Ventricular tachycardia originating from the left coronary aortic sinus

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Management of untreatable ventricular arrhythmias during pharmacologic challenges with sodium channel blockers for suspected Brugada syndrome

Pharmacologic challenge with sodium channel blockers is part of the diagnostic workout in patients with suspected Brugada syndrome. The test is overall considered safe but both ajmaline and flecainide detain well known pro-arrhythmic properties. Moreover, the treatment of patients with life-threatening arrhythmias during these diagnostic procedures is not well defined. Current consensus guidelines suggest to adopt cautious protocols interrupting the sodium channel blockers as soon as any ECG alteration appears. Nevertheless, the risk of life-threatening arrhythmias persists, even adopting a safe and cautious protocol and in absence of major arrhythmic risk factors. The authors revise the main published case studies of sodium channel blockers challenge in adults and in children, and summarize three cases of untreatable ventricular arrhythmias discussing their management. In particular, the role of advanced cardiopulmonary resuscitation with extra-corporeal membrane oxygenation is stressed as it can reveal to be the only reliable lifesaving facility in prolonged cardiac arrest

Right Ventricular Strain and Dyssynchrony Assessment in Arrhythmogenic Right Ventricular Cardiomyopathy: Cardiac Magnetic Resonance Feature-Tracking Study

BACKGROUND: Analysis of right ventricular (RV) regional dysfunction by cardiac magnetic resonance (CMR) imaging in arrhythmogenic RV cardiomyopathy (ARVC) may be inadequate because of the complex contraction pattern of the RV. Aim of this study was to determine the use of RV strain and dyssynchrony assessment in ARVC using feature-tracking CMR analysis. METHODS AND RESULTS: Thirty-two consecutive patients with ARVC referred to CMR imaging were included. Thirty-two patients with idiopathic RV outflow tract arrhythmias and 32 control subjects, matched for age and sex to the ARVC group, were included for comparison purpose. CMR imaging was performed to assess biventricular function; feature-tracking analysis was applied to the cine CMR images to assess regional and global longitudinal, circumferential, and radial RV strains and RV dyssynchrony (defined as the SD of the time-to-peak strain of the RV segments). RV global longitudinal strain (-17\ub15% versus -26\ub16% versus -29\ub16%; P-23.2%, SD of the time-to-peak RV longitudinal strain >113.1 ms, and SD of the time-to-peak RV circumferential strain >177.1 ms allowed correct identification of 88%, 75%, and 63% of ARVC patients with no or only minor CMR criteria for ARVC diagnosis. CONCLUSIONS: Strain analysis by feature-tracking CMR helps to objectively quantify global and regional RV dysfunction and RV dyssynchrony in patients with ARVC and provides incremental value over conventional cine CMR imaging

The increased risk of stroke/transient ischemic attack in women with a cardiac implantable electronic device is not associated with a higher atrial fibrillation burden

To evaluate if the increased thromboembolic risk in female patients may be related to a higher burden of atrial fibrillation (AF)

A global analysis of implants and replacements of pacemakers and cardioverter-defibrillators before, during, and after the COVID-19 pandemic in Italy

At the beginning of the COVID-19 emergency, non-urgent surgical procedures had to be deferred, but also emergencies were reduced. To assess the global trend of pacemaker (PM) and implantable cardiac-defibrillator (ICD) procedures performed in Italy before, during, and after the first COVID-19 emergency, all the Italian hospital discharge records related to PM/ICD procedures performed between 2012 and 2021, sent to the National Institute of Health, were reviewed. Compared to 2019, in 2020, there was a reduction of first PM implants (52,216 to 43,962, -16%; p < 0.01), but not replacements (16,591 to 17,331, + 4%; p = 0.16). In particular, in April 2020, there was a drop of first implants (- 53,4% vs the average value of April 2018 and April 2019; p < 0.01), while the reduction of replacements was less evident (-32.6%; p = NS). In 2021, PM procedures increased to values similar to the pre-pandemic period. A reduction of ICD procedures was observed in 2020 (22,355, -7% toward 2019), mainly in April 2020 (- 46% vs April 2018/April 2019; p = 0.03). In 2021, the rate of ICD procedures increased (+ 14% toward 2020). A non-significant reduction of "urgent" procedures (complete atrioventricular block for PM and ventricular fibrillation for ICD), even in April 2020, was observed. In 2020, there was a reduction of first PM implants and ICDs, offset by increased activity in 2021. No decrease in PM replacements was observed, and the drop in "urgent" PM and ICD procedures was not statistically significant

Uncommon cause of ST-segment elevation in V1-V3: incremental value of cardiac magnetic resonance imaging

Although ST-segment elevation in precordial leads is a characteristic of anterior left ventricular infarction (LVI), it may also be observed in patients with proximal right coronary occlusion. An isolated right ventricular infarction (RVI) accounts for only 3 % of all myocardial infarctions (MI) [1]; in these cases, the ST-segment elevation in the precordial leads V1\u2013V3 also may occur in the absence of inferior electrocardiographic changes [2], whereas the combination of RVI with inferior LVI suppresses ST-segment elevation in the precordial leads and yields an STsegment elevation in leads DII, DIII, and aVF [3]. Although certain electrocardiographic features have been suggested to help differentiate ST-segment elevation secondary to isolated RVI from LVI [3], it may be impossible to make a differential diagnosis on the basis of electrocardiography alone because these features are not pathognomonic. Furthermore, when a patient is admitted for typical chest pain, slight ST-segment elevation in leads V1\u2013V3 and significant increase of cardiac troponin but with normal coronary main vessels at the coronary angiography, the diagnosis of a RVI is challenging; taking into account the multiple causes of myocardial injury and treatment consequences, there is great clinical need to clarify the underlying reason for cardiac troponin release. Although some studies report that echocardiography is a valuable clinical tool for the evaluation of global RV function [4], geometric assumptions in modeling the complex RV shape restricts the ability of this technique in accurate and precise quantification of RV function; furthermore, RV function assessment can be difficult in patients with poor acoustic window or when minor alterations of RV function are present. Cardiac magnetic resonance (CMR) provides a comprehensive, multifaceted view of the heart and can be useful to characterize an infarct site and size accurately [5]. CMR in this particular setting can confirm the presence of a minor RVI and aid to exclude other potential causes of troponin rise with normal coronary main vessels at the coronary angiography, such as embolic myocardial infarction or myocarditis [6]. Acute MI treatment [7\u201310] and traditional predictors of long-term mortality after acute MI are well characterized [11\u201314] but with introduction of CMR, new predictors of cardiovascular events are emerging [15, 16] and the evaluation of RV function using CMR can improve risk stratification and potentially refine patient management after MI [17]. Moreover, the extent of myocardial scar characterized by CMR is significantly associated with the occurrence of spontaneous ventricular arrhythmias [18]. There have been few reports of anterior ST-segment elevation caused by isolated RVI due to right ventricle branch occlusion [19\u201321]. Occlusion of the conus branch has been described essentially as a complication of coronary angioplasty or during cardiac surgery [19\u201321]. Only one report described a spontaneous RVI with culprit lesion in the conus branch [22]. Assessment of isolated RVI due to a critical stenosis of the conus branch by magnetic resonance is never been reported