Attilio Maseri, Italian cardiologist of universal value

Attilio Maseri, Italian cardiologist of universal valu

Use of a novel sharp-tip, J-shaped guidewire to facilitate transseptal catheterization

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Microvolt T-wave alternans testing should be used to guide arrhythmic therapy in heart failure patients

Jackson et al. reported on a cohort of heart failure patients and concluded that microvolt T-wave alternans (MTWA) testing has limited utility in this population. Of note, this assessment was made in the complete absence of any outcomes data. The authors base their assessment on the fact that they deemed 318 of 648 patients to be ineligible for MTWA testing. The ineligibility was primarily attributable to the 38% incidence of atrial fibrillation which they reported while noting that this incidence was substantially higher than the 23% incidence reported in two earlier studies. Seventy-six patients were deemed ineligible for MTWA testing due to inability to exercise or continuous ventricular pacing. The authors ignored the availability of pharmacological and pacing protocols to test this latter group of patients. Moreover, patients who cannot exercise on a treadmill often are able to elevate their heart rate adequately for MTWA testing (≥105 b.p.m.) by means of isometric exercise or stepping in place

2.3 Postsurgical atrial tachycardias: Report of four cases not due to macro-reentry

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Superiority of Simulator-Based Training Compared With Conventional Training Methodologies in the Performance of Transseptal Catheterization

ObjectivesThis study aims to compare the performance of electrophysiology fellows in transseptal catheterization (TSP-C) after conventional (Conv-T) or simulator training (Sim-T).BackgroundCurrent training for TSP-C, an increasingly used procedure, relies on performance on patients with supervision by an experienced operator. Virtual reality, a new training option, could improve post-training performance.MethodsFellows inexperienced in TSP-C were enrolled and randomly assigned to Conv-T or Sim-T. The post-training performance of each fellow was evaluated and scored in 3 consecutive patient-based procedures by an experienced operator blinded to the fellow's training assignment.ResultsFourteen fellows were randomized to Conv-T (n = 7) or to Sim-T (n = 7) and, after training, performed 42 TSP-Cs independently. Training time was significantly longer for Conv-T than for Sim-T (median 30 days vs. 4 days; p = 0.0175). The Conv-T fellows had significantly lower post-training performance scores (median 68 vs. 95; p = 0.0001) and a higher number of recurrent errors (median 3 vs. 0; p = 0.0006) when compared with Sim-T fellows.ConclusionsThe TSP-C training with virtual reality results in shorter training times and superior post-training performance

Role of computed tomography coronary angiography in the management of coronary anomalies

Congenital abnormalities of coronary arteries are an uncommon cause of sudden cardiac death and are difficult to detect at coronary angiography. We describe two patients with acute coronary syndrome and non-occlusive coronary artery disease in which a 64-multidetector computed tomography (MDCT) coronary angiography showed the presence of a malignant coronary anomaly. Sixty-four-MDCT with the possibility of 3D reconstructions allows for easier diagnosis of coronary anomalies and provides essential details necessary for operative intervention

Do Beta-Blockers Impact Microvolt T-Wave Alternans Testing in Patients at Risk for Ventricular Arrhythmias? A Meta-Analysis

Beta-Blockers and Microvolt T-Wave Alternans.  Introduction: Results of microvolt T-wave alternans (MTWA) studies vary and may be influenced by whether beta-blocker therapy was withheld prior to MTWA assessment. We conducted a meta-analysis of the predictive value of MTWA screening for ventricular arrhythmic events in primary prevention patients with left ventricular dysfunction and examined whether results differed depending upon whether beta-blocker use was withheld prior to MTWA testing. Methods and Results: Prospective studies that evaluated whether MTWA predicted ventricular arrhythmic events published between January 1980 and September 2008 were identified. Summary estimates for the predictive value of MTWA were derived with random-effects models. Nine studies involving 3,939 patients were identified. Overall, an abnormal MTWA (positive and indeterminate) test was associated with an almost 2-fold increased risk for arrhythmic events (pooled RR = 1.95, 95% CI: 1.29–2.96; P = 0.002). However, significant heterogeneity across studies was observed (P = 0.024). In the 4 studies in which beta-blocker therapy was not withheld prior to MTWA assessment, an abnormal MTWA test was associated with a 5-fold increased risk for arrhythmic events (pooled RR = 5.39, 95% CI: 2.68–10.84; P < 0.001) and was robust to sensitivity analyses. In contrast, the association was much weaker in those studies where the use of beta-blocker therapy was withheld prior to MTWA testing (pooled RR = 1.40, 95% CI: 1.06–1.84; P = 0.02). Conclusions: In primary prevention patients with left ventricular dysfunction, the predictive power of MTWA varied widely, based on whether beta-blocker therapy was withheld prior to its assessment. This observation may explain the inconsistent results of MTWA studies in this population. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1009-1014, September 2010)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79161/1/j.1540-8167.2010.01757.x.pd

Real-world clopidogrel utilization in acute coronary syndromes : patients selection and outcomes in a single-center experience

Background: With this study, we sought to identify patient characteristics associated with clopidogrel prescription and its relationship with in-hospital adverse events in an unselected cohort of ACSs patients. Materials and Methods: We studied all consecutive patients admitted at our institution for ACSs from 2012 to 2014. Patients were divided into two groups based on clopidogrel or novel P2Y12 inhibitors (prasugrel or ticagrelor) prescription and the relationship between clopidogrel use and patient clinical characteristics and in-hospital adverse events was evaluated using logistic regression analysis. Results: The population median age was 68 years (57\u201377 year) and clopidogrel was prescribed in 230 patients (46%). Patients characteristics associated with clopidogrel prescription were older age, female sex, non-ST-elevation ACS diagnosis, the presence of diabetes mellitus and anemia, worse renal and left ventricular functions and a higher Killip class. Patients on clopidogrel demonstrated a significantly higher incidence of in-hospital mortality (4.8%) than prasugrel and ticagrelor-treated patients (0.4%), while a nonstatistically significant trend emerged considering bleeding events. However, on multivariable logistic regression analysis female sex, the presence of anemia and Killip class were the only variables independently associated with in-hospital death. Conclusion: Patients treated with clopidogrel showed a higher in-hospital mortality. However, clinical variables associated with its use identify a population at high risk for adverse events and this seems to play a major role for the higher in-hospital mortality observed in clopidogrel-treated patients

Prognostic Value of T-Wave Alternans in Patients With Heart Failure Due to Nonischemic Cardiomyopathy Results of the ALPHA Study

ObjectivesThe aim of this study was to assess the prognostic value of T-wave alternans (TWA) in New York Heart Association (NYHA) functional class II/III patients with nonischemic cardiomyopathy and left ventricular ejection fraction (LVEF) ≤40%.BackgroundThere is a strong need to identify reliable risk stratifiers among heart failure candidates for implantable cardioverter-defibrillator (ICD) prophylaxis. T-wave alternans may identify low-risk subjects among post-myocardial infarction patients with depressed LVEF, but its predictive role in nonischemic cardiomyopathy is unclear.MethodsFour hundred forty-six patients were enrolled and followed up for 18 to 24 months. The primary end point was the combination of cardiac death + life-threatening arrhythmias; secondary end points were total mortality and the combination of arrhythmic death + life-threatening arrhythmias.ResultsPatients with abnormal TWA (65%) compared with normal TWA (35%) tests were older (60 ± 13 years vs. 57 ± 12 years), were more frequently in NYHA functional class III (22% vs. 19%), and had a modestly lower LVEF (29 ± 7% vs. 31 ± 7%). Primary end point rates in patients with abnormal and normal TWA tests were 6.5% (95% confidence interval [CI] 4.5% to 9.4%) and 1.6% (95% CI 0.6% to 4.4%), respectively. Unadjusted and adjusted hazard ratios were 4.0 (95% CI 1.4% to 11.4%; p = 0.002) and 3.2 (95% CI 1.1% to 9.2%; p = 0.013), respectively. Hazard ratios for total mortality and for arrhythmic death + life-threatening arrhythmias were 4.6 (p = 0.002) and 5.5 (p = 0.004), respectively; 18-month negative predictive values for the 3 end points ranged between 97.3% and 98.6%.ConclusionsAmong NYHA functional class II/III nonischemic cardiomyopathy patients, an abnormal TWA test is associated with a 4-fold higher risk of cardiac death and life-threatening arrhythmias. Patients with normal TWA tests have a very good prognosis and are likely to benefit little from ICD therapy

Preliminary experience with the smooth muscle troponin-like protein, calponin, as a novel biomarker for diagnosing acute aortic dissection

Aims The early diagnosis of acute aortic dissection (AD) remains challenging. We sought to determine the utility of the troponin-like protein of smooth muscle, calponin, as a diagnostic biomarker of acute AD. Methods and results Immunoassays against calponin (acidic, basic, and neutral isoforms) were developed and the levels were compared in a convenience sample of 59 patients with radiographically proven AD [34 males, age 59+15 (SD) years] vs. 158 patients suspected of having AD at presentation (116 males, age 63+15 years) but whose final diagnosis was not AD. Basic calponin, which is the most specific and abundant in smooth muscle, and acidic calponin, respectively, showed greater than two-fold and three-fold elevations in patients with acute AD. Diagnostic performance as determined by receiver-operating characteristics curve analysis showed that both acidic and basic calponin have the potential to detect AD in the first 24 h [respective areas under the curve (AUCs) 0.63 and 0.58], with superior performance of basic calponin (when compared with acidic) in the initial 6 h (respective AUCs 0.63 and 0.67). Conclusion Circulating calponin levels were elevated in acute AD compared with controls. These biomarkers have the potential for use as an early diagnostic biomarker for acute AD. Keywords Aortic dissection ? Biomarke