Video-assisted thoracoscopic epicardial pacing: A contemporary overview.

Video-assisted thoracoscopic surgery (VATS) has revolutionized the approach and management of pulmonary and cardiac diseases, and its applications have significantly expanded in the last two decades. Beyond its established role in thoracic procedures, VATS has also emerged as a valuable technique for various electrophysiological procedures, including pacemaker implantations, ablation procedures, and left atrial appendage exclusion. This paper presents a thorough review of the existing literature on pacing procedures performed using a VATS approach. By analyzing and synthesizing the available studies, we aim to provide an in-depth understanding of the current knowledge and advancements in VATS-based pacing procedures. A key focus of this review is the detailed description of implantation techniques via a VATS approach.

Subcutaneous Implantable Cardioverter Defibrillator: A Contemporary Overview.

The difference between subcutaneous implantable cardioverter defibrillators (S-ICDs) and transvenous ICDs (TV-ICDs) concerns a whole extra thoracic implantation, including a defibrillator coil and pulse generator, without endovascular components. The improved safety profile has allowed the S-ICD to be rapidly taken up, especially among younger patients. Reports of its role in different cardiac diseases at high risk of SCD such as hypertrophic and arrhythmic cardiomyopathies, as well as channelopathies, is increasing. S-ICDs show comparable efficacy, reliability, and safety outcomes compared to TV-ICD. However, some technical issues (i.e., the inability to perform anti-bradycardia pacing) strongly limit the employment of S-ICDs. Therefore, it still remains only an alternative to the traditional ICD thus far. This review aims to provide a contemporary overview of the role of S-ICDs compared to TV-ICDs in clinical practice, including technical aspects regarding device manufacture and implantation techniques. Newer outlooks and future perspectives of S-ICDs are also brought up to date.

Economic analysis of remote monitoring in patients with implantable cardioverter defibrillators or cardiac resynchronization therapy defibrillators in the Trento area, Italy.

Introduction: Remote monitoring (RM) technologies have the potential to improve patient care by increasing compliance, providing early indications of heart failure (HF), and potentially allowing for therapy optimization to prevent HF admissions. The aim of this retrospective study was to assess the clinical and economic consequences of RM vs. standard monitoring (SM) through in-office cardiology visits, in patients carrying a cardiac implantable electronic device (CIED). Methods: Clinical and resource consumption data were extracted from the Electrophysiology Registry of the Trento Cardiology Unit, which has been systemically collecting patient information from January 2011 to February 2022. From a clinical standpoint, survival analysis was conducted, and incidence of cardiovascular (CV) related hospitalizations was measured. From an economic standpoint, direct costs of RM and SM were collected to compare the cost per treated patient over a 2-year time horizon. Propensity score matching (PSM) was used to reduce the effect of confounding biases and the unbalance of patient characteristics at baseline. Results: In the enrollment period, N = 402 CIED patients met the inclusion criteria and were included in the analysis (N = 189 patients followed through SM; N = 213 patients followed through RM). After PSM, comparison was limited to N = 191 patients in each arm. After 2-years follow-up since CIED implantation, mortality rate for any cause was 1.6% in the RM group and 19.9% in the SM group (log-rank test, p < 0.0001). Also, a lower proportion of patients in the RM group (25.1%) were hospitalized for CV-related reasons, compared to the SM group (51.3%; p < 0.0001, two-sample test for proportions). Overall, the implementation of the RM program in the Trento territory was cost-saving in both payer and hospital perspectives. The investment required to fund RM (a fee for service in the payer perspective, and staffing costs for hospitals), was more than offset by the lower rate of hospitalizations for CV-related disease. RM adoption generated savings of -€4,771 and -€6,752 per patient in 2 years, in the payer and hospital perspective, respectively. Conclusion: RM of patients carrying CIED improves short-term (2-years) morbidity and mortality risks, compared to SM and reduces direct management costs for both hospitals and healthcare services.

Appropriate use criteria of left atrial appendage closure devices: latest evidences.

Atrial fibrillation is the most common arrythmia and it is linked to an increased risk of stroke. Even if anticoagulation therapy reduces the rate of stroke the benefits of this therapy have to be balanced with the increased risk of hemorrhagic event. Left atrial appendage closure is a valid alternative to long-term anticoagulation in patients with atrial fibrillation and high hemorrhagic risk. Actually new devices with different features have been tested and introduced progressively in the clinical practice. Improvements in preprocedural imaging evaluation and the learning curve of the operators led to percutaneous left atrial appendage closure a safe and effective procedure. A good knowledge of different devices and the technique of implant is necessary for optimization percutaneous left atrial appendage closure and the reduction of complications during the acute phase and follow up.

Emergency Management of Electrical Storm: A Practical Overview.

Electrical storm is a medical emergency characterized by ventricular arrythmia recurrence that can lead to hemodynamic instability. The incidence of this clinical condition is rising, mainly in implantable cardioverter defibrillator patients, and its prognosis is often poor. Early acknowledgment, management and treatment have a key role in reducing mortality in the acute phase and improving the quality of life of these patients. In an emergency setting, several measures can be employed. Anti-arrhythmic drugs, based on the underlying disease, are often the first step to control the arrhythmic burden; besides that, new therapeutic strategies have been developed with high efficacy, such as deep sedation, early catheter ablation, neuraxial modulation and mechanical hemodynamic support. The aim of this review is to provide practical indications for the management of electrical storm in acute settings.

Programming Optimization in Implantable Cardiac Monitors to Reduce False-Positive Arrhythmia Alerts: A Call for Research.

No studies have investigated whether optimizing implantable cardiac monitors (ICM) programming can reduce false-positive (FP) alerts. We identified patients implanted with an ICM (BIOMONITOR III) who had more than 10 FP alerts in a 1-month retrospective period. Uniform adjustments of settings were performed based on the mechanism of FP triggers and assessed at 1 month. Eight patients (mean age 57.5 ± 23.2 years; 37% female) were enrolled. In 4 patients, FPs were caused by undersensing of low-amplitude premature ventricular contractions (PVCs). No further false bradycardia was observed with a more aggressive decay of the dynamic sensing threshold. Furthermore, false atrial fibrillation (AF) alerts decreased in 2 of 3 patients. Two patients had undersensing of R waves after high-amplitude PVCs; false bradycardia episodes disappeared or were significantly reduced by limiting the initial value of the sensing threshold. Finally, the presence of atrial ectopic activity or irregular sinus rhythm generated false alerts of AF in 2 patients that were reduced by increasing the R-R variability limit and the confirmation time. In conclusion, adjustments to nominal settings can reduce the number of FP episodes in ICM patients. More research is needed to provide practical recommendations and assess the value of extended ICM programmability.

COVID-19 pandemic and elderly: is the curtain dropped for urgent pacemaker implantations?

BACKGROUND: Permanent cardiac pacing is the therapy of choice for treating severe and/or symptomatic bradyarrhythmia. During the COVID-19 outbreak, it has been reported a decrease in the incidence of acute coronary syndrome, but few data are available about pacemaker implantation rates. This study aimed to analyze patients referred to our center with permanent cardiac pacing indication during the COVID-19 outbreak. METHODS: We compared the number, the characteristics and the outcomes of patients who underwent urgent pacemaker implantation between March and April 2019 (Group I) with those performed in the corresponding 2020 period (Group II). RESULTS: A total of 27 patients (Group I) were implanted in March-April 2019 and 34 patients (Group II) in the corresponding 2020 period. In both groups, about half of the patients received a dual-chamber pacemaker. No significant differences in baseline patients' characteristics were observed. The most frequent indication was advanced atrio-ventricular block with a prevalence of 78% and 62% in Group I and II, respectively. The rate of procedural complications, the in-hospital and 1-month mortality were also similar between the two groups. CONCLUSIONS: In our regional referral center, we observed a routine activity in terms of urgent pacemaker implantations for the treatment of symptomatic bradyarrhythmia during the COVID-19 outbreak.

Implantable cardioverter-defibrillators in elderly patients: outcome and predictors of mortality.

PURPOSE: The implantable cardioverter-defibrillator (ICD) is the therapy of choice for the prevention of sudden cardiac death. The number of elderly patients receiving ICDs is increasing. This study aimed to assess the outcome of patients according to their age at the time of implantation, and to identify variables potentially associated with patient survival. METHODS: Between June 2009 and December 2019, we retrospectively enrolled all consecutive patients in whom ICD implantation had been performed for primary or secondary prevention at our center. RESULTS: During the study period, 670 patients underwent ICD implantation. We stratified the population into four age-classes: Class 1 (23%) (pts aged less than 60 years), Class 2 (28%) (pts aged between 60 and 70 years), Class 3 (39%) (pts aged between 70 and 80 years) and Class 4 (9%) (pts aged 80 years or older). Over a median follow-up of 42 months, the rate of deaths in Class 4 was higher than in Classes 1 and 2 (log-rank test, P < 0.01), but was comparable to that in Class 3 (P = 0.407). With increasing age, we observed more complications at the time of implantation and during follow-up. On multivariate analysis, higher NYHA class, creatinine level and CHA2DS2-VASc score were identified as independent predictors of death, while age was not associated with worse prognosis. Higher body mass index, higher NYHA class and CHA2DS2-VASc score were also confirmed as independent predictors of hospitalizations or death due to any cause. CONCLUSION: This study showed good survival in ICD patients in all age-groups, including those aged ≥80 years. The CHA2DS2-VASc score seems to be a stronger predictor of death than age.

Is the systematic use of mapping systems during His Bundle catheter ablation cost-effective? A single-center experience.

AIM: Three-dimensional (3D) nonfluoroscopic mapping systems (NMSs) are generally used during the catheter ablation (CA) of complex arrhythmias. We evaluated the efficacy, safety, and economic advantages of using NMSs during His-Bundle CA (HB-CA). METHODS: A total of 124 consecutive patients underwent HB-CA between 2012 and 2019 in our EP Laboratory. We compared two groups: 63 patients who underwent HB-CA with fluoroscopy alone from 2012 to 2015 (Group I) and 61 patients who underwent HB-CA with the aid of NMSs from 2016 to 2019 (Group II). Two cost-effectiveness analyses were carried out: the alpha value (AV) (ie, a monetary reference value of the units of exposure avoided, expressed as $/man Sievert) and the value of a statistical life (VSL) (ie, the amount of money that a community would be willing to pay to reduce the risk of a person's death owing to exposure to radiation, it is not the cost value of a person's life). The cost reduction estimated by means of both these methods was compared with the real additional cost of using NMSs. RESULTS: The use of NMS resulted in reduced fluoroscopy time in Group II {median 1.35 min} in comparison with Group I {median 4.8 min (P < .05)}. The effective dose reduction (ΔE) was 1.16 milli-Sievert. CONCLUSION: The use of NMS significantly reduces fluoroscopy time. However, the actual reduction is modest and in our EP Laboratory this reduction is not cost-effective. Indeed, when the ΔE is referred to country and agency tables for absolute values of AV or VLS, it is not economically advantageous in almost all cases.

Epicardial left ventricular lead implantation in cardiac resynchronization therapy patients via a video-assisted thoracoscopic technique: Long-term outcome.

BACKGROUND: Epicardial placement of the left ventricular (LV) lead via a video-assisted thoracoscopic (VAT) approach is an alternative to the standard transvenous technique. HYPOTHESIS: Long-term safety and efficacy of VAT and transvenous LV lead implantation are comparable. To test it, we reviewed our experience and we compared the outcomes of patients who underwent implantation with the two techniques. METHODS: The VAT procedure is performed under general anesthesia, with oro-tracheal intubation and right-sided ventilation, and requires two 5 mm and one 15 mm thoracoscopic ports. After pericardiotomy at the spot of the epicardial target area, pacing measurements are taken and a spiral screw electrode is anchored at the final pacing site. The electrode is then tunneled to the pectoral pocket and connected to the device. RESULTS: 105 patients were referred to our center for epicardial LV lead implantation. After pre-operative assessment, 5 patients were excluded because of concomitant conditions precluding surgery. The remaining 100 underwent the procedure. LV lead implantation was successful in all patients (median pacing threshold 0.8 ± 0.5 V, no phrenic nerve stimulation) and cardiac resynchronization therapy was established in all but one patient. The median procedure time was 75 min. During a median follow-up of 24 months, there were no differences in terms of death, cardiovascular hospitalizations or device-related complications vs the group of 100 patients who had undergone transvenous implantation. Patients of both groups displayed similar improvements in terms of ventricular reverse remodeling and functional status. CONCLUSIONS: Our VAT approach proved safe and effective, and is a viable alternative in the case of failed transvenous LV implantation.

An Economic Analysis of the Systematic Use of Mapping Systems during Catheter Ablation Procedures: Single Center Experience.

INTRODUCTION: In this study we estimated the cost-effectiveness of adopting 3D Nonfluoroscopic Mapping Systems (NMSs) for catheter ablation (CA). METHODS: This study includes patients who underwent supraventricular tachycardia (SVT) CA and atrial fibrillation (AF) CA from 2007 to 2016. A comparison was conducted between a reference year (2007) and the respective years for the two types of procedure in which the maximum optimization of patients' exposure using NMSs was obtained. We compared the data of all SVT CA performed solely using fluoroscopy in 2007 (Group I) and all SVT CA procedures performed using fluoroscopy together with an NMS in 2011 (Group II). There was also an important comparison made between AF CA procedures performed in 2007 (Group III) and AF CA in 2012 (Group IV), where patients' treatment in both years included the use of an NMS but where the software and hardware versions of the NMS were different. Two cost-effectiveness analyses were carried out. The first method was based on the alpha value (AV): the AV is a monetary reference value of avoided unit of exposure and is expressed as $/mansievert. The second one was based on the value of a statistical life (VSL): the VSL does not represent the cost value of a person's life, but the amount that a community would be willing to pay to reduce the risk of a person's death. The costs estimated from these two methods were compared to the real additional cost of using an NMS during that type of procedure in our EP Lab. RESULTS: The use of NMS reduced the effective dose of about 2.3 mSv for SVT and 23.8 mSv for AF CA procedures. The use of NMS, applying directly AV or VSL values, was not cost-effective for SVT CA for the most countries, whereas the use of an NMS during an AF CA seemed to be cost-effective for most of them. CONCLUSIONS: In our analysis the cost-effectiveness of the systematic use of NMSs strongly depended on the AV and VSL values considered. Nonetheless, the approach seemed to be cost-effective only during AF CA procedures.

Extensive Use of 3D Nonfluoroscopic Mapping Systems for Reducing Radiation Exposure during Catheter Ablation Procedures: An Analysis of 10 Years of Activity.

PURPOSE: 3D nonfluoroscopic mapping systems (NMSs) are generally used in the catheter ablation (CA) of complex ventricular and atrial arrhythmias. The aim of this study was to evaluate the efficacy, safety, and long-term effect of the extended, routine use of NMSs for CA. METHODS: Our study involved 1028 patients who underwent CA procedures from 2007 to 2016. Initially, CA procedures were performed mainly with the aid of fluoroscopy. From October 2008, NMSs were used for all procedures. RESULTS: The median fluoroscopy time of the overall CA procedures fell by 71%: from 29.2 min in 2007 to 8.4 min in 2016. Over the same period, total X-ray exposure decreased by 65%: from 58.18 Gy⁎cm2 to 20.19 Gy⁎cm2. This reduction was achieved without prolonging the total procedure time. In AF CA procedures, the median fluoroscopy time fell by 85%, with an 86% reduction in total X-ray exposure. In SVT CA procedures, the median fluoroscopy time fell by 93%, with a 92% reduction in total X-ray exposure. At the end of the follow-up period, the estimated probability of disease-free survival was 67.7% at 12 months for AF CA procedures and 97.2% at 3 months for SVT CA, without any statistically significant difference between years. CONCLUSIONS: Our study shows the feasibility of using NMSs as the main imaging modality to guide CA. The extended, routine use of NMSs dramatically reduces radiation exposure, with only slight fluctuations due to the process of acquiring experience on the part of untrained operators, without affecting disease-free survival.

Pacemaker therapy in very elderly patients: survival and prognostic parameters of single center experience.

BACKGROUND: Permanent pacing is the therapy of choice for treating severe and/or symptomatic bradyarrhythmias. The number of very elderly patients receiving pacemakers is increasing and little is known about survival in this specific subgroup. This study is aimed at assessing the actual survival of patients requiring pacing therapy at age > 85 years and investigating variables associated with death. METHODS: Between 2010 and 2017, 572 patients aged ≥ 85 years underwent pacemaker implantation for conventional bradycardia indications in Department of Cardiology, S. Chiara Hospital, Italy. RESULTS: Thirty percent of patients were ≥ 90-year-old and comorbidities were frequent. Fifty-seven percent of patients required pacing for prognostic reasons (acquired atrioventricular block), and the remaining for relief of bradycardia symptoms. A dual-chamber pacemaker was implanted in 34% of patients. The 5-year survival was 45% (standard error: 3%), and the 8-year survival was 26% (standard error: 4%). The risk of death was similar in patients who received pacemaker for symptom relief and for prognostic reasons in the overall population (HR = 1.19, 95% CI: 0.93-1.52, P = 0.156), as well as in the ≥ 90-year-old group (HR = 1.39, 95% CI: 0.92-2.11, P = 0.102). At multivariate analysis, following variables were associated with death: higher age, lower ejection fraction, dementia/dysautonomia and diagnosis of cancer. The pacing indication and the implantation of a single chamber pacemaker were not associated with worse prognosis. CONCLUSIONS: This study showed a good life expectancy in patients aged ≥ 85 years who received a pacemaker. Strong risk factors for all-cause death were non-cardiac. Pacemaker therapy seems a clinically effective therapeutic option to improve survival and to control bradyarrhythmia-related symptoms in very elderly patients.

A Cost-Effective Analysis of Systematically Using Mapping Systems During Catheter Ablation Procedures in Children and Teenagers.

The aim of this study is to evaluate the cost-effectiveness of an extended use of 3D non-fluoroscopic mapping systems (NMSs) during paediatric catheter ablation (CA) in an adult EP Lab. This study includes 58 consecutive patients (aged between 8 and 18) who underwent CA from March 2005 to February 2015. We compare the fluoroscopy data of two groups: group I, patients who underwent CA from 2005 to 2008 using only fluoroscopy, and group II, patients who underwent CA from 2008 to 2015 performed also using NMSs. Two cost-effectiveness analyses were carried out: the first method was based on the alpha value (AV), and the second one was based on the value of a statistical life (VSL). For both methods, a children's correction factor was also considered. The reduction cost estimated from all these methods was compared to the real additional cost of using NMSs. The use of an NMS during a CA procedure has led to an effective dose reduction (ΔE) of 2.8 milli-Sievert. All presented methods are based on parameters with a wide range of values. The use of an NMS, applying directly AV values or VSL values, is not cost-effective for most countries. Only considering the children's correction factor, the CA procedure using an NMS seems to be cost-effective. The cost-effectiveness of a systematic use of NMSs during CA procedures in children and teenagers remains a challenging task. A positive result depends on which value of AV or VSL is considered and if the children's correction factor is applied or not.

The Benefit of a General, Systematic Use of Mapping Systems During Electrophysiological Procedures in Children and Teenagers: The Experience of an Adult EP Laboratory.

Standard imaging during electrophysiological procedures (EPs) uses fluoroscopy. The aim of this study was to evaluate the feasibility, efficacy, safety and effect of an extended use of non-fluoroscopic mapping systems (NMSs) for imaging during paediatric EPs in an adult EP laboratory focusing on the amount of X-ray exposure. This study is a retrospective analysis that includes consecutive young patients (83 pts, aged between 8 and 18) who underwent EPs from March 2005 to February 2015. We compare the fluoroscopy data of two groups of pts: Group I, pts who underwent EPs from 2005 to 2008 using only fluoroscopy and Group II, pts who underwent EPs from 2008 to 2015 performed also using NMSs. The use of an NMS resulted in reduced fluoroscopy time in Group II {median value 0.1 min (95 % CI [0.00-1.07])} compared to Group I {median value 3.55 min (95 % CI [1.93-7.83]) (MW test, P < 0.05)}. There was a complementary reduction in the total X-ray exposure from 2.53 Gy cm(2) (95 % CI [1.51-4.66]) in Group I to 0.05 Gy cm(2) in Group II (95 % CI [0.00-1.22]) (MW test, P < 0.05). Regarding ablation procedures, the median effective dose decreased from 3.04 mSv (95 % CI [1.22-6.89]) to 0.25 mSv (95 % CI [0.00-0.60]) (MW test, P < 0.05). The use of an NMS dramatically reduces fluoroscopy time and total X-ray exposure during EPs in children and teenagers in an adult EP laboratory. In our experience, this reduction is mainly related to the systematic day-to-day use of NMSs.

Intravenous contrast echocardiography after myocardial infarction: relationship among residual myocardial perfusion, contractile reserve and long-term remodelling.

OBJECTIVE: Previous studies have shown the potential role played by intracoronary myocardial contrast echocardiography (MCE) in predicting long-term remodelling and function after myocardial infarction (MI). Scanty data, however, are available on the role of intravenous MCE in this regard. The aim of this study was to assess the role of residual myocardial blood volume in the asynergic region in modulating ventricular volume changes over time post-MI. METHODS: Thirty-two consecutive patients with anterior MI were studied predischarge using low-dose dobutamine echocardiography (Dob) and intravenous triggered MCE. Videointensity plots were generated from the apical approach and fitted exponentially. Volumes were assessed at baseline, during Dob and at 8 months. RESULTS: Baseline volumes, which appeared related to the extent of the asynergic region (P < 0.01) but showed no relation with videointensity in that area, did not change at follow-up, although Dob had elicited significant contractile reserve. However, videointensity in the asynergic region showed a significant interaction (P = 0.044) with the change in diastolic volume over time, with patients with the highest videointensity reverting remodelling (n = 11, from 69 +/- 16 to 65 +/- 16 ml/m) as compared with the remaining population (n = 21, from 68 +/- 16 to 73 +/- 21 ml/m). This was not seen when Dob-derived parameters were used. Multivariate analysis ranked videointensity second (P = 0.066), after baseline stroke volume (P = 0.005), in predicting changes in volumes over time. CONCLUSIONS: Unlike inotropic reserve, residual myocardial blood volume in the dysfunctioning muscle, as assessed by predischarge quantitative intravenous MCE, has the potential to modulate remodelling in patients who suffered an anterior MI.

Myocardial contrast echocardiography and quantitative videointensity analysis after myocardial infarction: correlation between residual myocardial perfusion, contractile reserve and long-term remodeling.

BACKGROUND: Previous studies have shown the important role played by intracoronary myocardial contrast echocardiography (MCE) in predicting the long-term remodeling and function after myocardial infarction. The left ventricular volume is an important determinant of the clinical outcome following an acute event. No data, however, are available on the role of intravenous MCE in this regard. METHODS: Ten consecutive patients with an anterior myocardial infarction were studied using low-dose dobutamine stress echocardiography (Dob) and intravenous MCE 8 +/- 4 days after the acute event. In all patients the left anterior descending coronary artery (LAD) was identified as the infarct-related vessel. A LAD score was generated using the percent residual stenosis and its location (proximal, mid, distal portion). Quantitative myocardial videointensity plots were then generated for each of the 12 ventricular segments analyzed, while the volumes were assessed during Dob and after 8 +/- 4 months. A higher peak intensity in the dysfunctioning muscle, during intravenous MCE infusion, was assumed to reflect a greater myocardial blood volume. RESULTS: Despite no change in the wall motion score index (WMSI), the percentage changes in systolic volumes during inotropic stimulation showed a linear relation with the LAD score. Furthermore, a normalized myocardial gray level in the asynergic region, taken as the plateau value of the videointensity time curve, showed an inverse relationship with the percentage changes in systolic volumes at follow-up. CONCLUSIONS: The residual microcirculation in the dysfunctioning muscle, quantitatively assessed at intravenous MCE 8 +/- 4 days after the acute event, has the potential of predicting chronic remodeling following an anterior myocardial infarction, irrespective of changes in the WMSI. The product of the degree of the residual infarct-related artery stenosis and its proximity predicts the ventricular volume response during low-dose Dob.