The Dark Side of the Moon: The Right Ventricle.

The aim of this review article is to summarize current knowledge of the pathophysiology underlying right ventricular failure (RVF), focusing, in particular, on right ventricular assessment and prognosis. The right ventricle (RV) can tolerate volume overload well, but is not able to sustain pressure overload. Right ventricular hypertrophy (RVH), as a response to increased afterload, can be adaptive or maladaptive. The easiest and most common way to assess the RV is by two-dimensional (2D) trans-thoracic echocardiography measuring surrogate indexes, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler velocity of the lateral aspect of the tricuspid valvular plane. However, both volumes and function are better estimated by 3D echocardiography and cardiac magnetic resonance (CMR). The prognostic role of the RV in heart failure (HF), pulmonary hypertension (PH), acute myocardial infarction (AMI), and cardiac surgery has been overlooked for many years. However, several recent studies have placed much greater importance on the RV in prognostic assessments. In conclusion, RV dimensions and function should be routinely assessed in cardiovascular disease, as RVF has a significant impact on disease prognosis. In the presence of RVF, different therapeutic approaches, either pharmacological or surgical, may be beneficial.

Electrical storm in dilated cardiomyopathy treated using epicardial radiofrequency ablation as a first line therapy.

We report a patient with non-ischemic dilated cardiomyopathy and low left ventricular systolic function (28%) presenting with an electrical storm originated in epicardial scar and ablated by radiofrequency. This case report suggests that a strategy of epicardial catheter ablation is reasonable for the patient presenting with electrical storm related to structural disease with a low left ventricular ejection fraction.

Stepwise ablation approach versus pulmonary vein isolation in patients with paroxysmal atrial fibrillation: Randomized controlled trial.

BACKGROUND: Pulmonary vein isolation (PVI) is a central procedure for the treatment of paroxysmal atrial fibrillation (PAF). However, in patients with PAF and structural atrial disease, PVI may fail and cause progressive atrial remodeling, often leading to persistent/permanent atrial fibrillation. OBJECTIVE: We performed a prospective, single-blind, 2-center randomized controlled trial to compare the efficacy of PVI alone with that of PVI plus stepwise ablation in achieving sinus rhythm and nonatrial arrhythmia inducibility in patients with PAF refractory to antiarrhythmic therapy. METHODS: Patients were randomized to perform a first catheter ablation procedure either through PVI alone or through PVI plus substrate modification in stepwise ablation. Data were recorded at 3, 6, and 12 months after both ablation procedures. Patients who experienced atrial fibrillation/atrial tachycardia (AF/AT) recurrence were encouraged to undergo repeat ablation using the technique of the first ablation procedure. RESULTS: A total of 150 patients were enrolled (mean age 62.8 ± 8.7 years; 92 (61.3%) men; 104 (69.3%) hypertensive; AF mean duration 10.7 months), with 75 patients in each group. After 12 months of the first procedure, patients who were converted to sinus rhythm using stepwise ablation showed a significantly lower rate of AF/AT recurrence (26.7%) than did those who were treated using PVI alone (46.7%; P < .001). Similar results were observed in the 52 patients who underwent a second catheter ablation procedure. After adjusting for several potential confounders, the hazard ratio of 12-month AF/AT recurrence after the first ablation procedure was 0.53 (95% confidence interval 0.30-0.91) for those treated using stepwise ablation. CONCLUSION: In addition to PVI, stepwise ablation achieving sinus rhythm and nonatrial arrhythmia inducibility has relevantly improved the clinical outcome of the PAF control strategy.

[QT dispersion and myonecrosis after stent percutaneous coronary intervention]. / Dispersione dell'intervallo QT e miocardionecrosi dopo stenting coronarico.

BACKGROUND: QT dispersion (QTd) is the difference between the maximum and the minimum QT interval in the 12-lead ECG. There is currently no information on the relationship between QTd and creatine kinase (CK)-MB release in patients undergoing percutaneous coronary intervention (PCI). METHODS: Among 118 patients undergoing successful PCI stenting, QTd and corrected QTd (QTdc) were measured at standard 12-lead ECG before PCI and at 6 and 18 hours after PCI. The median of QTdc variation (deltaQTdc = baseline QTdc - QTdc at 6 hours) was 9.5 ms (range -48 / +89 ms). Patients were divided into two groups according to deltaQTdc: group A "recoverers" (deltaQTdc > 9.5 ms, n = 59, 50%), group B "non-recoverers" (deltaQTdc < 9.5 ms, n = 59, 50%). CK-MB release was compared in the two groups. RESULTS: Eighty-three percent of patients were male, with mean age of 62 years (range 41-80 years). Unstable angina was present in 35% of cases, with similar distribution in the two groups. PCI was performed in 1.94 lesions/patient with the implantation of 1.6 stent/patient. Compared to baseline, a reduction in both QTc and QTdc was documented at 6 and 18 hours after PCI (p < 0.05). Periprocedural variations (CK-MB > 2 upper limit of normal) was detected in 4 patients (7%) of group A and 12 patients (20%) in group B (p = 0.06). Peak CK-MB release was significantly lower in group A (13 +/- 14.3 IU/l) compared to group B (23.2 +/- 35 IU/l, p < 0.05). CONCLUSIONS: After successful coronary stenting there is a rapid normalization of QTd and QTdc. The lack of recovery of both QTd and QTdc is related to minor elevations of CK-MB and may therefore be further explored as a useful non-invasive marker of heterogeneous reperfusion after PCI.