Opportunities and drawbacks of the subcutaneous defibrillator across different clinical settings.

INTRODUCTION: The subcutaneous implantable cardioverter-defibrillator (S-ICD) is an established therapy for the prevention of sudden cardiac death (SCD) and an alternative to a transvenous implantable cardioverter-defibrillator system in selected patients. Beyond randomized clinical trials, many observational studies have described the clinical performance of S-ICD across different subgroups of patients. AREAS COVERED: Our review aimed to describe the opportunities and drawbacks of the S-ICD, focusing on their use in special populations and across different clinical settings. EXPERT OPINION: The choice to implant S-ICD should be based on the patient's tailored approach, which takes into account the adequate S-ICD screening at rest or during stress, the infective risk, the ventricular arrhythmia susceptibility, the progressive nature of the underlying disease, the work or sports activity, and the risk of lead-related complications.

Idiopathic thrombocytopenic purpura and percutaneous coronary stenting: a dangerous duo?

Dual antiplatelet therapy is a mainstay in the management of patients undergoing coronary stenting. Whether this is also appropriate in patients with a diagnosis of idiopathic thrombocytopenic purpura (ITP) is unclear. We report the case of a 66-year-old man with ITP admitted for an acute coronary syndrome. On admission platelets were 110 x 10(9)/L without petechiae or purpura, and coronary angiography revealed multivessel disease with significant left main involvement. Given the unfeasibility of surgical revascularization with cardiopulmonary bypass because of ITP, a staged percutaneous revascularization strategy was chosen. Both left circumflex and right coronary arteries were treated with bare-metal stenting during the index admission. After 4 weeks of strict clinical monitoring and evidence of a stable total platelet count on oral prednisone, percutaneous coronary intervention with drug-eluting stenting was performed in the left main and left anterior descending arteries. He was then discharged on lifelong aspirin and a 6-month clopidogrel regimen without thrombotic or bleeding complications. Given the paucity of data on ITP and stenting, no strict recommendations can be proposed and treatment should be individualized to minimize both bleeding and thrombosis risks. Nonetheless, this case suggests the feasibility of percutaneous revascularization in selected patients with multivessel coronary disease and ITP.