A Unique Case of Mitral Valve Double Papillary Muscle Rupture

Abstract Papillary muscle rupture is a rare and life-threatening complication of acute myocardial infarction (AMI). We present a unique case of double papillary muscle rupture in a patient with three vessel disease and acute thrombotic occlusion of left circumflex obtuse marginal artery as the culprit lesion. (Level of Difficulty: Beginner.

Cardioneuroablation for vasovagal syncope: insights on patients' selection, centre settings, procedural workflow and endpoints-results from an European Heart Rhythm Association survey.

AIMS Cardioneuroablation (CNA) is a catheter-based intervention for recurrent vasovagal syncope (VVS) that consists in the modulation of the parasympathetic cardiac autonomic nervous system. This survey aims to provide a comprehensive overview of current CNA utilization in Europe. METHODS AND RESULTS A total of 202 participants from 40 different countries replied to the survey. Half of the respondents have performed a CNA during the last 12 months, reflecting that it is considered a treatment option of a subset of patients. Seventy-one per cent of respondents adopt an approach targeting ganglionated plexuses (GPs) systematically in both the right atrium (RA) and left atrium (LA). The second most common strategy (16%) involves LA GP ablation only after no response following RA ablation. The procedural endpoint is frequently an increase in heart rate. Ganglionated plexus localization predominantly relies on an anatomical approach (90%) and electrogram analysis (59%). Less utilized methods include pre-procedural imaging (20%), high-frequency stimulation (17%), and spectral analysis (10%). Post-CNA, anticoagulation or antiplatelet therapy is prescribed, with only 11% of the respondents discharging patients without such medication. Cardioneuroablation is perceived as effective (80% of respondents) and safe (71% estimated <1% rate of procedure-related complications). Half view CNA emerging as a first-line therapy in the near future. CONCLUSION This survey offers a snapshot of the current implementation of CNA in Europe. The results show high expectations for the future of CNA, but important heterogeneity exists regarding indications, procedural workflow, and endpoints of CNA. Ongoing efforts are essential to standardize procedural protocols and peri-procedural patient management

Computed tomography-based identification of ganglionated plexi to guide cardioneuroablation for vasovagal syncope

This study shows that CT-based EFP-guided CNA for CI-VVS is feasible, can assist RF delivery with high precision, and has the potential to overcome the interpatient variability that affects CNA when performed solely by anatomic landmarks. Further larger studies with longer follow-up are required to improve CT-based identification of GPs and our understanding of GP pathophysiology

Clinical impact of aging on outcomes of cardioneuroablation for reflex syncope or functional bradycardia. Results from the cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs. The ELEGANCE multicenter study

Background: Cardioneuroablation (CNA) is a novel treatment for reflex syncope. The effect of aging on CNA efficacy is not fully understood. Objective: We assessed the impact of aging on candidacy and efficacy of CNA for treating vasovagal syncope (VVS), carotid sinus syndrome (CSS) and functional bradyarrhythmia. Methods: The ELEGANCE multicenter study assessed CNA in patients with reflex syncope or severe functional bradyarrhythmia. Patients underwent pre-CNA Holter ECG, head-up tilt testing (HUT) and electrophysiologic study. CNA candidacy and efficacy was assessed in 14 young (18-40 years), 26 middle-aged (41-60 years) and 20 older (&gt;60 years) patients. Results: Sixty patients (37 men; mean age: 51±16 years) underwent CNA. The majority (80%) had VVS, 8% CSS, and 12% functional bradycardia/AV block. Pre-CNA Holter ECG, HUT and EP findings did not differ across age groups. Acute CNA success was 93%, without differences between age groups (p=0.42). Post-CNA HUT response was negative in 53%, vasodepressor in 38%, cardioinhibitory in 7% and mixed in 2%, without differences across age groups (p=0.59). At follow-up (8 months, IQR:4-15), 53 (88%) patients were free of symptoms. Kaplan-Meier curves did not show differences in event-free survival between age groups (p=0.29). The negative predictive value of a negative HUT was 91.7%. Conclusions: CNA is a viable treatment for reflex syncope and functional bradyarrhythmia in all ages, and is highly effective in mixed VVS. HUT is a key-step of post-ablation clinical assessment

Cardioneuroablation for carotid sinus syndrome: a case series

Cardioinhibitory carotid sinus syndrome (CSS) is a neurally mediated (reflex) syncope, secondary to excessive vagal response to carotid sinus pressure. A growing body of studies have shown that catheter ablation of ganglionated plexi (GPs) or cardioneuroablation (CNA) is effective in treating patients with vasovagal syncope.1 To date, no studies systematically evaluated CNA in patients with CSS

Prenatal prediction of Shone's complex. The role of the degree of ventricular disproportion and speckle-tracking analysis

Shone's complex (SC) is characterized by sequential obstructions of left ventricular (LV) inflow and outflow. It can be associated with poor long-term prognosis when compared to Simple-Aortic Coarctation (S-CoA). We aimed to assess whether the degree of ventricular disproportion and 2D-speckle-tracking echocardiography (2D-STE) could improve the accuracy of prenatal prediction of SC

Substrates of scar-related ventricular arrhythmia in patients with hypertrophic cardiomyopathy: a cardiac magnetic resonance study

Contrast-enhanced cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) detects myocardial fibrosis in patients with hypertro- phic cardiomyopathy (HCM). We conducted a retrospective analysis of a pro- spectively collected and followed up cohort of consecutive patients with HCM implanted with a cardioverter defibrillator (ICD) that underwent pre- implant CMR. We sought to describe scar architecture and assess scar composition as a predictor of ven- tricular tachycardia/ventricular fibrillation (VT/VF). High scar mass (&gt;15% of LV mass) showed 44.8% positive predictive value (PPV) and 89.7% negative predictive value (NPV) for VT/VF, whereas BZ chan- nels identified VT/VF patients with 55.6% PPV and 96.8% NPV. Indeed, of 28 patients with scar &lt;15%, 3 had VT/VF, and 2 of them had BZ channels. The C-statistic was 0.77 (95% CI: 0.64-0.89) for scar mass and 0.88 (95% CI: 0.76-0.96) for BZ channels (P 1⁄4 0.11). Using scar channels instead of scar mass to stratify the risk of VT/VF allowed us to reclassify 12.5% of the cases and 12.0% of the controls (net reclassification index [NRI]: 0.24; SE: 0.10; P 1⁄4 0.01). High-risk patients with HCM displayed extensive LV scar with predominance of BZ tissue and relatively common BZ channels in the scar volume, possibly serving as substrates for re-entrant VA

Patients with Cardiac Implantable Electronic Device Undergoing Radiation Therapy: Insights from a Ten-Year Tertiary Center Experience

Background: The number of patients with cardiac implantable electronic devices (CIEDs) receiving radiotherapy (RT) is increasing. The management of CIED-carriers undergoing RT is challenging and requires a collaborative multidisciplinary approach. Aim: The aim of the study is to report the real-world, ten-year experience of a tertiary multidisciplinary teaching hospital. Methods: We conducted an observational, real-world, retrospective, single-center study, enrolling all CIED-carriers who underwent RT at the San Raffaele University Hospital, between June 2010 and December 2021. All devices were MRI-conditional. The devices were programmed to an asynchronous pacing mode for patients who had an intrinsic heart rate of less than 40 beats per minute. An inhibited pacing mode was used for all other patients. All tachyarrhythmia device functions were temporarily disabled. After each RT session, the CIED were reprogrammed to the original settings. Outcomes included adverse events and changes in the variables that indicate lead and device functions. Results: Between June 2010 and December 2021, 107 patients were enrolled, among which 63 (58.9%) were pacemaker carriers and 44 (41.1%) were ICD carriers. Patients were subjected to a mean of 16.4 (±10.7) RT sessions. The most represented tumors in our cohort were prostate cancer (12; 11%), breast cancer (10; 9%) and lung cancer (28; 26%). No statistically significant changes in device parameters were recorded before and after radiotherapy. Generator failures, power-on resets, changes in pacing threshold or sensing requiring system revision or programming changes, battery depletions, pacing inhibitions and inappropriate therapies did not occur in our cohort of patients during a ten-year time span period. Atrial arrhythmias were recorded during RT session in 14 patients (13.1%) and ventricular arrhythmias were observed at device interrogation in 10 patients (9.9%). Conclusions: Changes in device parameters and arrhythmia occurrence were infrequent, and none resulted in a clinically significant adverse event