Paolo Pieragnoli

University of Florence, Florens, Tuscany, Italy

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Publications (103)329.62 Total impact

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    ABSTRACT: Background: SonR sensor signal correlates well with myocardial contractility expressed in terms of LV dP/dt max. The aim of our study was to evaluate the changes in myocardial contractility during isometric effort in heart failure (HF) patients undergoing cardiac resynchronization therapy (CRT) with right atrial (RA) SonR sensor. Methods: Thirty one patients (19 men, 65 ± 7 years, LVEF 28% ± 5, in sinus rhythm) were implanted with a CRT-D device equipped with SonR sensor which was programmed in VVI mode at 40 bpm. Twenty four hours after implantation, each patient underwent a non-invasive hemodynamic evaluation at rest and during isometric effort, including: 1) measurement of beat-to-beat endocavitary SonR signal; 2) echocardiographic assessment; 3) continuous measurement of blood pressure with Nexfin method. The following contractility parameters were considered: 1) mean value of beat-to-beat SonR signal; 2) mean value of LV dP/dt by Nexfin system and 3) FS by echocardiography. Results: At the third minute of the isometric effort, mean value of SonR signal significantly increased from baseline (p<0.001). Similarly, mean value of both LV dP/dt by Nexfin and FS significantly increased compared to the resting condition (p<0.001; p<0.001). While in 27 (88%) patients SonR signal increased at the third minute of the isometric effort, in 4 (12%) patients, SonR signal decreased. In these patients, both LV dP/dt by Nexfin and FS consensually decreased. Conclusions: In CRT patients, SonR sensor is able to detect changes in myocardial contractility in a consensual way like non-invasive methods such as Nexfin system and echocardiography. This article is protected by copyright. All rights reserved.
    No preview · Article · Dec 2015 · Pacing and Clinical Electrophysiology
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    ABSTRACT: Introduction: QRS duration and morphology are currently recognized as recommended criteria for the selection of CRT candidates. It has recently been shown that patients with left bundle branch block (LBBB) derive substantial clinical benefit from CRT. The aim of this study is to investigate the prognostic impact of QRS axis deviation (AD) in HF patients with LBBB undergoing CRT. Methods and results: We retrospectively evaluated 707 HF patients with LBBB who underwent CRT at 5 centers. Baseline QRS axis was defined as normal (NA: -30° to 90°), right axis deviation (RAD: 90° to 180°) and left axis deviation (LAD: ←30°). The primary endpoint was a composite of all cause death/HF hospitalization. The risk of endpoint by AD was evaluated with both Kaplan-Meier and Cox proportional-hazard analysis. Among 707 patients (73% M, median age: 71[62,77]years), 323 (46%) had NA, 359 (51%) LAD and 25 (3.5%) RAD. Baseline clinical characteristics were similar between the 3 groups. Over a mean follow-up of 32±25 months, 141 deaths occurred (21%) and 36% (n = 255) met with the composite endpoint. A significantly higher proportion of RAD patients (52%) reached the endpoint (LAD 40%, NA 30%). KM analysis showed that RAD and LAD patients had worse event free survival and in multivariate analysis both LAD (HR: 1.40; 95%CI: 1.05-1.86; p = 0.021) and RAD (HR: 2.49; 95%CI: 1.31-4.74; p = 0.005) were independently associated with worse clinical outcome. Conclusions: Right or left axis deviation in the presence of LBBB in HF patients undergoing CRT are independent predictors of poor prognosis. This article is protected by copyright. All rights reserved.
    No preview · Article · Dec 2015 · Journal of Cardiovascular Electrophysiology
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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.
    Full-text · Article · May 2015 · Heart rhythm: the official journal of the Heart Rhythm Society
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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.
    No preview · Article · May 2015 · Journal of electrocardiology
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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: journals.permissions@oup.com.
    Full-text · Article · Feb 2015 · Europace
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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.
    Full-text · Article · Jan 2015 · Pacing and Clinical Electrophysiology
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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.
    Full-text · Article · Nov 2014 · Internal and Emergency Medicine
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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.
    Full-text · Article · Nov 2014 · Journal of Electrocardiology
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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.
    Full-text · Article · Jul 2014 · Clinical Physiology and Functional Imaging
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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.
    No preview · Article · Jun 2014 · Internal and Emergency Medicine
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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.
    Full-text · Article · Apr 2014 · Journal of Cardiovascular Medicine
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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.
    No preview · Article · Feb 2014 · Giornale italiano di cardiologia (2006)
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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.
    No preview · Article · Dec 2013 · Journal of Healthcare Engineering
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    ABSTRACT: Purpose: To date, clinical studies on hypertrophic cardiomyopathy (HCM) have assessed outcome irrespective of genetic background. However, the large proportion of patients with no detectable sarcomere myofilament gene mutations, possibly including phenocopies, may confound our perception of the the natural history of HCM due to sarcomeric myofilament mutations. We therefore investigated the clinical features and outcome of 250 HCM patients followed 6±3 years after genetic identification of such mutations. The impact of the implantable cardioverter-defibrillator (ICD), both in terms of appropriate intervention rates and adverse effects, was specifically assessed. Results: Overall, 16 pts (6%; incidence 1% per year) died of cardiovascular causes, including progressive heart failure (n=7), SCD (n=5), ischemic stroke (n=1) and other non cardiac diseases (n=3). Of these, 9 (5%) occurred in the subset of patents without ICD (group 1) including 3 sudden deaths; while 7 (11%) occurred among pts with ICD (group 2), of whom 3 had prior appropriate interventions. Two of the deaths in group 2 were sudden, occurring despite the device: unfortunately, neither an autopsy nor an ICD interrogation was performed in these pts, and the exact causes of death could not be ascertained. At final evaluation, 6±3 years after genetic testing, 34 pts (14%) were in NYHA class III/IV and 25 (10%) had overt LV systolic dysfunction (LVEF <50%). Survival in the two groups was comparable (p=0.15) despite more severe clinical profile and greater prevalence of end-stage in group 2. No difference in survival was observed based on the affected gene. Among the 64 pts with ICD, only 7 (11%; 2 in primary and 5 in secondary prevention) experienced appropriate shocks for VT of VF, with an overall annual incidence of 2%. However, 16 pts (25% of the ICD subset, including 2 with appropriate shocks) experienced device-related complications such as inappropriate ICD interventions (n=10; including 4 with electric storms due to lead fracture), infections (n=4) and lead dislocation (n=6). Conclusions: In HCM patients due to sarcomere myofilament mutations, cardiovascular mortality and sudden cardiac death was low even in the presence of multiple risk factors. End-stage progression appeared to be common, supporting the hypothesis of long-term disease progression to heart failure. The ICD allowed favourable survival rates in a subset of high risk HCM patients, at the cost of considerable complication rates, even when no appropriate interventions were recorded. Sudden cardiac death may occur even after ICD implantation.
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: Purpose: Recently cryoablation (CA) emerged as an alternative treatment modality to radiofrequency (RF) in ablating AVNRT. Aim of this study is to compare haemostatic system alterations in patients undergoing RF or CA for the treatment of AVNRT. Methods: Prothrombin fragment F1+2 (F1+2), Thrombin-Antithrombin complex (TAT), von Willebrand factor (vWF), plasminogen activator inhibitor type-1 (PAI-1), D-dimer (DD) and platelet function (quantified as AUC*min) were determined in 13 patients who underwent CA and 15 patients who underwent RF (13M/15F, mean age 51.9±16.7 years). Blood samples were obtained before the procedure (T0), immediately after (T1) and 24 hours later (T2). Results: Acute procedural success was achieved in all patients. During follow-up (68±38 days) no recurrences were observed. At T1 a statistically significant increase in F1+2, TAT and D-Dimer levels occurred, compared with pre-ablation values in both groups. At T2, F1+2, TAT and D-Dimer levels were similar to baseline values. At T0, T1 and T2 the comparison between CA and RF groups showed no significant differences in F1+2 and TAT levels. No statistically significant changes in PAI-1 and vWF plasma levels were observed in CA and RF groups. Concerning PAI-1 no significant differences were observed between CA and RF. At T2 vWF plasma levels were significantly (p<0.05) lower in CA than in RF. No statistically significant changes in platelet aggregation were observed at different time points in either group [Table 1].
    Full-text · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: AimsCHADS2 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 resultsIn 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/CHA2DS 2-VASc 1-2), moderate (CHADS2/CHA2DS 2-VASc 3-4), and high (CHADS2 5-6/CHA2DS 2-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 CHA2DS 2-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 CHA 2DS2-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.
    Full-text · Article · Jul 2013 · Europace
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    ABSTRACT: Background: In experimental models, ranolazine exerts a synergistic effect which enhances amiodarone's potential to suppress atrial fibrillation (AF). The clinical effect of ranolazine added to amiodarone for AF conversion has only undergone minimal investigation. Purpose: This study compared the safety and effectiveness of ranolazine in combination with amiodarone versus amiodarone alone for conversion of paroxysmal AF. Methods: We prospectively enrolled all consecutive patients with paroxysmal AF who were deemed eligible for pharmacologic cardioversion. Exclusion criteria were QTc>440msec, hepatic, renal, or thyroid disorders, acute coronary syndrome, prior use of ranolazine, and use of strong CYP3A inhibitors which could affect ranolazine's metabolism. Patients were randomized to either iv amiodarone alone (loading dose of 5md/kg followed by a maintenance dose of 50mg/h for 24h), or to the combination of iv amiodarone plus a single oral dose of ranolazine 1500mg. Patients remained on continuous ECG monitoring. We measured the time to conversion to sinus rhythm, and the proportion of patients with AF conversion within 12h and within 24h. Results: 72 patients were enrolled (mean age 59±7 years): 35 in the amiodarone-only group and 37 in the amiodarone plus ranolazine combination group. The two groups did not differ in terms of clinical characteristics and echocardiographic parameters, including left atrium diameter. Time to conversion was shorter in the combination group compared with the amiodarone-only group (8.4±3.8h vs.15.1±4.8 h; p<0.001). Conversion was achieved in more patients in the combination group as compared to the amiodarone-only group (57% vs. 20% at 12h, respectively, p=0.001; and 86% vs. 68% at 24h, respectively, p=0.07). There were no cases of excessive QT prolongation (>550msec) and no proarrhythmic events in either treatment group. Conclusions: The addition of ranolazine to standard amiodarone treatment is safe, and it leads to faster conversion of paroxysmal AF. Consistent with substantial preclinical research on ranolazine's AF-suppressing potential, the present clinical study demonstrates a synergistic effect of ranolazine and amiodarone for conversion of paroxysmal AF.
    No preview · Article · Jun 2013 · Europace
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    ABSTRACT: Purpose: Left bundle branch block (LBBB) is frequently observed in heart failure (HF) patients, and is recognized as both an adverse prognostic factor and a key-element for referring patients to cardiac resynchronization therapy (CRT). It has been previously defined as concordant (cLBBB) or discordant (dLBBB) when associated with a positive or negative T wave in leads I and V5-V6, respectively. Recently, dLBBB has been shown to be associated with a worse clinical, neurohormonal, and prognostic profile in systolic HF patients. Our aim was to evaluate the impact of CRT on the prognostic value of LBBB morphology in a population of systolic HF. Methods: A total of 406 consecutive systolic HF patients with LBBB (age 69±9 years, left ventricular ejection fraction, 26±6%), treated with CRT (CRT-P, n= 78; CRT-D, n= 328) from three Italian Centers underwent clinical, biohumoral, and echocardiographic characterization. All patients were then followed-up for cardiac events (median 31 months, range 1-137). Results: cLBBB was observed in 110 (27%) patients, dLBBB in 296 (73%). dLBBB was more frequent in patients with ischemic cardiomyopathy and associated with a shorter QRS duration and worse glomerular filtration rate (all p <0.05). No difference in pharmacological and device therapy was observed, except for a higher use of diuretics in dLBBB patients. At Kaplan-Meier analysis, dLBBB was associated with a worse prognosis for the composite end-point of sudden death and ICD shock (p<0.05), while no difference was observed in terms of either cardiac death or death due to HF progression. Conclusions: dLBBB, despite CRT, is associated with the occurrence of sudden death and implantable cardioverter defibrillator shock in systolic HF patients, identifying a subset with higher arrhythmic risk, needing an enhanced, targeted therapeutical effort.
    Full-text · Article · Mar 2013 · Journal of the American College of Cardiology
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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.
    Full-text · Article · Jan 2013 · Pacing and Clinical Electrophysiology
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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.
    No preview · Article · Dec 2012 · Internal and Emergency Medicine

Publication Stats

969 Citations
329.62 Total Impact Points

Institutions

  • 1995-2015
    • University of Florence
      • Dipartimento di Chirurgia e Medicina Traslazionale (DCMT)
      Florens, Tuscany, Italy
  • 2011-2014
    • Azienda Ospedaliero Universitaria Careggi
      • Department of Heart and Vessels
      Firenzuola, Tuscany, Italy