Introduction
Atrial fibrillation (AF) is the main cause of cardioembolic stroke. In high-bleeding-risk patients, long-life anticoagulation therapy is not permitted, and left atrial appendage (LAA) ...closure may be considered. LAA is also a critical substrate for AF. Epicardial LAA occlusion has several advantages: LAA ligation results in a favorable electrical and structural atrial remodeling, which decreases AF recurrence. Endocardial ablation alone is not efficient for all patients, and new evidence shows better outcomes in patients affected by persistent AF after a combined hybrid endo-epicardial ablation. Considering the synergic potential of these techniques, in this case series, they were both combined in a single procedure.
Methods and results
We describe the treatment of 5 patients referred for refractory AF ablation and LAA closure. All patients had high thrombotic and previous major hemorrhage, with relative contraindication to life-long therapy with anticoagulation. A combined procedure of LAA ligation and endo-epicardial ablation was scheduled with short-term anticoagulation. LAA closure was performed with an epicardial approach using the LARIAT system. Then, LA mapping and ablation were performed, endocardially and then epicardially.
All procedures were concluded without complications.
At follow-up, in all patients, transesophageal echocardiography showed the complete occlusion of the LAA; therefore, anticoagulation therapy was interrupted. All patients were asymptomatic, and in the sinus rhythm, no hemorrhage or ischemic events occurred.
Conclusion
The combination of percutaneous LAA ligation and endo-epicardial ablation was revealed to be feasible and safe and might represent a new approach for the treatment of refractory AF in patients with indication of LAA occlusion.
Background Cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) can identify areas of myocardial fibrosis in vivo in patients with hypertrophic cardiomyopathy (HCM). The ...aim of this study was to examine the association between clinical-morphological variables, risk factor for sudden death, and LGE findings in a consecutive, unselected population of HCM patients. Methods From January 2005 to August 2009, 124 HCM patients (53 ± 17 years, 86 men) were prospectively evaluated with CMR examination, assessing left ventricular (LV) hypertrophy, function, and LGE. Results In univariate analysis, patients were divided into tertiles according to the number of segments positive for LGE (first tertile, 0.3 ± 0.4; second tertile, 2.2 ± 0.4; third tertile, 5.2 ± 1.9 segments). Male gender ( P = .05), maximum LV wall thickness ( P = .002), nonsustained ventricular tachycardia ( P = .001), ejection fraction <50% ( P = .02), LV mass ( P = .02), left atrium dilation ( P = .04), perfusion defects ( P ≤ .001), and telesystolic volume ( P = .04) were all positively related with the number of segments of LGE. In multivariable analysis, male gender ( P = .007), maximum LV wall thickness ( P = .006), LV mass ( P = .031), and perfusion alterations ( P = .017) were independent predictors of LGE extent. Conclusions Our study shows an independent association, even at multivariate analysis, between the entity of LGE and maximum LV wall thickness, mass, and perfusion defects in patients with HCM. Whether the presence and the extent of LGE translates into clinical events later on awaits further long-term follow-up studies.
Anomalous fibromuscular bands in the left atrium were already described in the 19
th
century. Recently, the greater attention to the anatomy of the left atrium and the technological improvement have ...made their finding more frequent. Here, we present six cases, out of approximately 30,000 unselected echocardiograms, in which the use of the three-dimensional echo allowed a better definition of their anatomy, course, and motility.
Abstract
Background
Cardiac sarcoidosis (CS) is an inflammatory disease with various clinical presentations depending on the extension of cardiac involvement. The disease is often clinically silent, ...therefore diagnosis is challenging.
Case summary
We discuss the case of a middle-aged highly active individual presenting with an occasional finding of low heart rate during self-monitoring. The electrocardiogram shows a Mobitz 2 heart block; thanks to multimodality imaging CS was diagnosed and corticosteroid therapy improved cardiac conduction.
Discussion
To our knowledge, this is one of the first documented cases of occasional, early findings of CS in a middle-aged highly active individual who presented with cardiac conduction involvement. Despite the very early diagnosis, multimodality imaging suggested an advanced disease with no oedema detection at the cardiac magnetic resonance. Nevertheless, prompt corticosteroid therapy was able to improve clinical conduction. Although non-sustained ventricular arrhythmias were detected, electrophysiological study allowed to discharge the patient safely without implantable cardioverter-defibrillator implantation. Light-to-moderate physical activity was allowed at mid-term follow-up. A multidisciplinary evaluation should be considered to resume a high-intensity training.
Abstract
Background
Since 2014, European Guidelines have recommended using a novel clinical risk prediction model, called the HCM Risk-SCD, to identify which patients with hypertrophic cardiomyopathy ...(HCM) who are at higher risk for sudden cardiac death (SCD) and would benefit most from having a prophylactic cardioverter defibrillator (ICD) implantable. In recent years, evidence has called into question the effectiveness of this model in patient selection.
Material and Methods
Data from consecutive patients with HCM and ICD who were followed at our Cardiology Department from January 2000 to January 2022 were retrospectively collected.
Results
Among 702 HCM patients, 52 (7%) received an ICD (female, 31%; mean age at implantation, 49 ± 20; S-ICD, 13%; single-chamber ICD, 50%). Of them, 7 (13%) patients were implanted for secondary prevention while 45 (87%) for primary prevention. Out of the 45 primary prevention patients, 7 (16%) experienced 8 appropriate shocks (AS) while 10 (22%) had 15 inappropriate shocks (IS), during a mean follow up of 8 ± 5 years. Overall, mean HCM Risk-SCD score was 6.8 ± 4.7. Patients with AS showed a non-significant higher risk score when compared to non-AS subjects (7.1 ± 5.4 vs 4.8 ± 5.1, p=0.27). By stratifying study population according to pre-established and clinically adopted HCM Risk-SCD score cut-off (such as < 4 vs. > or = 4), we failed to highlight any significant difference in term of AS between groups. Indeed, out of 10 (22%) patients with HCM Risk-SCD score < 4, 3 (7%) experienced AS, while among 35 (78%) patients with HCM Risk-SCD score > or = 4, 4 (9%) had AS (30% vs. 11%, p=0.17).
Conclusions
The HCM Risk-SCD score does not seem to be able to predict the occurrence of life-threatening ventricular arrhythmias and AS in HCM patients. Our data highlight the need to elaborate a new score in order to improve SCD risk stratification and better select patients for ICD implantation.
Abstract
Introduction
Apical Hypertrophic Cardiomyopathy (ApHCM) characterized by persistent diastolic apical contraction results in dynamic apical small-vessel obstruction with microvascular ...ischemia. Of note, endomyocardial fibrosis (EMF) and calcification are described only in few patients.
Case presentation
We report 5 cases of ApHCM with apical intramyocardial calcification. They presented characteristic ECG pattern and fibrosis at echocardiogram. All patients presented a preserved ejection fraction (EF), except for one patient with mild reduced EF. Global longitudinal strain was reduced in 3 patients. Diastolic dysfunction was evidenced in 3 patients. Right ventricle involvement was detected in one patient only.On cardiac magnetic resonance, a superficial hypo-intense component, compatible with calcium and a deep layer featured by late gadolinium enhancement (LGE) related to fibrotic tissue, were revealed. LGE was present in all of patients in the apex. One patient presented an apical aneurysm, with high ESC-SCD risk score and ICD implantation.
Conclusion
EMF pathologic hallmarks were the endocardium and myocardium scarring, evolving to dystrophic calcification. In clinical practice, only a minority of ApHCM patients develops EMF and calcifications. Our clinical series is the largest one in literature. Analyzing patients’ history, a microvascular inflammatory trigger was evident in all of them, particularly severe chronic kidney disease, diabetes, high degree obesity, malaria infection, peripheral microangiopathy and form of thalassemia. This series could demonstrate the pathophysiological relation between apical fibrosis, calcification and microvascular ischemia due to hypertrophy and inflammatory conditions coexistence. A broader case series could evaluate any correlation with their long-term outcome and management strategies.
Abstract
Background
Subcutaneous ICD (S-ICD) is a safe and effective tool in preventing sudden cardiac death (SCD) and it has the potential to overcome the limitations of transvenous ICDs. Because of ...increased left ventricular mass and unpredictable electrical substrate, concerns regarding the safety and efficacy of S-ICD in hypertrophic cardiomyopathy (HCM) patients have been raised.
Material and Methods
We retrospectively collected clinical data from consecutive HCM patients who underwent ICD implantation and were followed at our Cardiology Department from January 2000 to January 2022.
Results
Among 702 HCM patients, 52 (7.4%) received an ICD (female, 30.7%; mean age at implantation, 49 ± 20; primary prevention, 86.5%; S-ICD, 13%; single-chamber ICD, 50%). During a mean follow up of 8 ± 5 years, 27 shocks occurred in 20 (38%) patients of which 11 appropriate shocks (AS) in 9 (17%) patients and 16 inappropriate shocks (IS) in 11 (21%) patients, respectively after 4.3 ± 3 and 5 ± 4 years. AS were due to ventricular tachycardia (7) and ventricular fibrillation (4) and occurred in 9 patients with transvenous ICD vs. 0 in S-ICD patients (100% vs. 0%, p=0.32). IS were due to AF (8), PSVT (3), sinus tachycardia (2), and oversensing (3), with a non-significant trend towards a higher rate in patients with transvenous ICD compared to those with S-ICD (33% vs 14%, p=0.41). Device-related complications (DC) were recorded in 14 (27%) patients and were secondary to lead fracture (6), pocket hematoma (3), pneumothorax (1), device malfunctioning (1), endocarditis (2), and venous thrombosis (1). Compared to S-ICD, transvenous ICD was associated with a non-significant higher risk of DC (31% vs. 0%, p=0.17).
Conclusions
In HCM patients at high risk of SCD, when compared to transvenous ICD, S-ICD is related to a non-significant lower rate of IS and DC, with similar rate of AS. Further randomized studies as well as large prospective registries are needed to confirm these findings.
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