Diagnosis and treatment of idiopathic premature ventricular contractions: A stepwise approach based on the site of origin

Premature ventricular contractions in the absence of structural heart disease are among the most common arrhythmias in clinical practice, with well-defined sites of origin in the right and left ventricle. In this review, starting from the electrocardiographic localization of premature ventricular contractions, we investigated the mechanisms, prevalence in the general population, diagnostic work-up, prognosis and treatment of premature ventricular contractions, according to current scientific evidence

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

Economic impact of remote monitoring on ordinary follow-up of implantable cardioverter defibrillators as compared with conventional in-hospital visits: a single-center prospective and randomized study

Few data are available on actual follow-up costs of remote monitoring (RM) of implantable defibrillators (ICD). Our study aimed at assessing current direct costs of 1-year ICD follow-up based on RM compared with conventional quarterly in-hospital follow-ups. Methods and results Patients (N=233) with indications for ICD were consecutively recruited and randomized at implant to be followed up for 1 year with standard quarterly inhospital visits or by RM with one in-hospital visit at 12 months, unless additional in-hospital visits were required due to specific patient conditions or RM alarms. Costs were calculated distinguishing between provider and patient costs, excluding RM device and service cost. The frequency of scheduled in-hospital visits was lower in the RM group than in the control arm. Follow-up required 47 min per patient/year in the RM arm versus 86 min in the control arm (p=0.03) for involved physicians, generating cost estimates for the provider of USD 45 and USD 83 per patient/- year, respectively. Costs for nurses were comparable. Overall, the costs associated with RM and standard follow-up were USD 103±27 and 154±21 per patient/year, respectively (p=0.01). RM was cost-saving for the patients: USD 97±121 per patient/year in the RM group versus 287± 160 per patient/year (p=0.0001). Conclusion The time spent by the hospital staff was significantly reduced in the RM group. If the costs for the device and service are not charged to patients or the provider, patients could save about USD 190 per patient/year while the hospital could save USD 51 per patient/year

Left Atrial Appendage Closure: A Current Overview Focused on Technical Aspects and Different Approaches

Several studies in literature have shown that 90% of emboli related to non-valvular atrial fibrillation originate from left atrial appendage. Percutaneous closure or surgical exclusion of left atrial appendage in patients with high bleeding and high cardioembolic risk is currently a well established procedure in literature, clinical practice and guidelines. Knowledge of different techniques of left atrial appendage closure is necessary to individualize the procedure according to the patient anatomy and pre-procedural imaging evaluations. In this review the authors will evaluate different left atrial appendage closure systems and the different pre and intra procedural imaging methods

The best approach for functional tricuspid regurgitation: A network meta-analysis

Objective: For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches to establish the possible gold standard. Methods: A systematic search was performed to identify all publications reporting the outcomes of four approaches for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis. Results: There were 31 included studies with 9663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA, and 6.4% RRA; early TR moderate-or-more was 9.6%, 4.8%, 4.6%, and 3.8%; late mortality was 22.5%, 18.2%, 11.9%, and 11.9%; late TR moderate-or-more was 27.9%, 18.3%, 14.3%, and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (–85% vs. no TA; –64% vs. SA; –32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches; however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes. Conclusions: Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provide more stable FTR across time

Temporary transvenous cardiac pacing: a survey on current practice

BACKGROUND: Temporary transvenous cardiac pacing (TTCP) is a standard procedure in current practice, despite limited coverage in consensus guidelines. However, many authors reported several complications associated with TTCP, especially development of infections of cardiac implantable electronic devices (CIED). The aim of this survey was to provide a country-wide picture of current practice regarding TTCP. METHODS: Data were collected using an online survey that was administered to members of the Italian Association of Arrhythmology and Cardiac Pacing. RESULTS: We collected data from 102 physicians, working in 81 Italian hospitals from 17/21 regions. Our data evidenced that different strategies are adopted in case of acute bradycardia with a tendency to limit TTCP mainly to advanced atrioventricular block. However, some centers reported a greater use in elective procedures. TTCP is usually performed by electrophysiologists or interventional cardiologists and, differently from previous reports, mainly by a femoral approach and with nonfloating catheters. We found high inhomogeneity regarding prevention of infections and thromboembolic complications and in post-TTCP management, associated with different TTCP volumes and a strategy for management of acute bradyarrhythmias. CONCLUSION: This survey evidenced a high inhomogeneity in the approaches adopted by Italian cardiologists for TTCP. Further studies are needed to explore if these divergences are associated with different long-term outcomes, especially incidence of CIED-related infections

Standard versus strict stability criteria in radiofrequency paroxysmal atrial fibrillation ablation using ablation index

Purpose: To compare the outcome of paroxysmal atrial fibrillation (AF) ablation via pulmonary vein isolation using Ablation Index (AI) with strict or standard stability criteria. Methods: We enrolled 130 consecutive naive patients affected by paroxysmal AF who underwent PVI at two high-volume centers. AI target was ≥380 at the posterior wall and ≥500 at the anterior wall. Strict versus standard stability criteria were set for Group 1 (65 patients) and Group 2 (65 patients), respectively. We compared those strategies with a historical cohort of 72 consecutive patients treated at same centers in the VISITALY study, using average force ≥10 g and strict stability criteria as target parameters. Interlesion distance target was <6 mm. Recurrence was defined as any AF, atrial tachycardia (AT) or atrial flutter (AFL) during the 12 months after ablation, excluding a 90-days blanking period. Results: Procedure duration (224.05 ± 47.21 vs. 175.61 ± 51.29 min; p <.001), fluoroscopy time (11.85 ± 4.38 vs. 10.46 ± 6.49 min; p =.019) and pericardial effusion rate (9.23% vs. 0%; p =.01) were higher in Group 1 than in Group 2. Freedom from AF/AT/AFL at 12 months was not significantly different (Group 1: 86.15%; Group 2: 90.77%; p =.42). Compared to VISITALY study, there were not significant differences in terms of recurrences. Conclusion: A strategy of PVI using AI with standard stability criteria performed the best in terms of procedure efficiency and safety. Twelve-months arrhythmia-free survival rate was comparable with other strategies pursuing an interlesion distance target <6 mm, regardless of the use of AI

Temporary transvenous cardiac pacing: a survey on current practice

BACKGROUND: Temporary transvenous cardiac pacing (TTCP) is a standard procedure in current practice, despite limited coverage in consensus guidelines. However, many authors reported several complications associated with TTCP, especially development of infections of cardiac implantable electronic devices (CIED). The aim of this survey was to provide a country-wide picture of current practice regarding TTCP. METHODS: Data were collected using an online survey that was administered to members of the Italian Association of Arrhythmology and Cardiac Pacing. RESULTS: We collected data from 102 physicians, working in 81 Italian hospitals from 17/21 regions. Our data evidenced that different strategies are adopted in case of acute bradycardia with a tendency to limit TTCP mainly to advanced atrioventricular block. However, some centers reported a greater use in elective procedures. TTCP is usually performed by electrophysiologists or interventional cardiologists and, differently from previous reports, mainly by a femoral approach and with nonfloating catheters. We found high inhomogeneity regarding prevention of infections and thromboembolic complications and in post-TTCP management, associated with different TTCP volumes and a strategy for management of acute bradyarrhythmias. CONCLUSION: This survey evidenced a high inhomogeneity in the approaches adopted by Italian cardiologists for TTCP. Further studies are needed to explore if these divergences are associated with different long-term outcomes, especially incidence of CIED-related infections

Role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia

Ventricular tachycardia is a major health issue in patients with structural heart disease (SHD). Implantable cardioverter defibrillator (ICD) therapy has significantly reduced the risk of sudden cardiac death (SCD) in such patients, but on the other hand, it has led to frequent ICD shocks as an emerging problem, being associated with poor quality of life, frequent hospitalizations and increased mortality. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias, as the coexistence of surviving myocardial fibres within fibrotic tissue leads to the formation of slow conduction pathways and to a dispersion of activation and refractoriness that constitutes the milieu for ventricular tachycardia circuits. Catheter ablation has repeatedly proven to be well tolerated and highly effective in treating VT and in the last two decades has benefited from continuous efforts to determine ventricular tachycardia mechanisms by integration with a wide range of invasive and noninvasive imaging techniques such as intracardiac echocardiography, cardiac magnetic resonance, multidetector computed tomography and nuclear imaging. Cardiovascular imaging has become a fundamental aid in planning and guiding catheter ablation procedures by integrating structural and electrophysiological information, enabling the ventricular tachycardia arrhythmogenic substrate to be characterized and effective ablation targets to be identified with increasing precision, and allowing the development of new ablation strategies with improved outcomes. In this review, we provide an overview of the role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia