Radiofrequency catheter ablation of atrioventricular nodal reciprocating tachycardia using intracardiac echocardiography in pregnancy

We describe a case report of a 32-year-old woman during the 10th week of pregnancy with symptomatic and recurrent atrioventricular nodal reciprocating tachycardia successfully treated by conventional radiofrequency ablation, under intracardiac echocardiography surveillance

Poster Session Po3-60 to Po3-133

Introduction: Transvenous extraction of Pacing (PL) and Defibrillating Leads (DL) is today a highly effective technique. The need of Transvenous Lead Removal (TLR) is currently rising due to the increasing number of device-related complications. Aim of this report is to analyze the longstanding experience performed in a single Italian Center. Methods: Since January 1997 to September 2007, 1211 patients (900 men, mean age 65.6 years, range 3-95) with 2102 leads (mean pacing period 68.9 months, range 1-336) were managed at our Center. PL were 1857 (1043 ventricular, 739 atrial, 75 coronary sinus leads), DL were 245 (231 ventricular, 2 atrial, 12 superior vena cava leads). Indications to TLR were class I in 33% and class II in 67% of the leads. We performed mechanical dilation using the Cook Vascular (Leechburg PA, USA) polypropylene sheaths and, if necessary, other intravascular tools (Catchers and Lassos, Osypka, Grentzig- Whylen, G); a Femoral Approach (FA) or a Jugular Approach (JA) through the internal jugular vein were performed in case of free-floating or difficult exposed leads. Results: Removal was attempted in 2099 leads because the technique was not applicable in 3 PL (0.1%); 2066 leads (1821 PL, all the 245 DL) were completely removed (98.3%), 19 (0.9%) partially removed, 14 (0.7%) not removed. Among 2025 exposed leads, 290 were removed by manual traction (14.3%), 1539 by mechanical dilatation using the venous entry site (76%), 13 by FA (0.6%) and 150 by JA (7.4%). All the 74 free-floating leads were completely removed, 21.6% by FA and 78.4% by JA. Major complications occurred in 8 cases (0.66%): cardiac tamponade (7 cases, 2 deaths), hemotorax (1 death). Conclusions: Our results suggest that in widely experienced centers TLR using mechanical dilation has a high success rate and a low incidence of serious complications. The use of the JA allows a very high effectiveness and safety in case of freefloating or difficult exposed leads

Cardiac resynchronization therapy after coronary sinus lead extraction: feasibility and mid-term outcome of transvenous reimplantation in a tertiary referral centre

Few data are available on cardiac resynchronization therapy (CRT) after coronary sinus (CS) lead extraction. We aimed to evaluate the feasibility and mid-term outcome of transvenous CS lead reimplantation in a tertiary referral centre.We enrolled all patients who were referred to our hospital for CS lead removal from December 2000 through to May 2009 and were transvenously reimplanted with a CRT system before June 2009. One-year follow-up was performed to evaluate the incidence of infections, malfunctions, and mortality. We studied 113 consecutive patients undergoing successful CS lead extraction; 90 patients (75 male, mean age 69.2, range 3584) underwent CS lead reimplantation (success rate: 95.6; right-sided approach: 64.4). In these patients, cardiac device infection was the usual indication for extraction (74.4) and the subsequent reimplantation was performed after a median time of 3 days. The coronary sinus lead was usually positioned in the left ventricular (LV) postero-lateral region (62.2); two procedures were required in two cases (2.2). Balloon angioplasty was necessary for two patients (failure in one), whereas for the others we used a conventional implant technique. During follow-up, we observed four cases (4.4) of local infection and six cases (6.7) of system malfunction, requiring reintervention (two cases during the same hospitalization). One-year mortality was 5.5.Left ventricular lead reimplantation is in our experience an effective and safe procedure, also in the case of right-sided approach. During follow-up, 1-year mortality was particularly low, whereas overall infection rate was higher than first implant procedures

Prognostic value of right ventricular refractory period heterogeneity in Type-1 Brugada electrocardiographic pattern

Aims: To investigate the prognostic significance of heterogeneity in the refractoriness of right ventricular (RV) outflow tract (RVOT) and RV apex at the electrophysiological study (EPS) in Brugada syndrome (BrS). Methods and results: A cohort of BrS patients (primary prevention) from five Italian centres was retrospectively analysed. Patients with spontaneous or drug-induced Type-1 electrocardiogram (ECG) + symptoms were offered an EPS for prognostic stratification. The primary endpoint was a composite of sudden cardiac death (SCD), resuscitated cardiac arrest, or appropriate intervention by the implantable cardioverter-defibrillator (ICD). Three hundred and seventy-two patients with BrS were evaluated (44 ± 15 years, 69% males, 23% with ICD): 4 SCDs and 17 ICD interventions occurred at follow-up (median 48, interquartile range: 36-60 months). Family history of SCD, syncope, and a spontaneous Type-1 ECG pattern were univariate predictors of the primary endpoint in the whole population. In patients undergoing EPS (n = 198, 53%, 44 ± 12 years, 71% males, 39% with ICD), 3 SCD and 15 ICD interventions occurred at follow-up. In this subset, the primary endpoint was not only predicted by ventricular tachycardia/fibrillation inducibility but also by a difference in the refractory period between RVOT and RV apex (ΔRPRVOT-apex) >60 ms. ΔRPRVOT-apex > 60 ms remained an independent predictor of SCD/ICD shock at bivariate analysis, even when adjusted for the other univariate predictors, showing the highest predictive power at C-statistic analysis (0.75, 95% confidence interval 0.63-0.86). Conclusions: Heterogeneity of RV refractory periods is a strong, independent predictor of life-threatening arrhythmias in BrS patients, beyond VT/VF inducibility at EPS and common clinical predictors

ANMCO position paper: guide to the appropriate use of the wearable cardioverter defibrillator in clinical practice for patients at high transient risk of sudden cardiac death

Extended risk stratification and optimal management of patients with a permanently increased risk of sudden cardiac death (SCD) are becoming increasingly important. There are several clinical conditions where the risk of arrhythmic death is present albeit only transient. As an example, patients with depressed left ventricular function have a high risk of SCD that may be only transient if there will be a significant recovery of function. It is important to protect the patients while receiving and titrating to the optimal dose the recommended drugs that may lead to an improved left ventricular function. In several other conditions, a transient risk of SCD can be observed even if the left ventricular function is not compromised. Examples are patients with acute myocarditis, during the diagnostic work-up of some arrhythmic conditions or after extraction of infected catheters while eradicating the associated infection. In all these conditions, it is important to offer a protection to these patients. The wearable cardioverter defibrillator (WCD) is of particular importance as a temporary non-invasive technology for both arrhythmia monitoring and therapy in patients with increased risk of SCD. Previous studies have shown the WCD to be an effective and safe therapy for the prevention of SCD caused by ventricular tachycardia/fibrillation. The aim of this ANMCO position paper is to provide a recommendation for clinical utilization of the WCD in Italy, based upon current data and international guidelines. In this document, we will review the WCD functionality, indications, clinical evidence, and guideline recommendations. Finally, a recommendation for the utilization of the WCD in routine clinical practice will be presented, in order to provide physicians with a practical guidance for SCD risk stratification in patients who may benefit from this device

[ANMCO Position paper. wearable cardioverter defibrillator appropriate use guidance for the management of patients at high transient risk of sudden cardiac death]

Extended risk stratification and optimal management of patients with a permanently increased risk of sudden cardiac death (SCD) is becoming increasingly important. There are several clinical conditions where the risk of arrhythmic death is present albeit only transient. As an example, patients with depressed left ventricular function have a high risk of SCD that may be only transient when there is a significant recovery of function. It is important to protect the patients while receiving the recommended measures and drugs that may either lead or not to an improved left ventricular function. In several other conditions a transient risk of SCD can be observed even if the left ventricular function is not compromised. Examples are patients with acute myocarditis, during the diagnostic work-up of some arrhythmic conditions or after extraction of infected catheters while eradicating the associated infection. In all these conditions it is important to offer a protection to these patients. The wearable cardioverter-defibrillator (WCD) is of particular importance as a temporary non-invasive technology for both arrhythmia monitoring and therapy in patients with increased risk of SCD. Previous studies have shown the WCD to be an effective and safe therapy for the prevention of SCD caused by ventricular tachycardia/fibrillation. The aim of this ANMCO position paper is to provide a recommendation for clinical utilization of the WCD in Italy, based upon current data and international guidelines. In this document we will review the WCD functionality, indications, clinical evidence as well as guideline recommendations. Finally, a recommendation for the utilization of the WCD in routine clinical practice will be presented, in order to provide physicians with a practical guidance for SCD risk stratification in patients who may benefit from this device

Echo state networks for the recognition of type 1 Brugada syndrome from conventional 12-LEAD ECG

Artificial Intelligence (AI) applications and Machine Learning (ML) methods have gained much attention in recent years for their ability to automatically detect patterns in data without being explicitly taught rules. Specific features characterise the ECGs of patients with Brugada Syndrome (BrS); however, there is still ambiguity regarding the correct diagnosis of BrS and its differentiation from other pathologies.This work presents an application of Echo State Networks (ESN) in the Recurrent Neural Networks (RNN) class for diagnosing BrS from the ECG time series.12-lead ECGs were obtained from patients with a definite clinical diagnosis of spontaneous BrS Type 1 pattern (Group A), patients who underwent provocative pharmacological testing to induce BrS type 1 pattern, which resulted in positive (Group B) or negative (Group C), and control subjects (Group D). One extracted beat in the V2 lead was used as input, and the dataset was used to train and evaluate the ESN model using a double cross-validation approach. ESN performance was compared with that of 4 cardiologists trained in electrophysiology.The model performance was assessed in the dataset, with a correct global diagnosis observed in 91.5 % of cases compared to clinicians (88.0 %). High specificity (94.5 %), sensitivity (87.0 %) and AUC (94.7 %) for BrS recognition by ESN were observed in Groups A + B vs. C + D.Our results show that this ML model can discriminate Type 1 BrS ECGs with high accuracy comparable to expert clinicians. Future availability of larger datasets may improve the model performance and increase the potential of the ESN as a clinical support system tool for daily clinical practice

Prolonged care delivery time and reduced rate of electrophysiological procedures during the lockdown period due to Covid-19 outbreak

Objectives: The aim of this study is to demonstrate how Electrophysiology activity has been impacted by the pandemic Coronavirus disease 2019 (COVID-19). Methods: In this multicenter retrospective study, we analyze all consecutive patients admitted for electrophysiological procedures during the COVID-19 lockdown in the Tuscany region of Italy, comparing them to patients hospitalized in the corresponding period of the previous year. Results: The impact of COVID-19 on cardiac arrhythmia management was impressive, with a reduction of more than 50% in all kinds of procedures. A gender gap was observed, with a more relevant reduction for female patients. Arrhythmic urgencies requiring a device implant showed a reduced time from symptoms to first medical contact but the time from first medical contact to procedure was significantly prolonged. Conclusion: Hospitals need to consider how outbreaks may affect health systems beyond the immediate infection. Routine activity should be based on a risk assessment between the prompt performance of procedure and its postponement. Retrospective observational analysis such as this study could be decisive in evidence-based medicine of any future pathogen outbreak. Nonstandard Abbreviations and Acronyms PM= pacemakerICD= implantable cardioverter defibrillatorECV= electrical cardioversionEPS= electrophysiological studyAP= ablations proceduresCIED= cardiac implantable electronic devicesWCD= wearable cardioverter defibrillatorEP Lab= Electrophysiology LaboratoriesAVNRT =atrioventricular nodal reentry tachycardiaAVRT= atrioventricular reentry tachycardiaAFL= atrial flutterAF= atrial fibrillationVT= ventricular tachycardiaAT= atrial tachycardi