Cardiac Magnetic Resonance as Risk Stratification Tool in Non-Ischemic Dilated Cardiomyopathy Referred for Implantable Cardioverter Defibrillator Therapy—State of Art and Perspectives

Non-ischemic dilated cardiomyopathy (DCM) is a disease characterized by left ventricular dilation and systolic dysfunction. Patients with DCM are at higher risk for ventricular arrhythmias and sudden cardiac death (SCD). According to current international guidelines, left ventricular ejection fraction (LVEF) <= 35% represents the main indication for prophylactic implantable cardioverter defibrillator (ICD) implantation in patients with DCM. However, LVEF lacks sensitivity and specificity as a risk marker for SCD. It has been seen that the majority of patients with DCM do not actually benefit from the ICD implantation and, on the contrary, that many patients at risk of SCD are not identified as they have preserved or mildly depressed LVEF. Therefore, the use of LVEF as unique decision parameter does not maximize the benefit of ICD therapy. Multiple risk factors used in combination could likely predict SCD risk better than any single risk parameter. Several predictors have been proposed including genetic variants, electric indexes, and volumetric parameters of LV. Cardiac magnetic resonance (CMR) can improve risk stratification thanks to tissue characterization sequences such as LGE sequence, parametric mapping, and feature tracking. This review evaluates the role of CMR as a risk stratification tool in DCM patients referred for ICD

APPLICAZIONE CLINICA DELLE NUOVE TECNOLOGIE IN ELETTROFISIOLOGIA CARDIACA: DAI NUOVI DEVICES ALLA GESTIONE IN REMOTO DEI PAZIENTI AFFETTI DA SCOMPENSO CARDIACO CRONICO

Nell‟ attuale pratica clinica cardiologica, a seguito dell‟ ampliamento delle indicazioni all‟ impianto di dispositivi per la stimolazione cardiaca e la prevenzione della morte cardiaca improvvisa ICD, CRT e delle recenti acquisizioni non solo in campo tecnologico ma anche nel settore farmacologico, è evidente la possibilità di poter fornire ai pazienti affetti da scompenso cardiaco cronico terapie sempre più adeguate al fine di migliorare la prognosi di tali pazienti. Il tutto si tramuta in un inevitabile incremento quasi esponenziale del lavoro di follow-up negli ambulatori dedicati alla diagnosi e cura dello scompenso cardiaco e negli ambulatori dedicati alla cardiostimolazione. Una possibilità di controllo di tali pazienti ci viene fornita da tutte le maggiori aziende produttrici di dispositivi impiantabili attraverso il monitoraggio remoto; ovvero la possibilità di controllare a distanza e quasi in “real time” le condizioni del sistema impiantato e lo stato clinico del paziente. Oltre ad un aumento del carico di lavoro da parte degli operatori sanitari all‟ interno della struttura di appartenenza, bisogna prendere in considerazione che la maggior parte dei pazienti, generalmente anziani e spesso non autosufficienti, hanno bisogno di assistenza per raggiungere le strutture dove vengono effettuate le visite ambulatoriali e i controlli 159 elettronici del dispositivo. Questo comporta uno sforzo organizzativo imponente con costi molto elevati in termini di risorse sia per le famiglie che per la società. Inoltre il modello organizzativo convenzionale basato su follow-up è poco performante al fine di prevenire gli episodi di riacutizzazione di compenso cardiaco e quindi di nuove ospedalizzazioni del paziente. L‟ evoluzione tecnologica ha portato ad un miglioramento delle capacità terapeutiche e diagnostiche da parte dei sistemi di monitoraggio remoto con affidabilità e quantità delle informazioni ricevute sovrapponibili al controllo tradizionale. Questo nuovo sistema di controllo e gestione dei pazienti apre necessariamente nuovi scenari di natura organizzativa, culturale, medicolegale, ed economica. Infatti gli operatori sanitari dedicati a questo tipo di sistema operativo devono necessariamente prevedere una interazione dinamica su un costante flusso di dati e far fronte in tempi brevi a controlli specialistici imprevisti che si rendono necessari per eventuali allarmi evidenziati dai sistemi di monitoraggio remoto, garantendo allo stesso tempo, la copertura di attività assistenziali ordinarie nell‟ ambito della propria Unità Operativa. Risulta evidente come il monitoraggio remoto sia in grado di rilevare precocemente situazioni clinicamente rilevanti nel follow-up dei pazienti 160 affetti da insufficienza cardiaca che altrimenti sarebbero rilevate solo al controllo programmato successivo e di calibrare il lavoro degli operatori sanitari su eventi selezionati. Infatti circa il 55% dei nostri pazienti durante un follow-up di medio-lungo termine non ha avuto nessun evento e su questi pazienti si è reso possibile ridimensionare il numero di controlli ambulatoriali a favore di pazienti con un evidente alto tasso di instabilità elettrica e/o emodinamica, ottenendo un prevenzione di potenziali eventi clinici avversi maggiori in circa il 10% della popolazione studiata ed evitando allo stesso tempo accessi alle strutture sanitarie in regime d‟urgenza

SISTEMA PER IL TRATTAMENTO DELLE ARITMIE SOPRAVENTRICOLARI

La presente invenzione è relativa a un sistema per il trattamento delle aritmie sopraventricolari. In particolare, la presente invenzione è relativa a un sistema per il trattamento farmacologico delle aritmie sopraventricolari, in assenza di terapia anticoagulante orale, comprendente moduli evoluti afferenti al settore tecnico dell’ICT applicato alla sanità digitale e alla medicina di precisione, ossia medicina e terapie personalizzate in base alle specifiche esigenze cliniche dell’utente

161 Biosensor in cardiology. T-care project: a preliminary study on innovative wearable non-invasive telemonitoring system

The demographic trend evolution and the modification of health needs highlight the requirement for a novel organization of the healthcare system. Telemedicine is a technological tool that allows a knockdown of geographic barriers being useful in the management of remote patient assistance. Telemedicine is roughly applied in different cardiology’s areas, from telemetric to implantable devices (loop recorders) in order to monitor cardiac rate, cardiac rhythm variations, and the onset of arrhythmic events. The aim of the present study is to assess the validity of wearable devices (T-shirt equipped with biosensors and bands with photopletimographic system) in monitoring EKG, cardiac rate, and pulse oximetry. We enrolled 38 patients, 25 of whom admitted to the Cardiology Unit, University of Bari. Main characteristics of the sample are listed in Table 1. The difference between traditional monitoring system and wearable biosensors in not statistically significant as shown in Figure 1; therefore the devices tested in this study show a satisfying level of reliability in monitoring cardiac rate, pulse oximetry, QT interval, QRS complexes, and onset of arrhythmic events. However, alerts produced by arrhythmias different from atrial fibrillation are not completely reliable; moreover, the software and the diagnostic algorithm need to be optimized for motion artefacts. For these reasons, results need to be reproduced on a large cohort of patients

VALUE OF THE MEDICAL-LEGAL INVESTIGATION. CORRESPONDENCE OF THE FINDINGS WITH LEGALLY ESTABLISHED REALITY

In recent years, violence against minors has been the subject of in-depth study in all its historical, social and cultural dimensions, being able to be identified and treated according to rigorous scientific methodologies. The A.A. report the case of an 8-year-old girl, who disappeared in a rural area, found dead a few hours later, on the recommendation of a young man who, despite having admitted to having gone away with the child, had not provided further details. The forensic inspection revealed that the discovery area included an area with burnt undergrowth about 4 meters in diameter. Examination of the external genitalia showed that the hymen was hemorrhagic in the right hemicycle, at 11 o'clock, with laceration of the most superficial layers of the anterior face. In the present case, therefore, despite having limited historical and circumstantial data, it was possible to reconstruct the following damaging dynamic: the little girl, after having gone away with her aggressor, was first the victim of an attempt of sexual violence by the latter and later immobilized by placing a foot on the slender abdomen. She had been covered with brushwood which the attacker had set fire to, thus killing her. This reconstruction of the criminal events, proposed to the investigating magistrate, was confirmed in each passage by the confessions made by the murderer, during the various degrees of trial, so much so that the final sentence reported in full the specific steps of the medico-legal relationship

Adherence to Pharmacotherapy in Post-Menopausal Women with Hypertension or Metabolic Syndrome: Real World Experience

Background: Adherence to medications is dependent upon a variety of factors, including individual characteristics of the patient, interactions with health care providers, and medication complexity. Even though several studies were conducted to test intervention strategies, results are uncertain. Aim: The aim of the study is to assess if a tailored combined intervention strategy improves medication adherence in a large population of post-menopausal women affected by hypertension or metabolic syndrome. Methods: We enrolled 6833 patients aged 50 to 69 years, 85.7% with hypertension, and 14.3% with metabolic syndrome. A network between patients, general practitioners, and cardiologists was established. Interventions included education, adequate information to patients, a simplified scheme of treatment, and periodic adherence assessment. These were either delivered as healthcare provider supports or using modern technology. Medication adherence was estimated by the proportion of days covered for all classes of drugs after the index date. Results: Non-adherent hypertensive women were 297 (5%), and those with metabolic syndrome were 73 (7.4%) (p &lt; 0.02). Considering only patients with cardiomyopathy non-adherent were 234 (5.4%), while without cardiomyopathy 136 (5.3%); non-adherent hypertensive postmenopausal women with cardiomyopathy were 194 (5.2%), non-adherent postmenopausal women with metabolic syndrome and cardiomyopathy were 40 (7.2%) (p &lt; 0.04). Non-adherent hypertensive postmenopausal women without cardiomyopathy were 103 (4.9%), and non-adherent postmenopausal women with metabolic syndrome and without cardiomyopathy were 33 (7.7%) (p &lt; 0.01). Conclusions: The rate of non-adherence in both settings of postmenopausal women was 7.7%, much lower than that described in the literature. This rate was increased in patients with metabolic syndrome; probably it is related to the complexity of the therapeutic scheme or to a poor consciousness of the disease. Therefore, implementing a tailored combined intervention can improve significantly patients’ adherence to medical therapy

Percutaneous extraction of a Micra AV transcatheter pacing system due to a rare sudden battery failure after 19 months from implantation: A first experience worldwide

IntroductionMicra AV Transcatheter Pacing System (TPS) represents an innovative second-generation leadless pacemaker which represents an effective alternative to conventional devices in selected cases. Intrinsic malfunctions of these devices are rare, requiring sometimes their retrieval. When performed in experienced centers, this procedure is safe. Case PresentationWe describe a case of sudden battery malfunction of a Micra AV TPS, which required the extraction and the placement of a new pacing system in the right ventricle. DiscussionThis case, which has never been reported, highlights the need to a careful fluoroscopic evaluation and the usefulness of remote monitoring

The Beneficial Role of Telemedicine for Arrhythmic Risk Stratification in Asymptomatic Brugada Syndrome: An Exemplary Case Report

Telemedicine and remote monitoring devices, including implantable loop recorders (ILR), are increasingly adopted in the cardiologic setting. These are valuable tools in the arrhythmic stratification of patients at risk of sudden cardiac death, providing a tailored therapeutic management to prevent lethal arrhythmias. We report a case of an asymptomatic 18-year-old boy with a family history of syncope and cardiac arrest, who had a diagnosis of Brugada syndrome with an inducible type 1 pattern and carrier of a missense mutation of the SCN5A gene. In light of the risk factors, although not recommended by current guidelines, we decided to proceed with the implantation of an ILR with remote monitoring service. A few months later, an episode of asymptomatic sustained polymorphic ventricular tachycardia was promptly observed by the remote monitoring, leading to a timely implantation of a subcutaneous cardiac implantable defibrillator

549 The role of conventional and speckle tracking echocardiography in the evaluation of leadless endocardial pacing with Micra-AV

Aims: Micra-AV pacing system is a leadless pacemaker (LP) implanted in the right ventricle which can provide atrio-ventricular (AV) synchronous pacing. Echocardiographic data assessing left ventricle contractility 24–48 h after Micra AV implantation are lacking. To evaluate via conventional echocardiography and speckle-tracking echocardiography (STE), which was the best pacing modality (VVI vs. VDD) able to ensure the most efficient hemodynamic performance assessed by left ventricle ejection fraction (LF-EF) and global longitudinal strain (GLS). Methods and results: We studied nine patients with high degree AV-block, enrolled in our Institution in a range of time of 5 months. All patients had first degree AV block (PQ interval between 160 and 340 ms). They were considered suitable candidates for MICRA-AV implantation according to current guidelines. Both LF-EF and GLS were performed 24–48 h after device implantation by two experienced echocardiographic physicians. The mean age of the population was 79 6 8 years (8 were male, 89%). Risk factors more represented were hypertension and dyslipidaemia. The maximum PQ interval was 256 6 51 ms. VDD pacing modality allows better LV-EF values than those obtained with a VVI stimulation (with a difference that was statistically significant difference, P-value 1⁄4 0.008). Similarly, we obtained better GLS values during VDD pacing as respect to VVI (P-value 1⁄4 0.008). Conclusions: Left ventricle ejection fraction and LV-GLS improve early after leadless MICRA-AV implantation during VDD as compared to VVI pacing modalit

Improvement of myocardial contractility with leadless endocardial single-lead atrial sensing ventricular pacing in patients with prolonged PQ interval

Aim: Micra AV represents a leadless endocardial pacing system able to detect atrial contractions providing atrioventricular synchrony. A reduction of myocardial contractility may be detected in case of first-degree atrioventricular block (AVB). Materials &amp; methods: In six patients with first-degree AVB (PQ interval &gt;= 220 msec) was evaluated the left ventricle global longitudinal strain (LV GLS) by speckle tracking (ST) echocardiography during single-lead atrial sensing ventricular pacing (VDD) stimulation as compared with spontaneous rhythm (SR), 24-48 h after Micra AV implantation. Results: A statistically significant difference between the two modalities was observed (LV GLS during SR: -14.7% [interquartile range (IQR) 5.5], LV GLS during VDD pacing: -16.1% [IQR 5.2]; p value = 0.041). Conclusion: Our preliminary results suggest an improvement of myocardial contractility with VDD pacing as compared with SR.What is this article about?The Micra AV is an electronic device placed in the heart chambers capable to supply the electrical activity of the heart. A reduction of cardiac contractility may be observed in patients with electrical disorders of the heart.What were the results?In six patients affected by electrical cardiac disorders, we observed an improvement of cardiac contractility using Micra AV as compared with the spontaneous electrical activity of the heart.What do the results of the study mean?The results of this study suggest that in patients carrying this electronic device should be preferred a specific modality of activation of the device as compared with the spontaneous electrical activity of the heart in order to improve the contractility of the cardiac walls.An improvement of myocardial contractility was observed during VDD pacing as compared with spontaneous rhythm in 6 patients with first-degree AVB after 24-48 h from Micra AV implantation