The MB score: a new risk stratification index to predict the need for advanced tools in lead extraction procedures.

AIMS: A validated risk stratification schema for transvenous lead extraction (TLE) could improve the management of these procedures. We aimed to derive and validate a scoring system to efficiently predict the need for advanced tools to achieve TLE success. METHODS AND RESULTS: Between November 2013 and March 2018, 1960 leads were extracted in 973 consecutive TLE procedures in two national referral sites using a stepwise approach. A procedure was defined as advanced extraction if required the use of powered sheaths and/or snares. The study population was a posteriori 1:1 randomized in derivation and validation cohorts. In the derivation cohort, presence of more than two targeted leads (odds ratio [OR] 1.76, P = 0.049), 3-year-old (OR 3.04, P = 0.001), 5-year-old (OR 3.48, P < 0.001), 10-year-old (OR 3.58, P = 0.008) oldest lead, implantable cardioverter-defibrillator (OR 3.84, P < 0.001), and passive fixation lead (OR 1.91, P = 0.032) were selected by a stepwise procedure and constituted the MB score showing a C-statistics of 0.82. In the validation group, the MB score was significantly associated with the risk of advanced extraction (OR 2.40, 95% confidence interval 2.02-2.86, P < 0.001) and showed an increase in event rate with increasing score. A low value (threshold = 1) ensured 100% sensibility and 100% negative predictive value, while a high value (threshold = 5) allowed a specificity of 92.8% and a positive predictive value of 91.9%. CONCLUSION: In this study, we developed and tested a simple point-based scoring system able to efficiently identify patients at low and high risk of needing advanced tools during TLE procedures.

First-in-human retrieval of chronically implanted Micra transcatheter pacing system.

We report the first-in-human retrieval of a chronically implanted Micra transcatheter pacing system (TPS; Medtronic, Minneapolis, MN, USA). A 41-year-old woman suffering from third-degree atrioventricular block was successfully implanted with a TPS in the low septum of the right ventricle. After 29 months, due to an increased electrical threshold and 100% pacing percentage, the device showed low battery voltage. Despite the long implant duration, the attempt of device retrieval using a snare loop inserted in the delivery system of a TPS was successful. In the same procedure, a new leadless pacemaker was implanted in the high right ventricular septum with optimal pacing threshold.

Management of a leadless pacemaker recall via extraction in a patient with a history of multiple previous device implants.

We describe a management strategy of a leadless pacemaker recall (LP) via extraction in a pacemaker-dependent patient with a history of multiple previous device implants. We performed a two-step procedure. First, we implanted a second LP in the right ventricle. Then, 3 days later for concerns about the stability of the newly-implanted device, we retrieved the first LP, 3 years after its original implant. The patient was hemodynamically stable throughout the two procedures and no adverse event occurred in the 3 days of coexistence of the two LPs. Although the limitation of a single case experience, this approach may be taken into consideration when facing similar high-risk cases.

Predicting the difficulty of a transvenous lead extraction procedure: Validation of the LED index.

INTRODUCTION: A lead extraction difficulty (LED) score was proposed to predict the difficult transvenous lead extraction (TLE) procedures, defined by means of the fluoroscopy time. The aim of this study was to validate the estimation model based on the LED index above 10 on an independent data set of TLE cases. METHODS: Consecutive patients undergoing TLE between January 2014 and January 2016 were included in this analysis. The fluoroscopy time related to the leads removal was dichotomized as above or below its 90th percentile (PCTL). RESULTS: In total, 446 permanent leads were removed during 233 TLE procedures. Complete procedural success was achieved in 232 (99.1%) patients. The LED index resulted >10 in 83(35.6%) procedures. Among these cases, 20 had fluoroscopy time above the 90th PCTL (23.3 minutes) and were classified as true positive. Over the 150 procedures with LED score <10, 147 were classified as true negative, and only 3 resulted false negative. The sensitivity, the specificity, and the negative predictive value of the LED index in predicting complex cases resulted 86.9 (confidence interval [CI] 66.4-97.2)%, 70.0 (CI 63.3-76.1)%, and 98.0 (CI 94.3-99.6)%, respectively. The multivariate logistic regression analysis confirmed a 12% increased risk of high fluoroscopy for each additional point of the LED score (OR 1.12, CI 1.05-1.21, P = 0.001). CONCLUSION: The validation of the estimation model based on the LED index <10 confirmed its high efficacy in predicting simple TLE procedures.

Hybrid Minimally Invasive Approach for Transvenous Lead Extraction: A Feasible Technique in High-Risk Patients.

INTRODUCTION: Despite the overall safety, transvenous lead extraction (TLE) remains a challenging procedure with inherent risks, where surgery can still be required in elective cases. In this study, we report our experience with a minimally invasive "hybrid" approach, defined as a procedure performed by an electrophysiologist with the support of a cardiac surgeon in the same operative session. METHODS AND RESULTS: We reported 12 cases of planned hybrid lead extraction; minithoracotomy and thoracoscopy were performed on 10 (83%) and 2 (17%) patients, respectively. A total of 25 leads out of 27 (median lead age 19 years) were successfully extracted with laser, mechanical or combined transvenous sheath. In 3 patients, the direct monitoring of vascular and myocardial integrity allowed for prompt treatment of potential vascular injury during the lead extraction maneuvers. Mean in-hospital stay was 4 ± 2 days. There were no major intraoperative complications and no deaths occurred after 30 days' follow-up. CONCLUSION: The hybrid approach, with minithoracotomy or thoracoscopy, is feasible and it might increase the safety in the most challenging TLE procedures: the minimally invasive surgical intervention allows for continuous monitoring of the critical cardiac structures and prompt treatment of potential complications.

The novel active fixation coronary sinus lead: efficacy and safety of transvenous extraction procedure.

AIMS: Benefits of cardiac resynchronization therapy (CRT) are well known for heart failure; however, some patients might experience complications related to the coronary sinus (CS) lead (high pacing threshold, phrenic nerve stimulation, and dislodgment) with unfavourable impact on quality of life, costs, and management. Lead stability is one of the most common unmet needs for CRT procedures. METHODS AND RESULTS: Recently, new model Medtronic 20066 Attain Stability(®) (Maastricht, The Netherlands) active fixation LV lead has been released, to overcome this issue. The lead has a small side helix of 0.20 mm (0.008 in.) that allows for secure placement of the lead within the vein at the desired location. We report our first experience with the extraction of this novel active fixation left ventricular lead. CONCLUSION: In our case, to our knowledge the first reported in humans, the extraction of this new model of active fixation lead was proved to be a safe and effective procedure at 8 months after implantation. Indeed, under angiographic and fluoroscopic check, there was no documented dissection or damage to the CS during and after removal of the lead. The rotation manoeuvre was effective when combined with moderate traction of the lead itself.

Coronavirus disease 2019 infection in patients with recent cardiac surgery: does chronic anticoagulant therapy have a protective effect?

AIMS: The aim of this study was to evaluate the clinical course of COVID-19 in patients who had recently undergone a cardiac procedure and were inpatients in a cardiac rehabilitation department. METHODS: All patients hospitalized from 1 February to 15 March 2020 were included in the study (n = 35; 16 men; mean age 78 years). The overall population was divided into two groups: group 1 included 10 patients who presented with a clinical picture of COVID-19 infection and were isolated, and group 2 included 25 patients who were COVID-19-negative. In group 1, nine patients were on chronic oral anticoagulant therapy and one patient was on acetylsalicylic acid (ASA) and clopidogrel. A chest computed tomography scan revealed interstitial pneumonia in all 10 patients. RESULTS: During hospitalization, COVID-19 patients received azithromycin and hydroxychloroquine in addition to their ongoing therapy. Only the patient on ASA with clopidogrel therapy was transferred to the ICU for mechanical ventilation because of worsening respiratory failure, and subsequently died from cardiorespiratory arrest. All other patients on chronic anticoagulant therapy recovered and were discharged. CONCLUSION: Our study suggests that COVID-19 patients on chronic anticoagulant therapy may have a more favorable and less complicated clinical course. Further prospective studies are warranted to confirm this preliminary observation.

Video-Assisted Thoracoscopic Monitoring of Laser Lead Extraction by Femoral Route.

A 72-year-old man with a dual-chamber implantable defibrillator was referred to our center for transvenous lead extraction because of pocket infection and presence of an abandoned lead. We decided to proceed with a video-assisted thoracoscopic approach because of patient history and documented complete occlusion of the right subclavian vein. During the use of excimer laser for persistent adhesions, the ventricular lead broke down at the level of cavoatrial junction. To successfully remove the remaining portion of lead, we decided to use the excimer laser by femoral route. A final angiography through the laser sheath showed the integrity of the myocardial wall. We report a case of laser-assisted transvenous lead extraction unconventionally performed by the femoral route. A preventive minimally invasive cardiac surgery was implemented to provide more safety in this high-risk procedure. This technique may avoid the need of a full sternotomy in case of major bleeding complications.

Efficacy of second-generation cryoballoon ablation in paroxysmal and persistent atrial fibrillation patients.

AIMS: In this study, we aimed to compare the efficacy of single pulmonary vein isolation with the second-generation cryoballoon (CB-Adv) and predictors of atrial fibrillation recurrences in patients with paroxysmal (PAF) and persistent atrial fibrillation (PersAF). METHODS: Consecutive PAF and PersAF patients undergoing CB-Adv for the first time were enrolled. Patients were followed with in-clinic visits including Holter ECG. Atrial arrhythmic episodes symptomatic or documented lasting more than 30 s were considered as recurrences. RESULTS: A total of 96 consecutive patients [77 men (80%), mean age 57.4 ±â€Š9.9 years] were included in this analysis. About 56 (58%) patients had PAF and 40 had (42%) PersAF. The mean procedural and fluoroscopy times were 116 ±â€Š24 and 33 ±â€Š12 min, respectively. Procedure-related complications occurred in four (4.2%) patients.At the 12-month follow-up, after a 3-month blanking period, freedom from recurrences was achieved in 59% [confidence interval (CI): 49-69%] of patients, 62% (CI: 48-75%) in PAF, and 54% (CI: 38-71%) in PersAF group. The difference was not statistically significant at the Kaplan-Meier survival analysis (P = 0.242). Cardioversion to restore sinus rhythm was less frequently needed in PAF group [5% (CI: 1-15%) vs. 25% (CI: 13-41%), P < 0.001]. Redo procedure was performed in 7% (CI: 3-15%) of patients. In the Cox regression analysis, early atrial-tachyarrhythmia recurrence was the only independent predictor of 1-year recurrence (hazard ratio 2.11, CI: 1.06-4.20, P = 0.03). CONCLUSION: The success rate at 12 months after a single CB-Adv procedure was 62% in patients with PAF and 54% in study participants with PersAF. Early atrial-tachyarrhythmia recurrence appeared to be the only independent predictor of late atrial fibrillation recurrence.

Thoracoscopic Implantation of an Array Electrode in the Pericardium Transverse Sinus to Reduce Defibrillation Threshold.

Among the implantable cardioverter defibrillator recipients, there is still a subgroup of patients in whom the defibrillation threshold is too high and the maximal shock output of the implantable cardioverter defibrillator can fail to terminate a ventricular arrhythmia. We report a new thoracoscopic minimally invasive approach to place a standard array electrode in the transverse pericardial sinus of a patient implanted with a cardiac resynchronization and defibrillation therapy device with persistent high defibrillation threshold. This approach was developed to achieve very low shock impedance with a consequent increase in the current flow and reduction of defibrillation threshold.

Unexpected challenging case of coronary sinus lead extraction.

An 84-year-old woman implanted with cardiac resynchronization therapy defibrillator underwent transvenous lead extraction 4 mo after the implant due to pocket infection. Atrial and right ventricular leads were easily extracted, while the attempt to remove the coronary sinus (CS) lead was unsuccessful. A few weeks later a new extraction procedure was performed in our center. A stepwise approach was used. Firstly, manual traction was unsuccessfully attempted, even with proper-sized locking stylet. Secondly, mechanical dilatation was used with a single inner sheath placed close to the CS ostium. Finally, a modified sub-selector sheath was successfully advanced over the electrode until it was free of the binding tissue. The post-extraction lead examination showed an unexpected fibrosis around the tip. No complications occurred during the postoperative course. Fibrous adhesions could be found in CS leads recently implanted requiring non-standard techniques for its transvenous extraction.

Ranolazine therapy in drug-refractory ventricular arrhythmias.

AIMS: Ranolazine is an antiischemic and antianginal agent, but experimental and preclinical data provided evidence of additional antiarrhythmic properties. The aim of this study was to evaluate the safety and efficacy of ranolazine in reducing episodes of ventricular arrhythmias in patients with recurrent antiarrhythmic drug-refractory ventricular arrhythmias or with chronic angina. METHODS: Seventeen implantable cardioverter defibrillator (ICD) recipients, who had experienced a worsening of their ventricular arrhythmia burden, and 12 ICD recipients with angina were enrolled. Patients were followed up for 6 months after the addition of ranolazine (postranolazine). Data were compared with before its administration (preranolazine). RESULTS: In the Arrhythmias group, a significant reduction was found in the median number of ventricular tachycardia episodes per patient (4 vs. 0, P = 0.01), and in ICD interventions in terms of both antitachycardia pacing (2 vs. 0, P = 0.04) and shock delivery (2 vs. 0, P = 0.02) after the addition of ranolazine. Moreover, fewer patients experienced episodes of nonsustained ventricular tachycardia (71 vs. 41%, P = 0.04), ventricular tachycardia (76 vs. 24%, P = 0.01), ICD antitachycardia pacing (47 vs. 18%, P = 0.02), and ICD shocks (47 vs. 6%, P = 0.03). In the Angina group, none of the patients developed major ventricular arrhythmias while on ranolazine treatment. No adverse effects were observed. CONCLUSION: In this small study, ranolazine proved to be effective, well tolerated, and safe in reducing ventricular arrhythmia episodes and ICD interventions in patients with recurrent antiarrhythmic drug-refractory events. In addition, none of the patients with chronic angina developed major ventricular arrhythmias.

[Efficacy of ACE-inhibitors in patients with recent myocardial infarction. Studies with zofenopril]. / Efficacia degli ACE-inibitori nei pazienti con recente infarto miocardico. Gli studi con zofenopril.

Several large-scale trials have demonstrated improved survival with the administration of ACE-inhibitors to patients with a recent myocardial infarction. Many ACE-inhibitors with different pharmacological properties have been shown to be safe and effective. More recently the data provided by the Survival of Myocardial Infarction Long-term Evaluation (SMILE) program indicate that zofenopril may favorably affect the prognosis of patients with a recent myocardial infarction and, according to the results of the SMILE-4 study, it may be superior to ramipril with respect to some variables (cardiovascular hospitalizations) when both these ACE-inhibitors are administered combined with acetylsalicylic acid.

[Role of nutrition in heart failure patients]. / Ruolo dell'alimentazione nel paziente scompensato.

Heart failure is the leading cause of death and hospitalization in industrialized countries and a major cause of healthcare costs. It is associated with severe symptoms and its prognosis remains poor. Further improvement is needed beyond the results of pharmacological treatment and devices. The role of nutrition has therefore been studied both in the early stages of heart failure, as a tool for the reduction of cardiovascular risk factors and in symptomatic heart failure, for the prevention and treatment of congestion and fluid overload. In addition, dietary supplements, such as n-3 polyunsaturated fatty acids and amino acids, may contribute to the improvement of prognosis and cardiac function, respectively. Finally, in advanced heart failure, nutrition may counteract the effects of muscle wasting and cardiac cachexia through an increase in caloric and protein intake and amino acid supplementation.

[Epidemiology, classification and prognosis of palpitations]. / II cardiopalmo: epidemiologia, classificazione e prognosi.

Palpitations can be defined as an unpleasant feeling of heart beat, which is perceived as particularly fast, irregular or intense. This feeling is usually associated with perception of movements and hits in the chest. From the pathophysiological point of view, current knowledge of the neural pathways responsible for the perception of heart beat remains to be clearly elucidated. It has been hypothesized that these pathways include different structures located both at the intracardiac and extracardiac level. Palpitations are a widely diffused complaint in the general population, and particularly in subjects affected by structural heart disease. Clinical presentation makes it possible to divide palpitations into four groups: extrasystolic, tachycardic, anxiety-related, and intense. From the etiological point of view, palpitations may be divided into the following groups: palpitations caused by arrhythmias, by structural heart disease (non-arrhythmic), by psychiatric disease, by systemic noncardiac disease, and by drug or illicit substance assumption. The prompt detection of the causes of palpitations allows to identify clinical conditions potentially at high risk and to choose the most appropriate therapeutic approach.

[Atrial fibrillation and flutter in athletes]. / La fibrillazione e il flutter atriale nell'atleta.

Atrial fibrillation (AF) is one of the most frequent findings in the general population, with an incidence of about 0.1% per year and a mean prevalence of 0.95%. However, prevalence values are known to vary with age, being very low (0.1-0.2%) in subjects less than 55 years old, the age group comprising the greatest number of individuals who practice sport at various levels. Long-term, regular, intense physical training determines an increase in vagal tone, leading to bradycardia, and during physical activity, particularly competitive sport, a marked release of catecholamines occurs as a result of both the intense physical effort and the emotional stress involved in competition. Both these adaptive phenomena on the part of the autonomous nervous system may promote the development of AF. Heart diseases with a certain degree of severity are not generally compatible with sport, unless the activity undertaken involves a low expenditure of energy and is noncompetitive. In any case, in the presence of AF, the arrhythmia must be well controlled and well tolerated during performance of the activity.

[Current limitations and new perspectives in the diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia]. / L'iter diagnostico della cardiomiopatia aritmogena del ventricolo destro: limiti attuali e nuove prospettive.

Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a genetic cardiomyopathy characterized by ventricular arrhythmias and structural abnormalities of the right ventricle. In ARVC/D there is a progressive replacement of right ventricular myocardium with fatty and fibrous tissue and ventricular arrhythmias of right ventricular origin. The precise prevalence of ARVC/D has been estimated to vary between 1 in 1000 to 1 in 5000 of the general population. ARVC accounts for approximately 3-10% of sudden deaths in young people under the age of 65 years. The purpose of this paper is to review the current knowledge of ARVC/D and its management. Particular attention will be focused on some of the recent advances in the understanding of the genetic basis of ARVC/D. Increasing evidence suggests that ARVC/D is a disease of desmosomal dysfunction. Attention will also be focused on the new and somewhat controversial concept that ARVC/D may present primarily as a left ventricular disease. In our experience ARVC/D typically presents as a right ventricular disease, unless a patient has advanced disease. Diagnosis of ARVC/D is challenging and requires a comprehensive evaluation with both non-invasive and invasive testing.