The Use of a Handheld Ultrasound Device to Guide the Axillary Vein Access during Pacemaker and Cardioverter-Defibrillator Implantation. A Feasibility Study

Background: Although ultrasound guidance for axillary vein (AV) access (USGAVA) has been described as a reliable technique for cardiac implantable electronic device (CIED) implantation, no data is available on the use of handheld ultrasound devices (HUD) in such a setting. Objective: We investigated the feasibility of using a HUD for USGAVA in patients referred to our Institution for CIED implantation. Methods: The procedure details of 80 consecutive patients undergoing USGAVA (Group-1) from June 2020 to June 2021 were prospectively collected and compared to those of an age and sex-matched cohort of 91 patients (Group-2) who had undergone AV access with the traditional venipuncture guided by fluoroscopic landmarks. Results: The two groups were comparable for the success rate of venous access (92.5% versus 93.4%, p = 0.82), complication rate (1.3% versus 0.9%, p = 1.0), and procedure time (71 ± 32 min versus 70 ± 29 min, p = 0.9). However, Group-2 had a longer X-ray exposure time (7.6 ± 8.4 min versus 5.7 ± 7.3 min, p = 0.03). In Group-1, the univariate logistic regression analysis demonstrated that the AV diameter was associated with successful USGAVA (odds ratio = 3.34, 95% confidence interval 1.47–7.59, p < 0.01), with a 3-fold increase of probability of success per each 1 mm increase in the AV diameter. Conclusions: USGAVA using a HUD for CIED implantation is a feasible, effective, and safe technique; moreover, it saves X-ray exposure time without lengthening the implant procedure time

Fusion beat in patients with heart failure treated with left ventricular pacing: may ECG morphology relate to mechanical synchrony? A pilot study

<p>Abstract</p> <p>Background</p> <p>Electrical fusion between left ventricular pacing and spontaneous right ventricular activation is considered the key to resynchronisation in sinus rhythm patients treated with single-site left ventricular pacing.</p> <p>Aim</p> <p>Use of QRS morphology to optimize device programming in patients with heart failure (HF), sinus rhythm (SR), left bundle branch block (LBBB), treated with single-site left ventricular pacing.</p> <p>Methods and Results</p> <p>We defined the "fusion band" (FB) as the range of AV intervals within which surface ECG showed an intermediate morphology between the native LBBB and the fully paced right bundle branch block patterns.</p> <p>Twenty-four patients were enrolled. Echo-derived parameters were collected in the FB and compared with the basal LBBB condition. Velocity time integral and ejection time did not improve significantly. Diastolic filling time, ejection fraction and myocardial performance index showed a statistically significant improvement in the FB. Interventricular delay and mitral regurgitation progressively and significantly decreased as AV delay shortened in the FB. The tissue Doppler asynchrony index (Ts-SD-12-ejection) showed a non significant decreasing trend in the FB. The indications provided by the tested parameters were mostly concordant in that part of the FB corresponding to the shortest AV intervals.</p> <p>Conclusion</p> <p>Using ECG criteria based on the FB may constitute an attractive option for a safe, simple and rapid optimization of resynchronization therapy in patients with HF, SR and LBBB.</p

Raccomandazioni per la prescrizione di attività fisica in prevenzione primaria

È noto che i soggetti che praticano regolare attività fisica hanno una minore incidenza di eventi cardiovascolari, ed è altresì noto che l’attività fisica può adeguatamente contrastare l’effetto sfavorevole dei fattori di rischio cardiovascolare. Nonostante queste evidenze, la popolazione pratica modesta attività fisica ed è troppo spesso sedentaria. Pertanto la prescrizione dell’attività fisica, quando indicata, deve essere un compito imprescindibile del cardiologo, il quale deve fornire al paziente precise indicazioni su tipologia, frequenza, intensità e durata dell’esercizio da svolgere. L’obiettivo di questo lavoro è di fornire alcune indicazioni pratiche al cardiologo ambulatoriale per una corretta prescrizione di attività fisica in prevenzione primaria

Handheld ultrasound device-guided axillary vein access for pacemaker and defibrillator implantation

While ultrasound assistance for accessing the axillary vein has been established as a reliable method for cardiac pacemaker and cardioverter-defibrillator leads implantation, there is a lack of information regarding the utilization of portable handheld ultrasound devices within this context. We describe our experience with the systematic use of a pocket-sized handheld ultrasound device during the implantation of transvenous cardiovascular implantable electronic devices

Concealed SARS-CoV-2 interstitial pneumonia unmasked by infarct-like acute myocarditis

A 38-year-old otherwise healthy man presented to the emergency department for sudden-onset oppressive chest pain. On admission, vital parameters were within normal limits and physical examination was unremarkable. Since the ECG showed mild ST-segment eleva- tion in the inferior leads (Panel A), he underwent urgent coronary angiography which ruled out obstructive coronary artery disease (Panel B). Transthoracic echocardiogram showed preserved left ven- tricular (LV) ejection fraction with inferolateral wall hypokinesis. The peak of high-sensitive troponin I was 4038 ng/L (normal value &lt;20). Acute myocarditis was suspected, and a cardiac magnetic resonance (CMR) was performed. High signal intensity (SI) of the mid-basal LV lateral wall on T2 short tau inversion recovery (STIR) sequences con- sistent with myocardial oedema (Panel C) and subepicardial late gado- linium enhancement in the same location (Panel D) were detected. Unexpectedly, areas of high SI on T2-STIR images were also noted on both lungs (Panel C), suggesting a pulmonary inflammatory pro- cess. Despite an initially negative chest X-ray, computed tomography revealed bilateral ground-glass opacity with multifocal consolidation and thickening of interlobular septa consistent with interstitial pneumonia (Panel E). Considering the ongoing coronavirus outbreak, a nasopharyngeal swab was obtained resulting positive for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection. The patient remained free from either cardiovascular or respiratory symptoms and presented only mild fever (37.5C). Laboratory tests detected an increase of transaminases and C-reactive protein (6.73 mg/dL; normal value &lt;0.5) with stable lymphocytopenia. After 20 days of hospitalization, he was discharged with the diagnosis of infarct-like myocarditis associated with subclinical SARS-CoV-2 respiratory infection. Acute myocarditis in the setting of SARS-CoV-2 infection has been anecdotally reported and its mechanism remains to be elucidated. So far, the SARS-CoV-2 genome has never been detected within the myocardium, suggesting an immune-mediated inflammatory myocardial injury. For the first time we reported a case of subclinical SARS-CoV-2 interstitial pneumonia occasionally unmasked by CMR performed for acute myocarditis

Role of cardiac magnetic resonance in MINOCA of unclear etiology: A case report of a suspicious paradoxical coronary embolism

The acronym MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) refers to myocardial infarction with normal or near-normal coronary arteries on invasive angiography. The broad spectrum of pathological mechanisms responsible for myocardial injury in MINOCA makes defining the exact underlying etiology challenging. We report the uncommon case of an acute myocardial infarction with normal coronary arteries suggestive of MINOCA caused by paradoxical coronary embolism due to a wide right-to- left shunting through a patent fossa ovalis. Integrated multimodality imaging diagnostic work-up, including cardiac magnetic resonance, transesophageal contrast echocardiography, and transcranial contrast Doppler, has been crucial for identifying the most likely mechanism underlying MINOCA

Impact of Improvement in Walking Speed on Hospitalization and Mortality in Females with Cardiovascular Disease

Cardiovascular disease (CVD) is the principal cause of death in women. Walking speed (WS) is strongly related with mortality and CVD. The rate of all-cause hospitalization or death was assessed in 290 female outpatients with CVD after participation in a cardiac rehabilitation/secondary prevention program (CR/SP) and associated with the WS maintained during a moderate 1 km treadmill-walk. Three-year mortality rates were 57%, 44%, and 29% for the slow (2.1 ± 0.4 km/h), moderate (3.1 ± 0.3 km/h), and fast (4.3 ± 0.6 km/h) walkers, respectively, with adjusted hazard ratios (HRs) of 0.78 (p = 0.24) and 0.55 (p = 0.03) for moderate and fast walkers compared to the slow walkers. In addition, hospitalization or death was examined four to six years after enrollment as a function of the change in the WS of 176 patients re-assessed during the third year after baseline. The rates of hospitalization or death were higher across tertiles of reduced WS, with 35%, 50%, and 53% for the high (1.5 ± 0.3 km/h), intermediate (0.7 ± 0.2 km/h), and low tertiles (0.2 ± 0.2 km/h). Adjusted HRs were 0.79 (p = 0.38) for the intermediate and 0.47 (p = 0.02) for the high tertile compared to the low improvement tertile. Improved walking speed was associated with a graded decrease in hospitalization or death from any cause in women undergoing CR/SP

Effectiveness of cardiac resynchronization therapy in heart failure patients with valvular heart disease: comparison with patients affected by ischaemic heart disease or dilated cardiomyopathy. The InSync/InSync ICD Italian Registry

AimsTo analyse the effectiveness of cardiac resynchronization therapy (CRT) in patients with valvular heart disease (a subset not specifically investigated in randomized controlled trials) in comparison with ischaemic heart disease or dilated cardiomyopathy patients.Methods and resultsPatients enrolled in a national registry were evaluated during a median follow-up of 16 months after CRT implant. Patients with valvular heart disease treated with CRT (n = 108) in comparison with ischaemic heart disease (n = 737) and dilated cardiomyopathy (n = 635) patients presented: (i) a higher prevalence of chronic atrial fibrillation, with atrioventricular node ablation performed in around half of the cases; (ii) a similar clinical and echocardiographic profile at baseline; (iii) a similar improvement of LVEF and a similar reduction in ventricular volumes at 6-12 months; (iv) a favourable clinical response at 12 months with an improvement of the clinical composite score similar to that occurring in patients with dilated cardiomyopathy and more pronounced than that observed in patients with ischaemic heart disease; (v) a long-term outcome, in term of freedom from death or heart transplantation, similar to patients affected by ischaemic heart disease and basically more severe than that of patients affected by dilated cardiomyopathy.ConclusionIn 'real world' clinical practice, CRT appears to be effective also in patients with valvular heart disease. However, in this group of patients the outcome after CRT does not precisely overlap any of the two other groups of patients, for which much more data are currently available

The BLOCK HF study

Background. Nei pazienti con blocco atrioventricolare la stimolazione del ventricolo destro consente di ripristinare un’adeguata frequenza cardiaca, ma un’elevata percentuale di stimolazione dall’apice del ventricolo destro pu  favorire lo sviluppo di disfunzione sistolica ventricolare sinistra. Scopo dello studio   stato valutare se in questa categoria di pazienti la stimolazione biventricolare possa indurre una riduzione della mortalit  e morbilit , nonch  del rimodellamento sfavorevole del ventricolo sinistro. Metodi. Sono stati arruolati pazienti con indicazione a stimolazione cardiaca per blocco atrioventricolare, scompenso cardiaco in classe NYHA I-III e frazione d’eiezione ventricolare sinistra ≤50%. I pazienti sono stati sottoposti ad impianto di dispositivo per resincronizzazione cardiaca, pacemaker o defibrillatore (ICD) (quest’ultimo in presenza di indicazione a defibrillazione) e sono stati randomizzati a stimolazione convenzionale del ventricolo destro o a stimolazione biventricolare. L’outcome primario era rappresentato dal verificarsi del primo evento di morte per ogni causa, dalla terapia d’urgenza per scompenso cardiaco con necessit  di trattamento per via endovenosa o da un aumento ≥15% dell’indice del volume telesistolico ventricolare sinistro. Risultati. Sono stati arruolati complessivamente 918 pazienti; di questi, ne sono stati randomizzati 691 seguiti per una media di 37 mesi. L’outcome primario si   verificato in 190 dei 342 pazienti (55.6%) assegnati a stimolazione del ventricolo destro e in 160 dei 349 pazienti (45.8%) assegnati a stimolazione biventricolare. I pazienti randomizzati a stimolazione biventricolare, rispetto a quelli sottoposti a stimolazione del ventricolo destro, hanno mostrato nel tempo una incidenza significativamente pi  bassa dell’outcome primario (hazard ratio 0.74; intervallo di confidenza 95% 0.60-0.90); nei pazienti sottoposti ad impianto di pacemaker o ICD sono stati osservati risultati sovrapponibili. Il 6.4% dei pazienti ha avuto complicanze correlate all’elettrocatetere ventricolare sinistro. Conclusioni. Nei pazienti con blocco atrioventricolare, disfunzione sistolica ventricolare sinistra e scompenso cardiaco in classe NYHA I-III, la stimolazione biventricolare   risultata superiore alla stimolazione convenzionale del ventricolo destro

Sindrome di Brugada: trappola elettrocardiografica simulante un infarto miocardio acuto antero-settale

Sindrome di Brugada: trappola elettrocardiografica simulante un infarto miocardio acuto antero-settale. Descrizione dei criteri elettrocardiografi e vettorcardiografici