Publications by authors named "Eraldo Occhetta"

74 Publications

Effectiveness and safety of antithrombotic strategies in elderly patients with acute myocardial infarction.

World J Cardiol 2020 Nov;12(11):513-525

Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy.

Background: Elderly patients represent a rapidly growing part of the population more susceptible to acute coronary syndromes and their complications. However, literature evidence is lacking in this clinical setting.

Aim: To describe the clinical features, in-hospital management and outcomes of "elderly" patients with myocardial infarction treated with antiplatelet and/or anticoagulation therapy.

Methods: This study was a retrospective analysis of all consecutive patients older than 80 years admitted to the Division of Cardiology of St. Andrea Hospital of Vercelli from January 2018 to December 2018 due to ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI). Clinical and laboratory data were collected for each patient, as well as the prevalence of previous or in-hospital atrial fibrillation (AF). In-hospital management, consisting of an invasive or conservative strategy, and the anti-thrombotic therapy used are described. Outcomes evaluated at 1 year follow-up included an efficacy ischemic endpoint and a safety bleeding endpoint.

Results: Of the 105 patients enrolled (mean age 83.9 ± 3.6 years, 52.3% males), 68 (64.8%) were admitted due to NSTEMI and 37 (35.2%) due to STEMI. Among the STEMI patients, 34 (91.9%) underwent coronary angiography and all of them were treated with percutaneous coronary intervention (PCI); among the NSTEMI patients, 42 (61.8%) were assigned to an invasive strategy and 16 (38.1%) of them underwent a PCI. No significant difference between the groups was found concerning the prevalence of previous or in-hospital de-novo AF. 10.5% of the whole population received triple antithrombotic therapy and 9.5% single antiplatelet therapy plus oral anticoagulation (OAC), with no significant difference between the subgroups, although a higher number of STEMI patients received dual antiplatelet therapy without OAC as compared with NSTEMI patients. A low rate of in-hospital death (5.7%) and 1-year cardiovascular death (3.3%) was registered. Seven (7.8%) patients experienced major adverse cardiovascular events, while the rate of minor and major bleeding at 1-year follow-up was 10% and 2.2%, respectively, with no difference between NSTEMI and STEMI patients.

Conclusion: In this real-world study, a tailored evaluation of an invasive strategy and antithrombotic therapy resulted in a low rate of adverse events in elderly patients hospitalized with acute myocardial infarction.
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http://dx.doi.org/10.4330/wjc.v12.i11.513DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7701903PMC
November 2020

Second European Society of Cardiology Cardiac Resynchronization Therapy Survey: the Italian cohort.

J Cardiovasc Med (Hagerstown) 2020 Sep;21(9):634-640

Heart and Vascular Theme, Karolinska University Hospital, Stockholm, and Karolinska Institutet, Stockholm, Sweden.

Aim: Adherence to guidelines was not homogeneous in Europe, according to the survey on cardiac resynchronization therapy conducted in 2008-2009. The aim of our study was to compare the results in the Italian and European cohorts of the Second European Cardiac Resynchronization Therapy Survey.

Methods: Patients' characteristics, procedural data and follow-up were collected. Italian records were compared with European countries.

Results: Italian hospitals enrolled 526 patients. The italian cohort was older (71.6 ± 9.5 vs. 68.4 ± 10.8; P < 0.00001), had less severe NYHA class (>II 47.2 vs. 59.6%; P < 0.00001), higher ejection fraction (30.3 ± 7.4 vs. 28.4 ± 8.2%; P < 0.00001), and less atrial fibrillation prevalence (34.4 vs. 41.2%; P = 0.00197) than the European cohort. Italian patients were more frequently hospitalized for heart failure in the previous year (51.9 vs. 46.2%; P = 0.01118) and had lower mean QRS duration (151 ± 26 vs. 157 ± 27 ms; P < 0.0001). CRT-D were more often implanted in Italian patients (79.3 vs. 69.3%; P < 0.00001). The complication rate was similar (4.6% vs. 5.6%; ns). The rate of use of ACEi/ARBs in Italy was lower than in Europe (77.2 vs. 86.9%; P < 0.00001). Patients were followed up in the implantation centre (92.1 vs. 86%; P = 0.00014), but rarely with remote monitoring (25.9 vs. 30%; P = 0.04792).

Conclusion: The survey demonstrates important similarities as well as substantial differences regarding most of the aspects evaluated. Efforts to implement adherence to guidelines will be endorsed in Italy.
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http://dx.doi.org/10.2459/JCM.0000000000001035DOI Listing
September 2020

Cardiac contractility modulation in left ventricular systolic dysfunction: one-year experience in a pilot study and design of a prospective registry.

Minerva Cardiol Angiol 2021 Feb 10;69(1):15-24. Epub 2020 Jul 10.

Division of Cardiology, Sant'Andrea Hospital, Vercelli, Italy.

Background: Cardiac contractility modulation (CCM) is a treatment option for patients suffering symptomatic chronic heart failure (CHF) with reduced left ventricular ejection fraction (LVEF) who are not eligible for cardiac resynchronization. Data on mid-term follow-up are limited to small observational studies. The aim of this study was to assess the impact of CCM on quality of life, symptoms, exercise tolerance and left ventricular function in patients with CHF and moderate-to-severe left ventricular systolic dysfunction.

Methods: Patients suffering CHF with LVEF <45% and NYHA class >II despite optimal medical therapy, underwent CCM implantation. Enrolled patients underwent baseline and 3, 6 and 12-months evaluation with ECG, echocardiogram, clinical assessment, 6-minute walking test and Minnesota Living with Heart Failure Questionnaire (MLWHFQ).

Results: Ten patients underwent CCM implantation. All patients were actively treated with the optimal pharmacological therapy as tolerated and had at least one hospitalization for worsening heart failure during the previous year. After a mean follow-up of 15 months, 9 patients were alive, while one patient died for worsening heart failure precipitated by pneumonia. Among the remaining 9 patients, LVEF improved non-significantly from 29.4±8% to 32.2±10% (P=0.092), 6-minute walking test distance improved from 179±73 m to 304±99 m (P<0.001), NYHA class reduced from 3.0±0.4 to 1.6±0.5 (P=0.003) and MLWHFQ score improved from 59.6±49 to 34.2±32 (P=0.037). Only 2 patients have been hospitalized during the 12 months. Overall, a net clinical benefit was detected in 6 out of 9 patients.

Conclusions: CCM could be effective in improving quality of life, symptoms and exercise tolerance, and reduces hospitalizations in patients with symptomatic CHF on top of optimal medical and electrical therapy. A prospective registry has been designed to identify the subsets of patients gaining more benefit, and to assess the long-term effect of CCM on those clinical endpoints.
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http://dx.doi.org/10.23736/S0026-4725.20.05219-6DOI Listing
February 2021

Impact on All-Cause and Cardiovascular Mortality of Cardiac Implantable Electronic Device Complications: Results From the POINTED Registry.

JACC Clin Electrophysiol 2020 04 29;6(4):382-392. Epub 2020 Jan 29.

Cardiology Unit, "Card. Giovanni Panico" Hospital, Tricase, Italy.

Objectives: This study aimed to determine how CIED-related complications affect all-cause and cardiovascular mortality over a long-term follow-up.

Background: Although complications related to implantable electronic device (CIED) implantation are steadily increasing in Europe, little is known about the impact of complications other than device infection on mortality.

Methods: The POINTED (Impact on Patient Outcome and health care utilization of cardiac ImplaNTable Electronic Device complications) registry was a prospective, multicenter, observational study designed to collect data on complications in patients undergoing de novo CIED implantation (NCT03612635). All consecutive patients were enrolled in 6 high-volume centers between January 2010 and December 2012 and followed up for at least 3 years. A complication was defined as any CIED-related adverse event requiring surgical revision after implantation.

Results: During follow-up (median 56.9 months), we observed 283 complications in 263 of 2811 consecutive patients (71 ± 14 years of age, 66.7% men). Early complications (≤30 days) were associated with significantly lower cumulative survival from cardiovascular death in comparison with late complications and with freedom from complications. On multivariate analysis, early complication, pneumothorax, and pocket hematoma were significantly associated with a higher risk of all-cause death, while device infection remained the only complication significantly associated with a higher risk of cardiovascular death.

Conclusions: All CIED-related complications are associated with an increased risk of cardiovascular mortality, and early complications are associated with an increased risk of all-cause mortality. These data underline the importance of specific measures aimed at reducing CIED complications and improving their management.
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http://dx.doi.org/10.1016/j.jacep.2019.11.005DOI Listing
April 2020

[Quality and performance in cardiac pacing and electrophysiology. An update to the 2010 Italian Association of Arrhythmology and Cardiac Pacing (AIAC) - Italian Federation of Cardiology (IFC) Document 'Structure and functional organization of Arrhythmology'].

G Ital Cardiol (Rome) 2020 May;21(5):385-393

Centro CardioAritmologico, Roma.

In the last decade the field of cardiac pacing and electrophysiology underwent major advancements thanks to both new ways of arrhythmia management and technological innovations. At the same time, the clinical competence and the procedural qualitative level of Cardiac Rhythm Centers have increased significantly. In 2010 an ad hoc Committee of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) and the Italian Federation of Cardiology (FIC) published a consensus document on the organization of Cardiac Rhythm Centers and on the standards of professional practice in pacing and electrophysiology in Italy. In particular, this document focused on the minimal requirements of a Center to be qualified as suitable to perform first, second and third-level cardiac pacing and electrophysiology activities. However, most of these indicators have been overcome over time. Thus, an update of the previously published organizational model appeared necessary. In this document several new requirements and indicators about the organization and performance of both operators and Cardiac Arrhythmia Centers have been introduced. These include: (i) "structural and procedural requirements" (types of diagnostic and therapeutic procedures performed, logistic structures, healthcare staff and technologies), (ii) "activity indicators" (number of procedures performed); (iii) "appropriateness indicators" (adherence to guideline recommendations); (iv) "outcome indicators" (procedural success and complications); and (v) "quality of care indicators" (management and continuity of care levels). By applying these requirements and indicators, each center can optimize its procedures, increasing its performance and effectiveness. Finally, a new model for the organization of the Italian network of Cardiac Arrhythmia Centers is also suggested.
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http://dx.doi.org/10.1714/3343.33141DOI Listing
May 2020

A randomized controlled trial of cardiac resynchronization therapy in patients with prolonged atrioventricular interval: the REAL-CRT pilot study.

Europace 2020 02;22(2):299-305

Clinica San Michele, via Montella 16, 81024 Maddaloni (CE), Italy.

Aims: A prolonged PR interval is known to be associated with increased mortality and a higher risk of developing atrial fibrillation (AF). We tested the hypothesis that cardiac resynchronization therapy (CRT) is superior to conventional dual-chamber pacing with algorithms for right ventricular pacing avoidance (DDD-VPA) in preserving systolic and diastolic function and in preventing new-onset AF in patients with normal systolic function, indication for pacing and prolonged atrioventricular conduction (PR interval ≥220 ms).

Methods And Results: We randomly assigned 82 patients with ejection fraction >35%, indication for pacing and PR interval ≥220 ms to CRT or to DDD-VPA. On 12-month follow-up examination, the study and control arms did not differ in terms of left ventricular end-systolic volume (44 ± 17 mL vs. 47 ± 16 mL, P = 0.511) or ejection fraction (55 ± 6% vs. 57 ± 8%, P = 0.291). The E to A mitral wave amplitude ratio was higher in the CRT arm (1.3 ± 1.3 vs. 0.8 ± 0.4, P = 0.046) and the E wave deceleration time was longer (262 ± 83 ms vs. 205 ± 51 ms, P = 0.027). Left atrial volume was smaller in the CRT arm (64 ± 17 mL vs. 84 ± 25 mL, P = 0.035). Moreover, the functional class was lower in CRT patients (1.4 ± 0.6 vs. 1.8 ± 0.5, P = 0.010). During follow-up, CRT was associated with a lower risk of new-onset AF [hazard ratio = 0.37 (0.13-0.98), P = 0.046].

Conclusion: Cardiac resynchronization therapy proved superior to DDD-VPA in terms of better diastolic function, less left atrial enlargement and lower risk of new-onset AF, at 12 months. These data need to be confirmed in a larger trial with longer follow-up.

Clinical Trial Registration: URL: http://clinicaltrials.gov/ Identifier: NCT02150538.
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http://dx.doi.org/10.1093/europace/euz321DOI Listing
February 2020

A randomized controlled trial of atrioventricular junction ablation and cardiac resynchronization therapy in patients with permanent atrial fibrillation and narrow QRS.

Eur Heart J 2018 12;39(45):3999-4008

Department of Cardiology, Hospital Clinic, Barcelona, Spain.

Aims: We tested the hypothesis that atrioventricular (AV) junction ablation in conjunction biventricular pacing [cardiac resynchronization (CRT)] pacing is superior to pharmacological rate-control therapy in reducing heart failure (HF) and hospitalization in patients with permanent atrial fibrillation (AF) and narrow QRS.

Methods And Results: We randomly assigned 102 patients (mean age 72 ± 10 years) with severely symptomatic permanent AF (>6 months), narrow QRS (≤110 ms), and at least one hospitalization for HF in the previous year to AV junction ablation and CRT (plus defibrillator according to guidelines) or to pharmacological rate-control therapy (plus defibrillator according to guidelines). After a median follow-up of 16 months, the primary composite outcome of death due to HF, or hospitalization due to HF, or worsening HF had occurred in 10 patients (20%) in the Ablation+CRT arm and in 20 patients (38%) in the Drug arm [hazard ratio (HR) 0.38; 95% confidence interval (CI) 0.18-0.81; P = 0.013]. Significantly fewer patients in the Ablation+CRT arm died from any cause or underwent hospitalization for HF [6 (12%) vs. 17 (33%); HR 0.28; 95% CI 0.11-0.72; P = 0.008], or were hospitalized for HF [5 (10%) vs. 13 (25%); HR 0.30; 95% CI 0.11-0.78; P = 0.024]. In comparison with the Drug arm, Ablation+CRT patients showed a 36% decrease in the specific symptoms and physical limitations of AF at 1 year follow-up (P = 0.004).

Conclusion: Ablation+CRT was superior to pharmacological therapy in reducing HF and hospitalization and improving quality of life in elderly patients with permanent AF and narrow QRS.

Clinicaltrials.gov Identifier: NCT02137187 (May 2018, date last accessed).
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http://dx.doi.org/10.1093/eurheartj/ehy555DOI Listing
December 2018

Long-term progression of rhythm and conduction disturbances in pacemaker recipients: findings from the Pacemaker Expert Programming study.

J Cardiovasc Med (Hagerstown) 2018 Jul;19(7):357-365

Cardiology Unit, 'Card. G. Panico' Hospital, Tricase.

Aims: Knowledge of the long-term progression of rhythm disorders requiring pacemaker implantation could have significant implications for the choice of device and its management during follow-up. Accordingly, we conducted an observational study to analyse the long-term progression of rhythm disorders requiring pacemaker implantation.

Methods: This multicentre, observational study enrolled 1810 pacemaker patients (age 71.6 ± 13.3 years, men 53.8%) consecutively evaluated during scheduled pacemaker follow-up visits. To evaluate the long-term progression of rhythm disorders, we analysed the patient's rhythm disorders at the time of device implantation and during follow-up. After pacemaker implantation, the rhythm disorders were reassessed and recorded at each scheduled pacemaker follow-up visit, and the spontaneous rhythm was analysed during pacemaker interrogation.

Results: During a median follow-up of 61.6 months, we observed a progression of the primary rhythm disorder in 295 patients (16.3%; worsening of the preexisting rhythm disorder in 7.7%; occurrence of a new rhythm disorder added to the preexisting one in 8.6%). Specifically, the cumulative per-year risks of developing the following disorders were: atrioventricular block (AVB) in patients implanted for sinus node disease (SND), 0.3%; permanent atrial fibrillation in SND patients, 2.9%; SND in AVB patients, 0.7%; and persistent AVB in patients implanted for chronic bifascicular block 3.0%.

Conclusion: Our results revealed that rhythm disorders requiring pacemaker implantation show long-term progression in a significant number of cases. In many cases, the progression is substantial and may require a change in pacing mode.
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http://dx.doi.org/10.2459/JCM.0000000000000673DOI Listing
July 2018

IntErnationaL eLeCTRicAl storm registry (ELECTRA): Background, rationale, study design, and expected results.

Contemp Clin Trials Commun 2017 Sep 9;7:69-72. Epub 2017 Jun 9.

Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy.

Electrical storm (ES) is defined as three or more episodes of ventricular fibrillation (VF) or ventricular tachycardia (VT) within 24 h and is associated with an increased cardiac and all-cause mortality. ES is a full arrhythmic emergency, its prevalence steadily increasing along with the number of implantable cardioverter-defibrillator implanted every year in developed countries. Nowadays, little evidence exists regarding clinical predictors of ES and their potential association on mortality and heart failure (HF), nor optimal pharmacological and non-pharmacological treatment has ever been codified. The intErnationaL eLeCTRicAl storm registry (ELECTRA) is a multicentre, observational, prospective clinical study with two major aims. First, to create an international database on ES encompassing clinical features, pharmacological management, and interventional treatment strategies. Second, to describe mortality and rehospitalization rates in patients with ES over a long follow-up. The primary endpoint is all-cause mortality 3 years after the ES index event. The main secondary endpoint is hospitalization for all causes 3 years after the ES index event. Other secondary endpoints includes ES recurrences, unclustered VTs/VFs recurrences, and hospitalizations for HF worsening. A minimum of 500 patients will be included in the registry, and all patients will be followed-up for a minimum of three years. The present paper describes the background and current rationale of the ELECTRA study and details the study design, from enrolment strategy to data collection methods to planned data analysis. A brief overview of the expected results and their potential clinical and research implications will also be presented (NCT02882139).
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http://dx.doi.org/10.1016/j.conctc.2017.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898505PMC
September 2017

Feasibility of cathodic-anodal left ventricular stimulation for alternative multisite pacing.

Pacing Clin Electrophysiol 2018 06 30;41(6):597-602. Epub 2018 Apr 30.

Department of Cardiology, University Hospital 'Maggiore della Carita`', Novara, Italy.

Background: Simultaneous cathodic-anodal capture by a bipole of a cardiac resynchronization therapy (CRT) left-ventricular (LV) catheter may depolarize a larger LV area than conventional multipoint pacing. We evaluated the feasibility of cathodic-anodal LV stimulation.

Methods: In 30 patients undergoing CRT with a quadripolar LV lead, we evaluated the cathodic and anodal capture threshold for each LV pole and compared QRS on electrocardiogram (ECG) during single-point cathodic biventricular stimulation (S-BS), multipoint BS (M-BS), and cathodic-anodal BS (CA-BS).

Results: Anodal capture was obtained by three poles in 23/30 patients, by two poles in five, and was not feasible in two. The mean single-point anodal threshold was 3.93 V versus single-point cathodic threshold of 1.95 V. On comparing ECGs, M-BS and CA-BS produced similar QRS wavefront activation in 90% of patients.

Conclusions: CA-BS is feasible and may be used in LV pacing to achieve a different wavefront of electrical activation. Further prospective studies are needed in order to verify the clinical impact of this kind of stimulation.
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http://dx.doi.org/10.1111/pace.13344DOI Listing
June 2018

External implantable defibrillator as a bridge to reimplant after explant for infection: Experience from two centers.

Pacing Clin Electrophysiol 2018 05 15;41(5):532-535. Epub 2018 Apr 15.

Division of Cardiology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy.

Background: The management of patients explanted for implantable converter defibrillator (ICD) infections may be complex when anti-bradycardia pacing and tachyarrhythmia protection are needed. We aimed to test the efficacy and safety of a conventional ICD externally connected to a transvenous dual-coil lead as bridging therapy before the reimplantation.

Methods And Results: We enrolled seven patients explanted for ICD infections and needed prolonged antibiotic therapy in two high-volume hospitals in Italy and treated them with a passive-can external ICD for a mean of 13 (4-30) days before reimplant. One patient experienced an electrical storm, efficaciously recognized by the external ICD and treated with antitachycardia pacing and shocks. On-demand pacing was granted for all the patients. No device-related complications were reported.

Conclusions: An external ICD seems safe and efficacious as a bridge to reimplant in patients explanted for ICD infections.
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http://dx.doi.org/10.1111/pace.13320DOI Listing
May 2018

Physical Activity Measured by Implanted Devices Predicts Atrial Arrhythmias and Patient Outcome: Results of IMPLANTED (Italian Multicentre Observational Registry on Patients With Implantable Devices Remotely Monitored).

J Am Heart Assoc 2018 02 24;7(5). Epub 2018 Feb 24.

Cardiology Unit "Card. G. Panico" Hospital, Tricase, Italy.

Background: To determine whether daily physical activity (PA), as measured by implanted devices (through accelerometer sensor), was related to the risk of developing atrial arrhythmias during long-term follow-up in a population of heart failure (HF) patients with an implantable cardioverter defibrillator (ICD).

Methods And Results: The study population was divided into 2 equally sized groups (PA cutoff point: 3.5 h/d) according to their mean daily PA recorded by the device during the 30- to 60-day period post-ICD implantation. Propensity score matching was used to compare 2 equally sized cohorts with similar characteristics between lower and higher activity patients. The primary end point was time free from the first atrial high-rate episode (AHRE) of duration ≥6 minutes. Secondary end points were: first AHRE ≥6 hours, first AHRE ≥48 hours, and a combined end point of death or HF hospitalization. Data from 770 patients (65±15 years; 66% men; left ventricular ejection fraction 35±12%) remotely monitored for a median of 25 months were analyzed. A PA ≥3.5 h/d was associated with a 38% relative reduction in the risk of AHRE ≥6 minutes (72-month cumulative survival: 75.0% versus 68.1%; log rank =0.025), and with a reduction in the risk of AHRE ≥6 hours, AHRE ≥48 hours, and the combined end point of death or HF hospitalization (all <0.05).

Conclusions: In HF patients with ICD, a low level of daily PA was associated with a higher risk of atrial arrhythmias, regardless of the patients' baseline characteristics. In addition, a lower daily PA predicted death or HF hospitalization.
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http://dx.doi.org/10.1161/JAHA.117.008146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866336PMC
February 2018

Clinically oriented device programming in bradycardia patients: part 2 (atrioventricular blocks and neurally mediated syncope). Proposals from AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

J Cardiovasc Med (Hagerstown) 2018 04;19(4):170-180

Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine University of Modena and Reggio Emilia Policlinico di Modena, Modena, Italy.

: The purpose of this two-part consensus document is to provide specific suggestions (based on an extensive literature review) on appropriate pacemaker setting in relation to patients' clinical features. In part 2, criteria for pacemaker choice and programming in atrioventricular blocks and neurally mediate syncope are proposed. The atrioventricular blocks can be paroxysmal or persistent, isolated or associated with sinus node disease. Neurally mediated syncope can be related to carotid sinus syndrome or cardioinhibitory vasovagal syncope. In sinus rhythm, with persistent atrioventricular block, we considered appropriate the activation of mode-switch algorithms, and algorithms for auto-adaptive management of the ventricular pacing output. If the atrioventricular block is paroxysmal, in addition to algorithms mentioned above, algorithms to maximize intrinsic atrioventricular conduction should be activated. When sinus node disease is associated with atrioventricular block, the activation of rate-responsive function in patients with chronotropic incompetence is appropriate. In permanent atrial fibrillation with atrioventricular block, algorithms for auto-adaptive management of the ventricular pacing output should be activated. If the atrioventricular block is persistent, the activation of rate-responsive function is appropriate. In carotid sinus syndrome, adequate rate hysteresis should be programmed. In vasovagal syncope, specialized sensing and pacing algorithms designed for reflex syncope prevention should be activated.
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http://dx.doi.org/10.2459/JCM.0000000000000629DOI Listing
April 2018

Clinically oriented device programming in bradycardia patients: part 1 (sinus node disease). Proposals from AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

J Cardiovasc Med (Hagerstown) 2018 04;19(4):161-169

Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

: Modern pacemakers have an increasing number of programable parameters and specific algorithms designed to optimize pacing therapy in relation to the individual characteristics of patients. When choosing the most appropriate pacemaker type and programing, the following variables must be taken into account: the type of bradyarrhythmia at the time of pacemaker implantation; the cardiac chamber requiring pacing, and the percentage of pacing actually needed to correct the rhythm disorder; the possible association of multiple rhythm disturbances and conduction diseases; the evolution of conduction disorders during follow-up. The goals of device programing are to preserve or restore the heart rate response to metabolic and hemodynamic demands; to maintain physiological conduction; to maximize device longevity; to detect, prevent, and treat atrial arrhythmia. In patients with sinus node disease, the optimal pacing mode is DDDR. Based on all the available evidence, in this setting, we consider appropriate the activation of the following algorithms: rate responsive function in patients with chronotropic incompetence; algorithms to maximize intrinsic atrioventricular conduction in the absence of atrioventricular blocks; mode-switch algorithms; algorithms for autoadaptive management of the atrial pacing output; algorithms for the prevention and treatment of atrial tachyarrhythmias in the subgroup of patients with atrial tachyarrhythmias/atrial fibrillation. The purpose of this two-part consensus document is to provide specific suggestions (based on an extensive literature review) on appropriate pacemaker setting in relation to patients' clinical features.
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http://dx.doi.org/10.2459/JCM.0000000000000630DOI Listing
April 2018

Persistence of ICD indication at the time of replacement in patients with initial implant for primary prevention indication: Effect on subsequent ICD therapies.

Indian Pacing Electrophysiol J 2017 Mar - Apr;17(2):29-33. Epub 2016 Nov 14.

Clinica Cardiologica A.O.U. Maggiore della Carità, Novara, Italy.

Background: Indication to implantable cardioverter defibrillator (ICD) for primary prevention of sudden death relies on left ventricular ejection fraction (LVEF). We measured the proportion of patients in whom indication to ICD persisted at the time of generator replacement (GR) and searched for predictors of appropriate therapies after GR.

Methods: We identified all consecutive patients who had received an ICD at our hospital, for LVEF ≤35% and no previous arrhythmias or unexplained syncope. Then, we included the 166 patients who outlived their first device and underwent GR.

Results: At the time of GR (mean follow-up 59 ± 20 months), ICD indication (i.e. LVEF ≤35% or previously treated ventricular arrhythmias) persisted in 114 (69%) patients. After GR, appropriate ICD therapies were delivered in 30 (26%) patients with persistent ICD indication and in 12 (23%) of the remaining patients (p = 0.656). Nonetheless, the annual rate of therapies was higher in the first group (1.08 versus 0.53 events/year; p < 0.001), as well as the rate of inappropriate therapies (0.03 versus 0 events/year; p = 0.031). The only independent predictor of appropriate ICD therapies after GR was the rate of shocks received before replacement (Hazard Ratio: 1.41; 95% confidence interval: 1.01-1.96; p = 0.041).

Conclusion: In heart failure with reduced LVEF, ICD indication persisted at the time of GR in 69% of patients. However, even in the absence of persistent ICD indication at GR, the risk of recurrence of arrhythmic events was not null.
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http://dx.doi.org/10.1016/j.ipej.2016.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5405747PMC
November 2016

Cardiac resynchronization therapy and electrical storm: results of the OBSERVational registry on long-term outcome of ICD patients (OBSERVO-ICD).

Europace 2018 06;20(6):979-985

Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi", Via Conca 71, Ancona 60126, Italy.

Aims: Electrical storm (ES) is a condition defined as three or more episodes of ventricular fibrillation (VF) or ventricular tachycardia (VT) within 24 h, and usually coexist with advanced heart failure in patients with structural heart disease. The aim of the present study is to test whether cardiac resynchronization therapy (CRT) can be associated with a lower incidence of ES.

Methods And Results: The OBSERVO-ICD (NCT02735811) is a multicentre, retrospective registry, enrolling all consecutive patients undergoing ICD or CRT-D implantation from 2010 to 2012 in five Italian high-volume arrhythmia centres. Propensity score matching was used to compare two equally sized cohorts of ICD and CRT-D patients with similar characteristics. The primary endpoint was the time free from ES. Secondary endpoints were time free from unclustered VT/VF episodes and time free from ES in CRT-D patients according to clinical or echographic response. CRT-D was associated with a 45% relative risk reduction in ES when compared with ICD (5.6% vs. 12.3%; log rank P = 0.014). CRT-responders presented lower rates of ES when compared with non-responders and negative responders according to both clinical and echographic criteria (log-rank P = 0.017 and 0.023, respectively). No ES was detected in any of the 133 full responders to CRT-D. Clinical and echographic positive responses, but not CRT-implant per se, were associated with lower estimate rates of unclustered VTs/VFs.

Conclusion: Patients with CRT had a lower incidence of ES when compared with propensity-matched ICD patients. The long-term benefit of CRT seems to be due to the improved haemodynamics, as CRT-responders performed markedly better over a long-term follow-up.
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http://dx.doi.org/10.1093/europace/eux166DOI Listing
June 2018

Occurrence of simultaneous cathodal-anodal capture with left ventricular quadripolar leads for cardiac resynchronization therapy: an electrocardiogram evaluation.

Europace 2017 Apr;19(4):596-601

Department of Cardiology, University Hospital 'Maggiore della Carità', Corso Mazzini 18, 28100 Novara, Italy.

Aims: The occurrence of left ventricular (LV) anodal activation during pacing with modern multipolar cardiac resynchronization therapy (CRT) systems has never been reported. The aim of our study was to demonstrate, by means of electrocardiogram (ECG) analysis, the occurrence of simultaneous cathodal-anodal LV capture with quadripolar LV leads.

Methods And Results: We studied 10 first-time recipients of a CRT device equipped with a quadripolar LV lead. During follow-up, standard supine 12-lead ECGs were obtained in available cathode-to-anode LV pacing configurations with a pulse amplitude equal to twice the pacing threshold. The occurrence of simultaneous cathodal-anodal LV capture was defined as the presence of variations in electrocardiographic ventricular activation (EVA) when the distal tip (cathode)-to-device can (anode) pacing configuration was compared with the distal tip (cathode)-to-proximal ring (anode) configuration. In eight patients, we found differences in EVA when different LV sites were paced through the unipolar LV tip and unipolar LV ring configurations. In these patients, a difference in EVA was detected in 61.5% (59 of 96) of the ECG leads (marked difference in 31.3%, slight difference in 30.2%). Changes in EVA between unipolar tip-to-can and bipolar tip-to-ring pacing that were suggestive of cathodal-anodal LV capture were found in six patients. In these patients, a total of 30 (41.7%) ECG leads showed a difference in EVA (marked difference in 20.8%, slight difference in 20.8%).

Conclusion: In our experience, additional anodal capture by the proximal LV ring during LV pacing is provable in most recipients of a resynchronization device equipped with a multipolar LV lead.
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http://dx.doi.org/10.1093/europace/euw046DOI Listing
April 2017

Effects of closed-loop stimulation vs. DDD pacing on haemodynamic variations and occurrence of syncope induced by head-up tilt test in older patients with refractory cardioinhibitory vasovagal syncope: the Tilt test-Induced REsponse in Closed-loop Stimulation multicentre, prospective, single blind, randomized study.

Europace 2018 05;20(5):859-866

Cardiology Unit, 'Card. G. Panico' Hospital, Via S. Pio X, 4, 73039 Tricase, LE, Italy.

Aims: Closed-loop stimulation (CLS) seemed promising in preventing the recurrence of vasovagal syncope (VVS) in patients with a cardioinhibitory response to head-up tilt test (HUTT) compared with conventional pacing. We hypothesized that the better results of this algorithm are due to its quick reaction in high-rate pacing delivered in the early phase of vasovagal reflex, which increase the cardiac output and the blood pressure preventing loss of consciousness.

Methods And Results: This prospective, randomized, single-blind, multicentre study was designed as an intra-patient comparison and enrolled 30 patients (age 62.2 ± 13.5 years, males 60.0%) with cardioinhibitory VVS, carrying a dual-chamber pacemaker incorporating CLS algorithm. Two HUTTs were performed one week apart: one during DDD-CLS 60-130/min pacing and the other during DDD 60/min pacing; patients were randomly and blindly assigned to two groups: in one the first HUTT was performed in DDD-CLS (n = 15), in the other in DDD (n = 15). Occurrence of syncope and haemodynamic variations induced by HUTT was recorded during the tests. Compared with DDD, DDD-CLS significantly reduced the occurrence of syncope induced by HUTT (30.0% vs. 76.7%; P < 0.001). In the patients who had syncope in both DDD and DDD-CLS mode, DDD-CLS significantly delayed the onset of syncope during HUTT (from 20.8 ± 3.9 to 24.8 ± 0.9 min; P = 0.032). The maximum fall in systolic blood pressure recorded during HUTT was significantly lower in DDD-CLS compared with DDD (43.2 ± 30.3 vs. 65.1 ± 25.8 mmHg; P = 0.004).

Conclusion: In patients with cardioinhibitory VVS, CLS reduces the occurrence of syncope induced by HUTT, compared with DDD pacing. When CLS is not able to abort the vasovagal reflex, it seems to delay the onset of syncope.
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http://dx.doi.org/10.1093/europace/eux015DOI Listing
May 2018

Clinically guided pacemaker choice and setting: pacemaker expert programming study.

Europace 2017 Sep;19(9):1500-1507

Institute of Cardiology, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy.

Aim: The aim of this multicentre, observational, transversal study was to evaluate pacemaker (PM) choice and setting in a large number of patients, in order to understand their relationship with the patients' clinical characteristics.

Methods And Results: The study enrolled a total of 1858 patients (71 ± 14 years, 54% male), consecutively evaluated during scheduled PM follow-up visits in 7 Italian cardiac arrhythmia centres. To evaluate the appropriateness of PM choice in relation to the patients' clinical characteristics, we analysed their rhythm disorders at the time of device implantation and the characteristics of the devices implanted. To evaluate the appropriateness of device setting, current rhythm disorders and device setting at the time of enrolment were analysed. In the overall study population, 64.3% of the patients received a PM with all of the features required for their rhythm disorder [80.8% in persistent atrioventricular (AV) block, 76.5% in atrial fibrillation needing pacing, 71.0% in sinus node disease, 58.7% in non-persistent atrioventricular block (AVB), 52.7% in neuro-mediated syncope]. The most frequent cause of inappropriate PM choice was the lack of an algorithm to promote intrinsic AV conduction in non-persistent AVB patients (38.1%). In 76.2% of the patients with an appropriate PM (n = 1301), the PM was optimally set for their rhythm disorder.

Conclusions: In the present 'real-world' registry, a large number of patients (35.7%) did not receive an optimal PM for their rhythm disorders. Moreover, one-fourth of appropriate PMs were not programmed according to the patients' clinical characteristics.
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http://dx.doi.org/10.1093/europace/euw256DOI Listing
September 2017

Comparison between IEGM-based approach and echocardiography in AV/PV and VV delay optimization in CRT-D recipients (Quicksept study).

Indian Pacing Electrophysiol J 2016 Mar-Apr;16(2):59-65. Epub 2016 Jun 3.

Cardiology Department, Ospedali Riuniti, Via Rivalta, 29, Rivoli, TO, Italy.

Background: AtrioVentricular (AV) and InterVentricular (VV) delay optimization can improve ventricular function in Cardiac Resynchronization Therapy (CRT) and is usually performed by means of echocardiography. St Jude Medical has developed an automated algorhythm which calculates the optimal AV and VV delays (QuickOpt™) based on Intracardiac ElectroGrams, (IEGM), within 2 min. So far, the efficacy of the algorhythm has been tested acutely with standard lead position at right ventricular (RV) apex. Aim of this project is to evaluate the algorhythm performance in the mid- and long-term with RV lead located in mid-septum.

Methods: AV and VV delays optimization data were collected in 13 centers using both echocardiographic and QuickOpt™ guidance in CRTD implanted patients provided with this algorhythm. Measurements of the aortic Velocity Time Integral (aVTI) were performed with both methods in a random order at pre-discharge, 6-month and 12-month follow-up.

Results: Fifty-three patients were studied (46 males; age 68 ± 10y; EF 28 ± 7%). Maximum aVTI obtained by echocardiography at different AV delays, were compared with aVTI acquired at AV delays suggested by QuickOpt. The AV Pearson correlations were 0.96 at pre-discharge, 0.95 and 0,98 at 6- and 12- month follow-up respectively. After programming optimal AV, the same approach was used to compare echocardiographic aVTI with aVTI corresponding to the VV values provided by QuickOpt. The VV Pearson Correlation were 0,92 at pre-discharge, 0,88 and 0.90 at 6-month and 12- month follow-up respectively.

Conclusions: IEGM-based optimization provides comparable results with echocardiographic method (maximum aVTI) used as reference with mid-septum RV lead location.
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http://dx.doi.org/10.1016/j.ipej.2016.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5832617PMC
September 2016

Non-invasively estimated left atrial stiffness is associated with short-term recurrence of atrial fibrillation after electrical cardioversion.

J Cardiol 2017 05 25;69(5):731-738. Epub 2016 Aug 25.

Wales Heart Research Institute, Cardiff University, Cardiff, UK.

Background: As atrial stiffness (K) is an important determinant of cardiac pump function, better mechanical characterization of left atrial (LA) cavity would be clinically relevant. Pulmonary venous ablation is an option for atrial fibrillation (AF) treatment that offers a powerful context for improving our understanding of LA mechanical function. We hypothesized that a relation could be detected between invasive estimation of K and new non-invasive deformation parameters and traditional LA and left ventricular (LV) function descriptors, so that K can be estimated non-invasively. We also hypothesized that a non-invasive surrogate of K would be useful in predicting AF recurrence after cardioversion.

Methods: In 20 patients undergoing AF ablation, LA pressure-volume curves were derived from invasive pressure and echocardiographic images; K was calculated during ascending limb of V-loop as ΔLA pressure/ΔLA volume. 2D-speckle-tracking echocardiographic LA and LV longitudinal strains and volumes, ejection fraction (EF) and ventricular stiffness (K), as obtained from mitral deceleration time, were tested as non-invasive K predictors. In 128 sinus rhythm patients 1 month after electrical cardioversion for persistent AF, non-invasively estimated K (computed-K) was tested as predictor of recurrence at 6 months.

Results: Tertiles of mean LA pressure correlated with increasing K (trend, p=0.06) and decreasing LA peak strain, LVEF, and LV longitudinal strain (p=0.029, p=0.019, and p=0.024). There were no differences in LA and LV volumes and K across groups. Multiple regression analysis identified LV longitudinal strain as the only independent predictor of K (p=0.014). Patients in highest quartile of computed-K (estimated as [log]=0.735+0.051×LV strain) tended to have highest AF recurrence rate (25%) as compared with remaining 3 quartiles (9%, 9%, 3%, p=0.09).

Conclusion: K can be assessed invasively in patients undergoing AF ablation and it can be estimated non-invasively using LV strain. AF recurrence after cardioversion tends to be highest in highest quartile of computed-K.
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http://dx.doi.org/10.1016/j.jjcc.2016.07.013DOI Listing
May 2017

Implantable cardioverter-defibrillator programming and electrical storm: Results of the OBSERVational registry On long-term outcome of ICD patients (OBSERVO-ICD).

Heart Rhythm 2016 10 9;13(10):1987-92. Epub 2016 Jun 9.

Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I-Lancisi-Salesi", Ancona, Italy.

Background: Electrical storm (ES) is defined as 3 or more episodes of ventricular fibrillation (VF) or ventricular tachycardia (VT) within 24 hours and is associated with increased cardiac and all-cause mortality.

Objective: The purpose of this study was to test whether aggressive implantable cardioverter-defibrillator (ICD) programming can be associated with ES.

Methods: The OBSERVational registry On long-term outcome of ICD patients (OBSERVO-ICD) is a multicenter, retrospective registry enrolling all consecutive patients undergoing ICD implantation from 2010 to 2012 in 5 Italian high-volume arrhythmia centers. Clinical history and risk factors were collected for all patients, as were ICD therapy-related variables such as detection zones and delays. The total number of arrhythmic episodes and therapies delivered by the ICD were collected through out-of-hospital visits and remote monitoring.

Results: The registry enrolled 1319 consecutive patients, of whom 62 (4.7%) experienced at least 1 ES during follow-up (median 39 months). Patients who experienced ES had a significantly lower VF detection zone (P = .002), more frequently had antitachycardia pacing therapies programmed off during capacitor charge (P = .001), and less frequently had an ICD set with delayed therapies for VT zones (P = .042) and VF zone (P = .036). Patients who experienced ES had a significantly higher incidence of death and heart failure-related death compared to patients with no ventricular arrhythmias and patients with unclustered VTs/VFs (P = .025 and P <.001, respectively).

Conclusion: Patients with ES had a more aggressive ICD programming setup, including lower VF detection rates, shorter detection times, and no antitachycardia pacing therapies during capacitor charge. This kind of ICD programming potentially could increase the likelihood of ES and the related risk of death.
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http://dx.doi.org/10.1016/j.hrthm.2016.06.007DOI Listing
October 2016

Acute contractile recovery extent during biventricular pacing is not associated with follow-up in patients undergoing resynchronization.

Int J Cardiol Heart Vasc 2016 Jun 1;11:66-73. Epub 2016 Apr 1.

Clinical Cardiology, Università del Piemonte Orientale, Department of Translational Medicine, Azienda Ospedaliero Universitaria "Maggiore della Carità", Corso Mazzini 28, 28100 Novara, Italy.

Background: It has been reported that contractility, as assessed using dobutamine infusion, is independently associated with reverse remodeling after CRT. Controversy, however, exists about the capacity of this approach to predict a long-term clinical response. This study's purpose was to assess whether long-term CRT clinical effects can be predicted according to acute inotropic response induced by biventricular stimulation (CRT on), as compared with AAI-VVI right stimulation pacing mode (CRT off), quantified at the time of implantation.

Methods: In 98 patients (ejection fraction 29 ± 10%), acute changes in left ventricular (LV) elastance (), arterial elastance (), and /, as assessed from slope changes of the force-frequency relation obtained when the heart rate increased, and also assessed while measuring triplane LV volumes and continuous noninvasive blood pressure, were related to death or rehospitalization during a 3-year follow-up. Other covariances tested were age, gender, disease etiology, QRS duration, amount of mitral regurgitation, LV diastolic volume, ejection fraction, and the degree of asynchrony and longitudinal strain at baseline.

Results: There was a marked increment in the slope with CRT (interaction  = 0.004), no change, and modest / increase (interaction  < 0.05). In Cox analysis, however, neither slope changes nor baseline values of , , and / were associated with long-term follow-up. Only ventricular diastolic volume (direct relation  = 0.002) and QRS duration (inverse relation  = 0.009) predicted death/rehospitalization.

Conclusions: Acute contractile recovery in CRT patients is not associated with 3 years prognosis. Instead, death or rehospitalization can be predicted from QRS duration and LV diastolic volume at baseline.
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http://dx.doi.org/10.1016/j.ijcha.2016.03.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5441335PMC
June 2016

External implantable defibrillator as a bridge to reimplant after implantable cardioverter-defibrillator explant.

Europace 2015 Nov 12;17(11):1726. Epub 2015 Oct 12.

Clinica Cardiologica, AOU Maggiore Della Carità, Novara, Italy.

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http://dx.doi.org/10.1093/europace/euv305DOI Listing
November 2015

Right ventricular septal pacing: Safety and efficacy in a long term follow up.

World J Cardiol 2015 Aug;7(8):490-8

Eraldo Occhetta, Rosaria Nappo, Emanuela Facchini, Andrea Magnani, Miriam Bortnik, Gabriella Francalacci, Gabriele Dell'Era, Laura Plebani, Paolo Marino, Cardiology Department, AOU Maggiore della Carità, 28100 Novara, Italy.

Aim: To evaluate the safety and efficacy of the permanent high interventricular septal pacing in a long term follow up, as alternative to right ventricular apical pacing.

Methods: We retrospectively evaluated: (1) 244 patients (74 ± 8 years; 169 men, 75 women) implanted with a single (132 pts) or dual chamber (112 pts) pacemaker (PM) with ventricular screw-in lead placed at the right ventricular high septal parahisian site (SEPTAL pacing); (2) 22 patients with permanent pacemaker and low percentage of pacing (< 20%) (NO pacing); (3) 33 patients with high percentage (> 80%) right ventricular apical pacing (RVA). All patients had a narrow spontaneous QRS (101 ± 14 ms). We evaluated New York Heart Association (NYHA) class, quality of life (QoL), 6 min walking test (6MWT) and left ventricular function (end-diastolic volume, LV-EDV; end-systolic volume, LV-ESV; ejection fraction, LV-EF) with 2D-echocardiography.

Results: Pacing parameters were stable during follow up (21 mo/patient). In SEPTAL pacing group we observed an improvement in NYHA class, QoL score and 6MWT. While LV-EDV didn't significantly increase (104 ± 40 mL vs 100 ± 37 mL; P = 0.35), LV-ESV slightly increased (55 ± 31 mL vs 49 ± 27 mL; P = 0.05) and LV-EF slightly decreased (49% ± 11% vs 53% ± 11%; P = 0.001) but never falling < 45%. In the RVA pacing control group we observed a worsening of NYHA class and an important reduction of LV-EF (from 56% ± 6% to 43% ± 9%, P < 0.0001).

Conclusion: Right ventricular permanent high septal pacing is safe and effective in a long term follow up evaluation; it could be a good alternative to the conventional RVA pacing in order to avoid its deleterious effects.
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http://dx.doi.org/10.4330/wjc.v7.i8.490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549783PMC
August 2015

Lack of interference of electromagnetic navigation bronchoscopy to implanted cardioverter-defibrillator: in-vivo study.

Europace 2014 Dec 31;16(12):1767-71. Epub 2014 Jul 31.

Department of Cardiology, University Hospital 'Maggiore della Carità', Novara, Italy.

Aims: Electromagnetic navigation bronchoscopy (ENB) (Superdimension) is a diagnostic and therapeutic tool in patients with lung lesions. Very small data are available about potential interference of ENB magnetic field to implanted cardioverter-defibrillators (ICDs) and any documentation of ICD behaviour if a ventricular tachyarrhythmia occurs during ENB is lacking. We tested a number of selected ICDs to assess if any interference occurs by ENB magnetic field on detection of clinical ventricular fibrillation and shock delivery.

Methods And Results: Thirteen patients undergoing an ICD implantation or elective replacement with a clinical indication to assess the efficacy of defibrillation underwent: (i) real-time telemetric recording from ICD during ENB activation to detect possible noise; (ii) defibrillation test during exposure to ENB board-generated magnetic field. All tested ICDs showed no noise detection at maximum sensitivity level. Induced ventricular fibrillation was correctly detected and cured by implanted device. No change in programmed ICD parameters was induced by exposure to ENB magnetic field.

Conclusion: All tested ICDs correctly operated and rescued the patients from induced ventricular fibrillation during ENB. Electromagnetic navigation bronchoscopy appears to be safe in heart patients with an ICD; however, close cardiac monitoring of these patients during ENB must be ensured as correct behaviour of all existing ICDs can only be presumed from compliance of the manufacturer to International Standards which establish procedures for electromagnetic interference checking on implantable devices on different ranges of frequency.
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http://dx.doi.org/10.1093/europace/euu156DOI Listing
December 2014

Ventricular Rate Stabilization In Patients With Permanent Atrial Fibrillation And Single-Chamber Ventricular Pacemaker: RARE-PEARL Study.

J Atr Fibrillation 2014 Apr-May;6(6):993. Epub 2014 Apr 30.

Formely, Medtronic BRC, Maastricht, The Netherlands.

In patients with permanent atrial fibrillation (AF) rate irregularity can cause symptoms and impair the pumping function of the heart. Ventricular pacing at a rate close to the mean spontaneous ventricular rate can result in a more stable ventricular rate. Specific algorithms for automatic Ventricular Rate Stabilization (VRS) were designed and implemented in commercially available pacemakers. To assess this dynamic rate control we designed the RARE-PEARL study: prospective, randomized, cross-over, double-blinded. Patients with permanent AF, symptomatic episodes of brady-tachycardia, left ventricular ejection fraction (LVEF) >40%, NYHA class I/II/III, were eligible for enrolment. Each patient (n = 67) was implanted with a single-chamber VVIR pacemaker (models C20 or T20, Vitatron BV, The Netherlands) equipped with the VRS algorithm. At the end of a four week stabilization period, patients were randomized to VRS algorithm ON or OFF (2 months) and then crossed-over for the second phase (2 months). Primary endpoint was patient's preference. Sixty six patients ended the study: 19 (29%) had no preference; 15 (23%) preferred algorithm OFF, 32 (48%) algorithm ON (p<0.0001, algorithm ON vs OFF). In 58% of patients the algorithm ON caused an increase of ventricular pacing percentage > 10%. The ventricular pacing percentage was 82±10% with algorithm ON vs 59±26% with algorithm OFF (p<0.0001). Symptoms did not differ significantly. The VRS algorithm significantly increases the ventricular pacing percentage in patients with permanent AF. This pacing function is preferred by the majority of patients implanted with a single-chamber VVIR pacemaker.
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http://dx.doi.org/10.4022/jafib.993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5135233PMC
April 2014