Riccardo Proietti | University of Milan (original) (raw)

Papers by Riccardo Proietti

International Journal of Cardiology, 2015

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and is associ... more Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and is associated with major morbidity and mortality. AF prevalence has been projected to increase in the coming decades and is expected to affect over 7.5 million Americans by the year 2050. There is growing evidence that obesity represents an important risk factor for new onset AF, with each increment in BMI associated with a 3-8% higher risk for new-onset of AF, independent of other conventional AF risk factors such as age, hypertension and heart failure. Several recent studies have also reported that obesity is also a risk factor for AF severity & chronicity. Although obesity may impact AF incidence via several mechanisms, a relation between local pericardial fat depots surrounding the heart and AF has been recently described which may have important pathophysiological implications. Pericardial fat represents one of several localized, fat depots, with unique properties due to its contiguity with cardiac structures and its shared blood supply with the heart microcirculation. Pericardial fat is also highly metabolically active and is an important source of several adipokines and cytokines. Importantly, pericardial fat appears to be more closely linked with metabolic risk than indices of systemic obesity such as BMI or waist circumference. Therefore, pericardial fat may partially explain the increased risk of AF seen in obesity and may promote AF arrhythmogenesis by local mechanisms. In this article, we review the characteristics of pericardial fat, the evidence of an association between pericardial fat and AF and the potential mechanisms for this association. We also summarize the evidence from several recent reports that have linked pericardial fat to AF prevalence, severity as well as outcome after AF ablation. We also briefly review whether interventions targeting pericardial fat could reduce AF incidence and recurrence.

Acta myologica : myopathies and cardiomyopathies : official journal of the Mediterranean Society of Myology / edited by the Gaetano Conte Academy for the study of striated muscle diseases, 2014

P-wave dispersion is a non invasive indicator of intra-atrial conduction heterogeneity producing ... more P-wave dispersion is a non invasive indicator of intra-atrial conduction heterogeneity producing substrate for reentry, which is a pathophysiological mechanism of atrial fibrillation. The relationship between P-wave dispersion (PD) and atrial fibrillation (AF) in Myotonic dystrophy type 1 (DM1) patients is still unclear. Atrial Preference Pacing (APP) is an efficient algorithm to prevent paroxysmal AF in patients implanted with dual-chamber pacemaker. Aim of our study was to evaluate the possible correlation between atrial preference pacing algorithm, P-wave dispersion and AF burden in DM1 patients with normal cardiac function underwent permanent dual-chamber pacemaker implantation. We enrolled 50 patients with DM1 (age 50.3 ± 7.3; 11 F) underwent dual-chamber pacemaker implantation for various degree of atrioventricula block. The study population was randomized following 1 months stabilization period to APP algorithm features programmed OFF or ON. Patients were assessed every 3 mon...

Indian pacing and electrophysiology journal, 2011

There is a general consensus that once a part of an implanted cardiac device becomes infected, it... more There is a general consensus that once a part of an implanted cardiac device becomes infected, it is usually impossible to cure the infection without completely removing all prosthetic material from the body. Consequently the Heart Rhythm Society (HRS) included the pocket infection or erosion as a class I indication for pacemaker lead exctraction. However, the procedure still carries a high risk of life-threatening complications due to fibrotic attachments between leads, veins, valves or other endocardial structures, notwithstanding specific tools and techniques that have been developed to assist the lead removal, preventing tissue laceration.

Indian pacing and electrophysiology journal, 2011

Implantable defibrillators are lifesavers and have improved mortality rates in patients at risk o... more Implantable defibrillators are lifesavers and have improved mortality rates in patients at risk of sudden death, both in primary and secondary prevention. However, they are unable to modify the myocardial substrate, which remains susceptible to life-threatening ventricular arrhythmias. Electrical storm is a clinical entity characterized the recurrence of hemodynamically unstable ventricular tachycardia and/or ventricular fibrillation, twice or more in 24 hours, requiring electrical cardioversion or defibrillation. With the arrival of the implantable cardioverter-defibrillator, this definition was broadened, and electrical storm is now defined as the occurrence of three or more distinct episodes of ventricular tachycardia or ventricular fibrillation in 24 hours, requiring the intervention of the defibrillator (anti-tachycardia pacing or shock). Clinical presentation can be very dramatic, with multiple defibrillator shocks and hemodynamic instability. Managing its acute presentation i...

Frontiers in Psychology, 2015

The implantable cardioverter defibrillator (ICD) saves lives but clinical experience suggests tha... more The implantable cardioverter defibrillator (ICD) saves lives but clinical experience suggests that it may have detrimental effects on mental health. The ICD shock has been largely blamed as the main offender but empirical evidence is not consistent, perhaps because of methodological differences across studies. To appraise methodologies of studies that assessed the psychological effects of ICD shock and explore associations between methods and results. A comprehensive search of English articles that were published between 1980 and 30 June 2013 was applied to the following electronic databases: PubMed, EMBASE, NHS HTA database, PsycINFO, Sciencedirect and CINAHL. Only studies testing the effects of ICD shock on psychological and quality of life outcomes were included. Data were extracted according to a PICOS pre-defined sheet including methods and study quality indicators. Fifty-four observational studies and six randomized controlled trials met the inclusion criteria. Multiple differences in methods that were used to test the psychological effects of ICD shock were found across them. No significant association with results was observed. Methodological heterogeneity of study methods is too wide and limits any quantitative attempt to account for the mixed findings. Well-built and standardized research is urgently needed.

Medical devices (Auckland, N.Z.), 2015

Atrial fibrillation (AF), the most common cardiac arrhythmia, confers a 5-fold risk of stroke tha... more Atrial fibrillation (AF), the most common cardiac arrhythmia, confers a 5-fold risk of stroke that increases to 17-fold when associated with mitral stenosis. At this time, the most effective long-term solution to protect patients from stroke and thromboembolism is oral anticoagulation, either with vitamin K antagonists (VKAs) or a novel oral anticoagulant (NOAC). Despite the significant benefits they confer, both VKAs and NOACs are underused because of their increased potential for bleeding, and VKAs are underused because of their narrow therapeutic range, need for regular international normalized ratio checks, and interactions with food or medications. In patients with nonvalvular AF, approximately 90% of strokes originate from the left atrial appendage (LAA); in patients with rheumatic mitral valve disease, many patients (60%) have strokes that originate from the left atrium itself. Surgical LAA amputation or closure, although widely used to reduce stroke risk in association with ...

Heart rhythm : the official journal of the Heart Rhythm Society, 2014

Patients with typical right atrial flutter (AFL) may also have underlying atrial fibrillation (AF... more Patients with typical right atrial flutter (AFL) may also have underlying atrial fibrillation (AF) or be at high risk of developing AF. Inducibility of AF among patients undergoing AFL ablation may be an important predictor of future occurrence of AF and may be useful in guiding management of this patient population. This study aimed to determine whether inducibility of AF at the time of AFL ablation is independently associated with the risk of future AF. Attempt at induction of AF by burst pacing was performed in consecutive patients who underwent AFL ablation. Time to incidence of AF after AFL ablation was examined using multivariable Cox proportional hazards models. All analyses were stratified by a history of AF. A total of 175 patients were retrospectively evaluated over a median follow-up period of 482 days. In patients without a documented history of AF (n = 93), the incidence of AF after AFL ablation was 18.7 per 100 person-years. In these patients, inducible AF was strongly...

Pacing and Clinical Electrophysiology, 2015

The aim of our study was to identify the early hemodynamic predictors of head-up tilt test (HUTT)... more The aim of our study was to identify the early hemodynamic predictors of head-up tilt test (HUTT) outcome in healthy patients with recurrent unexplained syncope. The study involved 95 patients (mean age 38 ± 15; 42 male) who were referred for the evaluation of the syncopal episodes from October 2012 to May 2013. According to the nitroglycerin-potentiated diagnostic tilt test response, the study population was divided into two groups: HUTT+ Group (61 patients, mean age 37 ± 10; 27 male) and HUTT- Group (34 patients, mean age 38 ± 11; 15 male) with no tilt-induced syncope. Finger arterial blood pressure (BP) was recorded during tilt testing. Left ventricular stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) were computed from the pressure pulsations. After nitroglycerin administration, the HUTT+ Group showed a significant increase in heart rate (92.0 ± 7.3 beats/min vs 68.9 ± 8.7 beats/min, P < 0.0001), with well-maintained systolic BP (111.6 ± 14.1 mm Hg vs 108.8 ± 11.5 mm Hg; P = 0.332) and diastolic BP (66.1 ± 8.5 mm Hg vs 63.1 ± 6.9 mm Hg; P = 0.0913); a significant decrease in SV (53.9 ± 8.0 mL vs 78.6 ± 8.2 mL; P < 0.0001) and CO (4.0 ± 0.5 L/min vs 5.8 ± 1.0 L/min; P < 0.001), and a significant increase in TPR (1.3 ± 0.3 U vs 0.9 ± 0.2 U, P < 0.0011). We tested three hemodynamic parameters (SV, CO, and TPR) as predictors of positive tilt test response with receiver-operating characteristic curve analysis. Our results show that, 2 minutes after nitroglycerin administration, a statistically significant decrease of SV values (<67 mL) strongly predicts (area under the curve, 0.985; P < 0.0001) the HUTT-positive response in healthy patients with recurrent unexplained syncope.

Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology, Jan 8, 2014

The purpose of this study was to evaluate the outcomes of purely substrate-guided ventricular tac... more The purpose of this study was to evaluate the outcomes of purely substrate-guided ventricular tachycardia (VT) ablation in patients with non-ischaemic dilated cardiomyopathy (NIDCM) and ischaemic cardiomyopathy (ICM) and the impact of acute procedural success on long-term outcome. One hundred and forty-two patients (65 ± 12 years old, 72% male) with ICM (n = 87) and with NIDCM (n = 55) underwent substrate-guided VT ablation. The ablation approach involved eliminating all LP regions and ablating all scar border zone regions with 10 or more out of 12 pace-matching. All patients were followed with regular implantable defibrillator interrogations for mean 641 ± 301 days. Complete acute success (no inducible VT) was achieved in 60 patients with ICM (69%) and in 29 patients with NIDCM (53%) (P = 0.03). Partial success (elimination of clinical VT only) was obtained in nine patients with ICM (10%) and in four patients with NIDCM (7%) (P = 0.14). Procedural failure (clinical VT still inducib...

Circulation, 2014

We read with interest the recent article by DeSimone et al 1 after observing such a case that occ... more We read with interest the recent article by DeSimone et al 1 after observing such a case that occurred in our department. A patient with severe ischemic cardiomyopathy, ejection fraction 10%, developed a stroke 3 days after defibrillator implantation. The patient had no history of atrial fibrillation and was on antithrombotic therapy with acetylsalicylic acid. A transesophageal echocardiogram preformed after the ischemic event showed a patent foramen ovale (PFO). Because an adjusted analysis for the ejection fraction was lacking in the article by DeSimone et al, 1 it is difficult to speculate whether the low ejection fraction (independent of a PFO) or a possible pacing lead-related thrombus passing through a PFO was a more likely potential cause for the patient's stroke.

Circulation. Arrhythmia and electrophysiology, 2014

For the past decade, electric pulmonary vein isolation (PVI) has become a procedure implemented w... more For the past decade, electric pulmonary vein isolation (PVI) has become a procedure implemented worldwide for the treatment of atrial fibrillation. Currently, 2 main approaches are used for PVI: ostial isolation of the PVs and wide antral PVI. The aims of this systematic review are to evaluate the relative merits of each technique with a pooled comparative analysis of efficacy and complications. Studies were identified by searching electronic databases for studies on ostial versus antral PVI. Information was extracted from each included trial. Odds ratio was the primary measure of treatment effect or side effects. The proportion of patients with recurrences of atrial fibrillation or other atrial tachyarrhythmias was evaluated at the end of the follow-up periods in 12 trials, including 1183 patients. The recurrence rate of total supraventricular arrhythmias was significantly lower in wide antral than in segmental PVI group (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P<0...

Annals of cardiothoracic surgery, 2014

Over the past two decades, invasive techniques to treat atrial fibrillation (AF) including cathet... more Over the past two decades, invasive techniques to treat atrial fibrillation (AF) including catheter-based and surgical procedures have evolved along with our understanding of the pathophysiology of this arrhythmia. Surgical treatment of AF may be performed on patients undergoing cardiac surgery for other reasons (concomitant surgical ablation) or as a stand-alone procedure. Advances in technology and technique have made surgical intervention for AF more widespread. Despite improvements in outcome of both catheter-based and surgical treatment for AF, recurrence of atrial arrhythmias following initial invasive therapy may occur.Atrial arrhythmias may occur early or late in the post-operative course after surgical ablation. Early arrhythmias are generally treated with prompt electrical cardioversion with or without antiarrhythmic therapy and do not necessarily represent treatment failure. The mechanism of persistent or late occurring atrial arrhythmias is complex, and these arrhythmias...

Acta myologica : myopathies and cardiomyopathies : official journal of the Mediterranean Society of Myology / edited by the Gaetano Conte Academy for the study of striated muscle diseases, 2013

The role that atrial pacing therapy plays on the atrial fibrillation (AF) burden is still unclear... more The role that atrial pacing therapy plays on the atrial fibrillation (AF) burden is still unclear. Aim of the study was to evaluate the effect of the atrial preference pacing algorithm on AF burden in patients affected by Myotonic Dystrophy type 1 (DM1) followed for a long follow up period. Sixty DM1 patients were -implanted with a dual chamber pacemaker (PM) for first degree or symptomatic type 1/type 2 second degree atrio-ventricular blocks- were followed for 2-years after implantation, by periodical examination. After 1 month of stabilization, they were randomized into two groups: 1) Patients implanted with conventional dual-chamber pacing mode (DDDR group) and 2) Patients implanted with DDDR plus Atrial Preference Pacing (APP) algorithm (APP ON group). The results showed that atrial tachycardia (AT)/AF burden was significantly reduced at 1 year follow up in the APP ON group (2122 ± 428 minutes vs 4127 ± 388 minutes, P = 0.03), with a further reduction at the end of the 2 year fo...

Pacing and Clinical Electrophysiology, 2014

Cognitive impairment (CI) comprises a measurable deficit of different cognitive domains (memory, ... more Cognitive impairment (CI) comprises a measurable deficit of different cognitive domains (memory, attention, problem solving, and motor speed), and has a high prevalence among congestive heart failure (CHF) patients. Only a few pilot studies have investigated the effects of cardiac resynchronization therapy (CRT) on cognitive performance. The purpose of this systematic review is to outline and evaluate results of published studies that assess the impact of CRT on neuropsychological function in CHF. Electronic databases were searched for articles containing the following terms: CRT, cognition, cognitive, and neurocognitive. A data extraction was performed according to our objective from each study. Effect sizes were computed using Hedges&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; g. The within-group formula was used for cohort studies with a pre-post design, while the between-group formula was used for studies that compared independent groups. Multiple outcomes were combined in domain-specific synthetic scores as well as in a global score for each study, and a fixed-effect model was used to estimate the summary effects. Only three studies met criteria for inclusion in the analysis. The results of these studies were discordant and methodological limitations were identified. The meta-analysis of cognitive outcomes showed a nonsignificant overall effect (Hedges&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; g = 0.131, 95% confidence interval: -0.16 to 0.422), while the summary effects on executive functioning and attention reached statistical significance (Hedges&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; g = 0.374, 95% confidence interval: 0.085-0.662 and Hedges&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; g = 0.343, 95% confidence interval: 0.051-0.635, respectively). CI and related negative consequences have been largely documented in patients with heart failure but very few studies have assessed the plausible benefits of CRT on patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; cognitive function. Despite the statistical significance of the domain-specific pooled effects, their validity and clinical relevance is lacking due to methodological limitations.

Pacing and Clinical Electrophysiology, 2012

Closed-loop stimulation (CLS) is a form of rate-adaptive pacing capable of providing an effective... more Closed-loop stimulation (CLS) is a form of rate-adaptive pacing capable of providing an effective pacing rate profile not only during physical exercise but also during mental stress. To test its effectiveness, CLS and accelerometer sensor (AS) rate response were compared intraindividually during a mental stress test (MST). Thirty-six patients (mean age 78.9 ± 6.4 years) implanted with a pacemaker with the CLS algorithm (Cylos, Biotronik, Berlin, Germany) underwent MSTs in different pacing configurations: nonrate-adaptive mode (VVI), AS mode (VVIR), and CLS mode, respectively. A modified Stroop test was used in order to induce mental stress. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure, and pacing percentage burden were collected for 5 minutes before, during, and 5 minutes after the test. Mean peak-HR during MST was significantly higher in CLS configuration than in VVIR and VVI modes (92.8 ± 12.6 vs 78.9 ± 6.5 vs 77.8 ± 7.5; P ≤ 0.001). The average HR increase during MST was also higher in CLS configuration than in VVIR and VVI modes (22.7 ± 16.7 vs 8.2 ± 8.6 vs 6.6 ± 6.3; P ≤ 0.001). The percentage of pacing beats during MST was higher in CLS configuration than with the other two algorithms (48.4 ± 17.9 vs 27.4 ± 17.5 vs 25.8 ± 17.6; P ≤ 0.001). The average peak-SBP was significantly higher during MST in CLS mode than in VVIR and VVI configurations (172.6 ± 15.5 vs 156.7 ± 12.2 vs 145.5 ± 13.7; P ≤ 0.001). The mean SBP increase showed a similar behavior (51.8 ± 24.7 vs 18.4 ± 13.7 vs 16.4 ± 10.3; P ≤ 0.001). CLS algorithm in a single-chamber device is more effective than AS in detecting an hemodynamic demand due to an emotional stress and supplying a proper HR increase. These results are even more surprising compared to previous data in dual-chamber pacemakers, because they imply that CLS algorithm can provide an appropriate rate-modulation in patients with AF and chronotropic incompetence.

Journal of Interventional Cardiac Electrophysiology, 2011

Purpose Radiofrequency catheter ablation (RFCA) of supraventricular tachyarrhythmias carries a sm... more Purpose Radiofrequency catheter ablation (RFCA) of supraventricular tachyarrhythmias carries a small but nonnegligible radiation risk. Studies in children already showed the feasibility of using three-dimensional mapping systems as the primary guide for catheter visualization and positioning in these RFCAs. We aim to demonstrate the feasibility and safety of such an approach in young and middle-aged patients. Methods Fifty patients (age 34±12) with supraventricular tachyarrhythmias underwent electrophysiological study; of these, 47 patients proceeded to RFCA guided by the EnSite NavX TM system (23 with atrioventricular nodal reentry tachycardia, 16 with an accessory pathway, six with typical atrial flutter, and two with right atrial tachycardia). Results In 38/50 cases (76%), electroanatomical mapping avoided fluoroscopy entirely, including four cases requiring access to the left heart chambers by a retrograde approach. In the remaining 12/50 cases (24%), fluoroscopy use was limited to 122±80 s, with a correspondingly low radiation exposure (dose area product 1.3± 1.1 mGy ×m 2 ). All procedures were acutely successful, with a procedural time of 113±37 minutes, and without incurring in any major complication. Over a mean follow-up of 12±3 months, we observed one recurrence of pre-excitation and one relapse of atrial flutter.

International Journal of Cardiology, 2013

Background: It is not clarified whether the transient, regional left ventricular dysfunction (TRL... more Background: It is not clarified whether the transient, regional left ventricular dysfunction (TRLVD) associated with several neurological disorders shares the same pathophysiology with the classical tako-tsubo cardiomyopathy occurring without overt neurological disease, and whether it is appropriate to include these patients in a single stress cardiomyopathy (SCM) condition. Methods: In February 2012, we systematically explored major electronic medical information sources to identify cases of TRLVD triggered by neurological disorders. Results: The 81 selected papers reported a total of 124 patients, suffering from neurological disorders, in whom TRLVD occurred: 117 with central nervous system diseases, 6 with peripheral nervous system diseases and 1 with both systems involved. Most patients were females (n=102), mean age was 63±15 years, and the majority presented with an apex-involving pattern. The most common disease described was subarachnoid hemorrhage (n=52), followed by stroke/transient ischemic attack (n=24), and seizures (n=18). TRLVD in neurological patients was often associated with need of inotropic support, orotracheal intubation, cerebrovascular spasm and delayed surgery. Conclusions: TRLVD is a complication of neurological diseases, in particular in female patients in post-menopausal phase. The predilection for neurological damage at or close to the insular cortex highlights the pivotal role of sympathetic over-activation. Many other similarities with tako-tsubo support the inclusion in a single SCM category.

Annals of Noninvasive Electrocardiology, 2012

We report about a case of a patient admitted to the Intensive Cardiac Care Unit for severe conges... more We report about a case of a patient admitted to the Intensive Cardiac Care Unit for severe congestive heart failure which showed modification of P-wave morphology and duration, correlated with the clinical evolution. In the case here described, we show that ECG analysis, specifically P wave, allow us to assess the hemodynamic evolution of the acute decompensated heart failure patient. Electrocardiographic examination is the first and the most simple and available diagnostic tool in the evaluation of patients with cardiac diseases. Usually, P-wave evaluation is not carefully assessed, in spite of very useful informations we can draw from its interpretation. We report about a patient admitted to our Intensive Cardiac Care Unit (ICCU) for severe congestive heart failure which showed peculiar modification of P-wave morphology and duration, well correlated with the clinical course.

The Canadian journal of cardiology, 2015

It is unknown whether implantable cardioverter-defibrillator (ICD) discharges actively contribute... more It is unknown whether implantable cardioverter-defibrillator (ICD) discharges actively contribute to a worse prognosis independent of the underlying arrhythmia. There is considerable variability in the reported risk of mortality after appropriate and inappropriate ICD shocks. The aim of our systematic review was to provide a reliable effect size of the association between ICD shock and mortality for both types of therapies. On the basis of a systematic literature search, 10 studies were considered eligible for inclusion in the analysis, and data on the hazard ratio (HR) of mortality after ICD shock were extracted from each study. On pooled analysis, a substantial difference was detected in the risk for subsequent mortality between appropriate and inappropriate shocks. Among patients receiving an appropriate ICD shock, the HR for cardiac death was 2.95 (95% confidence interval [CI], 2.12-4.11; P < 0.001) compared with an HR of 1.71 (95% CI, 1.45-2.02) for those receiving an inappr...

International Journal of Cardiology, 2015

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and is associ... more Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and is associated with major morbidity and mortality. AF prevalence has been projected to increase in the coming decades and is expected to affect over 7.5 million Americans by the year 2050. There is growing evidence that obesity represents an important risk factor for new onset AF, with each increment in BMI associated with a 3-8% higher risk for new-onset of AF, independent of other conventional AF risk factors such as age, hypertension and heart failure. Several recent studies have also reported that obesity is also a risk factor for AF severity &amp;amp;amp;amp;amp;amp;amp;amp;amp; chronicity. Although obesity may impact AF incidence via several mechanisms, a relation between local pericardial fat depots surrounding the heart and AF has been recently described which may have important pathophysiological implications. Pericardial fat represents one of several localized, fat depots, with unique properties due to its contiguity with cardiac structures and its shared blood supply with the heart microcirculation. Pericardial fat is also highly metabolically active and is an important source of several adipokines and cytokines. Importantly, pericardial fat appears to be more closely linked with metabolic risk than indices of systemic obesity such as BMI or waist circumference. Therefore, pericardial fat may partially explain the increased risk of AF seen in obesity and may promote AF arrhythmogenesis by local mechanisms. In this article, we review the characteristics of pericardial fat, the evidence of an association between pericardial fat and AF and the potential mechanisms for this association. We also summarize the evidence from several recent reports that have linked pericardial fat to AF prevalence, severity as well as outcome after AF ablation. We also briefly review whether interventions targeting pericardial fat could reduce AF incidence and recurrence.

Acta myologica : myopathies and cardiomyopathies : official journal of the Mediterranean Society of Myology / edited by the Gaetano Conte Academy for the study of striated muscle diseases, 2014

P-wave dispersion is a non invasive indicator of intra-atrial conduction heterogeneity producing ... more P-wave dispersion is a non invasive indicator of intra-atrial conduction heterogeneity producing substrate for reentry, which is a pathophysiological mechanism of atrial fibrillation. The relationship between P-wave dispersion (PD) and atrial fibrillation (AF) in Myotonic dystrophy type 1 (DM1) patients is still unclear. Atrial Preference Pacing (APP) is an efficient algorithm to prevent paroxysmal AF in patients implanted with dual-chamber pacemaker. Aim of our study was to evaluate the possible correlation between atrial preference pacing algorithm, P-wave dispersion and AF burden in DM1 patients with normal cardiac function underwent permanent dual-chamber pacemaker implantation. We enrolled 50 patients with DM1 (age 50.3 ± 7.3; 11 F) underwent dual-chamber pacemaker implantation for various degree of atrioventricula block. The study population was randomized following 1 months stabilization period to APP algorithm features programmed OFF or ON. Patients were assessed every 3 mon...

Indian pacing and electrophysiology journal, 2011

There is a general consensus that once a part of an implanted cardiac device becomes infected, it... more There is a general consensus that once a part of an implanted cardiac device becomes infected, it is usually impossible to cure the infection without completely removing all prosthetic material from the body. Consequently the Heart Rhythm Society (HRS) included the pocket infection or erosion as a class I indication for pacemaker lead exctraction. However, the procedure still carries a high risk of life-threatening complications due to fibrotic attachments between leads, veins, valves or other endocardial structures, notwithstanding specific tools and techniques that have been developed to assist the lead removal, preventing tissue laceration.

Indian pacing and electrophysiology journal, 2011

Implantable defibrillators are lifesavers and have improved mortality rates in patients at risk o... more Implantable defibrillators are lifesavers and have improved mortality rates in patients at risk of sudden death, both in primary and secondary prevention. However, they are unable to modify the myocardial substrate, which remains susceptible to life-threatening ventricular arrhythmias. Electrical storm is a clinical entity characterized the recurrence of hemodynamically unstable ventricular tachycardia and/or ventricular fibrillation, twice or more in 24 hours, requiring electrical cardioversion or defibrillation. With the arrival of the implantable cardioverter-defibrillator, this definition was broadened, and electrical storm is now defined as the occurrence of three or more distinct episodes of ventricular tachycardia or ventricular fibrillation in 24 hours, requiring the intervention of the defibrillator (anti-tachycardia pacing or shock). Clinical presentation can be very dramatic, with multiple defibrillator shocks and hemodynamic instability. Managing its acute presentation i...

Frontiers in Psychology, 2015

The implantable cardioverter defibrillator (ICD) saves lives but clinical experience suggests tha... more The implantable cardioverter defibrillator (ICD) saves lives but clinical experience suggests that it may have detrimental effects on mental health. The ICD shock has been largely blamed as the main offender but empirical evidence is not consistent, perhaps because of methodological differences across studies. To appraise methodologies of studies that assessed the psychological effects of ICD shock and explore associations between methods and results. A comprehensive search of English articles that were published between 1980 and 30 June 2013 was applied to the following electronic databases: PubMed, EMBASE, NHS HTA database, PsycINFO, Sciencedirect and CINAHL. Only studies testing the effects of ICD shock on psychological and quality of life outcomes were included. Data were extracted according to a PICOS pre-defined sheet including methods and study quality indicators. Fifty-four observational studies and six randomized controlled trials met the inclusion criteria. Multiple differences in methods that were used to test the psychological effects of ICD shock were found across them. No significant association with results was observed. Methodological heterogeneity of study methods is too wide and limits any quantitative attempt to account for the mixed findings. Well-built and standardized research is urgently needed.

Medical devices (Auckland, N.Z.), 2015

Atrial fibrillation (AF), the most common cardiac arrhythmia, confers a 5-fold risk of stroke tha... more Atrial fibrillation (AF), the most common cardiac arrhythmia, confers a 5-fold risk of stroke that increases to 17-fold when associated with mitral stenosis. At this time, the most effective long-term solution to protect patients from stroke and thromboembolism is oral anticoagulation, either with vitamin K antagonists (VKAs) or a novel oral anticoagulant (NOAC). Despite the significant benefits they confer, both VKAs and NOACs are underused because of their increased potential for bleeding, and VKAs are underused because of their narrow therapeutic range, need for regular international normalized ratio checks, and interactions with food or medications. In patients with nonvalvular AF, approximately 90% of strokes originate from the left atrial appendage (LAA); in patients with rheumatic mitral valve disease, many patients (60%) have strokes that originate from the left atrium itself. Surgical LAA amputation or closure, although widely used to reduce stroke risk in association with ...

Heart rhythm : the official journal of the Heart Rhythm Society, 2014

Patients with typical right atrial flutter (AFL) may also have underlying atrial fibrillation (AF... more Patients with typical right atrial flutter (AFL) may also have underlying atrial fibrillation (AF) or be at high risk of developing AF. Inducibility of AF among patients undergoing AFL ablation may be an important predictor of future occurrence of AF and may be useful in guiding management of this patient population. This study aimed to determine whether inducibility of AF at the time of AFL ablation is independently associated with the risk of future AF. Attempt at induction of AF by burst pacing was performed in consecutive patients who underwent AFL ablation. Time to incidence of AF after AFL ablation was examined using multivariable Cox proportional hazards models. All analyses were stratified by a history of AF. A total of 175 patients were retrospectively evaluated over a median follow-up period of 482 days. In patients without a documented history of AF (n = 93), the incidence of AF after AFL ablation was 18.7 per 100 person-years. In these patients, inducible AF was strongly...

Pacing and Clinical Electrophysiology, 2015

The aim of our study was to identify the early hemodynamic predictors of head-up tilt test (HUTT)... more The aim of our study was to identify the early hemodynamic predictors of head-up tilt test (HUTT) outcome in healthy patients with recurrent unexplained syncope. The study involved 95 patients (mean age 38 ± 15; 42 male) who were referred for the evaluation of the syncopal episodes from October 2012 to May 2013. According to the nitroglycerin-potentiated diagnostic tilt test response, the study population was divided into two groups: HUTT+ Group (61 patients, mean age 37 ± 10; 27 male) and HUTT- Group (34 patients, mean age 38 ± 11; 15 male) with no tilt-induced syncope. Finger arterial blood pressure (BP) was recorded during tilt testing. Left ventricular stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) were computed from the pressure pulsations. After nitroglycerin administration, the HUTT+ Group showed a significant increase in heart rate (92.0 ± 7.3 beats/min vs 68.9 ± 8.7 beats/min, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), with well-maintained systolic BP (111.6 ± 14.1 mm Hg vs 108.8 ± 11.5 mm Hg; P = 0.332) and diastolic BP (66.1 ± 8.5 mm Hg vs 63.1 ± 6.9 mm Hg; P = 0.0913); a significant decrease in SV (53.9 ± 8.0 mL vs 78.6 ± 8.2 mL; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) and CO (4.0 ± 0.5 L/min vs 5.8 ± 1.0 L/min; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), and a significant increase in TPR (1.3 ± 0.3 U vs 0.9 ± 0.2 U, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0011). We tested three hemodynamic parameters (SV, CO, and TPR) as predictors of positive tilt test response with receiver-operating characteristic curve analysis. Our results show that, 2 minutes after nitroglycerin administration, a statistically significant decrease of SV values (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;67 mL) strongly predicts (area under the curve, 0.985; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) the HUTT-positive response in healthy patients with recurrent unexplained syncope.

Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology, Jan 8, 2014

The purpose of this study was to evaluate the outcomes of purely substrate-guided ventricular tac... more The purpose of this study was to evaluate the outcomes of purely substrate-guided ventricular tachycardia (VT) ablation in patients with non-ischaemic dilated cardiomyopathy (NIDCM) and ischaemic cardiomyopathy (ICM) and the impact of acute procedural success on long-term outcome. One hundred and forty-two patients (65 ± 12 years old, 72% male) with ICM (n = 87) and with NIDCM (n = 55) underwent substrate-guided VT ablation. The ablation approach involved eliminating all LP regions and ablating all scar border zone regions with 10 or more out of 12 pace-matching. All patients were followed with regular implantable defibrillator interrogations for mean 641 ± 301 days. Complete acute success (no inducible VT) was achieved in 60 patients with ICM (69%) and in 29 patients with NIDCM (53%) (P = 0.03). Partial success (elimination of clinical VT only) was obtained in nine patients with ICM (10%) and in four patients with NIDCM (7%) (P = 0.14). Procedural failure (clinical VT still inducib...

Circulation, 2014

We read with interest the recent article by DeSimone et al 1 after observing such a case that occ... more We read with interest the recent article by DeSimone et al 1 after observing such a case that occurred in our department. A patient with severe ischemic cardiomyopathy, ejection fraction 10%, developed a stroke 3 days after defibrillator implantation. The patient had no history of atrial fibrillation and was on antithrombotic therapy with acetylsalicylic acid. A transesophageal echocardiogram preformed after the ischemic event showed a patent foramen ovale (PFO). Because an adjusted analysis for the ejection fraction was lacking in the article by DeSimone et al, 1 it is difficult to speculate whether the low ejection fraction (independent of a PFO) or a possible pacing lead-related thrombus passing through a PFO was a more likely potential cause for the patient's stroke.

Circulation. Arrhythmia and electrophysiology, 2014

For the past decade, electric pulmonary vein isolation (PVI) has become a procedure implemented w... more For the past decade, electric pulmonary vein isolation (PVI) has become a procedure implemented worldwide for the treatment of atrial fibrillation. Currently, 2 main approaches are used for PVI: ostial isolation of the PVs and wide antral PVI. The aims of this systematic review are to evaluate the relative merits of each technique with a pooled comparative analysis of efficacy and complications. Studies were identified by searching electronic databases for studies on ostial versus antral PVI. Information was extracted from each included trial. Odds ratio was the primary measure of treatment effect or side effects. The proportion of patients with recurrences of atrial fibrillation or other atrial tachyarrhythmias was evaluated at the end of the follow-up periods in 12 trials, including 1183 patients. The recurrence rate of total supraventricular arrhythmias was significantly lower in wide antral than in segmental PVI group (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P<0...

Annals of cardiothoracic surgery, 2014

Over the past two decades, invasive techniques to treat atrial fibrillation (AF) including cathet... more Over the past two decades, invasive techniques to treat atrial fibrillation (AF) including catheter-based and surgical procedures have evolved along with our understanding of the pathophysiology of this arrhythmia. Surgical treatment of AF may be performed on patients undergoing cardiac surgery for other reasons (concomitant surgical ablation) or as a stand-alone procedure. Advances in technology and technique have made surgical intervention for AF more widespread. Despite improvements in outcome of both catheter-based and surgical treatment for AF, recurrence of atrial arrhythmias following initial invasive therapy may occur.Atrial arrhythmias may occur early or late in the post-operative course after surgical ablation. Early arrhythmias are generally treated with prompt electrical cardioversion with or without antiarrhythmic therapy and do not necessarily represent treatment failure. The mechanism of persistent or late occurring atrial arrhythmias is complex, and these arrhythmias...

Acta myologica : myopathies and cardiomyopathies : official journal of the Mediterranean Society of Myology / edited by the Gaetano Conte Academy for the study of striated muscle diseases, 2013

The role that atrial pacing therapy plays on the atrial fibrillation (AF) burden is still unclear... more The role that atrial pacing therapy plays on the atrial fibrillation (AF) burden is still unclear. Aim of the study was to evaluate the effect of the atrial preference pacing algorithm on AF burden in patients affected by Myotonic Dystrophy type 1 (DM1) followed for a long follow up period. Sixty DM1 patients were -implanted with a dual chamber pacemaker (PM) for first degree or symptomatic type 1/type 2 second degree atrio-ventricular blocks- were followed for 2-years after implantation, by periodical examination. After 1 month of stabilization, they were randomized into two groups: 1) Patients implanted with conventional dual-chamber pacing mode (DDDR group) and 2) Patients implanted with DDDR plus Atrial Preference Pacing (APP) algorithm (APP ON group). The results showed that atrial tachycardia (AT)/AF burden was significantly reduced at 1 year follow up in the APP ON group (2122 ± 428 minutes vs 4127 ± 388 minutes, P = 0.03), with a further reduction at the end of the 2 year fo...

Pacing and Clinical Electrophysiology, 2014

Cognitive impairment (CI) comprises a measurable deficit of different cognitive domains (memory, ... more Cognitive impairment (CI) comprises a measurable deficit of different cognitive domains (memory, attention, problem solving, and motor speed), and has a high prevalence among congestive heart failure (CHF) patients. Only a few pilot studies have investigated the effects of cardiac resynchronization therapy (CRT) on cognitive performance. The purpose of this systematic review is to outline and evaluate results of published studies that assess the impact of CRT on neuropsychological function in CHF. Electronic databases were searched for articles containing the following terms: CRT, cognition, cognitive, and neurocognitive. A data extraction was performed according to our objective from each study. Effect sizes were computed using Hedges&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; g. The within-group formula was used for cohort studies with a pre-post design, while the between-group formula was used for studies that compared independent groups. Multiple outcomes were combined in domain-specific synthetic scores as well as in a global score for each study, and a fixed-effect model was used to estimate the summary effects. Only three studies met criteria for inclusion in the analysis. The results of these studies were discordant and methodological limitations were identified. The meta-analysis of cognitive outcomes showed a nonsignificant overall effect (Hedges&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; g = 0.131, 95% confidence interval: -0.16 to 0.422), while the summary effects on executive functioning and attention reached statistical significance (Hedges&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; g = 0.374, 95% confidence interval: 0.085-0.662 and Hedges&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; g = 0.343, 95% confidence interval: 0.051-0.635, respectively). CI and related negative consequences have been largely documented in patients with heart failure but very few studies have assessed the plausible benefits of CRT on patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; cognitive function. Despite the statistical significance of the domain-specific pooled effects, their validity and clinical relevance is lacking due to methodological limitations.

Pacing and Clinical Electrophysiology, 2012

Closed-loop stimulation (CLS) is a form of rate-adaptive pacing capable of providing an effective... more Closed-loop stimulation (CLS) is a form of rate-adaptive pacing capable of providing an effective pacing rate profile not only during physical exercise but also during mental stress. To test its effectiveness, CLS and accelerometer sensor (AS) rate response were compared intraindividually during a mental stress test (MST). Thirty-six patients (mean age 78.9 ± 6.4 years) implanted with a pacemaker with the CLS algorithm (Cylos, Biotronik, Berlin, Germany) underwent MSTs in different pacing configurations: nonrate-adaptive mode (VVI), AS mode (VVIR), and CLS mode, respectively. A modified Stroop test was used in order to induce mental stress. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure, and pacing percentage burden were collected for 5 minutes before, during, and 5 minutes after the test. Mean peak-HR during MST was significantly higher in CLS configuration than in VVIR and VVI modes (92.8 ± 12.6 vs 78.9 ± 6.5 vs 77.8 ± 7.5; P ≤ 0.001). The average HR increase during MST was also higher in CLS configuration than in VVIR and VVI modes (22.7 ± 16.7 vs 8.2 ± 8.6 vs 6.6 ± 6.3; P ≤ 0.001). The percentage of pacing beats during MST was higher in CLS configuration than with the other two algorithms (48.4 ± 17.9 vs 27.4 ± 17.5 vs 25.8 ± 17.6; P ≤ 0.001). The average peak-SBP was significantly higher during MST in CLS mode than in VVIR and VVI configurations (172.6 ± 15.5 vs 156.7 ± 12.2 vs 145.5 ± 13.7; P ≤ 0.001). The mean SBP increase showed a similar behavior (51.8 ± 24.7 vs 18.4 ± 13.7 vs 16.4 ± 10.3; P ≤ 0.001). CLS algorithm in a single-chamber device is more effective than AS in detecting an hemodynamic demand due to an emotional stress and supplying a proper HR increase. These results are even more surprising compared to previous data in dual-chamber pacemakers, because they imply that CLS algorithm can provide an appropriate rate-modulation in patients with AF and chronotropic incompetence.

Journal of Interventional Cardiac Electrophysiology, 2011

Purpose Radiofrequency catheter ablation (RFCA) of supraventricular tachyarrhythmias carries a sm... more Purpose Radiofrequency catheter ablation (RFCA) of supraventricular tachyarrhythmias carries a small but nonnegligible radiation risk. Studies in children already showed the feasibility of using three-dimensional mapping systems as the primary guide for catheter visualization and positioning in these RFCAs. We aim to demonstrate the feasibility and safety of such an approach in young and middle-aged patients. Methods Fifty patients (age 34±12) with supraventricular tachyarrhythmias underwent electrophysiological study; of these, 47 patients proceeded to RFCA guided by the EnSite NavX TM system (23 with atrioventricular nodal reentry tachycardia, 16 with an accessory pathway, six with typical atrial flutter, and two with right atrial tachycardia). Results In 38/50 cases (76%), electroanatomical mapping avoided fluoroscopy entirely, including four cases requiring access to the left heart chambers by a retrograde approach. In the remaining 12/50 cases (24%), fluoroscopy use was limited to 122±80 s, with a correspondingly low radiation exposure (dose area product 1.3± 1.1 mGy ×m 2 ). All procedures were acutely successful, with a procedural time of 113±37 minutes, and without incurring in any major complication. Over a mean follow-up of 12±3 months, we observed one recurrence of pre-excitation and one relapse of atrial flutter.

International Journal of Cardiology, 2013

Background: It is not clarified whether the transient, regional left ventricular dysfunction (TRL... more Background: It is not clarified whether the transient, regional left ventricular dysfunction (TRLVD) associated with several neurological disorders shares the same pathophysiology with the classical tako-tsubo cardiomyopathy occurring without overt neurological disease, and whether it is appropriate to include these patients in a single stress cardiomyopathy (SCM) condition. Methods: In February 2012, we systematically explored major electronic medical information sources to identify cases of TRLVD triggered by neurological disorders. Results: The 81 selected papers reported a total of 124 patients, suffering from neurological disorders, in whom TRLVD occurred: 117 with central nervous system diseases, 6 with peripheral nervous system diseases and 1 with both systems involved. Most patients were females (n=102), mean age was 63±15 years, and the majority presented with an apex-involving pattern. The most common disease described was subarachnoid hemorrhage (n=52), followed by stroke/transient ischemic attack (n=24), and seizures (n=18). TRLVD in neurological patients was often associated with need of inotropic support, orotracheal intubation, cerebrovascular spasm and delayed surgery. Conclusions: TRLVD is a complication of neurological diseases, in particular in female patients in post-menopausal phase. The predilection for neurological damage at or close to the insular cortex highlights the pivotal role of sympathetic over-activation. Many other similarities with tako-tsubo support the inclusion in a single SCM category.

Annals of Noninvasive Electrocardiology, 2012

We report about a case of a patient admitted to the Intensive Cardiac Care Unit for severe conges... more We report about a case of a patient admitted to the Intensive Cardiac Care Unit for severe congestive heart failure which showed modification of P-wave morphology and duration, correlated with the clinical evolution. In the case here described, we show that ECG analysis, specifically P wave, allow us to assess the hemodynamic evolution of the acute decompensated heart failure patient. Electrocardiographic examination is the first and the most simple and available diagnostic tool in the evaluation of patients with cardiac diseases. Usually, P-wave evaluation is not carefully assessed, in spite of very useful informations we can draw from its interpretation. We report about a patient admitted to our Intensive Cardiac Care Unit (ICCU) for severe congestive heart failure which showed peculiar modification of P-wave morphology and duration, well correlated with the clinical course.

The Canadian journal of cardiology, 2015

It is unknown whether implantable cardioverter-defibrillator (ICD) discharges actively contribute... more It is unknown whether implantable cardioverter-defibrillator (ICD) discharges actively contribute to a worse prognosis independent of the underlying arrhythmia. There is considerable variability in the reported risk of mortality after appropriate and inappropriate ICD shocks. The aim of our systematic review was to provide a reliable effect size of the association between ICD shock and mortality for both types of therapies. On the basis of a systematic literature search, 10 studies were considered eligible for inclusion in the analysis, and data on the hazard ratio (HR) of mortality after ICD shock were extracted from each study. On pooled analysis, a substantial difference was detected in the risk for subsequent mortality between appropriate and inappropriate shocks. Among patients receiving an appropriate ICD shock, the HR for cardiac death was 2.95 (95% confidence interval [CI], 2.12-4.11; P < 0.001) compared with an HR of 1.71 (95% CI, 1.45-2.02) for those receiving an inappr...