bluuebunny/crossref_metadata_2025_split huggingface dataset:
986 LEFT VENTRICULAR LEAD PLACEMENT FOR BIVENTRICULAR PACING INTO A LEFT LATERAL VEIN IN PATIENT WITH CONGENITAL ATRESIA OF THE CORONARY SINUS OSTIUM WHO UNDERWENT AORTIC VALVE REPLACEMENT
Authors: Santoro Amato , Barilli Maria , Marallo Carmine , Cameli Matteo 
Published: December 2022

Abstract

Introduction
Coronary sinus ostial atresia (CSOA) is a rare congenital heart anomaly consisting in the occlusion of the coronary sinus (CS) outlet in the right atrium. It is one of the causes of placement left lead failure in CS during cardiac resynchronization therapy (CRT) device implantation. The persistence of the left superior vena cava is the most common pathway that allows venous blood flow to drain into the right atrium and can represent a new possible way to reach a left ventricular vein from the CS.

Methods
A 66-year-old male suffering from sarcoidosis was studied after an episode of syncope under exertion. EKG showed a 1st degree atrioventricular block and a left bundle branch block (LBBB) with wide QRS (170 ms). Echocardiography found left ventricle dilatation, severe systolic dysfunction, and a severe low-flow low-gradient aortic stenosis for which he underwent aortic valve replacement. After surgery and finding of 2nd degree type II atrioventricular block, CRT implant was performed but the procedure was complicated by the finding of CSOA. The insertion of the left quadripolar lead along a left branch of the occluded CS was achieved with a push-and-pull technique of the lead over a guidewire, after the retrieval and the cannulation of the persistent left superior vena cava.

Results
A new approach was applied on a rare case of CSOA found during CRT procedure. The contrast medium (CM) in the left subclavian vein revealed the existence of the left superior vena cava that was than cannulated. CM injection in CS highlighted a posterior left branch that was approached with a specific guidewire and a subselector after selective venography. With a fine technique of sliding of the lead on a tensioned guidewire, the quadripolar catheter was successfully placed in the left ventricular vein. Left-ventricle-right ventricle delays and catheter thresholds were tested and a final QSR duration of 90 msec in CRT mode was obtained.

Conclusions
This case-report shows a complex technique, reported in parallel with other similar procedures, to help the approach toward a rare anatomical variant of CSOA accompanied by persistent left superior vena cava when a CRT implant is needed after cardiac valve surgery in a patient suffering from sarcoidosis.
925 THE TWIDDLER'S SYNDROME: A CASE REPORT
Authors: Campana Nicola , Licciardi Marco , Pinna Gabriele , Soro Cinzia , Sara Santus , Mohammad Ahmad , Nissardi Vincenzo , Piras Alessandra , Cadeddu Dessalvi Christian , Roberta Montisci 
Published: December 2022

Abstract

Introduction
The Twiddler's syndrome is a rare condition of malfunctioning of a cardiovascular implantable elettronic device (CIED) due to the rotation of the device around its own long axis within its pocket. This brings to the leads wrapping around the device case and consequently dislocating, resulting in a deficit in sensing and pacing.

Case Report
We present the case of an 82-year-old woman, affect by atrial and conduction tissue disease for which was implanted a dual-chamber PaceMaker (PM). She arrived at the emergency department for asthenia and a traumatic syncopal episode, preceded by intense general malaise, nausea and vomiting. At EKG findings of electroinduced atrial rhythm, electroinduced ventricular rhythm with loss of capture and emergence of spontaneous rhythm, with subsequent resumption of capture. At device telemetry check, rise of ventricular and atrial pacing thresholds together with sporadic ventricular capture losses. Chest×Ray showed entanglement of leads around the PM case and retraction of the ventricular catheter.
Therefore, the patient was admitted to the cardiology department, and the surgical pocket was revised with case extraction and leads debridement with subsequent optimization of their position. The next day, following device telemetry check, which showed good electrical parameters, and the follow-up chest X-Ray, which was normal, the patient was discharged.

Conclusion
All physicians, particularly cardiologists, must pay close attention to the evaluation of patients with CIEDs. First of all, meticulous analysis of the EKG must be performed, which is capable of showing loss of capture and abnormal QRS morphologies due to cardiac pacing at abnormal locations. In addition, it is necessary to perform the telemetry check of the device, infact findings of sensing deficits and/or elevation of pacing thresholds indicate device malfunctioning, which is not necessarily due to leads injuries. Displacement of the leads can be easily detected with a chest X-ray, always remembering to rule out the presence of Twiddler syndrome, however rare it may be.
765 PULSED FIELD ABLATION FOR PULMONARY VEIN ISOLATION: PRELIMINARY RESULTS OF A SINGLE CENTER EXPERIENCE
Authors: Capone Silvia , Cauti Filippo Maria , Rossi Pietro , Magnocavallo Michele , Polselli Marco , Bianchi Stefano 
Published: December 2022

Abstract

Background
Pulsed Field Ablation (PFA) is a new and promising non-thermal ablation modality for Pulmonary Vein Isolation (PVI) for the treatment of patients with Atrial Fibrillation (AF). It preferentially ablates myocardial tissue via electroporation leading to minimal effects on surrounding structures. We sought to evaluate safety and efficacy of PFA in our single center experience.

Methods
PFA was performed at optimized bipolar biphasic waveform using Farapulse system. A protocol of 8 pulses per vein, 4 in the basket configuration and 4 in the flower configuration was followed. The procedure was performed under general anesthesia. Fluoroscopy was used to guide single transseptal puncture. 1 mg of atropine was administered before starting applications. One third of patients underwent CTI ablation using radiofrequency during the same procedure. In one patient we mapped the left atrium before and after ablation using a high-density mapping catheter.

Results
We prospectively enrolled 21 patients (76% men, age 58,6 ± 9) who underwent PVI using PFA from July to September 2022 for the treatment of Paroxysmal AF (81%) or Persistent AF (19%). Acute pulmonary veins isolation was achieved in the totality of patients. Median skin-to-skin procedure time and catheter dwell time were 56 minutes and 29 minutes respectively. Median fluoroscopy time was 12 minutes. The average number of total applications was 34 ± 4. No adverse events were observed. After a median follow-up of 77 days, we observed early AF recurrence in two patients.

Conclusion
Preliminary results of our singe center experience confirm that PFA is a safe and effective ablation modality. Pulmonary vein isolation can be achieved very rapidly with short procedural time, catheter dwell time and fluoroscopy time. Further studies are needed to assess durability of the technique.
651 ZERO FLUOROSCOPY CARDIAC ABLATION: A NOVEL WORKFLOW FOR ATRIAL FIBRILLATION
Authors: Raffele Martina De , Bertini Matteo , Malagu´ Michele , Vitali Francesco , Balla Cristina , Pompei Graziella , Fiorio Alessio , Trichilo Michele , Guardigli Gabriele 
Published: December 2022

Abstract

Background and Rationale
A fluoroscopy-based approach to an electrophysiological procedure is widely validated and has been recognized as the gold standard for a long time. The use of fluoroscopy exposes both the healthcare staff and the patient to a non-negligible dose of radiation. To minimize the risks associated with the use of fluoroscopy, it would be reasonable to perform ablation procedures with zero fluoroscopy. This approach is widely used in simple ablation procedures, but not in complex procedures. In atrial fibrillation (AF) ablation procedures, fluoroscopy remains the main technology used, particularly to guide the transseptal puncture.

Main results and Implications
We present a workflow to perform a complete zero-fluoroscopy ablation for AF ablation procedures using a 3D electro-anatomical mapping system, intracardiac echocardiography and a novel steerable guiding sheath that can be visualized on the mapping system. We present two AF ablation procedures, one performed on a patient with paroxysmal AF (Fig.1) and one with persistent AF (Fig. 2, Fig 3) during which we applied this novel workflow, achieving a successful pulmonary vein isolation without complications and complete zero-fluoroscopy exposure.
571 SUCCESSFUL PERMANENT PACEMAKER IMPLANTATION IN A PATIENT WITH DEXTROCARDIA AND SITUS INVERSUS TOTALIS: LOOKING AT THE MIRROR.
Authors: Paolantonio Diana Di , Guida Giuseppina , Caravati Fabrizio , Ponti Roberto De 
Published: December 2022

Abstract

Background
Dextrocardia is a rare congenital condition with a prevalence of 0.83 per 10000 pregnancies. Its most common configuration is situs inversus totalis, also known as “mirror-image dextrocardia”. This case report presents a clinical case of symptomatic sinus node dysfunction requiring permanent pacemaker implantation (PPI) in a patient with mirror-image dextrocardia.

Case summary
A 81-year-old female patient with known situs inversus totalis presented with recurrent syncope. Sick sinus syndrome was diagnosed after documentation of critical pauses (&gt;6.3”) at 24-hour Holter monitoring, giving indication to elective PPI.
At admission, 12-lead ECG showed sinus bradycardia and right axis deviation on the frontal plane (standard peripheral leads position and precordial leads on the right side of the chest).
Transthoracic echocardiography was performed prior to the procedure with the ultrasound probe flipped and placed on the patient's right side of the thorax, thus achieving standard echocardiography windows and images. A preserved biventricular systolic function and the absence of relevant valvular disease or cardiac malformations was documented.
The next day, a dual-chamber pacemaker was implanted following standard technique with the operator standing on the right side of the patient and with right subclavian vein puncture; the pacemaker pocket was created in the right pectoral region. The entire procedure was performed under fluoroscopic guidance using horizontally 180° flipped views, therefore obtaining identical images to those of standard PPI procedures, helping the operator identify anatomical structures during lead positioning. [Fig. 1 a - b]
Chest X-ray confirmed correct pacemaker lead placement and absence of procedure-related complications. Stable and satisfactory lead parameters were observed at follow-up.

Discussion
In literature there are only a few case reports on PPI in situs inversus totalis. The symmetrical disposition of the anatomy makes transvenous PPI technically demanding. In this case the challenge was overcome by using flipped fluoroscopy images, to facilitate lead positioning maneuvres. This technique can be considered only in situs inversus totalis and not in other forms of dextrocardia, such as dextroversion and destroposition, because it is the only situation in which the anatomy is the mirror image of the normal one.
226 ECHOCARDIOGRAPHIC AND INVASIVE EVALUATION OF LEFT ATRIAL PRESSURE IN PATIENTS UNDERGOING CATHETER ABLATION FOR ATRIAL FIBRILLATION
Authors: Bonelli Andrea , Inciardi Riccardo Maria , Cersosimo Angelica , Dell´era Gabriele , Degiovanni Anna , Spinoni Enrico , Bosco Manuel , Arabia Gianmarco , Salghetti Francesca , Bellicini Mariagiulia , Brangi Elisa , Legati Michele , Pagnesi Matteo , Lombardi Carlo Mario , Curnis Antonio , Patti Giuseppe , Metra Marco 
Published: December 2022

Abstract

Aims
Estimation of left ventricle (LV) filling pressure is one of the most important parameters to provide information in clinical practice. However, the challenging in investigating this parameter through invasive methods makes it difficult to be used. The study aims to investigate the association between cardiac structure and function derived by transthoracic echocardiography (TTE) and left atrial (LA) invasive pressure (LAP).

Methods
The study was a multi-center prospective study enrolling 73 patients (mean age 65 ± 8, 27% female) undergoing primary catheter ablation for AF. Patients were evaluated and enrolled from June 2021 to April 2022. Complete TTE assessing measures of LV, LA and right ventricle (RV) structure and function including speckle tracking echocardiography, was performed at baseline.
Echocardiographic data have been assessed the same day of the invasive measurement of the LAP during AF ablative procedure. Linear regression analysis has been performed to assess the relationship between measures of cardiac structure and function and LAP. Logistic regression analysis assessed the parameters associated with elevated LAP (≥ 15mmHg).

Results
Baseline clinical characteristics of the study population did not differ according to elevated LAP vs. non-elevated LAP. Patients with elevated LAP showed instead abnormal measures of LV global longitudinal strain, measures of LA structure and function, except for LA maximal volume, and RV structure and function. After multivariable adjustment, including demographic factors and comorbidities, E/e`(p = 0,024), LA minimal volume (p = 0,009), LA emptying fraction (LAEF) (p = 0,012), LA Reservoir (p = 0,039), TAPSE (p = 0,010) and RV free wall strain (p = 0,028), but not LA maximal volume (p = 0,11), were significantly associated with LAP. Similarly, these measures, but nor LA maximal volume, were significant determinants of elevated LAP. Overall, LA minimal volume and LAEF showed the best diagnostic accuracy to predict elevated LAP (AUC 0.72 and 0.73, respectively).

Conclusions
Novel measures of LA structure and function, but not standard assessment by LA maximal volume, were significantly associated with LAP in patients affected by AF. These measures, along with measures of LV and RV function may be used in the diagnostic assessment of filling pressure in ambulatory settings.
892 ELECTRICAL STORM IN ISCHAEMIC HEART DISEASE: A CASE OF LEFT STELLATE GANGLION BLOCK AS BRIDGE TO URGENT PCI RESCUE
Authors: Mancini Nastasia , Crea Pasquale , Dattilo Giuseppe , Costa Francesco , Vizzari Giampiero , Baldi Enrico , Luzza Francesco , Carerj Scipione , Micari Antonio , Di Bella Gianluca 
Published: December 2022

Abstract
A 73 year-old man was admitted for syncope and sustained ventricular arrhythmia complicated by cardiogenic shock treated with electrical cardioversion and restoration of sinus rhythm.
Former smoker, he suffered by arterial hypertension, hypercholesterolemia and known heart failure with reduced ejection fraction. In the 1995 the patient underwent aortic valve replacement surgery with a mechanical prosthetic valve. The patient underwent coronary angiography that showed multivessel coronary artery disease with functional occlusion of posterior interventricular artery (rehabilitated by hetero-coronary circles) and critical stenosis of the middle left anterior descending artery. In this angiographic framework, the indication was collegial revaluation considering other patient's comorbidities (chronic renal dysfunction, mitral moderate-severe regurgitation). The patient underwent ICD implantation for secondary prevention.
Despite maximal medical therapy, the patient experienced new episodes of sustained VT complicated by hemodynamic instability. Hypokalemia, hypomagnesemia and hyperthyroidism were excluded as triggering factors for arrhythmias on laboratory investigations. In the following days due to persistent and symptomatic arrhythmias, configuring electrical storm, we decided to proceed with anatomical stellate ganglion block, guarantying a free interval from ventricular arrhythmia about six hours. The anesthetic has been injected at the C6 or C7 vertebral level with the Chassignac's tubercle, the cricoid cartilage, and the carotid artery serving as the anatomic landmarks to the procedure. An aspiration test must be done to avoid the suction of blood or cerebrospinal fluid, then a local anesthetic is injected, and the diffusion of the injectate is seen in real-time. Local anesthetic (lidocaine mixed with bupivacaine) is injected until the fluid spread along the paravertebral fascia to the stellate ganglion. The period free from VA allowed us to transfer the patient in another center in order to receive myocardial revascularization supported by ECMO. Left ganglion stellate block has a central role in the treatment of the refractory ventricular arrhythmias and may offer effective arrhythmia control giving time to rescue and/or other bridge therapy. In our case, it had a key role to perform an inter-hospital transfer and subsequent “rescue PCI therapy”. Thanks to Stellate ganglion block, the sinus rhythm was retained immediately, there were no ventricular tachycardia episodes for at least six hours allowing to perform myocardial revascularization supported by ECMO. No further ventricular arrhythmias occurred after revascularization, corroborating the ischemic trigger of electrical storm.
756 ZERO OR NEAR ZERO FLUOROSCOPY CATHETER ABLATION OF PREMATURE VENTRICULAR CONTRACTIONS: A MULTICENTRE EXPERIENCE
Authors: Mugnai Giacomo , Velagic Vedran , De Asmundis Carlo , Malagù Michele , Tomasi Luca , Bolzan Bruna , Chierchia Gian-battista , Stroker Erwin , Bertini Matteo 
Published: December 2022

Abstract

Background
Catheter ablation has become an established treatment option for premature ventricular complexes (PVCs). It is well known that the use of fluoroscopy exposes patients and medical staff to potentially harmful stochastic and deterministic effects of ionising radiations.
We sought to analyse procedural outcomes in terms of safety and efficacy using a “zero” or “near zero” X rays approach for treatment of PVCs.

Methods
The present retrospective, multicentre, observational study included 131 patients having undergone catheter ablation of PVCs using zero or “near zero” (less than 2 minutes) fluoroscopy between 2016 and 2020 in 4 high-volume centres. Baseline characteristics of the population, acute success and complications derived from the procedure were evaluated, as well as recurrence rate during follow-up.

Results
Median age was 51.0 years old [38-63], males were 77 (58.8%). Most often cause of ablation were palpitations (90.0%), followed by reduced left ventricular ejection fraction (4.6%) and pre-syncope (14.5%). Among the study population, 26 (19.8%) had a cardiopathy. The median PVC burden before ablation was 15.1% [6%-22.4%]. The most frequent PVC origin was right ventricular outflow tract (n=72; 55.0%) followed by the left ventricle (n=21; 16.0%), LVOT and cusps (n=18; 13.7%),aortomitral continuity (n=7; 5.3%).
A 3D electro-anatomical mapping system was used in all cases as well as a contact force catheter for mapping and ablation. The mean maximum radiofrequency power applied was 32.9 ± 4.1 W (median time: 370 sec). Median number of applications was 4.5 and mean total procedural time was 117.3 ± 47.5 minutes. Median best prematurity was 31.5 msec. We used isoprenaline in order to induce PVCs in 42% of cases and suppression of PVC was achieved in 127 patients (96.9%). There was only 2 complication (femoral hematoma and arteriovenous fistula conservatively treated). At 12 months, a complete success was documented in 109 patients (83.2%), a reduction in PVC burden was achieved in other 18 patients (13.7%) and a failure was recorded in 4 patients (3.1%).

Conclusion
The PVC ablation with “zero” or “near-zero” fluoroscopy is a safe procedure with no major complications and good rates of success and recurrence in our multicentre experience.
193 13 SECONDS OF ASYSTOLE IN YOUNG: IS A PACEMAKER NECESSARY?
Authors: Petrungaro Mattia , Berton Giampaolo , Scarà Antonio , Borrelli Alessio , Latorre Maria , Ruvo Ermenegildo De , Sciarra Luigi , Calò Leonardo 
Published: December 2022

Abstract

Introduction
Cardioinhibitory neurocardiogenic syncope (CNS) is caused by inappropriately trigger-activated cardiac reflex which finally precipitates asystole, sinus bradycardia, or atrioventricular block. In the absence of structural heart disease, the prognosis is excellent, but frequent syncopal episodes can have a significant impact on quality of life. No medical therapy has proved to be really effective and studies concerning pacemaker implantation are often controversial. However, in young individuals, especially those under 40 years of age, implanting a pacemaker may carry more risks than benefits. Thus, alternative techniques such as ablation of the cardiac atrial parasympathetic ganglia (GP) have emerged.

Case report
A 34-year-old man with frequent episodes of reflex syncope performed a tilt test in March 2022 that diagnosed cardio-inhibitory syncope with 13-second asystole interrupted with external cardiac massage and intravenous atropine. In May 2022 he had an MRI scan showing normal biventricular systolic function and absence of late-gadolinium enhancement and underwent loop recorder implantation. He came to our centre in June 2022 and underwent electrophysiological study and electroanatomical mapping of the right atrium (Carto 3) during general anaesthesia. The anatomical areas of the supero-posterior and infero-posterior GPs of the right atrium were identified by electroanatomical mapping of complex fractionated atrial electrograms (CFAE). Radiofrequency pulses (Thermocool 30 watts) were delivered at these points, resulting in the disappearance of the CFAEs and an increase in basal heart rate. The greatest number of ganglia are allocated on the posterior surface of the right atrium and in particular the supero-posterior GP is the nexus point for vagal input to the GPs before innervating the atria. Therefore, it was decided to localise and ablate exclusively the GPs of the right atrium. The procedure was completed without complications. The patient has not complained of any syncopal episodes since, and the loop has not recorded any significant pauses.

Conclusions
The anatomic ablation of GP only in the right atrium could represent a feasible method to reduce CNS, to increase the warning symptoms period, and to delay as much as possible pacemaker implant, especially in young patients who have experienced a related physical trauma. This approach significantly decreased the procedural time and risks.