[New frontiers in pacing: from myocardial pacing to conduction system pacing]. / Nuove frontiere dell'elettrostimolazione: dal pacing del miocardio comune al pacing del sistema di conduzione.

For many years, cardiac pacing has been based on the stimulation of right ventricular common myocardium to correct diseases of the conduction system. The birth and the development of cardiac resynchronization have led to growing interest in the correction and prevention of pacing-induced dyssynchrony. Many observational studies and some randomized clinical trials have shown that conduction system pacing (CSP) can not only prevent pacing-induced dyssynchrony but can also correct proximal conduction system blocks, with reduction of QRS duration and with equal or greater effectiveness than biventricular pacing. Based on these results, many Italian electrophysiologists have changed the stimulation target from the right ventricular common myocardium to CSP. The two techniques with greater clinical impact are the His bundle stimulation and the left bundle branch pacing. The latter, in particular, because of its easier implantation technique and better electric parameters, is spreading like wildfire and is representing a real revolution in the cardiac pacing field. However, despite the growing amount of data, until now, the European Society of Cardiology guidelines give a very limited role to CSP.

[Management of infections in patients with cardiac implantable electronic devices]. / La gestione delle infezioni nei pazienti portatori di dispositivi impiantabili.

Implantation of pacemakers and cardiac defibrillators is a life-saving treatment but can put our patients at risk of infections, increasing morbidity and mortality and prolonging hospitalization with a significant financial healthcare burden. A preventive strategy is crucial but, while several strategies such as administration of intravenous antibiotic therapy before implantation are well recognized, other uncertainties remain. The main gaps regard the use of periprocedural measures, including antibacterial envelope to prevent device infection, the appropriate management of antithrombotic therapy before and after device implantation and timing of device reimplantation. To address these issues, some important randomized clinical trials and a European Heart Rhythm Association consensus document have recently been published. The aim of this article is to review current knowledge on the management of infections in patients with cardiac implantable electronic devices to help not only electrophysiologists, but also physicians in their daily practice.

Leadless pacemakers as a new alternative for pacemaker lead-related superior vena cava syndrome: A case report.

Superior vena cava (SVC) syndrome is a rare disease induced by thrombosis and consequent occlusion of SVC, negatively affecting morbidity and mortality. The incidence of SVC syndrome from central venous catheters and pacemaker or defibrillator leads is increasing. Optimal treatment of pacemaker or defibrillator-related SVC syndrome is not well defined. Lead extraction causes mechanical trauma to the vessel wall. In addition, subsequent device implantation on the contralateral side can be an added factor for venous occlusion. The use of leadless pacemakers could be an interesting option to reduce the risk of SVC restenosis after lead extraction. We report a clinical case of PM leads-related SVC syndrome referred to our centers and treated with transvenous lead extraction, leadless pacemaker implantation and subsequent percutaneous angioplasty and stenting of the SVC and left innominate vein.

Reduction of admissions for urgent and elective pacemaker implant during the COVID-19 outbreak in Northern Italy.

AIMS: The coronavirus disease-19 (COVID-19) outbreak has been recently associated with lower hospitalization rates for acute coronary syndromes. Aim of the study was to investigate whether a similar behaviour is observed in admissions for urgent pacemaker implant. METHODS: This retrospective study included 1315 patients from 18 hospitals in Northern Italy with a high number of COVID-19 cases. Hospitalization rates for urgent pacemaker implant were compared between the following periods: 20 February to 20 April 2020 (case period); from 1 January to 19 February 2020 (intra-year control period); from 20 February to 20 April 2019 (inter-year control period). RESULTS: The incidence rate of urgent implants was 5.0/day in the case period, 6.0/day in the intra-year control period and 5.8/day in the inter-year control period. Incidence rate in the case period was significantly lower than both the intra-year [incidence rate ratio (IRR): 0.81, 95% CI 0.67-0.99, P = 0.040] and inter-year control periods (IRR: 0.79, 95% CI 0.66-0.95, P = 0.012); this reduction was highest after the national lockdown (IRR 0.68, 95% CI 0.52-0.91, P = 0.009). The prevalence of residents in rural areas undergoing urgent pacemaker implant was lower in the case period (36%) than in both the intra-year (47%, P = 0.03) and inter-year control periods (51%, P = 0.002). Elective pacemaker implants also decreased in the case period, with the incidence rate here being 3.5/day vs. 6.4/day in the intra-year (-45%) and 6.9/day in the inter-year period (-49%). CONCLUSION: Despite severe clinical patterns, the COVID-19 outbreak has negatively affected the population presentation to Emergency Departments for bradyarrhythmias requiring urgent pacemaker implant in Northern Italy. This mainly occurred after the national lockdown and concerned patients living in rural areas.

[Arrhythmias and sudden death in neuromuscular disorders]. / Aritmie e morte improvvisa nelle malattie neuromuscolari.

Neuromuscular diseases (NMD) are a broadly defined group of disorders that all involve injury or dysfunction of peripheral nerves, neuromuscular junction or muscle, often with dominant or recessive pattern of inheritance. Cardiac involvement is uncommon, in particular with cardiomyopathies and brady/tachyarrhythmias. The causes of cardiac involvement are unclear: replacement fibrosis, alteration of membrane permeability, sympathetic hyperactivity, or accumulation of toxic metabolites can play a role in the pathogenesis of cardiac disorders. The early diagnosis is of pivotal importance to prevent evolution of the disease: electrocardiographic alterations and arrhythmias, particularly if associated with family history for cardiomyopathy or sudden death, can be an early signal of cardiomyopathy associated with NMD. Genetic analysis can improve prognostic stratification, particularly related to arrhythmic risk, and guide to a tailored therapy.

Impact of COVID-19 lockdown in patients with implantable cardioverter and cardiac resynchronization therapy defibrillators: insights from daily remote monitoring transmissions.

In Italy, a strict lockdown was imposed from 8 March 2020 to stop the spread of the coronavirus disease 2019 (COVID-19). We explored the effect of this lockdown on data transmitted by remote monitoring (RM) of implantable cardioverter and cardiac resynchronization therapy defibrillators (ICDs/CRT-Ds). RM daily transmissions from ICDs and CRT-Ds were analyzed and compared in two consecutive 1 month frames pre and post-lockdown: period I (7 February-7 March 2020) and period II (8 March-7 April 2020). The study cohort included 180 patients (81.1% male, 63.3% ICDs and 36.7% CRT-Ds) with a median age of 70 (interquartile range 62-78) years. The median value of physical activity provided by accelerometric sensors showed a significant reduction between period I and II [13.1% (8.2-18.1%) versus 9.4% (6.3-13.8%), p < 0.001]. Eighty nine % of patients decreased their activity, for 43.3% the relative reduction was ≥ 25%. The mean heart rate decreased significantly [69.2 (63.8-75.6) bpm vs 67.9 (62.7-75.3) bpm, p < 0.001], but with greater reduction (≈3 beats/minute) in patients aged < 70 years. Resting heart rate and thoracic impedance showed minor variations. No differences were observed in device pacing % and arrhythmias. In cardiac patients, the lockdown imposed to contain COVID-19 outbreak significantly reduced the amount of physical activity and the mean heart rate. These side effects of in-home confinement quarantine should be taken in consideration for frail patients.

Remote monitoring temporal trends during COVID-19 pneumonia in patients with implanted defibrillators.

It is unknown whether some of the clinical parameters transmitted by remote monitoring (RM) of cardiac implanted devices could show recurrent patterns caused by COVID-19 infection. Our aim was to describe RM daily temporal trends for implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) recipients during COVID-19 infection. A 65-year-old woman with a CRT-D had a sudden increase of approximately 15 bpm and 10 bpm in nocturnal and mean heart rate, respectively, 11 days before hospitalization for COVID-19 pneumonia. At the same time physical activity decreased progressively and continuously. A 78-year-old woman with an ICD showed significant changes in RM trends starting from the COVID-19-related symptoms: strong decrease in physical activity, progressive increase in mean and nocturnal heart rate, irregular trend of heart rate variability, and rapid drop in thoracic impedance. Two months later, on hospitalization, computed tomography showed a "crazy-paving" pattern of the lungs, which is a clinical picture of COVID-19 pneumonia with concomitant pleural effusion. .

Impact of prior statin use on clinical outcomes in COVID-19 patients: data from tertiary referral hospitals during COVID-19 pandemic in Italy.

BACKGROUND: Epidemiological evidence suggests that anti-inflammatory and immunomodulatory properties of statins may reduce the risk of infections and infection-related complications. OBJECTIVE: We aimed to assess the impact of prior statin use on coronavirus disease (COVID-19) severity and mortality. METHODS: In this observational multicenter study, consecutive patients hospitalized for COVID-19 were enrolled. In-hospital mortality and severity of COVID-19 assessed with National Early Warning Score (NEWS) were deemed primary and secondary outcomes, respectively. Propensity score (PS) matching was used to obtain balanced cohorts. RESULTS: Among 842 patients enrolled, 179 (21%) were treated with statins before admission. Statin patients showed more comorbidities and more severe COVID-19 (NEWS 4 [IQR 2-6] vs 3 [IQR 2-5], p < 0.001). Despite having similar rates of intensive care unit admission, noninvasive ventilation, and mechanical ventilation, statin users appeared to show higher mortality rates. After balancing pre-existing relevant clinical conditions that could affect COVID-19 prognosis with PS matching, statin therapy confirmed its association with a more severe disease (NEWS ≥5 61% vs. 48%, p = 0.025) but not with in-hospital mortality (26% vs. 28%, p = 0.185). At univariate logistic regression analysis, statin use was confirmed not to be associated with mortality (OR 0.901; 95% CI: 0.537 to 1.51; p = 0.692) and to be associated with a more severe disease (NEWS≥5 OR 1.7; 95% CI 1.067-2.71; p = 0.026). CONCLUSIONS: Our results did not confirm the supposed favorable effects of statin therapy on COVID-19 outcomes. Conversely, they suggest that statin use should be considered as a proxy of underlying comorbidities, which indeed expose to increased risks of more severe COVID-19.

Oral anticoagulation and clinical outcomes in COVID-19: An Italian multicenter experience.

BACKGROUND: Since the body of evidence addressing the coagulation derangements caused by Coronavirus disease (COVID-19) has been constantly growing, we investigated whether pre-hospitalization oral anticoagulation (OAC) or in-hospital heparin treatment could have a protective role among COVID-19 patients. METHOD: In this cohort study, consecutive COVID-19 patients admitted to four different Italian Institutions were enrolled. Baseline demographic, clinical, laboratory, and radiological characteristics, as well as in-hospital treatment and outcomes were evaluated. The primary outcome was mortality. RESULTS: A total of 844 COVID-19 patients were enrolled as study cohort, n = 65 (7.7%) taking OACs prior to hospitalization. Regarding clinical outcomes, OAC patients developed acute hypoxemic respiratory failure (AHRF) more frequently than non-OAC patients as well as presenting a higher mortality rate (44.6% vs 19.8%, p < 0.001). At overall multivariate logistical regression, use of heparin (n = 394, 46.6%) was associated with a better chance of survival to hospital discharge (OR 0.60 [0.38-0.94], p < 0.001), in particular in patients with AHRF, with no association found with the use of OACs. In a sub-analysis, the highest mortality rate was found for AHRF patients when heparin was not administered. CONCLUSION: In our cohort, OACs appeared to be ineffective in reducing mortality rate, while heparin resulted to be a useful treatment when lung disease was sufficiently severe, potentially suggesting a crucial role of microthrombosis in severe COVID-19. Due to the relatively small number of COVID-19 patients treated with OACs included in our analysis and their higher number of comorbidities, larger studies are needed in order to confirm our findings.

Clinical Discussions in Antithrombotic Therapy Management in Patients With Atrial Fibrillation: A Delphi Consensus Panel.

BACKGROUND: In recent years, direct-acting oral anticoagulants (DOACs) have entered clinical practice for stroke prevention in non-valvular atrial fibrillation or prevention and treatment of venous thromboembolism. However, remaining uncertainty regarding DOAC use in some clinical scenarios commonly encountered in the real world has not been fully explored in clinical trials. METHODS: We report on use of a Delphi consensus process on DOAC use in non-valvular atrial fibrillation patients. The consensus process dealt with 9 main topics: (i) DOACs vs vitamin K antagonists in atrial fibrillation (AF) patients; (ii) therapeutic options for patients with stable total time in range treated with vitamin K antagonists; (iii) therapeutic options for patients aged > 85 years; (iv) therapeutic management of hyperfiltering patients; (v) pharmacologic interactions; (vi) therapeutic options in the long-term treatment (prevention) of patients with AF and acute coronary syndrome after the triple therapy; (vii) low doses of DOACs in AF patients; (viii) ischemic stroke in patients inappropriately treated with low doses of DOACs; (ix) management of patients taking DOACs with left atrial appendage thrombosis. RESULTS: A total of 101 physicians (cardiologists, internists, geriatricians, and hematologists) from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = somewhat agree; 4 = agree; 5 = strongly agree). Votes 1-2 were considered to be disagreement; votes 3-5 were considered to be agreement. Agreement among the respondents of ≥ 66% for each statement was considered consensus. A brief discussion of the results for each topic is also reported. CONCLUSIONS: In clinical practice, there is still uncertainty on DOAC use, especially in elderly, fragile, comorbid, and hyperfiltering patients.

CONTEXTE: Depuis quelques années, les cliniciens prescrivent des anticoagulants oraux directs (AOD) pour prévenir les accidents vasculaires cérébraux (AVC) chez les patients présentant une fibrillation auriculaire (FA) non valvulaire ou pour prévenir et traiter les thromboembolies veineuses. Cependant, les doutes que suscite encore l'emploi des AOD dans certains contextes courants de la pratique clinique n'ont pas encore été bien explorés dans le cadre des études cliniques. MÉTHODOLOGIE: Nous avons utilisé la méthode de Delphes, une démarche visant à dégager un consensus, afin d'évaluer le recours aux AOD chez des patients présentant une FA non valvulaire. L'étude comprenait 9 thèmes principaux : i) utilisation des AOD et des antagonistes de la vitamine K chez les patients présentant une FA; ii) options thérapeutiques pour les patients traités par un antagoniste de la vitamine K dont l'état se maintient depuis un certain temps dans une plage de valeurs normales; iii) options thérapeutiques pour les patients âgés de plus de 85 ans; iv) prise en charge thérapeutique des patients souffrant d'hyperfiltration; v) interactions pharmacologiques; vi) options thérapeutiques pour le traitement prolongé (préventif) des patients présentant une FA et un syndrome coronarien aigu après une trithérapie; vii) utilisation des AOD à faible dose chez les patients présentant une FA; viii) AVC ischémique chez les patients traités de façon inappropriée par un AOD à faible dose; ix) prise en charge des patients prenant un AOD qui présentent une thrombose de l'appendice auriculaire gauche. RÉSULTATS: Au total, 101 médecins (cardiologues, internistes, gériatres et hématologues) italiens ont exprimé leur degré d'accord avec chacun des énoncés proposés sur une échelle de Likert à 5 points (1 = tout à fait en désaccord; 2 = en désaccord; 3 = moyennement d'accord; 4 = d'accord; 5 = tout à fait d'accord). Une note de 1 ou 2 a été considérée comme un désaccord et une note de 3, 4 ou 5, comme un accord. On considérait qu'il y avait un consensus si 66 % ou plus des répondants étaient d'accord avec l'énoncé. Nous présentons également brièvement les résultats obtenus pour chacun des thèmes. CONCLUSIONS: Dans la pratique clinique, l'emploi des AOD soulève encore des doutes, en particulier chez les patients âgés, fragiles ou présentant des affections concomitantes ou une hyperfiltration.

Myocardial Scar on Surface ECG: Selvester Score, but Not Fragmentation, Predicts Response to CRT.

PURPOSE: Myocardial scar is directly related to the response to CRT after implantation. The extent of myocardial scar can be detected not only by cardiac magnetic resonance but also by two electrocardiographic scores: fragmented QRS (fQRS) and Selvester score (SSc). The aim of our study is to compare the role of baseline SSc and fQRS in predicting response to CRT in a cohort of heart failure patients with true left bundle branch block (LBBB). As a secondary endpoint, we assessed the association of both scores with overall and cardiac mortality, heart failure hospitalizations, ventricular arrhythmias requiring ICD intervention, and major adverse cardiovascular event (MACE). METHODS: We evaluated fQRS and SSc of 178 consecutive HF patients with severe systolic dysfunction (LVEF ≤ 35%), NYHA class II-III despite optimal medical treatment, and true-LBBB. Response to CRT was defined as the improvement of LVEF of at least 10% or as the reduction of LVESV of at least 15% at a 6-month follow-up. Each endpoint was related to fQRS and SSc. RESULTS: SSc ≥7 was significantly associated with the absence of echocardiographic response to CRT (OR: 0.327; 95% C.I. 0.155-0.689; p=0.003), while the presence of fQRS at baseline ECG was not (OR: 1.133; 95% C.I. 0.539-2.381; p=0.742). No correlation was found between SSc and overall mortality, cardiac death, ventricular arrhythmias, hospitalizations due to heart failure, or for MACE. Similar results were observed between fQRS and all secondary endpoints. CONCLUSION: In HF patients with true-LBBB and LVEF ≤35% eligible for CRT, myocardial scar assessed by calculating the SSc on preimplant ECG is an independent predictor of nonresponse after multiple adjustments. Neither SSc nor fQRS is associated with overall and cardiac death, ventricular arrhythmias, or hospitalization for heart failure at a 24-month follow-up.

Redefining the Prognostic Value of High-Sensitivity Troponin in COVID-19 Patients: The Importance of Concomitant Coronary Artery Disease.

BACKGROUND: Although studies assessing cardiovascular comorbidities and myocardial injury in Coronavirus disease 2019 (COVID-19) patients have been published, no reports focused on clinical outcomes of myocardial injury in patients with and without chronic coronary syndromes (CCS) are currently available. METHODS: In this study, consecutive COVID-19 patients admitted to four different institutions were screened for enrolment. Patients were divided into two groups (CCS vs. no-CCS). Association with in-hospital mortality and related predictors represented the main study outcome; myocardial injury and its predictors were deemed secondary outcomes. RESULTS: A total of 674 COVID-19 patients were enrolled, 112 (16.6%) with an established history of CCS. Myocardial injury occurred in 43.8% patients with CCS vs. 14.4% patients without CCS, as confirmed by high-sensitivity cardiac troponin (hs-cTn) elevation on admission or during hospitalization. The mortality rate in the CCS cohort was nearly three-fold higher. After adjusting for disease severity, myocardial injury resulted significantly associated with in-hospital mortality in the no-CCS group but not in CCS patients. CONCLUSIONS: Patients with CCS and COVID-19 showed high mortality rate. Myocardial injury may be a bystander in CCS patients and COVID-19, while in patients without known history of CCS, myocardial injury has a significant role in predicting poor outcomes.

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

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 ±â€Š9.5 vs. 68.4 ±â€Š10.8; P < 0.00001), had less severe NYHA class (>II 47.2 vs. 59.6%; P < 0.00001), higher ejection fraction (30.3 ±â€Š7.4 vs. 28.4 ±â€Š8.2%; 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 ±â€Š26 vs. 157 ±â€Š27 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.

Use of the new rotating dilator sheath TightRail™ for lead extraction: A bicentric experience.

AIM: The aim of this study is to assess the safety and efficacy of the new bidirectional rotational mechanical sheath TightRail™ (Spectranetics) for lead extraction. METHODS AND RESULTS: This is a bicentric prospective study that included patients who underwent a transvenous lead extraction (TLE) in two Italian centers (San Raffaele Hospital and Humanitas Gavazzeni Hospital). From November 2016 to December 2018, 26 patients underwent a TLE procedure in which the TightRail™ was used. The new TightRail Sub-C was used in 20 (76%) patients to overcome the fibrosis between the vessel and the first rib. Median age was 69 (IQR 60.7-79.5) years. The indication for TLE were infection (57.7%) or lead dysfunction (42.3%). A total of 57 leads (range 1-4), 40 of which using the TightRail (range 1-4), were extracted. Overall mean implant duration was 98.2.0 ± 66.5 months. Mean age of the lead extracted with the TightRail sheath was 99.1 ± 70.2 months and was higher compared to that of the leads extracted manually (84.4 ± 60.3 months, P = .001). The overall clinical success was 100% and complete procedural success without the use of a snare was achieved in 98.3%. There were no cases of death or major complications and only two minor complications occurred. All patients were event-free at 6-month follow-up. CONCLUSION: This initial experience using the TightRail™ suggests a high safety and efficacy profile for extractions in a wide range of lead age.

Sleep-disordered breathing and effectiveness of cardiac resynchronization therapy in heart failure patients: gender differences?

OBJECTIVES: This study evaluated heart failure (HF) patients who underwent cardiac resynchronization therapy (CRT) and who had device-documented sleep-disordered breathing (SDB). We found gender differences in acute changes in SDB due to CRT impact. BACKGROUND: SDB typically occurs in HF patients. However, the role of SDB and its response to CRT in HF patients, as well as the relation with gender are currently not fully researched. METHODS: Among 63 consecutive patients who received CRT with an SDB algorithm, 23 patients documented SDB at one-month cardiac device interrogation and represented our population. We defined a Sleep apnoea Severity SCore(SSSC), and consequently, patients were categorized to have mild, moderate, and severe sleep apnoea syndrome divided into two groups: Group-1: 18 males (78%); Group-2: 5 females (22%). We evaluated the variation of apnoea burden and CRT response based on gender differences. RESULTS: A significantly higher proportion of patients in the male group were non-responders to CRT at 12-months follow-up (p = 0.076) while in the female population 5/5 patients (100%) were responders to CRT at the same follow-up time (p = 0.021). Among Group-2 subjects, we documented a significant linear decrease in SSSC(p > 0,01) while in Group-1 the CRT effect on SSSC was variable. At 12-months follow-up, the difference in SSSC between the two groups was statistically significant (p < 0.001). CONCLUSIONS: Our study reports a correlation between CRT response and sleep apnoea burden considering gender differences. In particular, HF-women responders to CRT demonstrate a significant linear decrease in sleep apnoea burden determined through a device algorithm, when compared to a similar male population. Further research is needed to confirm these findings.

The influence of age on the psychological profile of patients with cardiac implantable electronic devices: results from the Italian population in a multicenter study conducted by the European Heart Rhythm Association.

BACKGROUND: Cardiac implantable electronic devices (CIEDs) are widely used to treat bradyarrhythmias or improve the prognosis of patients with heart failure (HF). AIMS: To evaluate age-related (≤ 75 vs. > 75 years) attitudes, worries, psychological effects and needs in an Italian CIEDs population. METHODS: Patients attending their periodical ambulatory evaluation received a questionnaire conceived by the European Heart Rhythm Association Scientific Initiatives Committee as part of a multicenter, multinational snapshot survey. Seven countries participated in the study, and 1646 replies were collected. Of these, 437 (27%) were from Italy. Present results refer to the Italian population only. CIEDs were stratified into devices to treat bradycardia or HF. RESULTS: The use of CIEDs was more common in advanced age. Older patients needed less information about CIEDs than younger ones (p = 0.044), who would prefer to be better informed about CIEDs-related consequences on psychologic profile (p = 0.045), physical (p < 0.001) and sexual (p < 0.001) activities, and driving limitations (p = 0.003). When compared to older subjects, younger individuals experienced more difficulties (p = 0.035), especially in their professional (p < 0.001) and private life (p = 0.033), feeling their existence was limited by the device (p < 0.001). Conversely, quality of life (HRQL) more often improved in the elderly (p = 0.001). Information about what to do with CIEDs at the end of life is scant independently of age. CONCLUSIONS: HRQL after CIEDs implantation improves more frequently in older patients, while the psychological burden of CIEDs is usually higher in younger patients. End of life issues are seldom discussed.

Severe Spontaneous Echo Contrast/Auricolar Thrombosis in "Nonvalvular" AF: Value of Thromboembolic Risk Scores.

BACKGROUND: Patients with atrial fibrillation (AF) have an increased thromboembolic risk that can be estimated with risk scores and sometimes require oral anticoagulation therapy (OAT). Despite correct anticoagulation, some patients still develop left atrial spontaneous echo contrast (SEC) or thrombosis. The value of traditional risk scores (R2 CHADS2 , CHADS2 , and CHA2 DS2 -VASc) in predicting such events remains controversial. METHODS AND RESULTS: The aim of our study was to explore variables linked to severe SEC or atrial thrombosis and evaluate the performance of traditional risk scores in identifying these patients. In order to do this, we retrospectively analyzed 568 patients with nonvalvular nonparoxysmal AF who underwent electrical cardioversion from January 2011 to December 2016 after OAT for a minimum of 4 weeks. A transesophageal echocardiogram was performed in 265 patients for various indications, and 24 exhibited left atrial SEC or thrombosis. Female gender, history of heart failure or left ventricular ejection fraction <40%, and high levels (>1 mg/dL) of C-reactive protein (CRP) were independently associated with left atrial SEC/thrombosis. A score composed by these factors (denominated HIS [Heart Failure, Inflammation, and female Sex]) showed a sensitivity of 79% and a specificity of 60% (area under receiver operating characteristic curve 0.695, P = 0.002) in identifying patients with a positive transesophageal echo; traditional risk scores did not perform as well. CONCLUSIONS: In patients with persistent AF and suboptimal anticoagulation, a risk score composed by history of heart failure, high CRP, and female gender identifies patients at high risk of left atrial SEC/thrombosis when its value is >1.

Magnitude of QRS duration reduction after biventricular pacing identifies responders to cardiac resynchronization therapy.

BACKGROUND: Several studies have investigated the association between native QRS duration (QRSd) or QRS narrowing and response to biventricular pacing. However, their results have been conflicting. The aim of our study was to determine the association between the relative change in QRS narrowing index (QI) and clinical outcome and prognosis in patients who undergo cardiac resynchronization therapy (CRT) implantation. METHODS AND RESULTS: We included 311 patients in whom a CRT device was implanted in accordance with current guidelines for CRT. On implantation, the native QRS, the QRSd and the QI during CRT were measured. After 6months, 220 (71%) patients showed a 10% reduction in LVESV. The median [25th-75th] QI was 14.3% [7.2-21.4] and was significantly related to reverse remodeling (r=+0.22; 95%CI: 0.11-0.32, p=0.0001). The cut-off value of QI that best predicted LV reverse remodeling after 6months of CRT was 12.5% (sensitivity=63.6%, specificity=57.1%, area under the curve=0.633, p=0.0002). The time to the event death or cardiovascular hospitalization was significantly longer among patients with QI>12.5% (log-rank test, p=0.0155), with a hazard ratio (HR) of 0.3 [95%CI: 0.11-0.78]. In the multivariate regression model adjusted for baseline parameters, a 10% increment in QI (HR=0.61[0.44-0.83], p=0.002) remained significantly associated with CRT response. CONCLUSIONS: Patients with a larger decrease in QRSd after CRT initiation showed greater echocardiographic reverse remodeling and better outcome from death or cardiovascular hospitalization. QI is an easy-to-measure variable that could be used to predict CRT response at the time of pacing site selection or pacing configuration programming.

Cardiac resynchronization therapy improves functional status and cognition.

BACKGROUND: Many trials demonstrated the beneficial effects on hospitalizations and mortality of cardiac resynchronization therapy (CRT). The purpose of this study was to evaluate CRT effects on functional performance and cognition, two determinants of disability, frailty development and survival. METHODS: All consecutive patients receiving a CRT device were evaluated at baseline and at the 6-month follow-up. Functional profile was assessed with the Short Physical Performance Battery (SPPB), a measure exploring balance, gait, strength and endurance, highly predictive of incident disability and mortality. The Mini-Mental State Examination (MMSE) was used to study the cognitive profile. RESULTS: We enrolled 54 patients; two of them died during the follow-up, two refused to continue the study. Age was 67±10years (men: 80%, LVEF: 28±5%); medical therapy was optimized (ACE-I/ARB: 84%, beta-blockers: 80%). After 6months, CRT was associated with the improvement of LVEF (35±8 vs. 28±5%, p<0.001) and NYHA Class (1.8±0.6 vs. 2.6±0.5, p<0.001), and with the reduction of left ventricular end-systolic diameter (50±9 vs. 57±9mm, p<0.001). SPPB improved in its total score (10.3±2.0 vs. 9.1±2.7, p<0.001) and in the scores exploring gait speed and strength and endurance. These changes were associated with a better cognitive profile (MMSE score: 27.0±3.5 vs. 25.9±4.8, p=0.009). Advanced age was an independent predictor of improved functional performance and cognition. CONCLUSIONS: CRT is associated with higher functional and cognitive profile after only 6months of therapy. These findings let us hypothesize a powerful effect of treatment to slow disability and frailty development in heart failure.