Paolo Pieragnoli

Azienda Ospedaliero Universitaria Careggi, Firenzuola, Tuscany, Italy

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Publications (87)250.63 Total impact

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    ABSTRACT: Cryoablation (CA) is an emerging tool for treatment of supraventricular tachyarrhythmias. Determinants of long-term success still need clarifying. to assess which patients' and procedural features influence long-term efficacy of CA for typical atrioventricular nodal reentrant tachycardia (AVNRT). 85 consecutive patients undergoing CA for typical AVNRT were divided into 3 groups of age [grp_A (≤20 yrs): 20 pts; grp_B (21-50 yrs): 30 pts; grp_C (≥51 yrs): 35 pts]. CA was performed for 5 minutes at -75°C in all; a 4-minute bonus was delivered if not contraindicated (i.e.: transient PR lengthening during first application, narrow Koch's triangle). Efficacy end-point was absence of recurrences at 12-month follow-up. CA was acutely successful in 85/85 (100%) patients. Bonus ablation was performed in 69 (81.2%). No permanent complications were observed. At follow-up, AVNRT recurrences occurred in 9 (10.6%) patients [grp_A: 0 (0%); grp_B: 2 (6.7%); grp_C: 7 (20%)]. Incidence of recurrences was significantly different between age groups [p: 0.047] and between patients receiving (7.2%) and not-receiving (25.0%) CA bonus [p: 0.038]. At multivariable analysis, age groups [OR: 5.917; 95% C.I. 1.372-25.518; p: 0.017] and bonus CA [OR: 0.115; 95% C.I. 0.018-0.724; p: 0.021] were the only independent predictors of recurrences. Furthermore, age as a continuous variable remained statistically associated with recurrences [OR: 1.046; 95% C.I. 1.002-1.091; p: 0.038]. CA is effective and safe for typical AVNRT ablation. Young age and CA bonus administration are independent predictors of success at 12 months. Incidence of recurrences is low in patients <21 years. Copyright © 2015. Published by Elsevier Inc.
    Heart rhythm: the official journal of the Heart Rhythm Society 05/2015; DOI:10.1016/j.hrthm.2015.05.035 · 4.92 Impact Factor
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    ABSTRACT: "Cardiac memory" (CM) refers to a change in repolarization induced by an altered pathway of activation, manifested after resumption of spontaneous ventricular activation (SVA). To investigate for the first time in humans the effects of left ventricular (LV) pacing on CM development through vectorcardiography (VCG). We studied 28 patients with heart failure (HF) and left bundle branch block (LBBB) treated with cardiac resynchronization therapy (CRT). Fourteen patients underwent biventricular (BIV) stimulation; the other 14 underwent LV stimulation only. VCG was acquired during SVA at baseline and during AAI and DDD pacing immediately after and 7 and 90days after the implant. At baseline, in both groups, the QRS and T vectors angles were those specific of LBBB pattern. During DDD pacing, QRS vector angle changed to the right and upward in BIV patients while no significant differences were observed in LV patients. During AAI pacing, T vector angle changed significantly in BIV patients, following the direction of the paced QRS and amplitude significantly increased. In LV patients no significant differences in T vector angles were observed. Only T vector amplitude significantly increased at 7days (p=0.03) and at 90days (p=0.008 vs baseline). In patients with LBBB, BIV pacing induces cardiac memory development as a significant change in T vector magnitude and angle, while LV pacing doesn't induce significant modifications in QRS and T vector angles and CM is manifested only as a significant T vector amplitude change. Copyright © 2015. Published by Elsevier Inc.
    Journal of electrocardiology 05/2015; DOI:10.1016/j.jelectrocard.2015.05.007 · 1.36 Impact Factor
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    ABSTRACT: The aim of this review is to formulate practical recommendations for the management of antithrombotic therapy in patients undergoing cardiac implantable electronic device (CIED) surgery by providing indications for a systematic approach to the problem integrating general technical considerations with patient-specific elements based on a careful evaluation of the balance between haemorrhagic and thromboembolic risk. Hundreds of thousands patients undergo implantation or replacement of CIEDs annually in Europe, and up to 50% of these subjects receive antiplatelet agents or oral anticoagulants. The rate of CIED-related complications, mainly infective, has also significantly increased so that transvenous lead extraction procedures are, consequently, often required. Cardiac implantable electronic device surgery is peculiar and portends specific intrinsic risks of developing potentially fatal haemorrhagic complications; on the other hand, the periprocedural suspension of antithrombotic therapy in patients with high thromboembolic risk cardiac conditions may have catastrophic consequences. Accordingly, the management of the candidate to CIED surgery receiving concomitant antithrombotic therapy is a topic of great clinical relevance yet controversial and only partially, if at all, adequately addressed in evidence-based current guidelines. In spite of the fact that in many procedures it seems reasonably safe to proceed with aspirin only or without interruption of anticoagulants, restricting to selected cases the use of bridging therapy with parenteral heparins, there are lots of variables that may make the therapeutic choices challenging. The decision-making process applied in this document relies on the development of a stratification of the procedural haemorrhagic risk and of the risk deriving from the suspension of antiplatelet or anticoagulant therapy combined to generate different clinical scenarios with specific indications for optimal management of periprocedural antithrombotic therapy. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email:
    Europace 02/2015; 17(6). DOI:10.1093/europace/euu357 · 3.05 Impact Factor
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    ABSTRACT: Cardiac resynchronization therapy (CRT) has been demonstrated to improve ventricular-arterial coupling by reducing effective arterial elastance (Ea) on long-term follow-up. Detailed invasive studies showing possible acute peripheral effects of CRT are not available. We evaluated the hemodynamic effects of CRT in patients with systolic dysfunction, in order to investigate the impact on ventricular-arterial coupling and, in particular, on Ea immediately after the initiation of pacing. We studied 37 heart failure patients undergoing CRT implantation based on conventional criteria. On implantation, left ventricular (LV) pressure and volume data were determined via a conductance catheter. Twelve patients with a standard indication for electrophysiologic study and preserved LV function served as a control group. In comparison with the control group, heart failure patients showed reduced systolic and diastolic function. LV end-systolic elastance (Ees: end-systolic pressure/volume) was impaired (0.79 ± 0.33 mm Hg/mL vs 1.84 ± 0.89 mm Hg/mL, P = 0.012) and Ees/Ea reduced (0.36 ± 0.17 vs 1.19 ± 1.81, P = 0.022). In heart failure patients, CRT immediately improved systolic function, increasing stroke work from 3.9 ± 1.8 L*mm Hg to 6.9 ± 3.3 L*mm Hg (P < 0.001) and Ees to 1.02 ± 0.62 mm Hg/mL (P = 0.001). Ea decreased from 2.59 ± 1.35 mm Hg/mL to 1.68 ± 0.91 mm Hg/mL (P < 0.001), leading to an increase in Ees/Ea to 0.70 ± 0.38 (P < 0.001). Our data indicate that switching CRT on induces an immediate reduction in arterial load, conceivably as a consequence of restored autonomic balance. ©2015 Wiley Periodicals, Inc.
    Pacing and Clinical Electrophysiology 01/2015; 38(4). DOI:10.1111/pace.12585 · 1.25 Impact Factor
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    ABSTRACT: The aim of the study was to evaluate the association between circulating (CPCs) and endothelial (EPCs) progenitor cells and left ventricular (LV) remodeling in chronic heart failure (HF). 85 HF patients, ranging 29-89 years, 83.5 % males, 45.9 % ischemic, NYHA functional class II-IV, with a LV ejection fraction ≤40 % were studied. LV ejection fraction, LV end-diastolic and end-systolic (LVESV) volumes, LV mass and tricuspid annular plane systolic excursion (TAPSE) were evaluated, and, when indicated, indexed for body surface area (BSA). CPCs and EPCs number was assessed using flow cytometry. CPCs were defined as CD34+, CD133+ and CD34+/CD133+. EPCs, identified through their expression of KDR, were defined as CD34+/KDR+, CD133+/KDR+ and CD34+/CD133+/KDR+. All EPCs were negatively related to LVESV/BSA (r = -0.24, p = 0.02 for all EPC's populations), and to LVmass/BSA (CD34+KDR+; r = -0.30, p = 0.005; CD133+KDR+; r = -0.31, p = 0.004; CD34+CD133+KDR+; r = -0.29, p = 0.007). No differences in EPCs levels in relation to cardiovascular risk factors, medications, etiology, age or gender were observed. CPCs number was higher in women, and lower in ischemic patients. In logistic regression analyses, the low EPCs' number was associated with an increased likelihood of abnormal LVmass/BSA. CPCs proved to be higher and EPCs lower in patients with severely abnormal LVmass/BSA (gr/m(2), ≥122 in women and ≥149 in men). Our results suggest a correlation between LV remodeling and progenitor cells. This is noteworthy considering that it has been suggested that bone marrow-derived EPCs participate in cardiac regeneration and function recovery in the setting of progressive HF.
    Internal and Emergency Medicine 11/2014; 10(3). DOI:10.1007/s11739-014-1149-5 · 2.41 Impact Factor
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    ABSTRACT: To investigate the LBBB Selvester Scoring System (LBBB-SSc) and the Simplified-SSc prognostic impact in predicting response to CRT, all cause and cardiac mortality, heart failure (HF) hospitalizations and onset of arrhythmias in HF patients undergoing CRT. We retrospectively evaluated LBBB-SSc and Simplified-SSc of 172 consecutive HF patients with true-LBBB who underwent CRT. Response to CRT was defined as the improvement of LVEF of at least 10% or as the reduction of LVESV of at least 15% at 6-month follow-up. Logistic regression analysis and Cox proportional hazard analysis were performed to evaluate each endpoint related risk according to LBBB-SSc and Simplified-SSc. The LBBB-SSc and the Simplified-SSc were inversely correlated with response to CRT. Myocardial scar at both scores was independently associated to non-response to CRT. No correlation was observed between LBBB-SSc or Simplified-SSc and other endpoints. In HF patients with true-LBBB, Simplified-SSc is able to predict response to CRT. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Electrocardiology 11/2014; 48(1). DOI:10.1016/j.jelectrocard.2014.10.014 · 1.36 Impact Factor
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    ABSTRACT: PurposeLeft ventricular (LV) torsion is an important parameter of LV performance and can be influenced by several factors. Aim of this investigation was to evaluate whether QRS prolongation in left bundle branch block (LBBB) may influence global LV twist and twisting/untwisting rate in chronic systolic heart failure (HF) patients.Methods We prospectively evaluated 30 healthy subjects (control group) and 100 chronic HF patients with severely impaired LV systolic function (ejection fraction ≤35%). Patients were divided into three groups according to QRS duration: A: QRS < 120 ms (n 49), B: 120 ≤ QRS ≤ 150 ms (n 28) and C: QRS > 150 ms (n 23). Patients in groups B and C presented LBBB. All subjects underwent standard trans-thoracic echocardiography and two-dimensional speckle-tracking echocardiography evaluation. Categorical variables were compared by the chi-square or the Fisher's exact test. Continuous variables were compared using the ANOVA test. Correlations between variables were analysed with linear regression.ResultsControl subjects presented higher torsion parameters, when compared with patients in any HF group. Among the three HF groups, no differences were detected in global twist (4·79 ± 3·54, 3·8 ± 3·0 and 4·15 ± 3·14 degrees, respectively), twist rate max (44·81 ± 25·03, 37·94 ± 19·09 and 37·61 ± 24·49 degrees s−1, respectively) and untwist rate max (−36·31 ± 30·89, −27·68 ± 34·67 and −39·62 ± 26·27 degrees s−1, respectively) (P>0·05 for all). At linear regression analysis, there was no relation between QRS duration and any torsion parameter (P>0·05 for all).Conclusions In patients with chronic severe systolic heart failure, QRS duration and LBBB morphology do not affect LV twisting and untwisting.
    Clinical Physiology and Functional Imaging 07/2014; DOI:10.1111/cpf.12181 · 1.33 Impact Factor
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    ABSTRACT: Cryoablation (CA) emerged as an alternative procedure to radiofrequency (RF). The aim of this study was to compare haemostatic system alterations in patients undergoing RF or CA for atrioventricular nodal reentrant tachycardia ablation. von Willebrand factor (vWF), spontaneous whole blood platelet aggregation, prothrombin fragment F1 + 2 (F1 + 2), thrombin-antithrombin complex (TAT), plasminogen activator inhibitor type-1 (PAI-1), and clot lysis time (CLT) were determined in 48 patients (27 CA; 21 RF; 19M/29F, mean age 49.6 ± 17.6 years). Blood samples were obtained before the procedure (T0), immediately after (T1), and 24 h later (T2). At T1 both procedures were associated with a significant increase in levels of the endothelial activation marker vWF. At T2 vWF levels were lower in CA than in RF group. No changes in whole blood platelet aggregation before and after ablation procedures were observed. At T1 both groups determined an increase in blood clotting activation markers, F1 + 2, TAT, and DD. At T2 F1 + 2, TAT and DD levels were similar to baseline values. The comparison between RF and CA showed no significant differences in F1 + 2 and TAT levels, whereas at T1 DD levels were higher in CA group than in RF group. Both procedures induced a significant decrease in CLT, whereas no changes in PAI-1 levels were found. There were no significant differences in CLT and PAI-1 levels. The fibrinolytic efficiency analysis showed that at T1 DD/TAT and DD/F1 + 2 ratios were lower in RF group and remained lower in RF than in CA group at T2. CA procedure may be associated with a lower degree of endothelial damage and with a higher fibrinolytic capacity respect to RF.
    Internal and Emergency Medicine 06/2014; DOI:10.1007/s11739-014-1090-7 · 2.41 Impact Factor
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    ABSTRACT: Metabolomic, a systematic study of metabolites, may be a useful tool in understanding the pathological processes that underlie the occurrence and progression of a disease. We hypothesized that metabolomic would be helpful in assessing a specific pattern in heart failure patients, also according to the underlining causes and in defining, prior to device implantation, the responder and nonresponder patient to cardiac resynchronization therapy (CRT). In this prospective study, blood and urine samples were collected from 32 heart failure patients who underwent CRT. Clinical, electrocardiography and echocardiographic evaluation was performed in each patient before CRT and after 6 months of follow-up. Thirty-nine age and sex-matched healthy individuals were chosen as control group. For each sample, 1H-NMR spectra, Nuclear Overhauser Enhancement Spectroscopy, Carr-Purcell-Meiboom-Gill and diffusion edited spectra were measured. A different metabolomic fingerprint was demonstrated in heart failure patients compared to healthy controls with high accuracy level. Metabolomics fingerprint was similar between patients with ischemic and nonischemic dilated cardiomyopathy. At 6-month follow-up, metabolomic fingerprint was different from baseline. At follow-up, heart failure patients' metabolomic fingerprint remained significantly different from that of healthy controls, and accuracy of cause discrimination remained low. Responders and nonresponders had a similar metabolic fingerprint at baseline and after 6 months of CRT. It is possible to identify a metabolomic fingerprint characterizing heart failure patients candidate to CRT, it is independent of the different causes of the disease and it is not predictive of the response to CRT.
    Journal of Cardiovascular Medicine 04/2014; 15(4). DOI:10.2459/JCM.0000000000000028 · 1.51 Impact Factor
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    ABSTRACT: In Italy tens of thousands of patients undergo implantation or replacement of cardiac implantable electronic devices (CIEDs) annually, and up to 50% of these subjects receive antiplatelet agents or oral anticoagulants. The rate of CIED-related complications, mainly infective, has also significantly increased, so that transvenous lead extraction procedures are often required. CIED surgery is peculiar and portends specific intrinsic risks of developing life-threatening hemorrhagic complications; on the other hand periprocedural discontinuation of antithrombotic therapy in patients at high thromboembolic risk may have catastrophic consequences. Accordingly, the management of candidates to CIED surgery who receive concomitant antithrombotic therapy is of great clinical relevance, though controversial and only partially, if not at all, adequately addressed in current evidence-based guidelines. Although for many procedures the administration of aspirin alone or continuation of anticoagulant therapy seems reasonably safe, with use of bridging therapy with parenteral heparins restricted to selected cases, there are multiple variables that may make therapeutic choices challenging. The aim of the present position paper is to provide practical recommendations for the management of antithrombotic therapy in patients undergoing CIED surgery by defining indications for a systematic approach integrating general technical considerations with patient-specific elements based on a careful evaluation of the balance between hemorrhagic and thromboembolic risk. The decision-making process applied in this document relies on the stratification of the procedural hemorrhagic risk and of the risk deriving from discontinuation of antiplatelet or anticoagulant therapy combined to produce different clinical scenarios with specific indications for optimal management of periprocedural antithrombotic therapy.
    Giornale italiano di cardiologia (2006) 01/2014; 15(1):56-72. DOI:10.1714/1394.15520
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    ABSTRACT: There have been substantial progresses in the technology of cardiac implantable electric devices (CIEDs) during the past decades. One of the progresses is represented by the development of a hemodynamic sensor embedded at the tip of a pacing lead that measures myocardial contractility by the analysis of myocardial mechanical vibrations occurring during the cardiac cycle. This sensor, providing continuous hemodynamic monitoring, could play an important role in clinical practice because of several clinical applications in CIEDs recipients. The objectives of this work are to report how this sensor operates and to review the main findings about its clinical applications.
    12/2013; 4(4):453-464. DOI:10.1260/2040-2295.4.4.453
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    ABSTRACT: CHADS2 and CHA2DS2-VASc scores are pivotal in assessing the risk of stroke in atrial fibrillation patients, and were recently proved to predict hospitalizations and mortality in specific clinical settings. Aim of this study was to evaluate whether these scores could predict clinical outcomes [first hospitalization for heart failure (HF) and a combined event of HF hospitalization and death for any cause] in patients candidates to cardiac resynchronization therapy and implantable defibrillator (CRT-D).METHODS AND RESULTS: In a retrospective multicentre Italian study, we enrolled 559 consecutive HF patients candidates to CRT-D, and we grouped them in three pre-specified risk classes: low (CHADS2/CHA2DS2-VASc 1-2), moderate (CHADS2/CHA2DS2-VASc 3-4), and high (CHADS2 5-6/CHA2DS2-VASc 5-8). All patients underwent regular follow-up at implanting centres every 6 months; data collection was extended till the 72th month of follow-up. At a median FU of 30 months, 143 patients (25.4%) were hospitalized for HF and 110 (19.5%) died. Event-free survival analysis showed a significant difference according to baseline CHADS2 and CHA2DS2-VASc scores (Log-Rank for HF P < 0.001 for CHADS2 and CHA2DS2-VASc; Log-Rank for combined end-point P = 0.001 for CHADS2, P < 0.001 for CHA2DS2-VASc). At multivariate analysis, independent predictors of endpoints were: previous atrial fibrillation (AF) or AF at implant, NYHA class, QRS duration and the CHA2DS2-VASc score (for HF hospitalization P = 0.013; for the combined event, P = 0.007), while the CHADS2 score was not independently associated with either the end-points.CONCLUSION: In CRT-D patients, pre-implant CHA2DS2-VASc score is an independent predictor of major clinical events at 30-month follow-up.
    Europace 07/2013; 16(1). DOI:10.1093/europace/eut190 · 3.05 Impact Factor
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    Journal of the American College of Cardiology 03/2013; 61(10). DOI:10.1016/S0735-1097(13)60668-3 · 15.34 Impact Factor
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    ABSTRACT: BACKGROUND: Previous studies have reported that the left ventricular (LV) pacing site is a major determinant of the hemodynamic response to cardiac resynchronization therapy (CRT). However, lead positioning in a lateral or posterolateral cardiac vein may not be optimal for every patient. The objective of this study was to assess the relationship between the right ventricular (RV)-to-LV conduction time and the systolic function during CRT on the basis of changes to LV pressure-volume loops. METHODS: Left ventricular pressure and volume data were determined using a conductance catheter during CRT device implantation in 10 patients. Four endocardial LV sites were systematically assessed at four atrioventricular delays. The RV-to-LV conduction time was measured as the time interval between spontaneous peak R waves, recorded through the RV lead and the LV catheter. RESULTS: The optimal pacing site varied among patients. However, the pacing site associated with the maximum RV-to-LV conduction time resulted in a stroke volume improvement comparable to the pacing site identified through individual hemodynamic optimization (41 ± 17 mL vs 44 ± 18 mL, P = 0.266). Moreover, the RV-to-LV conduction time recorded at each endocardial pacing site correlated positively with the increase in stroke volume (r = 0.537; P < 0.001), stroke work (r = 0.642; P < 0.001), and the pressure-derivative maximum (r = 0.646; P < 0.001) obtained with CRT. CONCLUSIONS: An optimal acute response to CRT can be obtained by positioning the LV lead at the site associated with the maximum RV-to-LV conduction time. A significant correlation appears to exist between RV-to-LV conduction time and the improvement in systolic function with CRT.
    Pacing and Clinical Electrophysiology 01/2013; 36(4). DOI:10.1111/pace.12068 · 1.25 Impact Factor
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    ABSTRACT: Smoking is associated with increased morbidity and mortality in cardiac patients. However, data on the prognostic impact of smoking in heart failure (HF) patients on cardiac resynchronization therapy with defibrillator (CRT-D) are absent. We investigated the effects of smoking on all-cause mortality and on a composite endpoint (all-cause death/appropriate device therapy), appropriate and inappropriate device therapy, in 649 patients with HF who underwent CRT-D between January 2003 and October 2011 in 6 Centers (4 in Italy and 2 in USA). 68 patients were current smokers, 396 previous-smokers (patients who had smoked in the past but who had quit before the CRT-D implant), and 185 had never smoked. The risk of each endpoint by smoking status was evaluated with both Kaplan-Meier and Cox proportional-hazard analysis. After adjusting for age, left ventricular ejection fraction, QRS width and ischemic etiology, both current and previous smoking were independent predictors of all-cause death [HR = 5.07 (95 % CI 2.68-9.58), p < 0.001 and HR = 2.43 (95 % CI 1.38-4.29), p = 0.002, respectively) and of composite endpoint [HR = 1.63 (1.04-2.56); p = 0.033 and HR = 1.46 (1.04-2.04) p = 0.027]. In addition, current smokers had a significantly higher rate of inappropriate device therapy compared to never smokers [HR = 21.74 (4.53-104.25), p = 0.005]. Our study indicates that in patients with HF who received a CRT-D device, current and previous smoking increase the event rate per person-time of death and of appropriate and inappropriate ICD therapy more than other known negative prognostic factors such as age, left ventricular dysfunction, prolonged QRS duration and ischemic etiology.
    Internal and Emergency Medicine 12/2012; 9(3). DOI:10.1007/s11739-012-0891-9 · 2.41 Impact Factor
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    ABSTRACT: Spontaneous behavior of ventricular extrasystoles (VE) was analysed. From a database containing 578 athletes with VE, 84 males and 11 females (29.9 ± 18.1 years) having ≥ 100 VE or repetitive VE [ventricular couplets (VC) or ventricular tachycardias (VT)] at first 24-hour Holter electrocardiographic monitoring (24-h-HM) (baseline) and at least 1-year of follow-up (3.1 ± 2.2 years) over the past 10 years were selected. The baseline was compared with the last 24-h-HM to establish DVE (VE reduction of at least 98%/24 h in the absence of VC or VT). SDVE was calculated as standard deviation of the number of VE on serial 24-h-HMs. DVE and SDVE were considered as dependent variables. Independent variables were: age, sex, type of sport, symptoms, baseline VE rate (BVE), baseline VC and VT, VE morphology, VE behavior during the baseline training session, disqualification from competitive sports, echocardiographic abnormalities. DVE occurred in 32 athletes (34%). SDVE varied from 0 to 12 658 VE/24 h (1916 ± 2649.9). Disappearance of VE during the baseline training session (DVET) correlated to DVE (P = 0.0319). BVE directly correlated to SDVE (P = 0.0008). Athletes' VE are highly variable over time, their variability depending on BVE, and they not infrequently tend to disappear. The only useful variable for predicting DVE is DVET.
    Scandinavian Journal of Medicine and Science in Sports 09/2012; 24(2). DOI:10.1111/j.1600-0838.2012.01526.x · 3.17 Impact Factor
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    ABSTRACT: During cardiac resynchronization therapy (CRT) device implantation, the pacing lead is usually positioned in the coronary sinus (CS) to stimulate the left ventricular (LV) epicardium. Transvenous LV endocardial pacing via transseptal puncture has been proposed as an alternative method. In the present study, we evaluated the acute hemodynamic effects of CRT through LV endocardial pacing in heart failure patients by analyzing LV pressure-volume relationships. LV pressure and volume data were determined via conductance catheter during CRT device implantation in 10 patients. In addition to the standard epicardial CS pacing, the following endocardial LV sites were systematically assessed: the site transmural to the CS lead, the LV apex, the septal midwall, the basal lateral free wall, and the midlateral free wall. Four atrioventricular delays were tested. There was a significant improvement of systolic function with CRT in all LV pacing configurations, whereas no differences in systolic or diastolic function were detected between LV epicardial and endocardial transmural sites. The optimal pacing site varied among patients but was rarely related to relatively longer activation delays, as assessed by analyzing endocardial electric activation maps. Nonetheless, positioning the pacing lead at the optimal endocardial LV site in each patient significantly improved LV performance in comparison with conventional CS site stimulation (stroke volume, 83 [79-112] mL versus 73 [62-89] mL; P=0.034). Pacing at the optimal individual LV endocardial site yields enhanced LV performance in comparison with conventional CS site stimulation. Endocardial LV pacing might constitute an alternative approach to CRT, when CS pacing is not viable.
    Circulation Arrhythmia and Electrophysiology 05/2012; 5(3):460-7. DOI:10.1161/CIRCEP.111.970277 · 5.42 Impact Factor
  • International journal of cardiology 12/2011; 155(2):302-4. DOI:10.1016/j.ijcard.2011.11.073 · 6.18 Impact Factor
  • Cardiac electrophysiology clinics 12/2011; DOI:10.1016/j.ccep.2011.08.012
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    ABSTRACT: The Seattle Heart Failure Model (SHFM) is a multimarker risk assessment tool able to predict outcome in heart failure (HF) patients. Aim: To assess whether the SHFM can be used to risk-stratify HF patients who underwent cardiac resynchronization therapy with (CRT-D) or without (CRT) an implantable defibrillator. The SHFM was applied to 342 New York Heart Association class III-IV patients who received a CRT (23%) or CRT-D (77%) device. Discrimination and calibration of SHFM were evaluated through c-statistics and Hosmer-Lemeshow (H-L) goodness-of-fit test. Primary endpoint was a composite of death from any cause/cardiac transplantation. During a median follow-up of 24 months (25th-75th percentile [pct]: 12-37 months), 78 of 342 (22.8%) patients died; seven patients underwent urgent transplantation. Median SHFM score for patients with endpoint was 5.8 years (25th-75th pct: 4.25-8.7 years) versus 8.9 years (25th-75th pct: 6.6-11.8 years) for those without (P < 0.001). Discrimination of SHFM was adequate for the endpoint (c-statistic always ranged around 0.7). The SHFM was a good fit of death from any cause/cardiac transplantation, without significant differences between observed and SHFM-predicted survival. The SHFM successfully stratifies HF patients on CRT/CRT-D and can be reliably applied to help clinicians in predicting survival in this clinical setting.
    Pacing and Clinical Electrophysiology 11/2011; 35(1):88-94. DOI:10.1111/j.1540-8159.2011.03258.x · 1.25 Impact Factor

Publication Stats

815 Citations
250.63 Total Impact Points


  • 2011–2015
    • Azienda Ospedaliero Universitaria Careggi
      • Department of Heart and Vessels
      Firenzuola, Tuscany, Italy
  • 1995–2015
    • University of Florence
      • Dipartimento di Chirurgia e Medicina Traslazionale (DCMT)
      Florens, Tuscany, Italy