Impact of Systematic Use of Intracardiac Ultrasound during Transseptal Catheterization in the Electrophysiology Laboratory.

Aims: To explore the impact of the use of intracardiac echocardiography (ICE) in the ablation of supraventricular arrhythmias requiring transseptal catheterization (TSC), whilst analyzing the reduction in periprocedural complications and complications specifically related to TSC.

Methods: A retrospective multicenter study collecting data from consecutive atrial fibrillation (AF) and supraventricular ablation procedures that required TSC was performed in five Italian centers. Based on physician discretion, TSC was performed with or without ICE.

International consensus statement on challenges for women in cardiovascular practice and research in the COVID-19 era.

The challenges to academic and professional development and career advancement of women in cardiology (WIC), imposed by the pandemic, not only impinge the female cardiologists' "leaky pipeline" but also make the "leakiness" more obvious. This consensus document aims to highlight the pandemic challenges WIC face, raise awareness of the gender equity gap, and propose mitigating actionable solutions derived from the data and experiences of an international group of female cardiovascular clinicians and researchers. This changing landscape has led to the need for highly specialized cardiologists who may have additional training in critical care, imaging, advanced heart failure, or interventional cardiology.

Optimization of coronary sinus lead placement targeted to right-to-left delay in patients undergoing cardiac resynchronization therapy.

Aims: Anatomical placement of the coronary sinus (CS) lead in basal or mid-ventricular positions of the posterior and lateral walls is associated with a better clinical outcome of cardiac resynchronization therapy (CRT). We hypothesized that optimization of CS lead placement targeted the right-to-left electrical delay (RLD) predicts an additional clinical benefit.

Methods And Results: The CS lead was placed according to current standards in 90 patients (Conventional group) and at the site of the longest RLD in 121 patients (RLD group).

Stop vasodepressor drugs in reflex syncope: a randomised controlled trial.

Objectives: Most elderly patients affected by reflex vasodepressor syncope take one or more hypotensive drugs. The role of these drugs in causing syncope has not yet been established. We hypothesised that recurrence of syncope and presyncope can be reduced by discontinuing/reducing vasoactive therapy without increasing the risk of cardiovascular and neurological events.

Syncope and Idiopathic (Paroxysmal) AV Block.

Syncope due to idiopathic AV block is characterized by: 1) ECG documentation (usually by means of prolonged ECG monitoring) of paroxysmal complete AV block with one or multiple consecutive pauses, without P-P cycle lengthening or PR interval prolongation, not triggered by atrial or ventricular premature beats nor by rate variations; 2) long history of recurrent syncope without prodromes; 3) absence of cardiac and ECG abnormalities; 4) absence of progression to persistent forms of AV block; 5) efficacy of cardiac pacing therapy. The patients affected by idiopathic AV block have low baseline adenosine plasma level values and show an increased susceptibility to exogenous adenosine. The APL value of the patients with idiopathic AV block is much lower than patients affected by vasovagal syncope who have high adenosine values.

Pacing for neurally-mediated syncope: How to decide?

Neurally-mediated syncope has a broad clinical spectrum which ranges from typical vasovagal syncope on one hand, to those situations in which reflex syncope occurs with uncertain, or even apparently absent, triggers or prodromes, on the other hand. Overlap of clinical features is frequent in clinical practice and makes any classification difficult to apply when selecting patients for cardiac pacing. Typically, the reflex is both hypotensive and cardio-inhibitory.

Assessment of the vasodepressor reflex in carotid sinus syndrome.

Background: Assessment of the vasodepressor reflex in carotid sinus syndrome is influenced by the method of execution of the carotid sinus massage and the coexistence of the cardioinhibitory reflex.

Methods And Results: Carotid sinus massage reproduced spontaneous symptoms in 164 patients in the presence of hypotension or bradycardia (method of symptoms). When an asystolic pause was induced, the vasodepressor reflex was reassessed after suppression of the asystolic reflex by means of 0.

Additional diagnostic value of very prolonged observation by implantable loop recorder in patients with unexplained syncope.

Introduction: In the literature, the average diagnostic yield of the implantable loop recorder (ILR) is reported to be 35% over an observation period generally less than 18 months. The aim of this study was to evaluate the diagnostic value of ILR during very prolonged observation.

Methods And Results: Consecutive patients who had received one or more (in the case of battery exhaustion before diagnosis) ILR (Reveal/plus/DX, Medtronic Inc.

Diving bradycardia: a mechanism of defence against hypoxic damage.

A feature of all air-breathing vertebrates, diving bradycardia is triggered by apnoea and accentuated by immersion of the face or whole body in cold water. Very little is known about the afferents of diving bradycardia, whereas the efferent part of the reflex circuit is constituted by the cardiac vagal fibres. Diving bradycardia is associated with vasoconstriction of selected vascular beds and a reduction in cardiac output.

Treatment of persistent sinus bradycardia with intermittent symptoms: are guidelines clear?

There is uncertainty in the aetiology of syncope in subjects with persistent sinus bradycardia (SB) (sick sinus syndrome). The results of pathophysiological studies suggest a reflex origin of syncope in the vast majority of subjects with SB. From a nosological point of view, 'syndrome' is defined as the association of signs and symptoms that have a pathophysiological correlation.

Using embryonic stem cells to form a biological pacemaker via tissue engineering technology.

Biological pacemakers can be achieved by various gene-based and cell-based approaches. Embryonic stem cells (ESCs)-derived pacemaker cells might be the most promising way to form biological pacemakers, but there are challenges as to how to control the differentiation of ESCs and to overcome the neoplasia, proarrhythmia, or immunogenicity resulting from the use of ESCs. As a potential approach to solve these difficult problems, tissue-engineering techniques may provide a precise control on the different cell components of multicellular aggregates and the forming of a construct with-defined architectures and functional properties.

Novel ICE-guided registration strategy for integration of electroanatomical mapping with three-dimensional CT/MR images to guide catheter ablation of atrial fibrillation.

Introduction: Image integration is used in AF ablation procedures. To maximize the efficacy of image integration, it is essential to obtain good alignment between the electroanatomical map and the 3D image of the heart. In the present study, we compared an ICE-guided landmark registration with an ICE-guided focused endocardial surface registration.

Current treatment of recurrent vasovagal syncope: between evidence-based therapy and common sense.

Vasovagal syncope is very frequent and benign and the vast majority of subjects do not need any specific treatment, but only reassurance and education. An unknown but small percentage of patients require specific treatment when syncope is very frequent or is responsible for major trauma. For these patients, there are some evidence-based therapies available and some first-line treatments appear to be established.

Is vasovagal syncope a disease?

Vavovagal syncope (VVS) is not generally associated with cardiovascular, neurological or other diseases, and, therefore, represents an isolated manifestation. Isolated VVS cannot be regarded as a disease for several reasons: spontaneous syncope occurs in about half of individuals during their lives, and the unidentified neural pathways involved in the vasovagal response are probably present in all healthy humans, with individual differences in susceptibility; VVS is induced during tilt testing in several subjects with no history of syncope; during haemorrhagic shock, the vasovagal reaction can be observed in subjects with no history of syncope; about 20% of astronauts, who are selected on the basis of their great resistance to orthostatic stress, experience syncope or presyncope on landing after a short-duration space flight; to date, no genetic basis of VVS has been demonstrated; subjects with VVS are generally normotensive and, importantly, have normal blood pressure regulation apart from the episodes of syncope; hormonal disorders or a generalized state of autonomic involvement, although frequently investigated, have never been clearly demonstrated. Isolated VVS should be distinguished from those forms that start in old age and which are often associated with cardiovascular or neurological disorders, and other dysautonomic disturbances such as carotid sinus hypersensitivity, post-prandial hypotension, and symptoms of autonomic dysfunction.

Successful treatment of electrical storm with oral quinidine in Brugada syndrome.

A patient implanted with a cardioverter-defibrillator for symptomatic Brugada syndrome was referred to our hospital 17 months later because of recurrent shocks due to ventricular fibrillation (VF). Isoprenaline was intravenously infused and prevented VF episodes, but VF recurred after every attempt of drug discontinuation. A total of 34 shocks were recorded over 25 days.

Neurally-mediated syncope.

"Neurally-mediated (reflex) syncope" refers to a reflex response that, when triggered, gives rise to vasodilation and/or bradycardia; however, the contribution of each of these two factors to systemic hypotension and cerebral hypoperfusion may differ considerably. The initial evaluation may lead to a certain diagnosis in the case of classical vasovagal syncope and of situational syncope. Classical vasovagal syncope is diagnosed if precipitating events such as fear, severe pain, emotional distress, instrumentation or prolonged standing, are associated with typical prodromal symptoms.

Antiarrhythmic drugs in patients with recurrent atrial fibrillation: where are we?

In patients with recurrent atrial fibrillation (AF), the hallmark of treatment has long been the use of antiarrhythmic drugs. The following strategies are available: a) any antiarrhythmic treatment; b) out-of-hospital episodic treatment ("pill-in-the-pocket" approach); c) prophylactic antiarrhythmic therapy; and d) hybrid therapy. The following patients with recurrent AF should not undergo any antiarrhythmic therapy: after the first AF episode; patients with rare, hemodynamically well-tolerated and short-lasting (a few hours) AF episodes; patients with perioperative AF, without history of recurrent AF; patients with AF during acute myocardial infarction or other acute diseases, without history of recurrent AF; and "holiday heart" syndrome.

Feasibility and safety of noninvasive pacemaker stress echocardiography with externally triggered stimulation.

The aim of this study was to assess the feasibility and safety of stress echocardiography by triggering an implanted pacemaker through an external stimulator. The implanted pacemaker was set in triggered mode with unipolar sensitivity of <2 mV. The external stimulator, connected to 2 skin electrodes, tracked the implanted pacemaker at increasing rates.

Sexual activity with and without the use of sildenafil: risk of cardiovascular events in patients with heart disease.

The data in the literature on the relationship between sexual activity, with and without the use of sildenafil, and the occurrence of cardiovascular events (ventricular arrhythmias, nonfatal myocardial infarction, stroke and death) have been reviewed in patients with heart disease. To date, only patients with ischemic heart disease (IHD) have been investigated. The prevalence of premature ventricular beats during sexual intercourse is similar to that observed during other daily activities.

In industrialized nations, a low socioeconomic status represents an independent predictor of mortality in patients with acute myocardial infarction.

Background: It has been widely demonstrated that in the general population a low socioeconomic status (SES) represents a risk factor for coronary heart disease (CHD). Both the incidence of and the mortality due to CHD are significantly higher in subjects with a low SES. Conventional risk factors only partly account for the social gradient in CHD.

An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation.

Aims: Permanent atrial fibrillation develops in many patients after ablation and pacing therapy. We compared a strategy that initially allowed patients to remain in atrial fibrillation with a strategy that initially attempted to restore and maintain sinus rhythm.

Methods And Results: In this multicentre randomized controlled trial, 68 patients affected by severely symptomatic paroxysmal atrial fibrillation were assigned, after successful atrioventricular junction ablation and pacing treatment, to antiarrhythmic drug therapy with amiodarone, propafenone, flecainide or sotalol and were compared with 69 patients assigned, after successful AV junction ablation and pacing treatment, to no antiarrhythmic drug therapy.

Head-up tilt testing potentiated with oral nitroglycerin: a randomized trial of the contribution of a drug-free phase and a nitroglycerin phase in the diagnosis of neurally mediated syncope.

Background: Since the pharmacological challenge with nitroglycerin (NTG) follows the initial drug-free phase in current tilt testing protocols, the effects of nitroglycerin alone and the appropriate duration of the basal phase are unknown.

Methods: To optimize the test, a randomized intra-patient comparison of two protocols was undertaken: a conventional nitroglycerin test (cHUT) consisting of passive upright posture at 60 degrees for 45 min followed, if negative, by sublingual NTG 0.4 mg spray, with the test continued for 20 min; and, accelerated nitroglycerin test (aHUT) consisting of passive upright posture at 60 degrees for 5 min--to rule out orthostatic hypotension--followed by sublingual NTG 0.