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

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

Cardiac electrophysiology and pacing educational and training needs among early-career cardiologists: a national survey of the Young Committee of the Italian Association of Arrhythmology and Cardiac Pacing.

BACKGROUND: Over the past three decades, cardiac electrophysiology and pacing, including device therapy and catheter ablation of arrhythmias, has rapidly developed as a subspecialty in cardiology. Currently, there is no clear perception about the needs in cardiac electrophysiology and pacing among early-career cardiologists. METHODS: To address these concerns, the Young Committee of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) carried out a survey among those under the age of 40 years to obtain detailed information on practical activities and formal lessons during the fellowship in cardiology and their satisfaction and proficiency level at the end of the fellowship. RESULTS: We obtained 334 answers to the survey. In invasive cardiac electrophysiology and pacing, the percentage of participants attending the activity for a longer time (3-6 months) is lower compared with those in noninvasive subspecialties. About 40% of participants did not receive lessons on interventional cardiology, cardiac electrophysiology and pacing. On the contrary, 71% of participants received an adequate number of lessons on clinical arrhythmology. The vast majority of the participants expressed satisfaction for the education received in the echocardiographic, cardiac interventional laboratories and clinical arrhythmology, but about half of the participants were unsatisfied with the education received in cardiac electrophysiology and pacing. In interventional arrhythmology, the majority of the participants declare their lack of proficiency with two peaks for more complex procedures, namely interventional electrophysiology procedures (82%) and cardiac resynchronization therapy (CRT) procedures (76%). CONCLUSION: The present survey among Italian early-career cardiologists suggests that the majority of participants consider themselves not confident in performing cardiac electrophysiology and pacing procedures. Due to the complexity of the treatment for heart rhythm disorders and the long learning curve, structured additional training in cardiac electrophysiology and pacing procedures is required after cardiology fellowship.

PDRN, a natural bioactive compound, blunts inflammation and positively reprograms healing genes in an "in vitro" model of oral mucositis.

Oral mucositis is a side effect hard to treat following high dose chemotherapy or radiotherapy. Adenosine A2A receptor stimulation blocks NF-κB and boosts the Wnt/ß-catenin signaling, thus blunting inflammation and triggering growth factor codifying genes. Polydeoxyribonucleotide (PDRN) is a registered drug that activates the A2A receptor. Therefore, the aim of this study was to evaluate PDRN effects in an "in vitro" model of oral mucositis induced by prompting an inflammatory phenotype in human gingival fibroblasts (GF) and human oral mucosal epithelial cells (EC). GF and EC were stimulated with LPS (2 µg/ml) alone or in combination with i) PDRN (100 µg/ml); ii) PDRN plus ZM241385 (1 µM) as an A2AR antagonist; iii) CGS21680 (1 µM) as an A2AR agonist. LPS boosted NF-κB, TNF-α and IL-6 expression, decreased IL-10 levels and downregulated both Wnt/ß-catenin, VEGF and EGF expression. PDRN reverted the LPS-induced phenotype as well as CGS21680. Co-incubation with ZM241385 abolished PDRN effects, thus confirming A2A receptor involvement in PDRN mechanism of action. These results suggest that PDRN efficacy may be due to a "dual mode" of action: NF-κB inhibition and Wnt/ß-catenin signaling activation. However, these interesting findings need to be confirmed by animal and clinical studies.

Preclinical and Clinical Applications of Biomaterials in the Enhancement of Wound Healing in Oral Surgery: An Overview of the Available Reviews.

Oral surgery has undergone dramatic developments in recent years due to the use of biomaterials. The aim of the present review is to provide a general overview of the current biomaterials used in oral surgery and to comprehensively outline their impact on post-operative wound healing. A search in Medline was performed, including hand searching. Combinations of searching terms and several criteria were applied for study identification, selection, and inclusion. The literature was searched for reviews published up to July 2020. Reviews evaluating the clinical and histological effects of biomaterials on post-operative wound healing in oral surgical procedures were included. Review selection was performed by two independent reviewers. Disagreements were resolved by a third reviewer, and 41 reviews were included in the final selection. The selected papers covered a wide range of biomaterials such as stem cells, bone grafts, and growth factors. Bioengineering and biomaterials development represent one of the most promising perspectives for the future of oral surgery. In particular, stem cells and growth factors are polarizing the focus of this ever-evolving field, continuously improving standard surgical techniques, and granting access to new approaches.

A three-dimensional computed model of ST segment abnormality in type 1 Brugada Pattern: A key role of right ventricular outflow tract orientation?

Since its first description, Brugada Syndrome is characterized by definite ECG abnormalities (J wave, elevated ST segment) confined in right precordial leads. Brugada Pattern (BP) could be found in one or more right precordial leads, at conventional or higher intercostal spaces. A recent study, conducted by our group, reported that slightly less than one half of patients with type 1 BP show a definite ST segment depression (≥0.1 mV with duration ≥ 0.08 s) in the inferior leads. With these premises, 4 distinct ST abnormalities phenotypes can be recognizable in Type 1 BP. We speculated the key role of orientation of right ventricular outflow tract in the thorax, particularly the inclination of anterior wall compared to the sternum, contributing to the determination of these various ECG phenotypes. An interactive program, ECGsim, able to simulate ECG appearance in several anatomical and electrical models, confirmed this assumption. This computed model affirmed the strict relationship between ST segment depression in the inferior leads and the ST segment elevation in right precordial leads, typical of type 1 BP. A horizontal right ventricular outflow tract, in fact, gives raise to abnormal BP vector directed both superiorly and anteriorly, explaining, at the same time, typical BP appearance in right precordial leads and ST segment depression in the inferior leads.

Functional atrial undersensing associated with device algorithm promoting AV conduction.

A 58-year-old woman received a dual chamber pacemaker (Medtronic) for sick sinus syndrome. Given intact AV conduction the Managed Ventricular Pacing mode algorithm (MVP) was programmed. The day after, she suffered from palpitations. Her ECG showed a possible loss of atrial capture accompanied by atrial undersensing. Telemetry-supported pacemaker control confirmed the loss of capture. Undersensing of atrial signal was functional, related to long atrial refractory period in MVP mode algorithm. Device algorithms could induce false suspicions. Awareness about the different pacing algorithms can be useful in order to avoid erroneous interpretations and to correct potential malfunctioning.

SafeR and escape junctional rhythm: A singular trigger for pacemaker-mediated tachycardia.

A 70-year-old man, who previously received a dual chamber pacemaker for paroxysmal AV block (Sorin Symphony DR 2550), was noted on telemetry to have multiple episodes of rapid ventricular pacing at approximately 120bpm. Evaluation of the telemetry strips revealed that all of the rapid ventricular pacing episodes were initiated by brief runs of escape junctional rhythm. Programmed bradycardia parameters were AAI SafeR with lower rate limit of 50bpm.

Spike on T wave! What went wrong?

An 80-year-old male, who previously received a dual chamber pacemaker, was referred to our ambulatory for dizziness and fatigue. The ECG obtained showed sinus rhythm, highly variable atrioventricular (AV) interval and alternation between spontaneous and paced ventricular complexes. A spike on the ascending part of the T wave was observed, suggesting ventricular undersensing. However, telemetry-supported pacemaker control showed inconstant atrial undersensing.

Tracking preference as unusual trigger of pacemaker-mediated tachycardia in a resynchronization device.

A 59-year-old woman with a history of congestive heart failure, who previously received a biventricular cardioverter-defibrillator was admitted with dyspnea and peripheral edema. She was noted on telemetry to have multiple self-terminated episodes of rapid ventricular pacing, consistent with pacemaker-mediated tachycardia. All episodes started after three consecutive ventricular extrasystoles. "Tracking preference" algorithm, designed to maintain atrial-tracked biventricular pacing in CRT devices, resulted turned on. It affected minimum PVARP and resulted the trigger for pacemaker mediated tachycardia.

A Case of Brugada Pattern Migrant from Right Precordial Leads to Peripheral Leads.

Since the first report in 1992, Brugada pattern (BP) diagnosis is mainly based on analysis of the precordial leads. In cases with no clear BP evidence in the conventional right precordial leads (4th intercostal space), limb leads analysis resulted helpful in suspecting BP. Fluctuations within right precordial leads between the diagnostic ECG pattern and nondiagnostic ECGs are well known. For the first time, in the patient herewith reported, the transformation of BP phenotype involves both precordial and peripheral leads, confirming that the analysis of all the 12 leads has a key role in BP diagnosis.

ST Segment Depression in the Inferior Leads in Brugada Pattern: A New Sign.

BACKGROUND: Brugada pattern (BP) is characterized by J wave and elevated ST segment in the right precordial leads. At times the ECG signs are present only with the electrodes displaced 1 or 2 intercostal spaces above. METHODS: We analyzed the electrocardiograms of 87 subjects with type 1 BP looking for ST segment depression (≥ 0.1 mV with duration ≥ 0.08 s) in the inferior leads. In 21 subjects, BP pattern was evident only with V1 -V2 electrodes at the 3rd or 2nd space. RESULTS: ST segment depression was present in 41 cases (47%). In the 21 patients with BP recognizable only at the 2nd or 3rd intercostal space, 10 (48%) presented a significant ST depression in the inferior leads. CONCLUSIONS: ST segment analysis in the inferior leads has never been considered for BP diagnosis. When accurately searched for, however, ST segment depression can be observed in those leads in BP, suggesting the need for further investigation.

Do patients with heart failure and right bundle branch block need biventricular pacing? A case of significant QRS narrowing by right ventricular pacing alone.

We report the case of a 56-year-old male with ischemic cardiomyopathy, severe left ventricular dysfunction and right bundle branch block (RBBB) with a wide QRS duration (180ms) who received dual-chamber implantable cardioverter-defibrillator for primary prevention of sudden death. After having placed the right ventricular lead in the middle of the inter-ventricular septum, a significant narrowing of QRS duration was observed, thus obtaining "de facto" a cardiac resynchronization therapy (CRT). This type of cardiac pacing could be an alternative to conventional CRT with left ventricular pacing in patients with wide QRS due to RBBB. The long-term effects of this RV only pacing strategy with ICD in patients with heart failure yet remain to be determined.

Role of three-dimensional imaging integration in atrial fibrillation ablation.

Atrial fibrillation is the most common arrhythmia and in symptomatic patients with a drug-refractory form, catheter ablation aimed at electrically disconnecting the pulmonary veins (PVs) has proved more effective than use of antiarrhythmic drugs in maintaining sinus rhythm during follow-up. On the other hand, this ablation procedure is complex, requires specific training and adequate clinical experience. A main challenge is represented by the need for accurate sequential positioning of the ablation catheter around each veno-atrial junction to deliver point-by-point radiofrequency energy applications in order to achieve complete and persistent electrical disconnection of the PVs. Imaging integration is a new technology that enables guidance during this procedure by showing a three-dimensional, pre-acquired computed tomography or magnetic resonance image and the relative real-time position of the ablation catheter on the screen of the electroanatomic system. Reports in the literature suggest that imaging integration provides accurate visual information with improvement in the procedure parameters and/or clinical outcomes of the procedure.

Use of a novel sharp-tip, J-shaped guidewire to facilitate transseptal catheterization.

AIMS: Transseptal catheterization (TSP-C) is a demanding procedure and at the same time one of the key points of atrial fibrillation ablation, an increasingly diffused procedure. This study prospectively evaluates the usefulness of a novel sharp-tip, J-shaped 0.014'' transseptal guidewire (TSP-GW) to facilitate TSP-C in case of resistant atrial septum (AS). METHODS AND RESULTS: Consecutive patients undergoing TSP-C for arrhythmia ablation in a single centre were considered for the study. TSP-C was performed according to a standardized technique. The criterion to use the TSP-GW was a resistant AS, defined as inability to perforate the fossa ovalis by applying moderate pressure to a standard Brockenbrough needle. The TSP-GW was inserted in the needle lumen and advanced to puncture the AS and enter the left atrium; subsequently, the transseptal assembly was advanced over the TSP-GW. Double transseptal puncture was routinely performed for ablation of atrial fibrillation. Eighty-one patients (54 males, 27 females; mean age 54 +/- 17 years, range 12-81) undergoing TSP-C were enrolled; 132 TSP-C procedures were planned and accomplished. Nineteen patients (23%) in 27 procedures showed a resistant AS. In all these procedures, the TSP-GW was safely and successfully used to accomplish the TSP-C. In patients with a resistant AS, only a significantly lower prevalence of structural heart disease was observed when compared with controls. No complication related to TSP-C was observed. CONCLUSION: The TSP-GW facilitates TSP-C in 23% of the patients, in whom a resistant AS is encountered. In this population, there was no clinical predictor of such anatomy.

Eagle's syndrome: importance of a corrected diagnosis and adequate surgical treatment.

Elongation of the styloid process and calcification of the stylohyoid ligament as pathological entities described by Eagle are often reported in the literature. The properly called Eagle's syndrome or stylalgia is characterized by a definite symptoms and etiology, that distinguish it from pathologies with partially overlapping symptoms depending on adjacent anatomical structures. A corrected differential diagnosis is paramount for choosing the most adequate treatment.