Cardiovascular safety of testosterone replacement therapy in men: an updated systematic review and meta-analysis

INTRODUCTION

The cardiovascular (CV) safety of testosterone (T) replacement therapy (TRT) is still conflicting. Recent data suggested a TRT-related increased risk of atrial fibrillation (AF). The aim of this study was to systematic review and meta-analyze CV risk related to TRT as derived from placebo controlled randomized trials (RCTs).

AREAS COVERED

An extensive Medline, Embase, and Cochrane search was performed. All placebo-controlled RCTs reporting data on TRT-related CV safety were considered. To better analyze the role of T on AF, population-based studies investigating the relationship between endogenous circulating T levels and AF incidence were also included and analyzed.

EXPERT OPINION

Out of 3.615, 106 studies were considered, including 8.126 subjects treated with TRT and 7.310 patients allocated to placebo. No difference between TRT and placebo was observed when major adverse CV events were considered. Whereas the incidence of non-fatal arrhythmias and AF was increased in the only trial considering CV safety as the primary endpoint, this was not confirmed when all other studies were considered (MH-OR 1.61[0.84;3.08] and 1.44[0.46;4.46]). Similarly, no relationship between endogenous T levels and AF incidence was observed after the adjustment for confounders Available data confirm that TRT is safe and it is not related to an increased CV risk.

SCN5A mutation is associated with a higher Shanghai Score in patients with type 1 Brugada ECG pattern

AIMS

Brugada syndrome (BrS) is an inherited arrhythmic disease characterized by a coved ST-segment elevation in the right precordial electrocardiogram leads (type 1 ECG pattern) and is associated with a risk of malignant ventricular arrhythmias and sudden cardiac death. In order to assess the predictive value of the Shanghai Score System for the presence of a SCN5A mutation in clinical practice, we studied a cohort of 125 patients with spontaneous or fever/drug-induced BrS type 1 ECG pattern, variably associated with symptoms and a positive family history.

METHODS

The Shanghai Score System items were collected for each patient and PR and QRS complex intervals were measured. Patients were genotyped through a next-generation sequencing (NGS) custom panel for the presence of SCN5A mutations and the common SCN5A polymorphism (H558R).

RESULTS

The total Shanghai Score was higher in SCN5A+ patients than in SCN5A- patients. The 81% of SCN5A+ patients and the 100% of patients with a SCN5A truncating variant exhibit a spontaneous type 1 ECG pattern. A significant increase in PR (P = 0.006) and QRS (P = 0.02) was detected in the SCN5A+ group. The presence of the common H558R polymorphism did not significantly correlate with any of the items of the Shanghai Score, nor with the total score of the system.

CONCLUSION

Data from our study suggest the usefulness of Shanghai Score collection in clinical practice in order to maximize genetic test appropriateness. Our data further highlight SCN5A mutations as a cause of conduction impairment in BrS patients.

TeleNEwCARe: An Italian case-control telegenetics study in patients with Hereditary NEuromuscular and CArdiac diseases

Telemedicine provides healthcare services remotely and represents a fundamental resource for the management of rare and fragile patients. Tele-health implementation is a main objective of the European Reference Networks (ERNs) mission to accelerate diagnosis for rare diseases. TeleNewCAre is a pilot case-control project which evaluates the efficacy and satisfaction of telegenetics for neuromuscular and cardiac adult patients, compared to face-to-face genetic counselling. The virtual sessions were co-hosted by a medical geneticist and a neurologist/cardiologist. Specific questionnaires (Clinical Genetics Satisfaction Questionnaire (CGS), Telemedicine Satisfaction Questionnaire (TSQ) and a Satisfaction Questionnaire for medical geneticists) were used to assess the effectiveness and fulfilment of telecounselling, both for patients and health care providers. Satisfaction expressed for telegenetics did not significantly differ from face-to-face counselling. The virtually enrolled patients declared they had the possibility to relate confidentially with the specialists, to share information and to be informed in an exhaustive way about their disease. Almost all patients declared themselves willing to reuse the telecounselling in the future. The multidisciplinary care was perceived as a significant added value. No overt technical problems were reported although the need for digital skills and tools can limit patients' compliance. Our experience supports telegenetics as a valid alternative to traditional genetic counselling in cardiac and neuromuscular patients. This innovative approach facilitates multidisciplinary care, grants a periodical follow up, without forcing patients to discomfortable travelling, and allows to maintain expert care. This result meets the ERNs needs to reduce patients' burden to access and monitor their healthcare.

Five waves of COVID-19 pandemic in Italy: results of a national survey evaluating the impact on activities related to arrhythmias, pacing, and electrophysiology promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

BACKGROUND

The subsequent waves of the COVID-19 pandemic in Italy had a major impact on cardiac care.

METHODS

A survey to evaluate the dynamic changes in arrhythmia care during the first five waves of COVID-19 in Italy (first: March-May 2020; second: October 2020-January 2021; third: February-May 2021; fourth: June-October 2021; fifth: November 2021-February 2022) was launched.

RESULTS

A total of 127 physicians from arrhythmia centers (34% of Italian centers) took part in the survey. As compared to 2019, a reduction in 40% of elective pacemaker (PM), defibrillators (ICD), and cardiac resynchronization devices (CRT) implantations, with a 70% reduction for ablations, was reported during the first wave, with a progressive and gradual return to pre-pandemic volumes, generally during the third-fourth waves, slower for ablations. For emergency procedures (PM, ICD, CRT, and ablations), recovery from the initial 10% decline occurred in most cases during the second wave, with some variability. However, acute care for atrial fibrillation, electrical cardioversions, and evaluations for syncope showed a prolonged reduction of activity. The number of patients with devices which started remote monitoring increased by 40% during the first wave, but then the adoption of remote monitoring declined.

CONCLUSIONS

The dramatic and profound derangement in arrhythmia management that characterized the first wave of the COVID-19 pandemic was followed by a progressive return to the volume of activities of the pre-pandemic periods, even if with different temporal dynamics and some heterogeneity. Remote monitoring was largely implemented during the first wave, but full implementation is needed.

Catheter ablation of well tolerated ventricular tachycardia in patients with structural heart disease and without automatic defibrillator implantation: long term follow-up

BACKGROUND

The occurrence of a sustained monomorphic ventricular tachycardias (SMVT) in patients with underlying structural heart disease (SHD) is considered related to poor prognosis. The purpose of our work was to evaluate if these patients could benefit from radiofrequency (RF) ablation, and the defibrillator (ICD) implantation could be deferred during follow-up.

METHODS

We reviewed consecutive patients with well-tolerated SMVT, SHD and left ventricular ejection fraction over 30%. These patients were treated by RF ablation and were discharged without ICD. The primary outcome was a composite of all-cause death and recurrence of SMVT; the secondary outcome was death from all causes.

RESULTS

62 patients were selected. After a median follow-up of 38.8 months, the primary outcome occurred in 24 (38.7%) and the secondary in 11 (17.7%) patients. The annual mortality rate was 4.3% and no patient died from sudden death.

CONCLUSIONS

RF ablation as a first-choice therapy seems to represent an effective and beneficial therapeutic approach.

Catheter ablation of well tolerated ventricular tachycardia in patients with structural heart disease: long term follow-up of 62 cases without automatic defibrillator implantation

Funding Acknowledgements

Type of funding sources: None.

Background

The occurrence of a sustained monomorphic ventricular tachycardias (SMVT) in patients with underlying structural heart disease (SHD) is considered correlated to a poor prognosis, based on historical data in patients with heterogeneous heart disease and clinical presentation; therefore the recommendation for implantation of automatic implantable cardioverter defibrillator (AICD) is strong. Information about prognosis of patients with SMVT is still limited, but recent studies have established that these patients represent a low-risk subgroup for sudden death that could benefit from radiofrequency (RF) ablation of the arrhythmic substrate and the AICD implantation could be deferred during the follow up.

Purpose

Patients with well-tolerated SMVT, SHD and left ventricular ejection fraction (LVEF) over 30% can benefit from a primary VT ablation strategy without the immediate need for AICD implantation.

Methods

We reviewed consecutive SHD patients with LVEF over 30% admitted for the occurrence of SMVT and who were treated by RF ablation as a first-choice therapy in a single Italian center, between 2009 and 2020 and who were discharged without AICD implantation. The primary outcome of the study was a composite of all-cause death and recurrence of VT. The secondary outcome was death from all causes. Patients with similar characteristics but who underwent AICD implantation during the same period served as control group.

Results

Clinical and electrophysiological features of 62 patients were analyzed (Table 1). In the study group, 88% were male; the median age was 72 years (IQR 55-81) and the median LVEF was 50.0% (IQR 40.0-55.0). The estimated success rate of ablative procedures (defined as VT no longer inducible) was around 82%. After a median follow-up of 38.8 months (IQR 15.6-76.1), the primary outcome occurred in 24 patients and the secondary outcome in 11 patients. All-cause mortality was 17%, corresponding to an annual mortality rate of 4.3%. Ten patients died for non-cardiovascular causes and one for advanced heart failure. No patient in the study died from sudden death. During the follow-up, 10 patients (16.1%) underwent AICD implantation due to VT relapse. At 36 months, between study and control groups, there was no difference in either the primary composite outcome (HR 1.03, 95% CI 0.45-2.21, p = 0.98) or in the secondary outcome (HR 1.4, 95% CI 0.48-4.54, p = 0.49).

Conclusions

Patients with well-tolerated SMVT, SHD and LVEF over 30% represent a subgroup of patients at lower risk that can benefit of RF ablation as a first-choice therapy. Delay in AICD implantation, after a possible VT relapse or clinical worsening, appears to represent a safe therapeutic strategy. Therefore, it is ethical and desirable to start a prospective randomized clinical trial to evaluate the benefit and cost-effectiveness of this strategy, as an alternative to AICD implantation.

P101 ARRHYTHMIC MITRAL VALVE PROLAPSE: COULD ELECTROANATOMICAL MAPPING AND CARDIAC MAGNETIC RESONANCE BE GOOD FRIENDS?

Background

There is an increasing awareness of the association between mitral valve prolapse (MVP) and sudden cardiac death (SCD), but risk stratification is still challenging. Mitral annular disjunction (MAD) is a recognized risk factor for arrhythmic complications. A multimodality imaging strategy, including advanced echocardiography, magnetic resonance (CMR) and electromechanical mapping, could improve risk stratification and management by combining anatomical and functional information.

Case Review

We report a case of a 50–year–old woman without cardiovascular risk factors, complaining for worsening palpitations in the last months. Echocardiogram documented bileaflet MVP with moderate regurgitation, MAD (12 mm in inferolateral wall) and normal ventricular systolic function. 24–hour Holter monitoring revealed a high (13%) premature ventricular complexes burden with ventricular bigeminy and non–sustained ventricular tachycardia. Stress test showed a reduction of the arrhythmias during exercise. CMR confirmed MAD but no late gadolinium enhancement areas were detected. The patient underwent electrophysiological study with electroanatomic mapping (CARTO). The latter revealed multifocal fragmented and delayed low voltage potentials close to the posterior papillary muscle and the posterior anular mitral area, respectively. Both locations were the targets of endoventricular radiofrequency ablation. However, due to her high arrhythmic risk profile the patient implanted a cardioverter defibrillator.

Discussion

In arrhythmic risk stratification of MVP with MAD, CMR could have technical limitations due to diffuse fibrosis patterns or irregular cardiac rhythm that could undermine a detailed and complete evaluation. Thus, electroanatomical mapping during electrophysiological testing could offer additional and complementary information that could improve risk stratification and further management.

P23 TIMING OF EJECTION FRACTION REASSESSMENT AFTER SACUBITRIL–VALSARTAN INITIATION FOR INDICATION TO DEFIBRILLATOR IMPLANTATION. A SINGLE CENTER EXPERIENCE

Background

Sacubitril/Valsartan (SV) has been validated for heart failure (HF) with reduced ejection fraction (EF) treatment. SV is effective on hard end–points as well as symptoms and heart remodeling. Present guidelines reccomend at least 3 month of optimized medical therapy (OMT). However, the best timing of EF assessment after SV initiation in order to proceed with defibrillator (ICD) implantation, is still unknown.

Purpose

Evaluate timing of improvement of EF after SV initiation in patients (pts) with systolic HF, candidates to primary prevention ICD implantation.

Methods

From 1 of february 2018, we evaluated retrospectively clinical and echocardiographic data of all consecutive pts with EF < 35% treated with SV and candidates to primary prevention ICD implantation. We evaluated clinical and echo follow up (Fup). Results have been analyzed with paired T–test.

Results

The study involved 95 pts (mean age 67±10 years, 70% male, ischaemic etiology 48%). Mean EF at enrollment was 30 ± 5% (ED vol 90 ±23 ml/m2; ES vol 62 ± 19 ml/m2, severe MR 23%) and NYHA III–IV 50%. In 58% pts reached the target dose of SV (97/103 mg bid). After a mean Fup of 6 months, mean EF of the study population increased to 37±7% (ED vol 80±19 ml/m2, ES vol 51±17 ml/m2, severe MR 5%, p < 0.001), and NYHA III–IV decreased to 8% (p = 0.01). Interestingly, thirty–one pts (32%) had their first Fup within 3 months and showed already an improvement [meanEF 28±5% to 35±6%; ΔEF 7±6%; NYHA III–IV 10 %]. Moreover, 49 pts (51%) had last Fup echo after 1 year (mean 13±6 months) and showed a further EF improvement (meanEF 41±8%; ΔEF 12±9%; p < 0.001).Sixteen pt (16%) underwent ICD (62%) or CRT–D (38%) implantation after 3±2 months of treatment and excluded from further FUP analysis. More favorable effects of treatment with SV were more evident in patient with non–ischaemic etiology of heart failure.

Conclusions

After SV initiation in systolic HF, favourable heart remodeling is clearly evident at 6 months FUP, but could be already observed after 3 months . These findings need to be validated from larger trials but suggest that the best timing of EF reassessment to decide for primary prevention ICD is likely between 3 and 6 months after SV initiation. However decision must be taken following close and individualized FUP for every patient, based on clinical characteristics and response to OMT.

[Is it time to implement Cardiac Arrest Centers in Italy? The integrated experience in the decade 2009-2019 between metropolitan area and Maggiore Hospital of Bologna]

Cardiac arrest (CA) is the third cause of death in Europe. This paper highlights the various treatments for the prevention and early management of CA and provides an overview of available evidence on the CA center concept. The experience of Maggiore Hospital of Bologna, Italy over the last 11 years is also outlined along with the treatments applied to patients with CA and their impact on improving outcomes. The new concept of the "Systems Saving Lives" approach is presented as a potential way for implementing Italian healthcare systems involved in the management of CA patients. Finally, the future perspective of implementation of CA centers in Italy is also described encouraging the healthcare professionals involved in the treatment of CA patients to consider a multidisciplinary approach (including a cardiologist, emergency physician, neurologist, physiatrist, radiologist, and intensivist).

[Brugada syndrome and early repolarization syndrome: similarities and differences. The lesson from case reports]

In subjects with cardiac arrest and aborted sudden death, the presence of an ECG pattern (spontaneous or drug-induced) suggesting a Brugada syndrome (BrS) is generally considered the proof of a BrS. We present three case reports of patients with resuscitated sudden death in whom a BrS was diagnosed, but in whom the real cause was probably an early repolarization syndrome (ERS). This distinction is not only theoretical but has also practical consequences. In fact, the arrhythmic substrate is different in the two conditions: right ventricular outflow tract in BrS, inferior ventricular wall in ERS. As a consequence, catheter ablation of the right ventricular outflow tract may be useful in BrS, whereas it is useless in ERS.

Timing of ejection fraction reassessment after sacubitril-valsartan initiation for indication to defibrillator implantation. A single center experience

Background

Sacubitril/Valsartan (SV) has recently been validated in the therapy of heart failure (HF) with reduced ejection fraction (EF). SV is effective on symptoms and heart remodeling. At the moment the best timing to EF assessment after SV initiation in order to proceed with defibrillator (ICD) implantation, it's unknown.

Purpose

Evaluate the timing of improvement of EF after SV initiation in patients (pts) with systolic HF, candidates to primary prevention ICD implantation.

Methods

We enrolled all consecutive pts candidates to primary prevention ICD implantation that underwent SV initiation from February 2018. We evaluated clinical and echo follow up (Fup). Results have been analyzed with paired T-test).

Results

The study involved 61 pts (mean age 67±10 years, 71% male, ischemic cardiopathy 44%, mean time from diagnosis 31 months) with mean EF at enrollment 30±5% (ED vol 94 ml/m2, ES vol 64 ml/m2, severe MR 21%) and mean NYHA 3±0.6. After a mean Fup of 6 months mean EF increased to 37±7% (ED vol 80 ml/m2, ES vol 51 ml/m2, severe MR 8%, p<0.004), NYHA decreased to 2±0.6 (p<0.04). In 69% pts SV dosage reached 97/103 mg bid. 28 pts (45%) had first Fup at 3 months and showed already mean EF 34±6% and mean NYHA 1.6±0.6 (p<0.04). 26 pts (43%) had last Fup echo after 1 year (mean 17±10 months) and showed further EF little improvement (38.3±8%, p 0.05).

Conclusions

After SV initiation in systolic HF, heart remodeling is already evident at 3 months Fup and better appreciable at 6 months Fup. Little non significant further EF improvement could be seen later. In our study best timing to decide for primary prevention ICD is likely between 3 and 6 months after SV initiation.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Mortality after cardioverter-defibrillator replacement: Results of the DECODE survival score index

BACKGROUND

Device replacement is the ideal time to reassess health care goals regarding continuing implantable cardioverter-defibrillator (ICD) therapy. Only few data are available on the decision making at this time.

OBJECTIVES

The goals of this study were to identify factors associated with poor prognosis at the time of ICD replacement and to develop a prognostic index able to stratify those patients at risk of dying early.

METHODS

DEtect long-term COmplications after implantable cardioverter-DEfibrillator replacement (DECODE) was a prospective, single-arm, multicenter cohort study aimed at estimating long-term complications in a large population of patients who underwent ICD/cardiac resynchronization therapy - defibrillator replacement. Potential predictors of death were investigated, and all these factors were gathered into a survival score index (SUSCI).

RESULTS

We included 983 consecutive patients (median age 71 years (63-78)); 750 (76%) were men, 537 (55%) had ischemic cardiomyopathy; 460 (47%) were implanted with cardiac resynchronization therapy - defibrillator. During a median follow-up period of 761 days (interquartile range 628-904 days), 114 patients (12%) died. In multivariate Cox regression analysis, New York Heart Association class III/IV, ischemic cardiomyopathy, body mass index < 26 kg/m², insulin administration, age ≥ 75 years, history of atrial fibrillation, and hospitalization within 30 days before ICD replacement remained associated with death. The survival score index showed a good discriminatory power with a hazard ratio of 2.6 (95% confidence interval 2.2-3.1; P < .0001). The risk of death increased according to the severity of the risk profile ranging from 0% (low risk) to 47% (high risk).

CONCLUSION

A simple score that includes a limited set of variables appears to be predictive of total mortality in an unselected real-world population undergoing ICD replacement. Evaluation of the patient's profile may assist in predicting vulnerability and should prompt individualized options, especially for high-risk patients.

Catecholaminergic Polymorphic Ventricular Tachycardia: Challenges During Resuscitation and Post-Cardiac Arrest Care

BACKGROUND

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare channelopathy involving cardiac calcium metabolism that often shows up at an early age with misleading clinical symptoms, such as emotion- or exercise-related syncope with a normal resting electrocardiogram. In addition, it might be the underlying cause of sudden cardiac arrest in children or young adults. The particular pathophysiology of CPVT makes it particularly challenging for both resuscitation and the subsequent intensive care management after return of spontaneous circulation (ROSC).

CASE REPORT

We describe a case of sudden cardiac arrest in an 11-year-old girl affected by CPVT, with a particular focus on the most challenging aspects of resuscitation and intensive care management in light of other experiences found in the literature. A warning about the prodysrythmicity of mild hypothermia induced in the context of post-ROSC targeted temperature management in this particular population of patients and its possible physiopathological basis are discussed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CPVT is a rare but potentially lethal cause of stress-related syncope and sudden cardiac arrest in children and young adults. The diagnosis of CPVT requires a high level of suspicion and an interdisciplinary approach, including some adjustments during resuscitation and post-cardiac arrest care.

P5238Rate, cause and costs of Heart Failure hospitalizations following ICD/CRT-D replacement: preliminary data from an Italian multicenter registry

Background

Heart failure hospitalizations (HFHs) likely represent the main health care expenditure also in implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-D) recipients yet the event rate of HFH and the associated costs after device replacement or upgrade are unknown.

Purpose

To report HFH rates and associated costs within 12 months following ICD/CRT-D device replacement or upgrade procedure from ICD to CRT-D.

Methods

The DEtect long-term COmplications after icD rEplacement (DECODE) was a prospective, single-arm, multicenter cohort study exploring complications in ICD/CRT-D recipients undergoing device replacement or upgrade from ICD to CRT-D. All clinical and survival data of these patients at 12-month follow-up were prospectively analyzed. For each adjudicated HFH, the admission and discharge date were recorded, and ICD-9-CM diagnoses and procedure codes were obtained. The estimated reimbursement for each hospitalization was calculated according to the 2012 Italian national reimbursement rates.

Results

Between 2013 and 2015, 983 patients (mean age = 71 years, mean LVEF = 35%, NYHA class I/II = 75.6%) were enrolled: 900 (91.6%) patients underwent device replacement (446 ICD/454 CRT-D) and 83 (8.4%) upgrade from ICD to CRT-D. After 12 months, 66 (6.7%) patients died, 40 (60.6%) for cardiovascular reasons. Fifty-five (5.6%) patients experienced at least 1 HFH. Overall, 91 HFH (9.6% event rate 95% CI, 7.7–11.7) occurred. Among the variables tested at univariate analysis, only LVEF ≤35%, AF history and renal disease were confirmed as HFH predictors at multivariate analysis. HFH rate was significantly higher following upgrade procedures and occurrence of HFH was associated with an eleven-fold increased mortality risk (95% CI: 5.9 to 20.5; p<0.0001). The cumulative cost associated with HFHs incurred over the 12 months follow-up was 515305 €. The mean cost per HFH was 5662±9497 € [ranging from 3144 € to 64479 €] while the mean cost per patient with events was 9369±12687 €.

Conclusion

Underlying cardiac disease and renal failure are the main drivers of HFH and mortality, and of higher healthcare expenditures in ICD/CRT-D recipients following device replacement or upgrade. Accurate clinical assessment is needed to support the decision-maker at the time of ICD replacement to take an appropriate clinical and economic sustainable decision.

Acknowledgement/Funding

None

Congenital myopathy with hanging big toe due to homozygous myopalladin (MYPN) mutation

Background

Myopalladin (MYPN) is a component of the sarcomere that tethers nebulin in skeletal muscle and nebulette in cardiac muscle to alpha-actinin at the Z lines. Autosomal dominant MYPN mutations cause hypertrophic, dilated, or restrictive cardiomyopathy. Autosomal recessive MYPN mutations have been reported in only six families showing a mildly progressive nemaline or cap myopathy with cardiomyopathy in some patients.

Case presentation

A consanguineous family with congenital to adult-onset muscle weakness and hanging big toe was reported. Muscle biopsy showed minimal changes with internal nuclei, type 1 fiber predominance, and ultrastructural defects of Z line. Muscle CT imaging showed marked hypodensity of the sartorius bilaterally and MRI scattered abnormal high-intensity areas in the internal tongue muscle and in the posterior cervical muscles. Cardiac involvement was demonstrated by magnetic resonance imaging and late gadolinium enhancement. Whole exome sequencing analysis identified a homozygous loss of function single nucleotide deletion in the exon 11 of the MYPN gene in two siblings. Full-length MYPN protein was undetectable on immunoblotting, and on immunofluorescence, its localization at the Z line was missed.

Conclusions

This report extends the phenotypic spectrum of recessive MYPN-related myopathies showing: (1) the two patients had hanging big toe and the oldest one developed spine and hand contractures, none of these signs observed in the previously reported patients, (2) specific ultrastructural changes consisting in Z line fragmentation, but (3) no nemaline or caps on muscle pathology.

[Premature ventricular beats: are they always benign? Diagnostic and therapeutic aspects]

Premature ventricular complexes (PVCs) are usually benign, and commonly only severely symptomatic patients are treated. In the literature, frequent PVCs have been reported to cause ventricular dysfunction, which may improve after PVC treatment. PVCs can also worsen the prognosis in patients with structural heart disease. Catheter PVC ablation is often the treatment of choice considering the high success rates. Ventricular dysfunction due to frequent PVCs is not always easy to identify as patients can be asymptomatic and the interpretation of imaging tests may be challenging in the presence of frequent PVCs. Treatment of patients with mild ventricular dysfunction is still a matter of debate.

Thorax Percutaneous Approach for Epicardial Ventricular Ablation in a Patient with Electrical Storm

Subxiphoid puncture is considered the standard approach for epicardial ablation of ventricular arrhythmia, but in some cases this access is impracticable due to the patient's anatomy. We describe the case of a patient with electrical storm and abnormal subdiaphragmatic anatomy that precluded the usual subxiphoid approach. In this patient the pericardial space was gained through a direct thorax puncture at the fifth intercostals space close to the mammary line. The tools and technique utilized in this case were similar to what is usually used for traditional subxiphoid puncture. The thorax percutaneous puncture was successfully carried out without complication.

Left Ventricular Reverse Remodeling Elicited by a Quadripolar Lead: Results from the Multicenter Per4mer Study

BACKGROUND

To understand the impact of a quadripolar left ventricular (LV) lead on reverse remodeling and phrenic nerve stimulation (PNS) in congestive heart failure patients treated by cardiac resynchronization therapy at 8-month follow-up (FU).

METHODS

One hundred and fifty-eight patients received an LV Medtronic Performa lead (Medtronic Inc., Minneapolis, MN, USA) and were reevaluated at FU by echocardiography and measurement of electrical parameters.

RESULTS

A targeted LV lead placement was achieved in 140 (89%) patients. Super responders and responders were 76 (50%) and 26 (18%), respectively, at FU; seven (4%) died and 13 (8%) were hospitalized for any cause. Nonischemic etiology was the only independent predictor of reverse remodeling. The configurations available only with the Performa leads reduced PNS occurrence at 8 V@0.4 ms from 43 (27%) to 14 (9%) of patients at implantation, and from 44 (28%) to 19 (12%) at last FU, compared to configurations available with bipolar leads. Patients with detectable PNS had >10/16 pacing configurations with a PNS safety margin >2 V both at implantation and at FU. During FU 16 (10%) patients had an adverse event possibly related to the lead or to modification of the underlying heart disease but 99% of these events were fixed by reprogramming of the pacing vector.

CONCLUSIONS

Performa Lead enables an increased capability to achieve a targeted lead positioning in the broad clinical scenario of large- and small-volume implanting centers, with a relevant impact on the occurrence of reverse remodeling compared to literature data. The enhanced management of PNS resulted in a dislodgement rate of only 1%.

Tachycardia-Induced Cardiomyopathy

This is a typical example of a tachycardia-induced cardiomyopathy due to incessant tachycardia with moderately increased ventricular rate. This was due to nonreentrant atrioventricular nodal tachycardia that gave rise to two ventricular complexes for every atrial complex. It describes a rare finding of the presence of retrograde concealed conduction in the fast pathway. Curative catheter ablation led to improvement of symptoms with reversal of tachycardia-induced cardiomyopathy.

Asystole induced by partial seizures: a rare cause of syncope

The clinical distinction between cardiovascular and epileptic causes of loss of consciousness is sometimes difficult, but becomes challenging when a primary epileptic seizure secondarily causes an asystole. Epilepsy can be correlated to severe bradycardia or asystole. The syndrome is called the ictal bradycardia syndrome. Ictal bradycardia and asystole have been implicated in the etiology of sudden unexpected death in epileptic patients (SUDEP). We present a case of traumatic syncope during an epileptic disorder ab esordio and we discuss the related literature.

Percutaneous occlusion of the left atrial appendage for systemic embolism prevention in patients with atrial fibrillation: state of the art and report of two cases

Atrial fibrillation is a benign arrhythmia but it is associated with an elevated thromboembolic risk. The treatment of choice is oral anticoagulation. However not all the patients can benefit from oral anticoagulation, due to bleeding risk or other contraindications. Considering that the most common embolic source in patients with atrial fibrillation is the left atrial appendage, different surgical techniques have been suggested for its closure. For patients at high risk, since August 2001 a device is available for percutaneous occlusion of the left atrial appendage (PLAATO). The PLAATO device consists of a self-expandable nitinol cage with small anchors on its surface to avoid systemic migration. The implantation procedure is performed with local anesthesia. It requires transseptal puncture and the device is delivered to the appendage through a specially designed sheath. The maneuver is performed under transesophageal and fluoroscopic guidance. At present more than 250 patients have been implanted, and the results, as far as the safety and the effectiveness are concerned, are really promising. We report 2 cases of recently successfully implanted at our Center.

Ablation of left atrial flutter in a patient surgically treated for atrial fibrillation. Does it indicate a possible hybrid approach?

Surgical treatment of atrial fibrillation (AF) has a high success rate and nowadays simpler and faster procedures have been proposed. The following is a description of the case of a patient who, after a modified Maze procedure, developed an atypical left atrial flutter and underwent a successful radiofrequency ablation procedure. A 71-year-old male underwent surgical biological valve replacement and a concomitant modified Maze procedure. After surgery the patient developed a persistent atrial arrhythmia with severe symptoms and refractory to any drug. For this reason, an electrophysiological study was planned. We performed a three-dimensional atrial mapping using the real-time position management system (Boston Scientific). Right atrial mapping indicated an early activation area on the septum. After transseptal puncture, left atrial mapping showed a reentry circuit around the mitral annulus with positive entrainment. A linear lesion was made between the mitral annulus and the superior right pulmonary vein and sinus rhythm was restored. After 7 months of follow-up the patient is asymptomatic and still in stable sinus rhythm. In conclusion, the follow-up of surgical AF may be improved by close collaboration between the surgeon and electrophysiologist. The available data suggest that a combined surgical and percutaneous approach could be the strategy of choice.

Accelerated QRS widening as an independent predictor of cardiac death or of the need for heart transplantation in patients with congestive heart failure

We analyzed QRS interval for 6 months or more in 82 patients with dilated cardiomyopathy. At 1 year, the incidence of cardiac death/need for heart transplantation was higher among patients with QRS-interval widening of 0.5 msec/month or greater (p = 0.002). At multivariate analysis, QRS widening independently and unfavorably predicted cardiac death/need for heart transplantation (p = 0.029). Randomized prospective studies are necessary to confirm the prognostic value of accelerated QRS widening in patients with dilated cardiomyopathy and to investigate its significance in selecting candidates for electrical resynchronization and heart transplantation.

Hospitalization for congestive heart failure: is it still a cardiology business?

BACKGROUND

Hospital management of CHF and predictors of hospital mortality remain unclear.

METHODS

To address these issues, we analyzed the hospital admissions for CHF during 1996 in a large university hospital. Patients discharged with the principal diagnosis of CHF were considered eligible for the study.

RESULTS

Among the 1511 patients (3% of all discharges) who satisfied the inclusion criteria, 75% were treated in general medicine departments (GMD) and 22% in cardiology units (CU). Patients admitted to GMD were older than those treated in CU (79+/-10 vs. 68+/-15 years, P<0.001), included a higher proportion of females (56% vs. 37%, P<0.001), and presented a higher rate of hospital mortality (13% vs. 4%, P<0.001). The overall mean length of stay was 11+/-9 days. At multivariate analysis, length of stay was not associated with the department (i.e. GMD/CU) (P=0.273).

CONCLUSIONS

CHF is a common lethal condition often requiring treatment in GMD. Length of stay appears to depend more on patients' characteristics than on differences in practice between GMD and CU. Patients admitted to GMD present higher rates of comorbidity and hospital mortality. Strategies are urgently needed to improve hospital management of CHF.

Rationally designed strings of promiscuous CD4(+) T cell epitopes provide help to Haemophilus influenzae type b oligosaccharide: a model for new conjugate vaccines

The age-related and T cell-independent immunological properties of most capsular polysaccharides limit their use as vaccines, especially in children under 2 years of age. To overcome these limitations, polysaccharide antigens have been successfully conjugated to a variety of carrier proteins, such as diphtheria toxoid or tetanus toxoid (TT) and the diphtheria mutant (CRM197) to produce very successful glycoconjugate vaccines. The increasing demand for new conjugate vaccines requires the availability of additional carriers providing high and long-lasting T helper cell immunity. Here we describe the design and construction of three recombinant carrier proteins (N6, N10, N19) constituted by strings of 6, 10 or 19 human CD4(+) T cell epitopes from various pathogen-derived antigens, including TT and proteins from Plasmodium falciparum, influenza virus and hepatitis B virus. Each of these epitopes is defined as universal in that it binds to many human MHC class II molecules. When conjugated to Haemophilus influenzae type b (Hib) oligosaccharide, these carriers elicit a potent anti-Hib antibody response in mice. In the case of the N19-Hib conjugate, this response is at least as good as that observed with CRM197-Hib, a conjugate vaccine currently used for mass immunization. We also show that some of the universal epitopes constituting the recombinant carriers are specifically recognized by two human in vitro systems, suggesting that T cell memory is provided by the selected epitopes. The data indicate that rationally designed recombinant polyepitope proteins represent excellent candidates for the development and clinical testing of new conjugate vaccines.

Role of statins in the management of dyslipidemia after cardiac transplant: randomized controlled trial comparing the efficacy and the safety of atorvastatin with pravastatin

BACKGROUND

Cardiac transplant patients are at increased risk of dyslipidemia, a known pathogenetic factor in chronic rejection. The aim of this study was to compare the efficacy and the safety of treatment with atorvastatin (AT) and treatment with pravastatin (PV) in a population of dyslipidemic transplant patients.

METHODS

Thirty-nine transplant patients were randomized to receive a 4-month cycle of therapy with AT or PV, in a cross-over sequence. We analyzed the effects on their lipid profiles using Student t-test for paired data.

RESULTS AND CONCLUSION

Atorvastatin was significantly more effective than PV in reducing total cholesterol (33% vs 21%, p < 0.001), LDL cholesterol (45% vs 30%, p = 0.001), and triglycerides (24% vs 7.7%, p < 0.001), at lower doses and with comparable tolerability and safety.

Increasing plasma homocysteine during follow-up in heart transplant recipients: effects of folate and renal function

BACKGROUND

Hyperhomocysteinemia is a common finding in heart transplant recipients and may represent a risk factor for graft failure. However, the time-course, determinants and effects of medical therapy on total homocysteine plasma levels after heart transplantation remain undetermined. The aim of this study was to prospectively analyze 1) the time-course of total homocysteine in heart transplant recipients; 2) the effects of folate supplements and cyclosporine A on total homocysteine; 3) the relation among renal function, serum vitamin levels, and total homocysteine.

METHODS

Fifty-two heart transplant recipients consecutively evaluated for routine follow-up during 1998 were included in the study (mean age 54 +/- 12 years; 28% female). Among the 52 patients, 10 patients were treated with folate for the entire period of the study (Group F), while 26 patients never received folate (Group NF). The remaining 16 patients who did not take folate on a regular basis were excluded from subgroup analysis. Total homocysteine and creatinine plasma levels were assayed at entry into the study (time 0) and at the end of the study, 12 months later (time 12).

RESULTS

Homocysteinemia increased significantly from time 0 to time 12 (p < 0.001), regardless of creatinine plasma levels (p = 0.03) and folate intake (p < 0.01). However, total homocysteine levels were lower in Group F compared to Group NF at time 0 and time 12 (p < 0.02). On multivariate analysis, time of follow-up, serum creatinine and lack of folate intake were positive independent predictors of total homocysteine.

CONCLUSIONS

Homocysteinemia increased over time in heart transplant recipients, regardless of renal function and folate administration. Lower total homocysteine levels were associated with folate intake, suggesting that folate supplements may play a role in the prevention of vascular allograft disease.

Size determination of bacterial capsular oligosaccharides used to prepare conjugate vaccines

We recently described the use of ion exchange chromatography for analysis and the industrial scale preparation of pools of oligosaccharides of intermediate chain length from polysaccharides of Haemophilus influenzae type b (Hib) and Neisseria meningitidis groups A and C. These negatively charged "sized" oligosaccharides are activated and conjugated to the carrier protein (CRM197) to prepare the corresponding glycoconjugate vaccines. Characterization and accurate determination of the degree of polymerization (DP) of the pool of oligosaccharides is essential for the consistent production of these conjugate vaccines. This paper describes the colorimetric assays used for determination of the average DP of the Hib and meningococcal oligosaccharides, and the qualification of these assays achieved by size characterization of the respective oligosaccharides by use of physicochemical methods, including liquid chromatography, mass spectrometry (ionspray) and NMR spectroscopy.

Morphometric and tridimensional studies of tubular cystic degeneration in rat kidney following exposure to cisplatin

Cisplatin, a widely used chemotherapeutic agent, is characterized by a dose-limiting renal toxicity. Cystic tubular dilatation is the most typical histopathological alteration encountered in cisplatin-treated rats. The purpose of the present study was to explore by a morphometric approach the development of cystic degeneration and, in particular, to analyse, by computer-assisted tridimensional reconstructions, the spatial structure and the tubular origin of cisplatin-induced renal cysts. This study was performed on rats given 8 mg/kg cisplatin i.p. for four days and sacrificed 4, 7, 14, 21, 50 and 60 days after last drug administration. The relative area occupied by cystic tubules increased rapidly in the outer stripe of outer medulla (OSOM) and reached a maximum 21 days after the end of treatment. Cystic dilatations appeared later in the kidney cortex and the inner stripe of outer medulla (ISOM). The tridimensional study of cystic tubules located in OSOM confirmed previous reports indicating that they arise from proximal straight tubules and showed that cystic degeneration was not associated with atrophy or degeneration in more proximal parts of the nephron. Moreover, cystic tubules located in ISOM were found to originate from distal straight tubules and/or the loop of Henle, an observation which, to our knowledge, has not been reported so far in cisplatin-treated rats.

Processing of interleukin-1 in cells of monocytic lineage is differentiation-dependent

The interleukin-1 (IL-1) alpha and beta precursor proteins are processed and released from several cell types in the absence of a canonical signal peptide. To gain some insight into the mechanisms that allow the production of IL-1 alpha and beta, we have investigated by immunoprecipitation the synthesis, their release and processing in a promyeloblastic cell line of tumoral origin, U937, and in peripheral blood monocytes. We show that U937 monocytic cells, on induction with a tumor-promoting agent, synthesize and release into the culture medium proIL-1 beta but do not process it. Similarly, peripheral blood monocytes left in adherence for 24 h or longer, prior to addition of lipopolysaccharide, synthesize and release proIL-1 alpha and beta without detectable processing of either cytokine. Processing and release of IL-1 alpha and beta by peripheral blood monocytes can be observed when monocytes are left to adhere for periods less than 15 h before lipopolysaccharide addition. IL-1 alpha and beta show similar kinetics of release from the cells, suggesting the existence of a common mechanism regulating their secretion. Since peripheral blood monocytes left in adherence in the presence of lipopolysaccharide differentiate into macrophages, we conclude that release and processing of IL-1 can occur independently and that processing depends on the stage of differentiation of monocytes, i.e. only the monocytes at an early stage of differentiation produce 17-kDa IL-1 alpha and beta.

Human interleukin-1 beta gene

We report the nucleotide sequence of the human chromosomal gene which encodes the interleukin-1 beta protein (IL-1 beta). The gene spans a region of 7.5 kb and the coding part is divided into seven exons. Comparison with the homologous mouse gene reveals that the structural organization is conserved through evolution. In addition to this, human and murine IL-1 beta genes show extensive sequence homology within the intervening sequences.

The murine interleukin 1 beta gene: structure and evolution

We have isolated from a genomic library a murine recombinant clone containing the gene coding for interleukin-1 beta m-RNA. A 7000 b.p. DNA fragment has been sequenced. Sequences homologous with human IL-1 beta cDNA have been found distributed within 7 exons. The translation of these sequences allows the prediction of a protein 269 aminoacids long. Hybridization of P388D1 RNA from cells stimulated with phorbol myristic acetate with a genomic DNA probe shows the existence of a 1.6 Kb murine IL-1 beta mRNA which is absent in the unstimulated cells. The comparative analysis between the murine IL-1 beta and the human IL-1 alpha genes shows extreme conservation of the aminoacids at the exon junctions. This observation together with the similarity in number and size of the exons suggests that these genes have diverged from a common ancestor.