Use of Diltiazem in Chronic Rate Control for Atrial Fibrillation: A Prospective Case-Control Study

Atrial fibrillation (AF) is a multifaceted disease requiring personalised treatment. The aim of our study was to explore the prognostic impact of a patient-specific therapy (PT) for rate control, including the use of non-dihydropyridine calcium channel blockers (NDDC) in patients with heart failure (HF) or in combination with beta-blockers (BB), compared to standard rate control therapy (ST), as defined by previous ESC guidelines. This is a single-centre prospective observational registry on AF patients who were followed by our University Hospital. We included 1112 patients on an exclusive rate control treatment. The PT group consisted of 125 (11.2%) patients, 93/125 (74.4%) of whom were prescribed BB + NDCC (±digoxin), while 85/125 (68.0%) were HF patients who were prescribed NDCC, which was diltiazem in all cases. The patients treated with a PT showed no difference in one-year overall survival compared to those with an ST. Notably, the patients with HF in ST had a worse prognosis (p p = 0.039). Our results suggest a potential outcome benefit of NDCC for rate control in AF patients, either alone or in combination with BB and in selected patients with HF

Personalizing configuration for atrial fibrillation external electrical cardioversion to improve first shock efficacy

Background Despite the common use of biphasic electrical cardioversion (ECV) to convert atrial fibrillation (AF), we lack definite recommendations on electrode configuration. Methods We adopted a quasi-experimental design enrolling all candidates to ECV for AF. In the first stage, two units were involved, one using antero-apical pads (AAP) and the second antero-posterior adhesive patches (APP). These data enabled the creation of a decision algorithm to personalize the ECV approach, which was subsequently validated during the second stage. Results A total of 492 patients were enrolled overall. In the first stage, APP and AAP presented similar conversion rates (87.4 vs. 86.9% at first attempt of a step-up protocol, P = 0.661). While body surface area (BSA) <= 2.12 m(2) was an independent predictor in the overall population, the two components (height and weight) acted differently in the two configurations: being height <= 1.73 m(2) a significant cut-off value in the AAP subgroup, and weight <83 kg in the APP subgroup. Considering these cut-offs, we developed a decision algorithm for electrode configuration. In the second stage, algorithm validation confirmed an improvement in the first shock efficacy with respect to the results of the first stage (93.2 vs. 87.2%, P = 0.025), with a significant reduction in shock impedance (70.8 +/- 15.3 vs. 81.8 +/- 15.6, P < 0.001). Conclusion Patients with high BSA require high energy shocks for sinus rhythm restoration with ECV. Weight seems to affect more APP configuration, while height seems to impact more for the AAP. These findings have the potential to optimize ECV in clinical practice

Exploring Microphone Technologies for Digital Auscultation Devices

The aim of this work is to present a preliminary study for the design of a digital auscultation system, i.e., a novel wearable device for patient chest auscultation and a digital stethoscope. The development and testing of the electronic stethoscope prototype is reported with an emphasis on the description and selection of sound transduction systems and analog electronic processing. The focus on various microphone technologies, such as micro-electro-mechanical systems (MEMSs), electret condensers, and piezoelectronic diaphragms, intends to emphasize the most suitable transducer for auscultation. In addition, we report on the design and development of a digital acquisition system for the human body for sound recording by using a modular device approach in order to fit the chosen analog and digital mics. Tests were performed on a designed phantom setup, and a qualitative comparison between the sounds recorded with the newly developed acquisition device and those recorded with two commercial digital stethoscopes is reported

PROSPECTIVE STUDY ON PHOTOPLETYSMOGRAPHIC AND ELECTROENCEPHALOGRAPHIC SIGNALS FOR THE MONITORING OF CANDIDATES TO ELECTRICAL CARDIOVERSION OF ATRIAL ARRHYTHMIAS (PPEEG-AF PILOT STUDY)

Atrial fibrillation (AF) is the most common arrhythmia, and its incidence is constantly increasing. It is associated with higher stroke risk and the presence of sleep disorders and dementia. The choice between rhythm and rate control in AF patients remains a debated topic, and it should be tailored on specific patient characteristics. In specific situations, electrical cardioversion (ECV) for rhythm control represents the preferred choice; in particular, in patients affected by cardiopathy and/or heart failure. Because of relevant AF social costs, there is a growing interest in developing new devices for large-scale screening and monitoring programs in patients affected or at risk of AF, to reduce the incidence of disabling events.The aim of this study was to evaluate the feasibility of the use of a set-up for multi-parametric monitoring of candidates to AF ECV. In particular, new technologies were exploited for photoplethysmographic (PPG) and electroencephalographic (EEG) signal registration, integrated with clinical and instrumental data. We analyzed the effect of AF ECV on heart rate variability (HRV) and vascular age parameters derived from PPG signals registered with Empatica (CE 1876/MDD 93/42/EEC; Empatica S.r.l, Milan, Italy), and on EEG sleep pattern registered with Neurosteer (IEC 60601-1-2; Neurosteer Inc., Herzliya, Israel).24 patients were enrolled, 75% males, mean age 65.6 +/- 8.5 years. HRV analyses considering time frames registered before and after ECV showed a significant reduction of most variables (p<0.001), only LF/HF ratio did not differ significantly. Considering HRV parameters, comparisons between PPG signals registered during day or night before and after ECV showed a significant difference in SD1/SD2 ratio (p=0.035) and HF (p=0.002). Regarding vascular age parameters, a significant reduction was observed in both turning point ratio (TPR) and a wave after ECV (p < 0.001). Moreover, we observed that patients with Mini-Mental State Examination (MMSE) <= 28 presented higher values of TPR (65.9 +/- 1.6 versus 64.2 +/- 1.4, p=0.035) and CHA(2)DS(2)-VASc score (congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age, sex category) (2.9 +/- 0.9 versus 1.7 +/- 1.2, p=0.022). Considering sleep patterns, a tendency to higher coherence was observed in registrations acquired during AF than in presence of sinus rhythm, or considering signals registered before and after ECV for each patient.In conclusion, the use of this new setup of multiparametric monitoring of candidates to ECV showed significant modifications on vascular age parameters derived from PPG signals measured before and after ECV. Moreover, a possible AF effect on sleep pattern registered with Neurosteer was noticed, but more data are necessary to confirm these preliminary results

Postoperative Gastroesophageal Reflux After Laparoscopic Heller-Dor for Achalasia: True Incidence with an Objective Evaluation

Abstract INTRODUCTION: The most common complication after laparoscopic Heller-Dor (LHD) is gastroesophageal reflux disease (GERD). The present study aimed (a) to analyze the true incidence of postoperative reflux by objectively assessing a large group of LHD patients and (b) to see whether the presence of typical GERD symptoms correlates with the real incidence of postoperative reflux. METHODS: After LHD, patients were assessed by means of a symptom score, endoscopy, esophageal manometry, and 24-h pH monitoring. Patients were assigned to three groups: those did not accept to perform 24-h pH monitoring (group NP); those with normal postoperative pH findings (group A); and those with pathological postoperative acid exposure (group B). RESULTS: Four hundred sixty-three of the 806 LHD patients agreed to undergo follow-up 24-h pH monitoring. Normal pH findings were seen in 423 patients (group A, 91.4 %), while 40 (8.6 %) had a pathological acid exposure (group B). The median symptom scores were similar: 3.0 (IQR 0-8) in group A and 6.0 (IQR 0-10) in group B (p\u2009=\u20090.29). At endoscopy, the percentage of esophagitis was also similar (11 % in group A, 19 % in group B; p\u2009=\u20090.28). CONCLUSIONS: This study demonstrated that, after LHD was performed by experienced surgeons, the true incidence of postoperative GERD is very low. The incidence of this possible complication should be assessed by pH monitoring because endoscopic findings and symptoms may be misleading

Mucosal Perforation During Laparoscopic Heller Myotomy Has No Influence on Final Treatment Outcome

Background The aims of the study were (a) to examine the final outcome in patients experiencing accidental mucosal perforation during laparoscopic Heller myotomy with Dor fundoplication (LHD) and (b) to evaluate whether perforation episodes might influence the way in which surgeons subsequently approached the LHD procedure. Methods We studied all consecutive patients that underwent LHD between 1992 and 2015. Patients were divided into two main groups: those who experienced an intraoperative mucosal perforation (group P) and those whose LHD was uneventful (group NP). Two additional groups were compared: group A, which consisted of patients operated by a given surgeon immediately before a perforation episode occurred, and group B, which included those operated immediately afterwards. Results Eight hundred seventy-five patients underwent LHD; a mucosal perforation was detected in 25 patients (2.9 %), which was found unrelated to patients\u2019 symptom\u2019s score and age, radiological stage, manometric pattern, or the surgeon\u2019s experience. The median postoperative symptom score was similar for the two groups as the failure rate: 92 failures in group NP (10.8 %) and 4 in group P (16 %) (p\u2009=\u20090.34); moreover, symptoms recurred in 2 patients of group A (10 %) and 3 patients of group B (15 %) (p\u2009=\u20090.9). Conclusions Accidental perforation during LHD is infrequent and impossible to predict on the grounds of preoperative therapy or the surgeon\u2019s personal experience. Despite a longer surgical procedure and hospital stay, the outcome of LHD is much the same as for patients undergoing uneventful myotomy. A recent mucosal perforation does not influence the surgeon\u2019s subsequent performance

The SSR-based molecular profile of 1005 grapevine (Vitis vinifera L.) accessions uncovers new synonymy and parentages, and reveals a large admixture amongst varieties of different geographic origin

A collection of 1005 grapevine accessions was genotyped at 34 microsatellite loci (SSR) with the aim of analysing genetic diversity and exploring parentages. The comparison of molecular profiles revealed 200 groups of synonymy. The removal of perfect synonyms reduced the database to 745 unique genotypes, on which population genetic parameters were calculated. The analysis of kinship uncovered 74 complete pedigrees, with both parents identified. Many of these parentages were not previously known and are of considerable historical interest, e. g. Chenin blanc (Sauvignon Ã\u97 Traminer rot), Covè (Harslevelu selfed), Incrocio Manzoni 2-14 and 2-15 (Cabernet franc Ã\u97 Prosecco), Lagrein (Schiava gentile Ã\u97 Teroldego), Malvasia nera of Bolzano (Perera Ã\u97 Schiava gentile), Manzoni moscato (Raboso veronese Ã\u97 Moscato d'Amburgo), Moscato violetto (Moscato bianco Ã\u97 Duraguzza), Muscat of Alexandria (Muscat blanc à petit grain Ã\u97 Axina de tres bias) and others. Statistical robustness of unexpected pedigrees was reinforced with the analysis of an additional 7-30 SSRs. Grouping the accessions by profile resulted in a weak correlation with their geographical origin and/or current area of cultivation, revealing a large admixture of local varieties with those most widely cultivated, as a result of ancient commerce and population flow. The SSRs with tri- to penta-nucleotide repeats adopted for the present study showed a great capacity for discriminating amongst accessions, with probabilities of identity by chance as low as 1. 45 Ã\u97 10-27 and 9. 35 Ã\u97 10-12 for unrelated and full sib individuals, respectively. A database of allele frequencies and SSR profiles of 32 reference cultivars are provided. © 2010 Springer-Verlag

Percutaneous Mitral Valve Repair with the MitraClip System in the Current Clinical Practice

Severe mitral valve regurgitation (MR) carries a significant burden both in prognosis and quality of life of patients, as well as on healthcare systems, with high rates of hospitalization for heart failure. While mitral valve surgery constitutes the first-line treatment option for primary MR in suitable patients, surgical treatment for secondary severe MR remains controversial, with a substantial lack of evidence on a survival benefit. In recent decades, percutaneous mitral valve repair has emerged as an alternative treatment for patients deemed not suitable for surgery. Among several devices under development or evaluation, the MitraClip system is the most widespread and is supported by the strongest evidence. While the role of MitraClip in patients with chronic primary MR who are not deemed suitable for surgery is well established, with consistent data showing improvement in both prognosis and quality of life, MitraClip treatment in secondary MR is a rapidly evolving field. Two recent randomized clinical trials generated apparently controversial results but actually provided an interesting pathophysiologic frame that could help discerning patients who will benefit from the procedure versus patients who will not. In this review, we will discuss current treatment options for mitral regurgitation, focusing on percutaneous mitral valve repair with the MitraClip system