Impact of acute changes of left ventricular contractility on the transvalvular impedance: validation study by pressure-volume loop analysis in healthy pigs

BACKGROUND: The real-time and continuous assessment of left ventricular (LV) myocardial contractility through an implanted device is a clinically relevant goal. Transvalvular impedance (TVI) is an impedentiometric signal detected in the right cardiac chambers that changes during stroke volume fluctuations in patients. However, the relationship between TVI signals and LV contractility has not been proven. We investigated whether TVI signals predict changes of LV inotropic state during clinically relevant loading and inotropic conditions in swine normal heart. METHODS: The assessment of RVTVI signals was performed in anesthetized adult healthy anesthetized pigs (n = 6) instrumented for measurement of aortic and LV pressure, dP/dtmax and LV volumes. Myocardial contractility was assessed with the slope (Ees) of the LV end systolic pressure-volume relationship. Effective arterial elastance (Ea) and stroke work (SW) were determined from the LV pressure-volume loops. Pigs were studied at rest (baseline), after transient mechanical preload reduction and afterload increase, after 10-min of low dose dobutamine infusion (LDDS, 10 ug/kg/min, i.v), and esmolol administration (ESMO, bolus of 500 µg and continuous infusion of 100 µg·kg-1·min-1). RESULTS: We detected a significant relationship between ESTVI and dP/dtmax during LDDS and ESMO administration. In addition, the fluctuations of ESTVI were significantly related to changes of the Ees during afterload increase, LDDS and ESMO infusion. CONCLUSIONS: ESTVI signal detected in right cardiac chamber is significantly affected by acute changes in cardiac mechanical activity and is able to predict acute changes of LV inotropic state in normal heart

Long-Term Follow-Up In Paroxysmal Atrial Fibrillation Patients With Documented Isolated Trigger

AimsSupraventricular tachycardias may trigger atrial fibrillation (AF). The aim of the study was to evaluate the prevalence of supraventricular tachycardia (SVT) inducibility in patients referred for AF ablation and to evaluate the effects of SVT ablation on AF recurrences.Methods and results249 patients (mean age: 54 ± 14 years) referred for paroxysmal AF ablation were studied. In all patients, only AF relapses had been documented in the clinical history. 47 patients (19%; mean age: 42 ± 11 years) had inducible SVT during the electrophysiological study and underwent an ablation targeted only at SVT suppression. Ablation was successful in all 47 patients. The ablative procedures were: 11 slow-pathway ablations for atrioventricular nodal re-entrant tachycardia; 6 concealed accessory pathway ablations for atrioventricular re-entrant tachycardia; 17 focal ectopic atrial tachycardia ablations; 13 with only one arrhythmogenic pulmonary vein. No recurrences of SVT were observed during the follow-up (32 ± 18 months). 4 patients (8.5%) showed recurrence of at least one episode of AF. Patients with inducible SVT had less structural heart disease and were younger than those without inducible SVT.ConclusionA significant proportion of candidates for AF ablation are inducible for an SVT. SVT ablation showed a preventive effect on AF recurrences. Those patients should be selected for simpler ablation procedures tailored only to the triggering arrhythmia suppression

Il Reddito di Cittadinanza e il processo di attuazione locale: un’analisi delle capacità amministrative

Italy has been a laggard in Europe in the adoption of anti-poverty measures, particularly with reference to Minimum Income schemes. The first relevant intervention in this field, in terms of the size of the benefits granted and the breadth of the audience reached, was undoubtedly the Citizenship Income (Reddito di Cittadinanza – RdC), adopted by the Conte government in 2019. RdC is a monetary aid granted to poor families through an electronic card and associated with an activation or a social inclusion project. It is based on a multilevel design, involving national, regional, and municipal institutions (the National Insurance Agency, Job Centers, and municipal social services) and local actors (companies and the third sector). According to the literature, its poor results stem from the lack of adequate governance and organizational arrangements to manage it. The RdC, in fact, requires the capacity to design and manage different combinations of interventions, tailored tonthe complex needs of beneficiaries, as well as the ability to coordinate the multilevel and multi-actor network of public, private, and third sector organizations involved in the process. We thus propose an analytical framework to assess the presence of the specific administrative capacities needed to effectively implement a policy in each context. The framework is based on three dimensions: planning and management, coordination, and analysis. Each dimension is gauged using five different variables. We then apply the framework to the case of the Veneto Region to assess the impact of administrative capacities on the implementation of RdC. We do this by comparing the implementation between CPI (employment centres) and ATS (social assistant units). The analysis is based on interviews to case managers (N = 56) conducted between September 2020 and March 2021, and three focus groups (March-April 2021). We also implemented two surveys dedicated to CPI to assess any difference between the opinions of standard case-managers and the newly hired «navigator». The first was administered in October 2021 (N = 165), the second in June-July 2021 (N = 100). Thanks to this data we were able to assess each of the 15 variables identified, providing the reader with an overview of the Veneto experience

Cardiac Resynchronization Therapy: An Overview on Guidelines

Cardiac resynchronization therapy (CRT) is included in international consensus guidelines as a treatment with proven efficacy in well-selected patients on top of optimal medical therapy. Although all the guidelines strongly recommend CRT for LBBB with QRS duration greater than 150 milliseconds, lower strength of recommendation is reported for QRS duration of 120 to 150 milliseconds, especially if not associated with LBBB. CRT is not recommended for a QRS of less than 120 milliseconds. No indication emerges for guiding the implant based on echocardiographic evaluation of dyssynchrony. Many data indicate that CRT is underused and there is heterogeneity in its implementation

Cardiac Resynchronization Therapy: An Overview on Guidelines

Cardiac resynchronization therapy (CRT) is included in international consensus guidelines as a treatment with proven efficacy in well-selected patients on top of optimal medical therapy. Although all the guidelines strongly recommend CRT for LBBB with QRS duration greater than 150 milliseconds, lower strength of recommendation is reported for QRS duration of 120 to 150 milliseconds, especially if not associated with LBBB. CRT is not recommended for a QRS of less than 120 milliseconds. No indication emerges for guiding the implant based on echocardiographic evaluation of dyssynchrony. Many data indicate that CRT is underused and there is heterogeneity in its implementation

Cardiac resynchronization therapy: How did consensus guidelines from Europe and the United States evolve in the last 15\u202fyears?

Cardiac resynchronization therapy (CRT) was proposed around 20 years ago, and its clinical use rapidly moved from pioneering experiences to randomized controlled trials (RCT). Since 2002 recommendations for CRT have been included in international consensus guidelines that even in an early phase recommended CRT as an effective treatment for improving symptoms, reducing hospitalizations and mortality in well-selected patients with wide QRS, left ventricular dysfunction and moderate to severe heart failure (NYHA classes III\u2013IV), on optimal medical therapy. Subsequently the indications were extended to mild (NYHA class II) heart failure (associated with left ventricular dysfunction and wide QRS) and more recently also to appropriately selected patients with conventional indications for pacing having a left ventricular ejection fraction of 50% or less and NYHA class I\u2013III. While all the guidelines strongly recommend CRT in case of LBBB with QRS duration >150 ms, lower strength of recommendations, with some heterogeneity, appears when QRS duration is 130\u2013150 ms, especially if not associated with LBBB. Of note, according to recent guidelines, CRT is not recommended in case of QRS duration <130 ms, which is now the lower limit for candidacy to CRT, differently from the 120 ms limit used before. Despite consensus guidelines, many data indicate that CRT is still underused, with great heterogeneity in its implementation, both in North America and Europe, thus requiring a more organized patient referral

Identification of maternal uniparental isodisomy of chromosome 10 in a patient with mitochondrial DNA depletion syndrome

Letter to the Edito