[Management of electrical storm in implantable cardioverter-defibrillator recipients]. / La gestione della tempesta aritmica nel paziente portatore di defibrillatore impiantabile.

The term "electrical storm" (ES) indicates a state of cardiac electrical instability manifested by several episodes of ventricular tachyarrhythmias (VTs) within a short time. In patients with an implantable cardioverter-defibrillator (ICD), ES is best defined as three appropriate VT detections in 24h, treated by antitachycardia pacing, shock or eventually untreated but sustained in a VT monitoring zone. ES seems to have a low immediate mortality (1%) but frequently (50-80%) leads to hospitalization. Antiarrhythmic drugs have been shown to be very effective in treating ES in patients without ICD, whereas in ICD recipients, device programming is probably a key issue to prevent ES. Since sympathetic overreactivity is an important trigger, the risk of shock delivery should be minimized. Antitachycardia pacing can successfully terminate a significant percentage of fast VTs. Important parameters such as the number of VT cycles needed for VT detection can be increased from nominal values to allow spontaneous termination, and safety features that deliver a shock after a programmable time window independent of programming of antitachycardia pacing (sustained rate duration) should be prolonged or disabled. In some cases it may be advisable to turn off the ICD tachy mode to avoid multiple ineffective shocks. Substrate mapping and VT ablation may be useful for the treatment and prevention of ES.

[Responsibilities for the remote monitoring of heart failure patients]. / La responsabilità nel controllo a distanza del paziente con scompenso cardiaco.

Heart failure patients may frequently undergo repeat hospitalizations, and for this reason recent guidelines recommend a multidisciplinary approach including remote clinical state management through systems such as electronic devices, portable or implantable, with the aim of simplifying patient management and optimizing healthcare resources. This different way of healthcare organization has brought about new levels of responsibility, including device manufacturers responsible for the technical aspects, healthcare facilities responsible for the information systems used for patient clinical data transmission and for ambulatory patient access, and in particular the clinicians who should ensure the process supervision by providing prompt medical assistance if alarm signals are received. The use of telemedicine, however, may engender technical problems of varying difficulties. In terms of responsibility, service providers are not liable for damage deriving from technical default, except in the case of willful misconduct or gross negligence. No less important are the legal issues concerning permissions, conflicts of jurisdiction among nations, problems of service inaccessibility, as well as the identification of medical liability in relation to the activity of a multidisciplinary team, besides issues relating to informed consent and privacy protection. In conclusion, risk management with telemedicine may provide more accurate information and better traceability of operators' activity.