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Aims The study evaluated the positivity rate, haemodynamic responses, and prognosis in terms of syncopal recurrence among patients with situational syncope (SS) stratified according to the underlying situational triggers. Methods and results We retrospectively evaluated all consecutive patients with SS who underwent nitroglycerine (NTG)-potentiated head-up tilt test (HUTT) at Syncope Unit of the University of Campania 'Luigi Vanvitelli'—Monaldi Hospital from 1 March 2017 to 1 May 2023. All patients were followed for at least one year. The study population was divided according to the underlying triggers (micturition, swallow, defaecation, cough/sneeze, post-exercise). Two hundred thirty-six SS patients (mean age 50 ± 19.3 years; male 63.1%) were enrolled; among them, the situational trigger was micturition in 109 patients (46.2%); swallow in 32 (13.6%) patients; defaecation in 35 (14.8%) patients; post-exercise in 41 (17.4%) patients; and cough/sneeze in 17 (7.2%) patients. There were no significant differences in baseline clinical characteristics and HUTT responses between different situational triggers. The Kaplan–Meier analysis did not show a statistically different rate of syncope recurrence across patients stratified by baseline situational triggers (log-rank P = 0.21). Conclusion Situational syncope appears to be a homogenous syndrome, and different triggers do not impact the HUTT response or syncope recurrence at 1 year. [ABSTRACT FROM AUTHOR]

A 75-year-old man with hypertrophic obstructive cardiomyopathy underwent placement of a long-sensing vector implantable loop recorder (ILR) for unexplained syncope. One month later, ILR remote monitoring revealed unstable R-wave amplitudes ranging from very high (>1.9 mV) to very low (<0.2 mV) values. During an in-hospital clinic visit, the only site to establish communication with the ILR was the left posterior axillary area. Chest computed tomography confirmed ILR migration into the anterior costophrenic recess. The device was retrieved with forceps during video thoracoscopy without further complications. This is the first case report of migration of an implantable loop recorder diagnosed by remote monitoring. [ABSTRACT FROM AUTHOR]

Background: Remote monitoring is recommended for patients with implantable cardiac monitors (ICMs), but compared to other cardiac implantable devices, ICMs are less accurate and transmit a higher number of alerts. Objective: The aim of this study was to investigate the predictors of false‐positive (FP) arrhythmic alerts in patients with unexplained syncope who were implanted with ICM and followed by an automatic remote monitoring system. Methods: We retrospectively evaluated all consecutive patients who received a long‐sensing vector ICM for unexplained syncope between January 2019 to September 2021 at our Syncope Unit. The primary endpoint was the incidence of the first FP episode. The secondary endpoints included assessing the incidence of FP episodes for all types of algorhythms and indentifying the reasons for the misdetection of these episodes. Results: Among 105 patients (44.8% males, median age 51 years), 51 (48.6%) transmitted at least one FP alert during a median follow‐up of 301 days. The presence of pre‐ventricular complexes (PVCs) on the resting electrocardiogram was the only clinical characteristic associated with an increased risk of FP alerts (adjusted Hazard ratio [HR] 5.76 [2.66–12.4], p = 0.010). The other significant device‐related variables were a low‐frequency filter at 0.05 Hz versus the default 0.5 Hz (adjusted HR 3.82 [1.38–10.5], p = 0.010) and the R‐wave amplitude (adjusted HR 0.35 [0.13–0.99], p = 0.049). Conclusion: Patients who have PVCs are at higher risk of inappropriate ICM activations. To reduce the occurrence of FP alerts, it may be beneficial to target a large R‐wave amplitude during device insertion and avoid programming a low‐frequency filter at 0.05 Hz. [ABSTRACT FROM AUTHOR]

Background The traditional nitroglycerin (NTG) head-up tilt test (HUTT) is time-consuming and the test duration is a barrier to widespread utilization in clinical practice. It was hypothesized that a short-duration protocol is not inferior to the traditional protocol regarding the positivity rate and has a similar distribution of hemodynamic response. Methods and results Patients undergoing HUTT were randomized 1:1 to a 10 min passive phase plus a 10 min 0.3 mg NTG if the passive phase was negative (Fast) or to a 20 min passive phase plus a 15 min 0.3 mg NTG if the passive phase was negative (Traditional). A sample size of 277 patients for each group achieved 80% power to detect an expected difference of 0% with a non-inferiority margin of -10% using a one-sided t -test and assuming a significant level alpha of 0.025. A total of 554 consecutive patients (mean age 46.6 ± 19.3 years, 47.6% males) undergoing HUTT for suspected vasovagal syncope were randomly assigned to the Fast (n = 277) or Traditional (n = 277) protocol. A positive response was defined as the induction of syncope in presence of hypotension/bradycardia, and was observed in 167 (60.3%) patients with Fast and in 162 (58.5%) patients with the Traditional protocol. There was a trend of lesser vasodepressor response (14.8% Fast vs. 20.6% Traditional) which was significant during the passive phase (P = 0.01). Conclusion The diagnostic value of the Fast HUTT protocol is similar to that of the Traditional protocol and therefore the Fast protocol can be used instead of the Traditional protocol. [ABSTRACT FROM AUTHOR]

Sudden cardiac death (SCD) is one of the leading causes of cardiovascular death in general population. SCD primary prevention requires the correct selection of patients at increased risk who may benefit from implantable cardioverter-defibrillator (ICD). Despite several noninvasive arrhythmic risk indexes are available, their ability to stratify the SCD risk among asymptomatic patients with cardiac disease at increased arrhythmic risk is debated. The programmed ventricular stimulation (PVS) is an invasive approach historically used for SCD risk stratification in patients with acquired or inherited cardiac disease and is currently included in international guidelines. Aim of this review is to summarize all available data about the role of PVS for the SCD risk stratification in different clinical settings. [ABSTRACT FROM AUTHOR]

Background: Air entrapment has been recently described as a cause of inappropriate shock (IAS) among patients who underwent subcutaneous implantable cardioverter‐defibrillator (S‐ICD) implantation. Data about this complication are lacking in the literature. Methods: In this meta‐summary 14 case reports describing IAS due to air entrapment were included. Patients' characteristics, S‐ICD implant technique and air entrapment properties were collected. Results: All patients experienced IAS within 4 days following S‐ICD implant. The subcutaneous air was demonstrated by chest x‐ray in 11 cases (73.3%). The sensing vector was reprogrammed in 11 cases (73.3%), and ICD was switched off in 2 cases (1.3%). Conclusions: IAS due to air entrapment is an early complication of S‐ICD implant. No association was observed between the implant technique and air retention. Diagnosis is confirmed by chest x‐ray and device interrogation. Management includes switching off the device or, preferably, changing the sensing vector. [ABSTRACT FROM AUTHOR]

Aims: Myotonic dystrophy type 1 (DM1) predisposes to the development of life-threatening arrhythmias and sudden cardiac death. Our study aimed to evaluate the prognostic value of programmed ventricular stimulation (PVS) in DM1 patients with conduction system disease.Methods and Results: Arrhythmic CArdiac DEath in MYotonic dystrophy type 1 patients (ACADEMY 1) is a double-arm non-randomized interventional prospective study. Myotonic dystrophy type 1 patients with permanent cardiac pacing indication were eligible for the inclusion. The study population underwent to pacemaker (PM) or implantable cardioverter-defibrillator (ICD) implantation according to the inducibility of ventricular tachyarrhythmias at PVS. Primary endpoint of the study was a composite of appropriate ICD therapy and cardiac arrhythmic death. The secondary study endpoint was all-cause mortality. Seventy-two adult-onset DM1 patients (51 ± 12 years; 39 male) were enrolled in the study. A ventricular tachyarrhythmia was induced in 25 patients (34.7%) at PVS (PVS+) who underwent dual chambers ICD implantation. The remaining 47 patients (65.3%) without inducible ventricular tachyarrhythmia (PVS-) were treated with dual-chamber PM. During an average observation period of 44.7 ± 10.2 months, nine patients (12.5%) met the primary endpoint, four in the ICD group (16%) and five (10.6%) in the PM group. Thirteen patients died (18.5%), 2 in the ICD group (8%) and 11 in PM group (23.4%). The Kaplan-Meier analysis did not show a significantly different risk of both primary and secondary endpoint event rates between the two groups.Conclusions: The inducibility of ventricular tachyarrhythmias has shown a limited value in the arrhythmic risk stratification among DM1 patients. [ABSTRACT FROM AUTHOR]

Background: Although radiofrequency (RF) catheter ablation of cavo‐tricuspid isthmus (CTI) is an established treatment for typical right atrial flutter (RAFL), it remains to be established whether local tissue impedance (LI) is able to predict effective CTI ablation and what LI drop values during ablation should be used to judge a lesion as effective. We aimed to investigate the ability of LI to predict ablation efficacy in patients with RAFL. Methods: RF delivery was guided by the DirectSense™ algorithm. Successful single RF application was defined according to a defragmentation of atrial potentials (DAP), reduction of voltage (RedV) by at least 80% or changes on unipolar electrogram (UPC). The ablation endpoint was the creation of bidirectional conduction block (BDB) across the isthmus. Results: 392 point‐by‐point RF applications were analyzed in 48 consecutive RAFL patients. The mean baseline LI was 105.4 ± 12Ω prior to ablation and 92.0 ± 11Ω after ablation (p < 0.0001). According to validation criteria, absolute drops in impedance were larger at successful ablation sites than at ineffective ablation sites (DAP: 17.8 ± 6Ω vs. 8.7 ± 4Ω; RedV: 17.2 ± 6Ω vs. 7.8 ± 5Ω; UPC: 19.6 ± 6Ω vs. 10.1 ± 5Ω, all p < 0.0001). LI drop values significantly increased according to the number of criteria satisfied (ranging from 7.5Ω to 19.9). BDB was obtained in all cases. No procedure‐related adverse events were reported. Conclusions: A LI‐guided approach to CTI ablation was safe and effective in treating RAFL. The magnitude of LI drop was associated with effective lesion formation and BDB and could be used as a marker of ablation efficacy. Clinical trial registration: Catheter Ablation of Arrhythmias with a High‐Density Mapping System in Real‐World Practice (CHARISMA). URL: http://clinicaltrials.gov/ Identifier: NCT03793998. [ABSTRACT FROM AUTHOR]