Massimo Zecchin

BACKGROUND: The role of atrial pacing support is unclear in patients receiving cardiac resynchronization therapy–defibrillator (CRT-D) without sinus node dysfunction. METHODS: We conducted a randomized, parallel-group, noninferiority trial to evaluate whether a 2-lead CRT-D capable of atrial sensing (but no pacing) by a floating dipole on the right ventricular lead (CRT-DX) is not inferior to a 3-lead CRT-D with a conventional atrial lead. Between October 17, 2018, and March 5, 2024, a total of 636 patients (68±10 years old, 28.6% women) with standard CRT-D indication, optimized medical therapy, and resting sinus rate ≥45 beats/min were randomized 1:1 to CRT-DX (atrial tracking without atrial pacing mode 35 beats/min) or CRT-D (atrial tracking with atrial pacing mode 50 beats/min) at 23 Italian sites. A centralized block-randomization procedure stratified by site was used, with patients and primary outcome assessors blinded to treatment assignment. The primary end point was a 1-year composite of all-cause mortality, cardiovascular hospitalization, and lead-related complications (loss of functionality not correctable by device reprogramming). Secondary end points included each individual component of the primary end point separately, echocardiographic reverse remodeling, and 6-minute walk test distance at 12 months. RESULTS: The primary end point occurred in 41 (13.1%) patients in the CRT-DX group and 47 (15.6%) patients in the CRT-D group, corresponding to a hazard ratio of 0.82 (95% CI, 0.54–1.25). This confirmed noninferiority (prespecified relative margin of 1.20) in both the per-protocol ( P =0.039) and intention-to-treat ( P =0.044) analyses. Individual components showed no significant differences, except for lead complications related to right atrial functionality (4 [1.3%] patients in the CRT-DX group versus 13 [4.2%] patients in the CRT-D group; P =0.040). Reverse remodeling responders were 203 (77.5% of 262) patients receiving CRT-DX and 190 (76.3% of 249) patients receiving CRT-D ( P =0.83). Walking distance did not differ between 2 study arms (404 versus 398 m; P =0.62). After a median follow-up of 2.4 years, only 1 patient receiving CRT-DX required implantation of a standard atrial lead. CONCLUSIONS: The 2-lead CRT-DX system without atrial pacing is noninferior to conventional 3-lead CRT-D, with fewer atrial lead–related complications. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03587064.

Myotonic dystrophy is a hereditary disorder with systemic involvement. The Italian Neuro-Cardiology Network-“Rete delle Neurocardiologie” (INCN-RNC) is a unique collaborative experience involving neurology units combined with cardio-arrhythmology units. The INCN facilitates the creation of integrated neuro-cardiac teams in Neuromuscular Disease Centers for the management of cardiovascular involvement in the treatment of myotonic dystrophy type 1 (MD1).

Myotonic dystrophy is a hereditary disorder with systemic involvement. The Italian Neuro-Cardiology Network (INCN-RNC) is a unique collaborative experience involving neurology units combined with cardio-arrhythmology units. The INCN facilitates the creation of integrated neuro-cardiac teams in Neuromuscular Disease Centers for the management of cardiovascular involvement in the treatment of MD1.

Le cardiomiopatie sono malattie primitive del miocardio con importante componente genetica. Esordiscono in genere tra i 30 e i 50 anni e sono le più comuni cause di morte improvvisa e scompenso cardiaco nel giovane adulto. Le principali cardiomiopatie riscontrate nella pratica clinica sono la cardiomiopatia dilatativa, la cardiomiopatia aritmogena e la cardiomiopatia ipertrofica. Nonostante il progresso delle conoscenze degli ultimi anni, reso possibile in particolare dalla diffusione di tecniche di sequenziamento genico di nuova generazione e da metodiche di imaging avanzate, la diagnosi, l’inquadramento eziologico e la gestione delle cardiomiopatie rimangono complessi e per alcuni aspetti controversi. Questa rassegna ha lo scopo di proporre delle flow-chart operative, integrando le più recenti evidenze scientifiche con i protocolli gestionali del Dipartimento Cardiotoracovascolare dell’Ospedale di Trieste, uno dei Centri di riferimento nazionali per le cardiomiopatie e lo scompenso cardiaco con esperienza trentennale in tale ambito.

The aim of this document is the management and organization of patients in need of urgent access to electrophysiology (EP) and pacing procedures during the COVID-19 emergency. Specifically, non-deferrable procedures or irreplaceable with a drug therapy prior to the resolution of the COVID-19 virus emergency [pacemaker (PM) implant/replacement/urgent defibrillator (implantable cardioverter-defibrillator, ICD) or arrhythmic storm or other indication of non-deferrable ablation]. The pacing and electrophysiological procedures urgent as they may be, less and less frequently represent situations of emergency, therefore for almost all cases, it is possible to perform a swab test to determine the positivity to COVID-19 of the patient. In cases where this is not possible, due to situations of emergency, the recommendations and procedures we have indicated are advisable, if not mandatory, in order to avoid the spreading of the virus to healthcare personnel and other patients.

A 64-year-old man underwent catheter ablation (CA) of atrial fibrillation with intracardiac echocardiography (ICE) assistance. As the probe was advanced toward the right atrium, sudden abdominal pain was felt by the patient with hypotension and tachycardia requiring fluids and vasopressors for hemodynamic stabilization. The inferior vena cava (IVC) was injured by the passing probe and open repair was then performed. To our knowledge, this is the first reported case of symptomatic IVC laceration by the probe used for ICE during CA.

Aim: During radiotherapy, in patients with implantable cardioverter-defibrillators (ICDs) malfunctions are considered more likely if doses more than 2 Gy reach the ICD site; however, most malfunctions occur with high-energy (>10 MV) radiations, and the risk is less defined using 6-MV linear accelerators. The purpose of the study is to experimentally evaluate the occurrence of malfunctions in ICDs radiated with a 6-MV linear accelerator at increasing photon doses. Methods: Thirty-two ICDs from all manufacturers (31 explanted and one demo) were evaluated; all devices with a sufficient battery charge underwent multiple radiations with a 6-MV photon beam reaching a cumulative dose at ICD site of 0.5, 1, 2, 3, 5 and 10 Gy and interrogated after every session. All antitachycardia therapies were left enabled; two ICDs were connected to a rhythm simulator (one simulating a complete atrioventricular block without ventricular activity) and visually monitored by external ECG and the ICD programmer during radiation. Results: Thirteen ICDs were excluded before radiation because of battery depletion; after radiation up to the cumulative dose at the cardiac implantable electronic device site of 10 Gy, in the remaining 19 devices, programmation and battery charge remained unchanged and no switch to safety mode was observed; oversensing, pacing inhibition or inappropriate antitachycardia therapy were neither recorded nor visually observed during radiation. Conclusion: With a low-energy accelerator, neither malfunctions nor electromagnetic interferences were detected radiating the ICDs at doses usually reaching the ICD pocket during radiotherapy sessions. In this context, magnet application to avoid oversensing and inappropriate therapy seems, therefore, useless.