with DCM.

CONCLUSIONS

In patients with NICM undergoing VT ablation, the strategy of LP abolition and VT noninducibilty were associated with better outcomes in terms of long-term VT recurrences and cardiac survival. Graphic Abstract: A graphic abstract is available for this article.

High-Density Characterization of the Ventricular Electrical Substrate During Sinus Rhythm in Post-Myocardial Infarction Patients

OBJECTIVES

The aim of this study was to characterize, during sinus rhythm, the electric activation abnormalities in post-myocardial infarction patients undergoing ablation of ventricular tachycardia (VT) in order to identify specific signatures of those abnormal electrograms (EGMs).

BACKGROUND

In the setting of VT ablation, substrate characterization hinges on the identification of local abnormal ventricular activity (LAVA) and late potentials (LPs) that are considered to be related to the VT circuit.

METHODS

Patients scheduled for VT ablation underwent high-density ventricular substrate mapping. The substrate map during sinus rhythm was then compared with the activation maps of the clinical VT. Abnormal EGMs (LAVA and LPs) during sinus rhythm were characterized according to their configuration, duration, and amplitude and distinguished as belonging to bystander region or to the re-entrant circuit. Underlying electrophysiological mechanisms (wave-front collision, slow conduction) were identified on the activation maps and assigned to corresponding EGMs.

RESULTS

Ten patients satisfied the criteria to be enrolled in the study. A mean of 5 ± 1 slow-conduction areas and 4 ± 2 wave-front collisions were identified. LAVA was due to slow conduction in 60.5%, followed by wave-front collision (17.5%). LPs were caused by slow conduction in 52% of cases and by wave-front collision in 43% of cases. During sinus rhythm, entrance and exit sites were characterized by LAVA, while at the VT isthmus, only LPs were identified. Cutoff values of duration <24.5 ms (95% sensitivity and 99% specificity) and amplitude <0.14 mV (90% sensitivity and 48.1% specificity) discriminated those LPs belonging to the circuit from those playing a bystander role.

CONCLUSIONS

In the setting of post-myocardial infarction cardiomyopathy, specific EGM signatures are expressions of distinct electrophysiological phenomena. LAVA and LPs may play a bystander or an active role in the VT circuit, but only LPs with low amplitude and short duration predicted the VT isthmus.

Septal Late Gadolinium Enhancement and Arrhythmic Risk in Genetic and Acquired Non-Ischaemic Cardiomyopathies

BACKGROUND

In many genetic and acquired non-ischaemic cardiomyopathies (NICM) there have been frequent reports of involvement of the interventricular septum (IVS) by late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR). However, no studies have investigated the relationship between septal LGE and arrhythmias in different NICM subtypes.

METHODS

This study enrolled 103 patients with septal LGE at baseline CMR and different NICM: hypertrophic (n=29) or lamin A/C gene (LMNA)-associated (n=23) cardiomyopathy, and acute (n=30) or previous (n=21) myocarditis. During follow-up, the occurrences of malignant ventricular arrhythmias (MVA) and major bradyarrhythmias (BA) were evaluated.

RESULTS

At 4.9±0.7 years of follow-up, the occurrence of MVA and major BA in genetic vs acquired NICM were 10 of 52 vs 12 of 51, and 10 of 52 vs 4 of 51, respectively (both p=n.s.). However, MVA occurred more frequently in LMNA-NICM (eight of 23 vs two of 29 hypertrophic, p=0.015) and in previous myocarditis (nine of 21 vs three of 30 acute, p=0.016), while major BAs were particularly common in LMNA-NICM patients only (nine of 23 vs one of 29 hypertrophic, p=0.003). Different patterns of septal LGE were consistently retrospectively identified at baseline CMR: junctional and limited to the base in 79.3% of uneventful hypertrophic NICM; extended and focally transmural in LMNA-NICM with follow-up arrhythmias (both p<0.05); transitory in patients with acute myocarditis, who, differently from the post-myocarditis ones, showed follow-up arrhythmias only in the presence of unmodified LGE at follow-up CMR (five of 13, p=0.009).

CONCLUSION

Septal LGE was significantly associated with MVA at the 5-year follow-up in LMNA-NICM or previous myocarditis, and with major BA in LMNA-NICM only. These differences correlated with heterogeneous patterns of IVS LGE in different NICM.

Modeling nanoribbon peeling

The lifting, peeling and exfoliation of physisorbed ribbons (or flakes) of 2D material such as graphene off a solid surface are common and important manoeuvres in nanoscience. The feature that makes this case peculiar is the structural lubricity generally realized by stiff 2D material contacts. We model theoretically the mechanical peeling of a nanoribbon of graphene as realized by the tip-forced lifting of one of its extremes off a flat crystal surface. The evolution of shape, energy, local curvature and body advancement are ideally expected to follow a succession of regimes: (A) initial prying, (B) peeling with stretching but without sliding (stripping), (C) peeling with sliding, (D) liftoff. In the case where in addition the substrate surface corrugation is small or negligible, then (B) disappears, and we find that the (A)-(C) transition becomes universal, analytical and sharp, determined by the interplay between bending rigidity and adsorption energy. This general two-stage peeling transition is identified as a sharp crossover in published data of graphene nanoribbons pulled off an atomic-scale Au(111) substrate.

P5695Catheter ablation of ventricular tachycardia in patients with acute vs. previous myocarditis

Background

Ventricular tachycardias (VT) may occur late after myocarditis, as well as in the acute inflammatory phase of the disease. However, the role of catheter ablation (CA) in preventing VT recurrences in patients with acute (AM) vs. previous myocarditis (PM) has never been investigated so far.

Purpose

To evaluate the results of CA performed in patients presenting with VA and biopsy-proved myocarditis at different inflammatory stages.

Methods

We enrolled 46 consecutive patients (74% males, mean age 43±12y, mean LVEF 46±9%) with myocarditis and VT at index hospitalization. Based on endomyocardial biopsy and cardiac magnetic resonance (CMR) results, the patients were divided into AM and PM groups: in AM group, myocarditis was biopsy-proved, according to the ESC criteria; PM patients had a history of biopsy-proved myocarditis more than 12 months before, with no current signs of active inflammation (negative biopsy according to the ESC criteria; nonischaemic LGE at CMR with negative Lake-Louise criteria; absence of unexplained troponin abnormalities). ICD were implanted upon clinical indications. All of the patients underwent electroanatomical mapping (EAM) and VT CA. During 3 (2.5–3.5)y FU, VT recurrences were evaluated by 2/y Holter ECG and ICD interrogation.

Results

At baseline, 23 patients (50%) had AM, and 23 PM. Overall, 16 AM and 21 PM patients underwent ICD implant (p=n.s.). The clinical VT was monomorphic in 22 AM and 23 PM patients, respectively (p=n.s.) with a dominant right-bundle branch block with superior axis (RS) morphology in both groups (16 AM vs. 17 PM cases, p=n.s.). However, RS morphology was associated with left ventricular inferoposterior LGE at CMR in 9/16 AM vs. 17/17 PM patients (p=0.003). Similarly, inferoposterior localization of low-voltage areas at EAM was found in 11/16 AM vs. 17/17 PM patients (p=0.018). Furthermore, CMR showed a greater LGE transmural extension in AM patients (65±19%) as compared to PM ones (40±25%, p<0.001). Epicardial EAM and CA were performed in 14 AM vs. 15 PM patients, with endocardial-only approach adopted in the remaining cases (p=n.s.). VT CA was defined as successful (class A) in all of the subjets. However, during FU VT recurrences were documented in 7/23 AM vs. 0/23 PM patients (p=0.009). Four AM cases underwent redo CA late after myocarditis (1.5±0.3y after index hospitalization), with no further VT recurrences in FU.

Conclusion

In myocarditis patients presenting with VT, CA results are significantly better in PM cases as compared to AM ones. These findings are consistent with the different underlying substrate, and suggest the best role for ablation strategy after myocarditis healing.

Acknowledgement/Funding

None

Cardiac and Neuromuscular Features of Patients With LMNA-Related Cardiomyopathy

BACKGROUND

Mutations in the LMNA (lamin A/C) gene have been associated with neuromuscular and cardiac manifestations, but the clinical implications of these signs are not well understood.

OBJECTIVE

To learn more about the natural history of LMNA-related disease.

DESIGN

Observational study.

SETTING

13 clinical centers in Italy from 2000 through 2018.

PATIENTS

164 carriers of an LMNA mutation.

MEASUREMENTS

Detailed cardiologic and neurologic evaluation at study enrollment and for a median of 10 years of follow-up.

RESULTS

The median age at enrollment was 38 years, and 51% of participants were female. Neuromuscular manifestations preceded cardiac signs by a median of 11 years, but by the end of follow-up, 90% of the patients had electrical heart disease followed by structural heart disease. Overall, 10 patients (6%) died, 14 (9%) received a heart transplant, and 32 (20%) had malignant ventricular arrhythmias. Fifteen patients had gait loss, and 6 had respiratory failure. Atrial fibrillation and second- and third-degree atrioventricular block were observed, respectively, in 56% and 51% of patients with combined cardiac and neuromuscular manifestations and 37% and 33% of those with heart disease only.

LIMITATIONS

Some of the data were collected retrospectively. Neuromuscular manifestations were more frequent in this analysis than in previous studies.

CONCLUSION

Many patients with an LMNA mutation have neurologic symptoms by their 30s and develop progressive cardiac manifestations during the next decade. A substantial proportion of these patients will have life-threatening neurologic or cardiologic conditions.

PRIMARY FUNDING SOURCE

None.

A novel homozygous mutation in the TRDN gene causes a severe form of pediatric malignant ventricular arrhythmia

BACKGROUND

Triadin is a protein expressed in cardiac and skeletal muscle that has an essential role in the structure and functional regulation of calcium release units and excitation-contraction coupling. Mutations in the triadin gene (TRDN) have been described in different forms of human arrhythmia syndromes with early onset and severe arrhythmogenic phenotype, including triadin knockout syndrome.

OBJECTIVE

The purpose of this study was to characterize the pathogenetic mechanism underlying a case of severe pediatric malignant arrhythmia associated with a defect in the TRDN gene.

METHODS

We used a trio whole exome sequencing approach to identify the genetic defect in a 2-year-old boy who had been resuscitated from sudden cardiac arrest and had frequent episodes of ventricular fibrillation and a family history positive for sudden death. We then performed in vitro functional analysis to investigate possible pathogenic mechanisms underlying this severe phenotype.

RESULTS

We identified a novel homozygous missense variant (p.L56P) in the TRDN gene in the proband that was inherited from the heterozygous unaffected parents. Expression of a green fluorescent protein (GFP)-tagged mutant human cardiac triadin isoform (TRISK32-L56P-GFP) in heterologous systems revealed that the mutation alters protein dynamics. Furthermore, when co-expressed with the type 2 ryanodine receptor, caffeine-induced calcium release from TRISK32-L56P-GFP was relatively lower compared to that observed with the wild-type construct.

CONCLUSION

The results of this study allowed us to hypothesize a pathogenic mechanism underlying this rare arrhythmogenic recessive form, suggesting that the mutant protein potentially can trigger arrhythmias by altering calcium homeostasis.

Usefulness of Electroanatomical Mapping with Contact Force Monitoring for Accessory Pathways Ablation in Pediatric Population

The current approach for catheter ablation (CA) of accessory pathways (AP) includes the use of standard catheters under fluoroscopic visualization. We hypothesize that use of contact force (CF) irrigated tip catheters might increase procedural safety in pediatric patients compared to standard irrigated tip catheters, by decreasing the number of radiofrequency (RF) pulses required to obtain AP elimination. Seventy-one pediatric patients (13.7 ± 2.5 years, 45 male) with ventricular pre-excitation were enrolled in the study. CA was performed with a standard irrigated tip catheter up to June 2013 in 41 patients (Group S) and with a CF sensing irrigated tip catheter later on in 30 patients (Group CF). In the Group CF, RF was applied with a minimal CF of 5 g; CF > 35 g was avoided. Group CF procedures required less fluoroscopy (6.8 ± 4.8 min), compared to Group S (12.2 ± 10.8 min, p = 0.007). The number of RF pulses was smaller in Group CF compared to Group S (2.5 ± 2.0 vs 5.5 ± 1.9, p < 0.01). The mean CF during the effective RF pulse was 18 ± 7.7 g, force-time integral was 1040.7 ± 955.9 gs, Ablation Index was 513.0 ± 214.2. The procedure was acutely successful in 70 patients; at 12 months follow-up 2 patients had AP recurrence, one for each group. No major complications were reported. The use of CF irrigated tip catheters was associated with a smaller number of RF pulses and less fluoroscopy, as compared to mapping and ablation with standard irrigated tip catheters.

Phrenic Nerve Limitation During Epicardial Catheter Ablation of Ventricular Tachycardia

OBJECTIVES

This study sought to investigate the incidence of phrenic nerve (PN) limitation and the utility of displacing the PN with a balloon.

BACKGROUND

The PN can limit the epicardial ablation of ventricular tachycardia (VT).

METHODS

From 2010 to 2017, 363 patients undergoing VT epicardial ablation at a single center were studied. Before the ablation, we used high output (20-mA) pacing maneuvers to verify the course of the PN. When we observed its capture, we used 1 of 3 different approaches to protect it: 1) non-balloon strategy (nerve-sparing ablation); 2) PN displacement with a small balloon (6 mm × 20 mm); or 3) PN displacement with a large balloon (20 mm × 45 mm).

RESULTS

PN capture occurred in 25 patients (7%) at the target ablation site. The most common cause was myocarditis (12 patients [48%]), and the incidence of the PN limitation was significantly higher in myocarditis than in other causes (19% vs. 4%, respectively; p = 0.0002). PN displacement was attempted in 7 patients by using large balloons and in 6 patients with small balloons, resulting in successful PN displacements and complete late potential (LP) abolition in 6 patients (86%) and 3 patients (50%), respectively. Among the 12 patients in whom the non-balloon strategy was used, only 1 patient (8%) achieved LP abolition (compared with the large balloon group; p = 0.002), whereas 3 patients experienced PN paralysis.

CONCLUSIONS

The PN limited the epicardial ablation in 7% of patients. Because nerve-sparing ablations often resulted in PN injuries, a possible solution could be to displace the PN with a large balloon, leading to a safer procedure and completion of LP abolition.

Detachment Dynamics of Graphene Nanoribbons on Gold

Metal-surface physisorbed graphene nanoribbons (GNRs) constitute mobile nanocontacts whose interest is simultaneously mechanical, electronic, and tribological. Previous work showed that GNRs adsorbed on Au(111) generally slide smoothly and superlubrically owing to the incommensurability of their structures. We address here the nanomechanics of detachment, as realized when one end is picked up and lifted by an AFM cantilever. AFM nanomanipulations and molecular-dynamics (MD) simulations identify two successive regimes, characterized by (i) a progressively increasing local bending, accompanied by the smooth sliding of the adhered part, followed by (ii) a stick-slip dynamics involving sudden bending relaxation associated with intermittent jumps of the remaining adhered GNR segment and tail end. AFM measurements of the vertical force exhibit oscillations which, compared with MD simulations, can be associated with the successive detachment of individual GNR unit cells of length 0.42 nm. Extra modulations within one single period are caused by steplike advancements of the still-physisorbed part of the GNR. The sliding of the incommensurate moiré pattern that accompanies the GNR lifting generally yields an additional long-period oscillation: while almost undetectable when the GNR is aligned in the standard "R30" orientation on Au(111), we predict that such feature should become prominent in the alternative rotated "R0" orientation on the same surface, or on a different surface, such as perhaps Ag(111).

Thermal stability of the layered modification of Cu0.5ZrTe2 in the temperature range 25-900 °C

The thermal stability of the layered modification of the Cu_0.5ZrTe₂ polycrystalline intercalation compound, synthesized at room temperature, has been studied in the temperature range 25-900 °C. A change in the occupation of the octahedral and tetrahedral coordinated sites in the interlayer space of the zirconium ditelluride was observed using in-situ time-resolved synchrotron X-ray powder diffraction experiments. The formation of the rhombohedral CuZr₂Te₄ phase, which is stable in the temperature range 300-700 °C, has been observed. The copper intercalation at room temperature leads to the formation of a phase in which the Cu atoms occupy only octahedral sites in the interlayer space. At temperatures above the decay temperature of the rhombohedral CuZr₂Te₄, a layered phase with Cu atoms uniformly distributed between octahedral and tetrahedral sites in the interlayer space is stable. The changes in the crystal structure independent of temperature are in agreement with the previously proposed model, according to which the stability of the layered or the rhombohedral phase is determined by the entropy factor associated with the distribution of the intercalated atoms between the octahedral and tetrahedral sites in the interlayer space.

Catheter ablation of ventricular tachycardia in nonischemic cardiomyopathy

The number of patients with nonischemic cardiomyopathy (NICM) undergoing catheter ablation of ventricular tachycardia (VT) has increased by the years, however, there are no randomized studies of VT ablation in this population. Many studies have reported more mixed or inferior outcome after the ablation in patients with NICM as compared to in those with ischemic cardiomyopathy (ICM)-likely because of the heterogeneous VT substrates in each etiology. While, various ablation strategies for substrate modification in the setting of ICM, including low voltage area ablation, late potential abolition, and local abnormal ventricular activity elimination, have been well established, it is still unknown which ablation strategy is effective for prevention of recurrence VTs in NICM patients. Therefore, this review will highlight the recent progress made in VT ablation in patients with NICM.

Lifted graphene nanoribbons on gold: from smooth sliding to multiple stick-slip regimes

Graphene nanoribbons (GNRs) physisorbed on a Au(111) surface can be picked up, lifted at one end, and made to slide by means of the tip of an atomic-force microscope. The dynamic transition from smooth sliding to multiple stick-slip regimes, the pushing/pulling force asymmetry, the presence of pinning, and its origin are real frictional processes in a nutshell, in need of a theoretical description. To this purpose, we conduct classical simulations of frictional manipulations of a 30 nm-long GNR, one end of which is pushed or pulled horizontally while held at different heights above the Au surface. These simulations allow us to clarify theoretically the emergence of stick-slip originating from the short 1D edges rather than the 2D "bulk", the role of adhesion, of lifting, and of graphene bending elasticity in determining the GNR sliding friction. The understanding obtained in this simple context is of additional value for more general cases.

Updated clinical overview on cardiac laminopathies: an electrical and mechanical disease

Cardiac laminopathies, associated with mutations in the LMNA gene, encompass a wide spectrum of clinical manifestations, involving electrical and mechanical alterations of cardiomyocytes. Thus, dilated cardiomyopathy, bradyarrhythmias and atrial or ventricular tachyarrhythmias may occur in a number of combined phenotypes. Nowadays, some attempt has been made to identify clinical predictors for the most life-threatening complications of LMNA-associated heart disease, i.e. sudden cardiac death and end-stage heart failure. The goal of this manuscript is to combine the most recent evidences in an updated review to show the state-of-the-art of such a complex disease group. This is supposed to be the starting point to collect more data and design new ad hoc studies to identify clinically useful predictors to stratify risk in mutation carriers, including probands and their asymptomatic relatives.

Clinical characteristics and prognostic impact of atrial fibrillation in patients with chronic heart failure

AIM

To assess the prevalence, clinical characteristics and independent prognostic impact of atrial fibrillation (AF) in chronic heart failure (CHF) patients, and the potential protective effect of disease-modifying medications, particularly beta-blockers (BB).

METHODS

We retrospectively reviewed the charts of patients referred to our center since January 2004, and collected all clinical information available at their first visit. We assessed mortality to the end of June 2015. We compared patients with and without AF, and assessed the association between AF and all-cause mortality by multivariate Cox regression and Kaplan-Meyer analysis, particularly accounting for ongoing treatment with BB.

RESULTS

A total of 903 patients were evaluated (mean age 68 ± 12 years, 73% male). Prevalence of AF was 19%, ranging from 10% to 28% in patients ≤ 60 and ≥ 77 years, respectively. Besides the older age, patients with AF had more symptoms (New York Heart Association II-III 60% vs 44%), lower prevalence of dyslipidemia (23% vs 37%), coronary artery disease (28% vs 52%) and left bundle branch block (9% vs 16%). On the contrary, they more frequently presented with an idiopathic etiology (50% vs 24%), a history of valve surgery (13% vs 4%) and received overall more devices implantation (31% vs 21%). The use of disease-modifying medications (i.e., BB and ACE inhibitors/angiotensin receptor blockers) was lower in patients with AF (72% vs 80% and 71% vs 79%, respectively), who on the contrary were more frequently treated with symptomatic and antiarrhythmic drugs including diuretics (87% vs 69%) and digoxin (51% vs 11%). At a mean follow-up of about 5 years, all-cause mortality was significantly higher in patients with AF as compared to those in sinus rhythm (SR) (45% vs 34%, P value < 0.05 for all previous comparisons). However, in a multivariate analysis including the main significant predictors of all-cause mortality, the univariate relationship between AF and death (HR = 1.49, 95%CI: 1.15-1.92) became not statistically significant (HR = 0.98, 95%CI: 0.73-1.32). Nonetheless, patients with AF not receiving BB treatment were found to have the worst prognosis, followed by patients with SR not receiving BB therapy and patients with AF receiving BB therapy, who both had similarly worse survival when compared to patients with SR receiving BB therapy.

CONCLUSION

AF was highly prevalent and associated with older age, worse clinical presentation and underutilization of disease-modifying medications such as BB in a population of elderly patients with CHF. AF had no independent impact on mortality, but the underutilization of BB in this group of patients was associated to a worse long-term prognosis.

Biophysical aspects and novel treatments of atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF) is a cardiac arrhythmia caused by various mechanisms, such as multiple re-entering wavelets, high frequency activity, and rotor sources.

EVIDENCE ACQUISITION

This narrative review was based on papers found on PubMed and MEDLINE up to May 2016. The search terms were "atrial fibrillation" in combination with "catheter ablation, pathophysiology, antiarrhythmic drugs".

EVIDENCE SYNTHESIS

Antiarrhythmic drugs are the cornerstone of therapy in AF, but their efficacy and safety might have to be improved. In case of failure of pharmacologic therapies, other treatments can be considered. A better understanding of the important role of the pulmonary veins has led to new approaches, such as ablation procedures, which were initially only surgical, while percutaneous options were later added. However, these strategies may present various technical complications also when performed by skilled operators. A promising field of investigation is the genetics of AF, as highlighted by studies on the role of micro-RNA.

CONCLUSIONS

Relevant improvement on the knowledge of the electrophysiological basis of genesis and maintenance of AF has been done in order to treat a very common arrhythmia, but further studies, as those in the genetics field, can open new challenging therapeutic horizons.

Update on cardiotoxicity of anti-cancer treatments

BACKGROUND AND AIMS

Anti-cancer treatments markedly improved the prognosis of patients, but unfortunately might be hampered by cardiotoxicity. Both symptomatic and asymptomatic clinical forms of heart failure have been reported, which may be reversible or irreversible. The aim of this review is to provide an overview of the antineoplastic agents associated with cardiac toxicity and of the available diagnostic techniques.

METHODS AND METHODS

This narrative review is based on material from MEDLINE and PUBMED up to November 2015. We looked at the terms antineoplastic drugs and cardiac toxicity in combination with echocardiography, troponins, cardiac magnetic resonance, and positron emission tomography.

RESULTS

Anthracyclines, monoclonal antibodies, fluoropyrimidines, taxanes, alkylating agents, vinka alkaloids were reported to induce different clinical manifestations of cardioxicity. Chest radiotherapy is also associated with various forms of cardiac damage, which are indistinguishable from those found in patients with heart disease of other aetiologies and that may even appear several years after administration. Among diagnostic techniques, echocardiography is a noninvasive, cost-effective, and widely available imaging tool. Nuclear imaging and cardiac magnetic resonance may be used but are not so widely available and are more difficult to perform. Finally, some biomarkers, such as troponins, may be used to evaluate cardiac damage, but establishing the optimal timing of troponin assessment remains unclear and defining the cut-off point for positivity is still an important goal.

CONCLUSIONS

Cardiotoxicity of anti-cancer treatments is associated with development of heart failure. Novel diagnostic tools might be relevant to early recognize irreversible forms cardiac diseases.

The implantable cardioverter defibrillator in primary prevention: a revision of monocentric study group

AIMS

To evaluate the outcome of a population implanted with an implantable cardioverter defibrillator (ICD) for primary prevention in terms of mortality, morbidity and appropriate and inappropriate interventions. Secondly, to compare the performances of single-chamber vs. dual-chamber devices.

METHODS

We examined all patients with CAD or CMD who received an ICD in primary prevention with at least 6 months of follow-up. For each patient were evaluated, primarily, survival, complications related to the implantation and performance of the device (antitachycardia pacing/shock).

RESULTS

Of 193 patients, 163 were men (84.5). Mean age was 64.4 ± 10 years. One hundred and twenty patients (62%) were affected by CAD and 73 (38%) by CMD. The ejection fraction was 26 ± 6%. Fifty-three patients (27.5%) received a dual-chamber ICD, whereas 140 (72.5%) received a single-chamber ICD. There were periprocedural complications in 5.2% of the patients. At a mean follow-up of 49.9 months, 55 patients (28.5%) died. Appropriate interventions were documented in 40 patients (20.7%). In 36 patients (18%), inappropriate interventions occurred. Patients implanted with dual-chamber ICD had an overall mortality of 17% compared to 32.4% for those implanted with single-chamber ICD (P = 0.029). Mortality was higher in patients with CAD (33.9%) (P = 0.032). Among the fatalities, 69% occurred in patients who had an ejection fraction 25% or less at the time of implantation and 31% in patients with an ejection fraction greater than 25% (P = 0.013).

CONCLUSIONS

The 4-year survival was 72%. The overall mortality was higher in patients with CAD. More than two-thirds of the deceased had an ejection fraction less than 25%. The dual-chamber ICD patients had a significantly lower mortality rate.

Pressure-induced penetration of guest molecules in high-silica zeolites: the case of mordenite

A synthetic high-silica mordenite (HS-MOR) has been compressed in both non-penetrating (silicone oil, s.o.) and penetrating [methanol : ethanol : water (16 : 3 : 1) (m.e.w.), water : ethanol (3 : 1) (w.e.), and ethylene glycol (e.gl.)] pressure transmitting media (PTM).

The etiology-filling pattern-pulmonary artery pressure score: a simple tool for risk stratification of patients with systolic heart failure

Heart failure (HF) is a leading cause of morbidity and mortality. The detection of patients at high risk for death is a major challenge in HF management. The authors compared the prognostic value of 23 clinical Doppler echocardiography and cardiopulmonary exercise indexes in a stable, moderately symptomatic, systolic HF outpatient population receiving optimal medical therapy. The end point was the incidence of overall mortality. Between January 2002 and December 2008, a total of 146 patients with left ventricular (LV) ejection fraction 0.31±0.8 and New York Heart Association functional class II or III were enrolled. The prognostic power of single variables was assessed using chi-square test for categoric variables and t test for continuous variables. Variables associated with the prespecified end point were included as predictors in a binary logistic regression multivariate model. At multivariate analysis, "restrictive" LV filling pattern (P=.004), ischemic etiology (P=.022), pulmonary artery systolic pressure (PASP) ≥50 mm Hg (P=.027), and peak oxygen uptake (VO(2) ) <15.9 mL/kg/min (P=.046) resulted independent predictors of the outcome. A simple risk score was then obtained using these significant independent variables, excluding peak VO(2) because of only borderline significance. Patients with ischemic etiology, restrictive LV filling pattern, and PASP ≥50 mm Hg have a very high risk of death (odds ratio, 33.77; 95% confidence interval, 5.74-198.8; P<.001, compared with patients with no risk factors). In this high-risk group, evaluation of peak VO(2) could be superfluous. A very simple clinical echocardiographic model based on etiology-LV filling and pulmonary pressure is a powerful tool for risk stratification of systolic HF in ambulatory patients.

[Measles in the Local Health Unit Naples 4: vaccination coverage, epidemic 2001-2002 and prevention strategies]

The authors have analysed vaccination coverage for measles. The active offer of the vaccine brought about an increase of the vaccination coverage but participation to vaccination proved unsatisfactory between 1995 and 2000. The measles epidemic reported 1367 cases, of which 125 were hospitalised (3 cases presented complications). The target for the next years is to reach a vaccination coverage of 95% or more and recuperate the non vaccinated, starting with the 1990 birth cohort.

[Role of transesophageal echocardiography in the evaluation of the potential embolic risk in left atrial thrombosis. Report of a clinical case]

We describe the case of a 73-year-old man with cardiac failure due to hypertensive heart disease, chronic atrial fibrillation, prior ischemic stroke and acute ischemia of the left leg probably embolic in nature, in whom transthoracic echocardiography (TTE) detected a large left atrial mass compatible with thrombus. Transesophageal echocardiography (TEE) was performed to better evaluate the atrial mass. TTE showed a mass that was firmly attached to the wall of the left atrium, compact, homogeneous and stationary, indicating a relatively low embolic risk. On the other hand TEE clearly detected a marked motility and echographic unhomogeneity of the atrial mass, suggesting a poorer prognosis and urgent surgical referral due to high impending embolik risk. This case further supports the superiority of TEE to TTE in the assessment of intracardiac masses and, in particular, of embolik risk in a patient with left atrial thrombosis.