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ABSTRACT: Intracardiac echo has been widely used to guide electrophysiological procedures and particularly atrial fibrillation ablation. The image refers to a case of transseptal puncture guided by intracardiac echo, with detection of a thrombus over the sheath just before the passage in the left atrium. This allowed the avoidance of a possible serious complication.
Journal of Cardiovascular Medicine 05/2013; · 1.51 Impact Factor
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Leonardo Calò,
Alessio Gargaro, Ermenegildo De Ruvo,
Gabriele Palozzi,
Luigi Sciarra,
Marco Rebecchi,
Fabrizio Guarracini,
Alessandro Fagagnini,
Enrico Piroli,
Ernesto Lioy,
Antonio Chirico
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ABSTRACT: INTRODUCTION: Few data are available on actual follow-up costs of remote monitoring (RM) of implantable defibrillators (ICD). Our study aimed at assessing current direct costs of 1-year ICD follow-up based on RM compared with conventional quarterly in-hospital follow-ups. METHODS AND RESULTS: Patients (N = 233) with indications for ICD were consecutively recruited and randomized at implant to be followed up for 1 year with standard quarterly in-hospital visits or by RM with one in-hospital visit at 12 months, unless additional in-hospital visits were required due to specific patient conditions or RM alarms. Costs were calculated distinguishing between provider and patient costs, excluding RM device and service cost. The frequency of scheduled in-hospital visits was lower in the RM group than in the control arm. Follow-up required 47 min per patient/year in the RM arm versus 86 min in the control arm (p = 0.03) for involved physicians, generating cost estimates for the provider of USD 45 and USD 83 per patient/year, respectively. Costs for nurses were comparable. Overall, the costs associated with RM and standard follow-up were USD 103 ± 27 and 154 ± 21 per patient/year, respectively (p = 0.01). RM was cost-saving for the patients: USD 97 ± 121 per patient/year in the RM group versus 287 ± 160 per patient/year (p = 0.0001). CONCLUSION: The time spent by the hospital staff was significantly reduced in the RM group. If the costs for the device and service are not charged to patients or the provider, patients could save about USD 190 per patient/year while the hospital could save USD 51 per patient/year.
Journal of Interventional Cardiac Electrophysiology 03/2013; · 1.17 Impact Factor
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Ermenegildo de Ruvo,
Serena Dottori,
Luigi Sciarra,
Marco Rebecchi,
Borrelli Alessio,
Scarà Antonio,
Lucia De Luca,
Anna Maria Martino,
Fabrizio Guarracini,
Alessandro Fagagnini,
Ernesto Lioy,
Leonardo Calò
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ABSTRACT: PURPOSE: Cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFL) has become the preferred treatment for this arrhythmia. The aims of this study were to assess the impact of respiratory gating (RG) on electroanatomical mapping of CTI and to assess the efficiency of CTI ablation guided by the Carto3® system equipped with the new respiration gating software. METHODS: Forty-four consecutive patients (mean age, 60 ± 13 years; 25 male) undergoing cavotricuspid ablation for symptomatic common AFL were randomly assigned to CARTO™ mapping with or without enabling RG module (Group A, RG OFF, Group B, RG ON). RESULTS: A significant reduction in mean RA volume, CTI central length and CS ostium maximum diameter has been observed in the RG maps. The mean total procedural, fluoroscopy and radiofrequency (RF) time were 102.9 ± 35.3, 10.6 ± 3.3, 22.9 ± 14.2 min in group A and 75.3 ± 21.7, 3.6 ± 4.5, 10.4 ± 5.7 min in group B, respectively (p < 0.05). CONCLUSIONS: Electroanatomical mapping systems' accuracy may be strongly influenced by respiration movements. The current study showed that automatic respiratory gated acquisition resulted in a better visualization of CTI, and this determines a relevant reduction in fluoroscopy and RF times.
Journal of Interventional Cardiac Electrophysiology 10/2012; · 1.17 Impact Factor
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Journal of Interventional Cardiac Electrophysiology 03/2012; 34(3):231-5. · 1.17 Impact Factor
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Leonardo Calò,
Marco Rebecchi,
Luigi Sciarra,
Lucia De Luca,
Alessandro Fagagnini,
Lorenzo Maria Zuccaro,
Pietro Pitrone,
Serena Dottori,
Maurizio Porfirio, Ermenegildo de Ruvo,
Ernesto Lioy
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ABSTRACT: Catheter ablation of ganglionated plexi (GP) in the left atrium has been proposed in different subgroup of patients with atrial fibrillation (AF). Anatomic studies found a high prevalence of GP in the posterior surface of the right atrium (RA). Experimental data suggested the potential role of right atrial GP in the AF initiation and maintenance. The aim of our study was to assess the efficacy of GP ablation in RA in patients with vagal AF.
Thirty-four patients without structural heart diseases were randomly assigned for a selective ablation procedure targeted on the elimination of vagal reflex evoked by high frequency stimulation or an extensive approach at anatomic sites of GP. All patients underwent Holter ECG and heart rate variability evaluation at baseline and at 3, 6, 12, and 18 months of follow-up. At a mean follow-up of 19.7±5.2 months, AF recurred in 5 of 17 patients with anatomic ablation and in 13 of 17 patients with a selective approach (P=0.01). No patient had major complications. After ablation, heart rate variability parameters showed a significant parasympathetic (and sympathetic) denervation in the first 6 months, which was more prominent in patients with anatomic GP ablation and in those without AF recurrence.
This study demonstrates that in a selected population of vagal paroxysmal AF, the anatomic ablation of GPs in the RA is effective in about 70% of patients. These results confirm that atrial vagal denervation can abolish AF, as suggested by experimental and clinical data.
Circulation Arrhythmia and Electrophysiology 12/2011; 5(1):22-31. · 6.46 Impact Factor
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Leonardo Calò,
Tiziana De Santo,
Francesca Nuccio,
Luigi Sciarra,
Lucia De Luca,
Lorenza Mangoni di S Stefano,
Enrico Piroli,
Lorenzo Zuccaro,
Marco Rebecchi, Ermenegildo de Ruvo,
Ernesto Lioy
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ABSTRACT: Microvolt T-wave alternans (MTWA) has been proposed as a predictor of the risk of ventricular tachyarrhythmias (VT) and sudden cardiac death (SCD). Aim of this study was to perform a systematic review of the literature and a meta-analysis of MTWA in primary prevention patients with ischemic and nonischemic cardiomyopathy.
The positive predictive value (PPV), negative predictive value (NPV), and relative risk (RR) of MTWA in predicting death, cardiac death, and SCD during follow-up were reported.
Fifteen studies involving 5681 patients (mean age 62 years, mean ejection fraction 32%) were included. The summary PPV during the average 26-month follow-up was 14% (95% CI: 13-15); NPV was 95% (95% CI: 94-96), and the univariate RR was 2.35 (95% CI: 1.68-3.28). The predictive value of MTWA was similar in patients with ischemic and nonischemic cardiomyopathy. The average RR for SCD or VT events of an abnormal MTWA was 2.40, similar to that for cardiac death. When we grouped the studies together depending upon whether beta-blockers were withheld prior to MTWA screening, the beta-blockers group showed an RR of 5.88. By contrast, the group in which beta-blocker therapy was withheld had an RR of 1.63.
A positive MTWA determined an approximately 2.5-fold higher risk of cardiac death and life-threatening arrhythmia and showed a very high NPV both in ischemic and nonischemic patients. An abnormal MTWA test was associated with a 5-fold increased risk for cardiac mortality in the low-indeterminate group and about a 6-fold increased risk in beta-blockers group.
Annals of Noninvasive Electrocardiology 10/2011; 16(4):388-402. · 1.10 Impact Factor
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ABSTRACT: We present the case of a patient with a heart failure episode induced by acute right ventricular pacing. After reversal of beta-blockers because of chronic obstructive pulmonary disease (COPD) exacerbation, the following sinus tachycardia caused a 2:1 atrioventricular block and consequent continuous right ventricular pacing. He was treated with the selective I(f) inhibitor ivabradine, that reduced both ventricular pacing percentage and heart rate without affecting atrioventricular conduction. Ivabradine may be a valuable option in treatment of patients with atrioventricular conduction disturbances.
Indian pacing and electrophysiology journal 09/2011; 11(5):149-52.
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Europace 04/2011; 13(8):1194. · 1.98 Impact Factor
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Rong Bai,
Luigi Di Biase,
Prasant Mohanty,
Aaron B Hesselson, Ermenegildo De Ruvo,
Peter L Gallagher,
Claude S Elayi,
Sanghamitra Mohanty,
Javier E Sanchez,
J David Burkhardt, [......],
Shane M Bailey,
Jason D Zagrodzky,
Robert Canby,
Monia Minati,
Larry D Price,
C Lynn Hutchins,
Melody A Muir,
Leonardo Calo,
Andrea Natale,
Gery F Tomassoni
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ABSTRACT: Intraoperative modality for "real-time" left ventricular (LV) dyssynchrony quantification and optimal resynchronization is not established. This study determined the feasibility, safety, and efficacy of intracardiac echocardiography (ICE), coupled with vector velocity imaging (VVI), to evaluate LV dyssynchrony and to guide LV lead placement at the time of cardiac resynchronization therapy (CRT) implant.
One hundred and four consecutive heart failure patients undergoing ICE-guided (Group 1, N = 50) or conventional (Group 2, N = 54) CRT implant were included in the study. For Group 1 patients, LV dyssynchrony and resynchronization were evaluated by VVI including visual algorithms and the maximum differences in time-to-peak (MD-TTP) radial strain. Based on the findings, the final LV lead site was determined and optimal resynchronization was achieved. CRT responders were defined using standard criteria 6 months after implantation.
Both groups underwent CRT implant with no complications. In Group 1, intraprocedural optimal resynchronization by VVI including visual algorithms and MD-TTP was a predictor discriminating CRT response with a sensitivity of 95% and specificity of 89%. Use of ICE/VVI increased number of and predicted CRT responders (82% in Group 1 vs 63% in Group 2; OR = 2.68, 95% CI 1.08-6.65, P = 0.03).
ICE can be safely performed during CRT implantation. "Real-time" VVI appears to be helpful in determining the final LV lead position and pacing mode that allow better intraprocedural resynchronization. VVI-optimized acute resynchronization predicts CRT response and this approach is associated with higher number of CRT responders.
Journal of Cardiovascular Electrophysiology 04/2011; 22(9):1034-41. · 3.06 Impact Factor
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Luigi Sciarra,
Marco Rebecchi, Ermenegildo De Ruvo,
Lucia De Luca,
Lorenzo Maria Zuccaro,
Alessandro Fagagnini,
Leonardo Corò,
Giuseppe Allocca,
Ernesto Lioy,
Pietro Delise,
Leonardo Calò
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ABSTRACT: Supraventricular tachycardia may trigger atrial fibrillation (AF). The aim of the study was to evaluate the prevalence of supraventricular tachycardia (SVT) inducibility in patients referred for AF ablation and to evaluate the effects of SVT ablation on AF recurrences.
Two hundred and fifty-seven patients (185 males; mean age: 53.4 ± 14.6 years) referred for AF ablation were studied. In all patients only AF relapses had been documented in the clinical history. Twenty-six patients (10.1%; mean age: 43.4 ± 13.3 years; 17 males) had inducible SVT during electrophysiological study and underwent an ablation targeted only at SVT suppression. Ablation was successful in all 26 patients. The ablative procedures are: 12 slow-pathway ablations for atrioventricular nodal re-entrant tachycardia; 9 concealed accessory pathway ablations for atrioventricular re-entrant tachycardia; and 5 focal ectopic atrial tachycardia ablations. No recurrences of SVT were observed during the follow-up (21 ± 11 months). Two patients (7.7%) showed recurrence of at least one episode of AF. Patients with inducible SVT had less structural heart disease and were younger than those without inducible SVT (interventricular septum thickness: 8.4 ± 1.6 vs. 11.0 ± 1.4 mm, P < 0.01; left atrial diameter: 37.0 ± 3.0 vs. 44.0 ± 2.2 mm, P < 0.01; age: 43.4 ± 13.3 vs. 57.3 ± 11.2 years, P < 0.01). Prevalence of paroxysmal AF was higher in patients with inducible SVT when compared with those with only AF (84.6 vs. 24.6%, P < 0.01).
A significant proportion of candidates to AF ablation are inducible for a SVT. SVT ablation showed a preventive effect on AF recurrences. Those patients should be selected for simpler ablation procedures tailored only on the triggering arrhythmia suppression.
Europace 12/2010; 12(12):1707-12. · 1.98 Impact Factor
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ABSTRACT: Atrial fibrillation is the most common arrhythmia in clinical practice. Ion channel blocking agents are often characterized by limited long-term efficacy and several side effects. In addition, ablative invasive procedures are neither easily accessible nor always efficacious. The "upstream therapy," which includes angiotensin-converting enzyme inhibitors, aldosterone receptor antagonists, statins, glucocorticoids, and ω-3 poly-unsaturated fatty acids, targets arrhythmia substrate, influencing atrial structural and electrical remodeling that play an essential role in atrial fibrillation induction and maintenance. The mechanisms involved and the most important clinical evidence regarding the upstream therapy influence on atrial fibrillation are presented in this review. Some open questions are also proposed.
Pacing and Clinical Electrophysiology 10/2010; 34(1):111-28. · 1.35 Impact Factor
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ABSTRACT: A relative high rate of clinical and device-related adverse events (AE) is generally reported in patients with implantable defibrillators for cardiac resynchronization therapy (CRT-D). Aim of this study was to compare a daily remote monitoring (RM) to a standard program of in-office visits.
We retrospectively analyzed RM database and hospital files of 99 CRT-D consecutive patients who were visited in the out-patient clinic every 3-4 months; thirty-three patients were in addition controlled remotely with RM (RM group). Kaplan-Meier curves of clinical or device-related AE-free rates were obtained. During a median follow-up of 7 months, clinical AEs were: ventricular and atrial arrhythmias in 14 and 11 patients, low CRT pacing in nine, heart failure, strokes, or death in 15. Device-related AEs were: insufficient pacing/sensing performances in nine patients, lead dislodgement in five. As comparing the RM group with the remaining patients, Kaplan-Meier curves of clinical AEs diverged to significantly different rates: 23.8% (confidence interval [CI] 0.1%-47.5%) in the RM group and 48.7% (21.6-75.7%) in the remaining patients (P = 0.00002), with a hazard ratio of 0.14 (CI 0.06-0.37). Nondivergent Kaplan-Meier curves were obtained for device-related AE-free rates.
CRT-D patients followed with quarterly in-office visits without a daily RM system had an 86% higher risk of delayed detection of clinical AEs, during a median follow-up of 7 months.
Pacing and Clinical Electrophysiology 10/2010; 34(2):208-16. · 1.35 Impact Factor
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Leonardo Calò,
Marco Rebecchi,
Antonella Sette,
Annamaria Martino, Ermenegildo de Ruvo,
Luigi Sciarra,
Lucia De Luca,
Lorenzo Maria Zuccaro,
Giuseppe Giunta,
Antonio Ciccaglioni,
Ernesto Lioy,
Francesco Fedele
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ABSTRACT: Inappropriate sinus tachycardia (IST) is characterized by an elevated heart rate (HR) at rest and an exaggerated HR response to physical activity or emotional stress. Beta-blockers and calcium channel blockers are the first-line therapy but sometimes are poorly tolerated due to side effects.
The purpose of this study was to evaluate the efficacy and safety of ivabradine, a selective inhibitor of the I(f) current of the sinoatrial node, in patients affected by IST.
Eighteen consecutive symptomatic patients (2 men and 16 women; mean age 45 +/- 15 years) affected by IST were enrolled in the study. Every patient underwent resting ECG, 24-hour Holter ECG, and exercise ECG at baseline and at 3-month and 6-month follow-up.
Sixteen patients (14 women; mean age 41 +/- 14 years) completed the study. Holter ECG assessment showed a significant reduction of medium HR (P <.001) and maximal HR (P <.001, basal vs 3-6 months; P = .02, 3 vs 6 months). Minimal HR slightly decreased at 3 months and then stabilized (P = .49, 3 vs 6 months) despite an increased drug dose. Stress test showed a significant decrease at rest (P <.001) and maximal HR (P <.05), suggesting an increased tolerance to physical stress, which was confirmed by a progressive increase of maximal load reached (>100 W) during stress test at 3 months (75%) and 6 months (85%). One patient was excluded because of phosphenes despite dose lowering, and another patient did not complete the protocol.
Ivabradine could represent an effective and safe alternative to calcium channel blockers and beta-blockers for treatment of IST.
Heart rhythm: the official journal of the Heart Rhythm Society 09/2010; 7(9):1318-23. · 4.56 Impact Factor
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ABSTRACT: Tachycardia-induced cardiomyopathy may be provoked by several arrhythmias; it may reverse following stable restoration of sinus rhythm. We report the case of a 33-year-old man who was diagnosed to have a dilated cardiomyopathy. Over a few months, the cardiomyopathy reversed. Subsequently, atrial tachycardia, associated with a recurrent impairment of left ventricular function, occurred. Adenosine infusion during atrial tachycardia caused transient atrioventricular block without the interruption of arrhythmia, which is consistent with a micro-reentrant mechanism. Electroanatomic mapping during tachycardia showed a focus arising from the left superior pulmonary vein ostium. After successful catheter ablation of the focus, left ventricular function fully recovered.
Journal of Cardiovascular Medicine 12/2008; 9(11):1147-51. · 1.51 Impact Factor
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Heart rhythm: the official journal of the Heart Rhythm Society 09/2008; 5(8):1103-4. · 4.56 Impact Factor
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Leonardo Calò, Ermenegildo De Ruvo,
Luigi Sciarra,
Roberto Gricia,
Giovanna Navone,
Lucia De Luca,
Francesca Nuccio,
Antonella Sette,
Cristian Pristipino,
Alessandro Dulio,
Fiorenzo Gaita,
Ernesto Lioy
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ABSTRACT: The elimination of complex fractionated atrial electrograms (CFAEs) has been proposed as a potential target for guiding successful AF substrate ablation. The possibility to efficiently map the atria and rapidly identify CFAEs sites is necessary, before the CFAEs ablation becomes a routine approach. The aims of this study, conducted in patients with persistent and permanent atrial fibrillation (AF), were to analyze by CARTO mapping in the right (RA) and in the left atrium (LA) during AF: (1) the diagnostic accuracy of a new software for CFAEs analysis, (2) the spatial distribution of CFAEs, (3) the regional beat to beat AF intervals (FF).
Twenty-five consecutive patients (four women, 58.8 +/- 11.4 years) undergoing radiofrequency catheter ablation for persistent and permanent AF were enrolled in the study. The CFAE software showed a high sensitivity (90%) and specificity (91%) in the identification of CFAEs, using a specific setting of parameters. The LA had a significantly higher prevalence of CFAEs as compared with the RA (30.5% vs 20.3%, P = 0.016). The CFAEs were mostly present in the septum and in the area of coronary sinus ostium (CS os). The FF intervals were significantly shorter in the LA than in the RA (P < 0.01).
CARTO system has a high diagnostic accuracy in the identification of CFAEs. Atrial electrical activity (CFAEs, mean FF intervals) during AF showed a significant spatial inhomogeneity.
Journal of Cardiovascular Electrophysiology 06/2008; 19(10):1024-30. · 3.06 Impact Factor
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ABSTRACT: Left anterior accessory pathways are considered to be rare. The junction between the mitral and aortic valves consists of a continuous fibrous tissue. Nevertheless, muscular pathways connecting the left atrial and ventricular myocardium through the fibrous ring between these valves have been observed very rarely. Few reports about successful ablation of left anterior accessory pathways are available. We describe the case of a young patient with episodes of recurrent palpitations due to atrioventricular tachycardia through a manifest left anterior accessory pathway. Complete elimination of the accessory pathway was achieved by means of an ablative procedure via the transaortic retrograde approach.
Journal of Cardiovascular Medicine 01/2008; 8(12):1065-8. · 1.51 Impact Factor
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Leonardo Calò, Ermenegildo De Ruvo,
Antonella Sette,
Luigi Sciarra,
Roberto Scioli,
Francesco Sebastiani,
Marco Topai,
Renzo Iulianella,
Giovanna Navone,
Ernesto Lioy,
Fiorenzo Gaita
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ABSTRACT: The prognosis of dilated cardiomyopathy is generally poor. The cause of ventricular dysfunction often cannot be identified. In most cases, the clinical history of cardiomyopathy is irreversible but, in some cases, potentially curable causes may be identified. The development of cardiomyopathy may be correlated to atrial or to ventricular arrhythmias. In this scenario, atrial fibrillation is the most frequent cause of ventricular dysfunction, even if it may also be secondary to heart failure. The diagnosis of tachycardia-induced cardiomyopathy can be made only after the improvement of the left ventricular function once the cardiac frequency has slowed down.
Journal of Cardiovascular Medicine 04/2007; 8(3):138-43. · 1.51 Impact Factor
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ABSTRACT: The aim of this study was to compare--in patients with persistent and permanent atrial fibrillation (AF)--the efficacy and safety of left atrial ablation with that of a biatrial approach.
Left atrium-based catheter ablation of AF, although very effective in the paroxysmal form of the arrhythmia, has an insufficient efficacy in patients with persistent and permanent AF.
Eighty highly symptomatic patients (age, 58.6 +/- 8.9 years) with persistent (n = 43) and permanent AF (n = 37), refractory to antiarrhythmic drugs, were randomized to two different ablation approaches guided by electroanatomical mapping. A procedure including circumferential pulmonary vein, mitral isthmus, and cavotricuspid isthmus ablation was performed in 41 cases (left atrial ablation group). In the remaining 39 patients (biatrial ablation group), the aforementioned approach was integrated by the following lesions in the right atrium: intercaval posterior line, intercaval septal line, and electrical disconnection of the superior vena cava.
During follow-up (mean duration 14 +/- 5 months), AF recurred in 39% of patients in the left atrial ablation group and in 15% of patients in the biatrial ablation group (p = 0.022). Multivariable Cox regression analysis showed that ablation technique was an independent predictor of AF recurrence during follow-up.
In patients with persistent and permanent AF, circumferential pulmonary vein ablation, combined with linear lesions in the right atrium, is feasible, safe, and has a significantly higher success rate than left atrial and cavotricuspid ablation alone.
Journal of the American College of Cardiology 07/2006; 47(12):2504-12. · 14.16 Impact Factor
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ABSTRACT: The aim of this study was to assess the efficacy of preoperative and postoperative treatment with n-3 polyunsaturated fatty acids (PUFAs) in preventing the occurrence of atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG).
Postoperative AF is a common complication of CABG. There is growing clinical evidence that PUFAs have cardiac antiarrhythmic effects.
A total of 160 patients were prospectively randomized to a control group (81 patients, 13 female, 64.9 +/- 9.1 years) or PUFAs 2 g/day (79 patients, 11 female, 66.2 +/- 8.0 years) for at least 5 days before elective CABG and until the day of discharge from the hospital. The primary end point was the development of AF in the postoperative period. The secondary end point was the hospital length of stay after surgery. All end points were independently adjudicated by two cardiologists blinded to treatment assignment.
The clinical and surgical characteristics of the patients in the two groups were similar. Postoperative AF developed in 27 patients of the control group (33.3%) and in 12 patients of the PUFA group (15.2%) (p = 0.013). There was no significant difference in the incidence of nonfatal postoperative complications, and postoperative mortality was similar in the PUFA-treated patients (1.3%) versus controls (2.5%). After CABG, the PUFA patients were hospitalized for significantly fewer days than controls (7.3 +/- 2.1 days vs. 8.2 +/- 2.6 days, p = 0.017).
This study first demonstrates that PUFA administration during hospitalization in patients undergoing CABG substantially reduced the incidence of postoperative AF (54.4%) and was associated with a shorter hospital stay.
Journal of the American College of Cardiology 06/2005; 45(10):1723-8. · 14.16 Impact Factor
