Implantable Loop Recorders in Patients with Unexplained Syncope: Does Ethnic Background Influence Diagnostic Yield?

BACKGROUND: Implantable loop recorders (ILRs) are a central tool in the evaluation of unexplained syncope. These devices record and store electrocardiograms, both automatically and on patient-dependent activation. Therefore, obtaining optimal diagnostic results relies on a patient's comprehension and collaboration. OBJECTIVES: To evaluate the effect of ethnic background and mother-tongue language on the diagnostic yield (DY) of ILRs. METHODS: Patients at two medical centers in Israel, who had ILRs as part of syncope workup were included. Inclusion criteria were age over 18 years and an ILR for at least one year (or less if the cause of syncope was detected). Patient demographics, ethnic background, and previous medical history were recorded. All findings from ILR recordings, activation mode (manual vs. automatic), and treatment decisions (none, ablation, device implantation) were collected. RESULTS: The study comprised 94 patients, 62 Jews (i.e., ethnic majority) and 32 non-Jews (i.e., ethnic minority). While baseline demographic characteristics, medical history, and drug therapy were similar in both groups, Jewish patients were significantly older at the time of device implantation: 64.3 ± 16.0 years of age vs. 50.6 ± 16.9, respectively; (P < 0.001). Arrhythmias recorded in both groups as well as treatment decisions and device activation mode were similar. Total follow-up time from device implantation was longer in the non-Jewish vs. the Jewish group (17.5 ± 12.2 vs. 24.0 ± 12.4 months, respectively; P < 0.017). CONCLUSIONS: The DY of ILR implanted for unexplained syncope did not seem to be influenced by patient's mother-tongue language or ethnicity.

Protective Effects of BNT162b2 Vaccination on Aerobic Capacity Following Mild to Moderate SARS-CoV-2 Infection: A Cross-Sectional Study Israel.

Patients previously infected with acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may experience post-acute adverse health outcomes, known as long COVID. The most reported symptoms are fatigue, headache and attention/concentration issues, dyspnea and myalgia. In addition, reduced aerobic capacity has been demonstrated in both mild and moderate COVID-19 patients. It is unknown whether COVID-19 vaccination mitigates against reduced aerobic capacity. Our aim was to compare the aerobic capacity of vaccinated and unvaccinated individuals previously infected with SARS-CoV-2. Methods: Individuals aged 18 to 65 years with laboratory-confirmed mild to moderate COVID-19 disease were invited to Ziv Medical Centre, Israel, three months after SARS-CoV-2 infection. We compared individuals unvaccinated at the time of infection to those vaccinated in terms of aerobic capacity, measured using symptom-limited cardiopulmonary exercise test (CPET). Results: We recruited 28 unvaccinated and 22 vaccinated patients. There were no differences in baseline demographic and pulmonary function testing (PFT) parameters. Compared with unvaccinated individuals, those vaccinated had higher V'O2/kg at peak exercise and at the anaerobic threshold. The V'O2/kg peak in the unvaccinated group was 83% of predicted vs. 100% in the vaccinated (p < 0.002). At the anaerobic threshold (AT), vaccinated individuals had a higher V'O2/kg than those unvaccinated. Conclusions: Vaccinated individuals had significantly better exercise performance. Compared with vaccinated individuals, a higher proportion of those unvaccinated performed substantially worse than expected on CPET. These results suggest that vaccination at the time of infection is associated with better aerobic capacity following SARS-CoV-2 infection.

Effects of hemodialysis with cooled dialysate on high-sensitivity cardiac troponin I and brain natriuretic peptide.

BACKGROUND: Hemodialysis (HD) triggers recurrent and cumulative ischemic insults to the brain and the heart. Cooled dialysate may have a protective effect on major organs and improve hemodynamic tolerability of dialysis. The aim of the study was to compare HD with cooled dialysate with routine dialysis in terms of hemodynamic stability and levels of high-sensitivity Troponin I (hs-TnI) and N-terminal pro b-type natriuretic peptide (NTproBNP) pre and postdialysis. METHODS: The 45 patients were randomized into two groups. The first group received a 35.5°C dialysate first (hypothermic dialysis) and the second group a 36.5°C dialysate first (routine dialysis). Then groups crossed over, so each group received the alternate dialysate (self-controls) For each patient, the first sample was collected at the beginning of dialysis, and a second sample was taken at the end of dialysis. RESULTS AND CONCLUSION: hs-TnI and NTproBNP increased after routine HD by 10.7 ng\ml (p < 0.001) and (12.0 pg/µl) (p < 0.001), respectively, and by -3.1 ng\ml (p = 0.25) and (4.3 pg/µl) (p < 0.001), respectively after hypothermic HD. Our study results showed a tendency towards less rise in hsTnI and NTproBNP during hypothermic HD (35.5°C) as compared to routine HD (36.5°C). Neither arm experienced statistically significant changes in blood pressure. Further studies in larger cohorts and long follow up are warranted in order to confirm that lower rise in (hs-TnI) and NTproBNP actually translate into lower clinical risk for cardiovascular events.

Postprocedural Radial Artery Compression Time In Chronic AnticoaguLated patients using StatSeal: The PRACTICAL-SEAL study.

BACKGROUND: Patients on uniterrupted chronic oral anticoagulation (OAC) therapy are at high-risk of bleeding during cardiac catheterization. We aimed to investigate the safety and efficacy of the StatSeal® disc for adjunct hemostasis in patients undergoing transradial coronary angiography under uninterrupted OAC therapy. METHODS: Patients who underwent transradial cardiac catheterization without interrupted OAC therapy were included in this study. RESULTS: Among 180 patients, 85 (47.2%) patients were on warfarin and 95 (52.8%) patients on novel oral anticoagulants (NOACs). Patients on NOACs were older (72.9 ± 9.6 versus 69.7 ± 10.8 years, P < 0.001) and had more atrial fibrillation/flutter (94.7% versus 62.4%, P < 0.001), whereas patients on Warfarin were more often women (43.5% versus 26.3%, P = 0.02) and had mechanical heart valves (27.1% versus 0%, P < 0.001). Intravenous unfractioned heparin (UFH) was administered in 96.5% of patients on warfarin (3799 ± 1342 units) and 93.7% patients on NOACs (4028 ± 1362 units), P = 0.27. There were no differences in terms of type and sheath size and the need for ad hoc coronary intervention. Time-to-first release of the hemostatic wristband was 56.2 ± 12.6 min and complete hemostasis was achieved in 71.1 ± 13.0 min, with shorter times among patients on NOACs (54.1 ± 11.7 and 58.5 ± 13.2 min, 68.9 ± 11.7 versus 73.6 ± 14.0 min, P = 0.02, for both). There were no significant differences in terms of bleeding. There was no radial artery occlusion among 112 participants who underwent color Doppler ultrasound. CONCLUSION: The present study shows that in patients undergoing transradial coronary angiogram under contemporary uninterrupted OAC therapy and periprocedural administration of UFH, the use of StatSeal® disc for adjunctive hemostasis was associated with short times to complete hemostasis.

Does Routine Sedation Influence Anxiety and CRP levels in Patients Undergoing Elective Coronary Catheterization?

BACKGROUND: Cardiac catheterization is associated with patient anxiety. Benzodiazepines are often used to relieve anxiety in this setting. The association between anxiety level and C-reactive protein (CRP) remains equivocal. We sought to determine whether anxiety and CRP levels in patients undergoing elective left heart catheterization differ when routine sedation with midazolam is administered. METHODS: Patients undergoing elective left heart catheterization were randomly assigned to receive 2 mg of midazolam intravenously or placebo before access insertion in a double-blinded manner. Levels of anxiety were assessed using the State-Trait Anxiety Inventory for Adults (short form) and high-sensitivity CRP at the time of admission and discharge. Surrogate markers for anxiety, such as blood pressure and pulse, were recorded before and after the procedure. Patient-perceived discomfort was measured with a visual analog scale (VAS) on a 0-10 scale. RESULTS: One hundred patients (52 receiving treatment, 48 receiving placebo) participated in the study. Baseline demographic characteristics and previous medical conditions were well balanced between groups. Anxiety level, systolic blood pressure, and diastolic blood pressure were all higher at procedure start than post procedure, but did not differ between the groups. CRP levels were similar at both time points for patients in both groups (0.77 ± 2.53 mg/L pre procedure and 0.70 ± 2.08 mg/L post procedure in the midazolam group vs 0.79 ± 1.39 mg/L pre procedure and 0.83 ± 1.45 mg/L post procedure in the placebo group). Discomfort level assessment was also alike (2.6 ± 2.4 in the treatment group vs 3.4 ± 2.5 in the placebo group; P=.12). CONCLUSIONS: Intravenous midazolam administration does not seem to relieve patient discomfort and anxiety nor does it influence CRP level. Therefore, an approach tailored to the patient is advisable.

Routine fixed-dose heparin vs. ACT-guided heparin administration for elective PCI and its influence on patient in-hospital outcome: a retrospective study.

OBJECTIVE: Activated clotting time (ACT)-based heparin dosing during percutaneous intervention (PCI) is recommended by Society guidelines. However, the relationship between ACT and outcome in the setting of elective PCI has not been sufficiently studied. We sought to evaluate the in-hospital outcome of patients undergoing elective PCI while receiving fixed-dose heparin without ACT measurement versus those with ACT-guided management. METHODS: This retrospective study included consecutive patients undergoing elective PCI in a single-center between 11/2015 and 12/2018. Patients were divided into two groups, depending on whether ACT was measured. Heparin-only anticoagulation and non-femoral procedures were allowed. Patient demographics, procedural data and in-hospital outcomes were collected. The primary outcome was in-hospital major adverse cardiovascular events (MACE), secondary (safety) outcomes were in-hospital definite stent thrombosis, Bleeding Academic Research Consortium bleeding, access-related complications (any) as well as peri-procedural complications. RESULTS: In total, 500 procedures were included in the study, 151 ACT and 349 fixed-dose. Patient demographics and medical history in both groups were well balanced, but those having ACTs were younger (63.2 ± 10.9 vs. 66.5 ± 11.3; P = 0.003) and less likely to have a history of coronary artery disease (74 vs. 82%; P = 0.032) or kidney failure. Procedural data were similar; however, total heparin dose and procedure length were higher in the ACT group (6232 ± 1388 vs.5032 ± 417 units; P < 0.001; 40.1 ± 14.0 vs. 30.3 ± 12.7 min; P < 0.001). Primary and secondary outcome events were rare and similar (MACE 1.1 vs. 1.3%; P = 0.86). CONCLUSIONS: A fixed-dose heparin injection (5000 IU) approach for elective PCI while omitting ACT offers slightly shortened procedural time and similar in-hospital safety profile.

Lipid profile as a strong indicator of coronary plaques: noninvasive assessment by multislice computerized tomography.

BACKGROUND: Most acute coronary syndrome disorders occur as a consequence of atherosclerotic plaque rupture. Lipids are involved in atherosclerotic plaque buildup. Advances in image quality of coronary computed tomography have enabled improved characterization of coronary plaques. The aim of our study was to evaluate the association between lipid profile and coronary plaque presence in general and soft plaques in particular. METHODS: In this cross-sectional survey, 258 consecutive patients presenting with chest pain either or both with low-to-moderate risk for coronary artery disease, were included. All patients were tested for lipid profile prior to cardiac imaging on a 64-slice computer tomography. Multivariate logistic regression models were used to assess the odds ratios (ORs) and 95% confidence interval (CI) for the relationship between blood lipid levels and prevalence of coronary plaques. RESULTS: Age, total cholesterol levels, hypertension, hyperlipidemia (dichotomous) and risk factor index, all were independently associated with prevalence all kind of plaques, especially with soft plaques. No significant relationships were detected among BMI, current smoking, diabetes or triglycerides levels. In a multivariate logistic regression, hyperlipidemia was associated with presence of coronary plaque risk with adjusted OR of 2.28 (95% CI 1.30-4.01), total cholesterol with adjusted OR = 1.05 (95% CI 1.01-1.06), and risk factor index (1-6) with adjusted OR = 2.23 (95% CI 1.40-3.55). CONCLUSION: Hyperlipidemia is strongly associated with prevalence of coronary plaques (P < 0.001) in individuals with low-to-intermediate risk for coronary artery disease, based on cardiac CT. Cardiac CT may serve as a noninvasive alternative for the early diagnosis of CAD in such individuals.

Complicated acute myocardial infarction with simultaneous occlusion of two coronary arteries.

Simultaneous occlusion of two coronary arteries in acute MI is infrequent and may be accompanied by cardiogenic shock. Prompt restoration of normal coronary flow can salvage the myocardium and decrease a possible risk of death from complications.

Small-Size vs Large-Size Burr for Rotational Atherectomy.

BACKGROUND: Rotational atherectomy (RA) has been traditionally performed via the transfemoral approach, mostly utilizing large guide catheters (≥7 Fr), which can accommodate the passage of large burrs (≥1.75 mm). However, contemporary data show that using smaller sheath and catheter sizes reduces the risk of procedural access-site related complications. Therefore, the aim of this study was to assess the feasibility of performing RA using smaller burrs and subsequently smaller-sized sheath catheters. METHODS: A total of 220 patients underwent RA procedures between January 2011 and July 2017. We compared 162 patients who underwent RA using a maximal burr size of 1.5 mm (small-burr group) with 58 patients who underwent RA using burrs >1.5 mm in diameter (large-burr group). Clinical, procedural, safety, and feasibility data were evaluated and compared between the two groups. RESULTS: Baseline characteristics of the two groups were quite similar other than a higher prevalence of smoking (21.0% vs 5.2%; P<.01) and a lower body weight (80.9 ± 17.5 kg vs 86.8 ± 17.2 kg; P=.03) in the small-burr group vs the large-burr group. The indications for the procedure for the small-burr group vs large-burr group were stable angina in 53% vs 62%, unstable angina in 16% vs 17%, non-ST elevation myocardial infarction (MI) in 26% vs 17%, and ST-elevation MI in 3.7% vs 3.4%, respectively (P=NS for all). The target-vessel (TV) diameter was significantly larger in the large-burr group vs the small-burr group (3.5 ± 0.3 mm vs 3.2 ± 0.5 mm, respectively; P<.01). Importantly, a sheath size >6 Fr was used in 56.0% of the small-burr group vs 89.5% of the large-burr group (P<.01). Moreover, in 53% of the small-burr group, a guide catheter >6 Fr was used. Radial access was used in 33% of the small-burr group and 17% of the large-burr group (P=.03). Procedural success was achieved in 93% of the small-burr group and 100% of the large-burr group (P=.07). CONCLUSION: In the majority of cases, RA can be successfully performed using smaller-sized burrs while achieving a high procedural success rate. Notably, our study also highlights the overuse of large sheaths and catheters to deliver small burrs. These results further support the contemporary strategy of using 6 Fr guide catheters, thereby increasing the possibility of using the radial approach for more complex interventional procedures.

Radial versus femoral approach for saphenous vein grafts angiography and interventions.

BACKGROUND: Coronary angiography and intervention to saphenous venous grafts (SVGs) remain challenging. This study aimed to investigate the feasibility and safety of the radial approach compared to femoral access in a large cohort of patients undergoing SVG angiography and intervention. METHODS: Data from 1,481 patients from Canada, United States, and Spain who underwent procedures between 2010 and 2016 were collected. Patients must have undergone SVG coronary angiography and/or intervention. Demographics, procedural data, and in-hospital complications were recorded. RESULTS: Procedures were undertaken by either the radial (n = 863, 211 intervention) or femoral (n = 618, 260 intervention) approach. The mean number of SVGs per patient was similar between groups (radial 2.3 ± 0.7 vs femoral 2.6 ± 1.1, P = .61), but the radial group required a fewer number of catheters (2.6 ± 1.7 vs 4.1 ± 1.1, P < .001). Fluoroscopy time was comparable between groups, and there was a trend toward lower contrast volume in the radial group (P = .045). Overall, the total dose of heparin was significantly higher in the radial group (P < .001); however, radial patients experienced significantly less access-site bleeding complications (P < .001). Outpatients undergoing radial SVG interventions had a higher likelihood of a same-day discharge home (P < .001). CONCLUSIONS: Radial access for SVG angiography and intervention is safe and feasible, without increasing fluoroscopy time. In experienced centers, radial access was associated with fewer catheters used, lower contrast volume, and lower rate of vascular access-site bleeding complications. Moreover, outpatients undergoing SVG percutaneous coronary intervention though the radial approach had a higher likelihood of a same-day discharge home.

Sheathless guiding catheter from a femoral approach for complex percutaneous coronary interventions -An unusual solution for an often-encountered problem.

Sheathless guiding catheters are a valuable tool in the catheterization labor and may assist the operator when dealing with heavily calcified and tortuous vessels. Nevertheless, when hostile anatomy prevents successful percutaneous coronary interventions (PCI) from the radial access, transfemoral use of sheathless guide can assist in overcoming these challenges in a safe manner.

Radial versus femoral approach for same-day inter-facility transfer for percutaneous coronary intervention.

BACKGROUND: The use of radial approach for coronary angiography, followed by same-day inter-facility transfer for percutaneous coronary intervention (PCI) has not yet been evaluated. OBJECTIVES: We sought to assess the safety and feasibility of using the transradial as compared to the transfemoral approach in patients undergoing diagnostic angiogram with same-day transfer to a PCI facility. METHODS: Patients that underwent diagnostic coronary angiography between January 2011 and June 2017 in a referring facility, and were transferred for same-day PCI were included. Patients' demographics, as well as procedural data and in-hospital outcome, were collected. RESULTS: Three hundred fifty-two participants were included. Of these, 36 (10.2%) patients received transradial access. Patients in the transradial group were older (68 ± 10 vs 62 ± 12 years, P = 0.007), and received a significantly higher total dose of heparin including both, diagnostic and PCI procedures (5935 ± 1865 vs 10029 ± 2771 units, P < 0.001). None of the transradial patients experienced bleeding or access-related complications. In the transfemoral group, 9 (3%) vascular-access complications were recorded. Contrast volume was lower for transradial patients (177 ± 47 vs 216 ± 75 mL, P < 0.001). A higher proportion of outpatients were discharged from the PCI-center the same day after transradial procedures (53% vs 1.3%, P < 0.001). CONCLUSIONS: Transradial access for inter-facility transfer for PCI after diagnostic angiogram appears safe and feasible, without increasing the risk for ischemic hand complications. Transradial access was associated with fewer bleeding and vascular access-site complications, and with a higher likelihood for a same-day discharge home in outpatients.

Effects of hypertonic saline solution on body weight and serum creatinine in patients with acute decompensated heart failure.

AIM: To test the safety and effectiveness of hypertonic saline solution (HSS + F) as a strategy for weight loss and prevention of further deterioration of renal function. METHODS: Patients admitted with acute decompensated heart failure (ADHF) who received HSS + F were included in the study. After a period of a standard ADHF treatment, our patients received an intravenous infusion of furosemide (250 mg) combined with HSS (150 mL of 3% NaCl) twice a day for a mean duration of 2.3 d. Our primary outcomes were weight loss and a change in serum creatinine per day of treatment. The parameters of the period prior to treatment with HSS + F were compared with those of the period with HSS + F. RESULTS: A total of 47 patients were included. The mean creatinine on admission was 155 µmol/L ± 65 µmol/L, the ejection fraction was 40% ± 17%. The experimental treatment (HSS + F) resulted in greater weight loss per day of treatment than the standard treatment (-1.4 kg/d ± 1.4 kg/d vs -0.4 kg/d ± 1.0 kg/d, P = 0.0168). Importantly, the change in creatinine was not significantly different. CONCLUSION: This study supports the effectiveness of HSS + F on weight loss in patients with ADHF. The safety profile, particularly with regard to renal function, leads us to believe that HSS + F may be a valuable option for those patients presenting with ADHF who do not respond to conventional treatment with intravenous furosemide alone.

Nitroglycerin-Derived Pd/Pa for the Assessment of Intermediate Coronary Lesions.

OBJECTIVES: To assess the predictive value of Pd/Pa after nitroglycerin administration (Pd/Pa[N]) as compared with standard fractional flow reserve (FFR). METHODS: Consecutive patients with intermediate coronary lesions assessed by FFR between January 2014 and October 2015 were included. We measured Pd/Pa at baseline, Pd/Pa(N), and Pd/Pa after incremental doses of intracoronary adenosine. RESULTS: A total of 134 patients (27% females; mean age, 65 years) were included. The diagnostic performance of Pd/Pa(N) and identification of cut-off value for Pd/Pa(N) compared with FFR threshold of 0.8 using receiver-operating characteristic (ROC) area under the curve analysis was between 0.98 (95% confidence interval, 0.95-1.00; P<.05) for 48 µg and 0.86 (95% confidence interval, 0.79-0.94; P<.05) for 240 µg adenosine. Pd/Pa(N) ≤0.8 had 100% positive predictive value. Pd/Pa(N) ≥0.94 provided 100% negative predictive value with a high sensitivity (>92%). Optimal diagnostic accuracy of Pd/Pa(N) was achieved for values ≤0.84. The Pearson's correlation between Pd/Pa(N) and FFR varied between 0.89 for 24 µg adenosine and 0.77 for 240 µg (P<.01). CONCLUSION: Pd/Pa(N) values can be used for diagnosis of hemodynamically significant lesions. Pd/Pa(N) correlates well with standard FFR. Pd/Pa(N) cut-off of ≤0.8 can be considered significant without need for adenosine injection. The value of using adenosine whenever Pd/Pa(N) is ≥0.94 is limited.

Randomized Trial of Compression Duration After Transradial Cardiac Catheterization and Intervention.

BACKGROUND: Radial artery occlusion is a known complication following transradial cardiac catheterization. A shorter duration of postprocedural radial clamp time may reduce radial artery occlusion (RAO) but might be associated with incomplete hemostasis. METHODS AND RESULTS: In total, 568 patients undergoing transradial diagnostic cardiac catheterization were randomly assigned to either 20 minutes (ultrashort) or 60 minutes (short) hemostatic compression time using patent hemostasis. Subsequently, clamp pressure was reduced gradually over 20 minutes. Access site hemostasis and RAO were assessed after clamp removal. Repeated assessment of RAO was determined at 1 week in 210 (37%) patients. Mean age was 64±11 years, and 30% were female. Percutaneous coronary intervention was performed in 161 patients. RAO immediately after clamp removal was documented in 14 (4.9%) and 8 (2.8%) patients in the 20- and 60-minute clamp application groups, respectively (P=0.19). The incidence of grade 1 hematoma was higher in the 20-minute group (6.7% versus 2.5%, P=0.015). RAO at 1 week after the procedure was 2.9% and 0.9% in the 20- and 60-minute groups, respectively (P=0.36). Requirement for clamp retightening (36% versus 16%, P=0.01) was higher among patients who had RAO. Need for clamp retightening was the only independent predictor of RAO (P=0.04). CONCLUSIONS: Ultrashort radial clamp application of 20 minutes is not preferable to a short duration of 60 minutes. The 60-minute clamp duration is safe and provides good access site hemostasis with low RAO rates. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02269722.

Radiotherapy-Induced Cardiac Implantable Electronic Device Dysfunction in Patients With Cancer.

Radiotherapy can affect the electronic components of a cardiac implantable electronic device (CIED) resulting in malfunction and/or damage. We sought to assess the incidence, predictors, and clinical impact of CIED dysfunction (CIED-D) after radiotherapy for cancer treatment. Clinical characteristics, cancer, different types of CIEDs, and radiation dose were evaluated. The investigation identified 230 patients, mean age 78 ± 8 years and 70% were men. A total of 199 patients had pacemakers (59% dual chamber), 21 (9%) cardioverter-defibrillators, and 10 (4%) resynchronizators or defibrillators. The left pectoral (n = 192, 83%) was the most common CIED location. Sixteen patients (7%) experienced 18 events of CIED-D after radiotherapy. Reset to backup pacing mode was the most common encountered dysfunction, and only 1 (6%) patient of those with CIED-D experienced symptoms of atrioventricular dyssynchrony. Those who had CIED-D tended to have a shorter device age at the time of radiotherapy compared to those who did not (2.5 ± 1.5 vs 3.8 ± 3.4 years, p = 0.09). The total dose prescribed to the tumor was significantly greater among those who had CIED-D (66 ± 30 vs 42 ± 23 Gy, p <0.0001). Multivariate logistic regression analysis identified the total dose prescribed to the tumor as the only independent predictor for CIED-D (odds ratio 1.19 for each increase in 5 Gy, 95% confidence interval 1.08 to 1.31, p = 0.0005). In conclusion, in this large population of patients with CIEDs undergoing radiotherapy for cancer treatment, the occurrence of newly diagnosed CIED-D was 7%, and the reset to backup pacing mode was the most common encountered dysfunction. The total dose prescribed to the tumor was a predictor of CIED-D. Importantly, although the unpredictability of CIEDs under radiotherapy is still an issue, none of our patients experienced significant symptoms, life-threatening arrhythmias, or conduction disorders.