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Dilated cardiomyopathy is a primitive heart muscle condition, characterized by structural and functional abnormalities, in the absence of a specific cause sufficient to determine the disease. It is, though, an 'umbrella' term that describes the final common pathway of different pathogenic processes and gene-environment interactions. Performing an accurate diagnostic workup and appropriate characterization of the patient has a direct impact on the patient's outcome. The physician should adapt a multiparametric approach, including a careful anamnesis and physical examination and integrating imaging data and genetic testing. Aetiological characterization should be pursued, and appropriate arrhythmic risk stratification should be performed. Evaluations should be repeated thoroughly at follow-up, as the disease is dynamical over time and individual risk might evolve. The goal is an all-around characterization of the patient, a personalized medicine approach, in order to establish a diagnosis and therapy tailored for the individual patient., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: We developed and validated an algorithm for prediction of heart failure (HF) hospitalizations using remote monitoring (RM) data transmitted by implanted defibrillators., Methods and Results: The SELENE HF study enrolled 918 patients (median age 69 years, 81% men, median ejection fraction 30%) with cardiac resynchronization therapy (44%), dual-chamber (38%), or single-chamber defibrillators with atrial diagnostics (18%). To develop a predictive algorithm, temporal trends of diurnal and nocturnal heart rates, ventricular extrasystoles, atrial tachyarrhythmia burden, heart rate variability, physical activity, and thoracic impedance obtained by daily automatic RM were combined with a baseline risk-stratifier (Seattle HF Model) into one index. The primary endpoint was the first post-implant adjudicated HF hospitalization. After a median follow-up of 22.5 months since enrolment, patients were randomly allocated to the algorithm derivation group (n = 457; 31 endpoints) or algorithm validation group (n = 461; 29 endpoints). In the derivation group, the index showed a C-statistics of 0.89 [95% confidence interval (CI): 0.83-0.95] with 2.73 odds ratio (CI 1.98-3.78) for first HF hospitalization per unitary increase of index value (P < 0.001). In the validation group, sensitivity of predicting primary endpoint was 65.5% (CI 45.7-82.1%), median alerting time 42 days (interquartile range 21-89), and false (or unexplained) alert rate 0.69 (CI 0.64-0.74) [or 0.63 (CI 0.58-0.68)] per patient-year. Without the baseline risk-stratifier, the sensitivity remained 65.5% and the false/unexplained alert rates increased by ≈10% to 0.76/0.71 per patient-year., Conclusion: With the developed algorithm, two-thirds of first post-implant HF hospitalizations could be predicted timely with only 0.7 false alerts per patient-year., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

A 64-year-old man underwent catheter ablation (CA) of atrial fibrillation with intracardiac echocardiography (ICE) assistance. As the probe was advanced toward the right atrium, sudden abdominal pain was felt by the patient with hypotension and tachycardia requiring fluids and vasopressors for hemodynamic stabilization. The inferior vena cava (IVC) was injured by the passing probe and open repair was then performed. To our knowledge, this is the first reported case of symptomatic IVC laceration by the probe used for ICE during CA., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020.)

The aim of this document is the management and organization of patients in need of urgent access to electrophysiology (EP) and pacing procedures during the COVID-19 emergency. Specifically, non-deferrable procedures or irreplaceable with a drug therapy prior to the resolution of the COVID-19 virus emergency [pacemaker (PM) implant/replacement/urgent defibrillator (implantable cardioverter-defibrillator, ICD) or arrhythmic storm or other indication of non-deferrable ablation]. The pacing and electrophysiological procedures urgent as they may be, less and less frequently represent situations of emergency, therefore for almost all cases, it is possible to perform a swab test to determine the positivity to COVID-19 of the patient. In cases where this is not possible, due to situations of emergency, the recommendations and procedures we have indicated are advisable, if not mandatory, in order to avoid the spreading of the virus to healthcare personnel and other patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions please email: journals.permissions@oup.com.)

Aims: Malfunctions of cardiac implantable electronical devices (CIED) have been described after high-energy radiation therapy even in the absence of direct exposure to ionizing radiation, due to diffusion of neutrons (n) causing soft errors in inner circuits. The purpose of the study was to analyse the effect of scattered radiation on different types and models of CIED and the possible sources of malfunctions., Methods and Results: Fifty-nine explanted CIED were placed on an anthropomorphous phantom of tissue-equivalent material, and a high-energy photon (15 MV) radiotherapy course (total dose = 70 Gy) for prostate treatment was performed. All devices were interrogated before and after radiation. Radiation dose, the electromagnetic field, and neutron fluence at the CIED site were measured. Thirty-four pacemakers (PM) and 25 implantable cardioverter-defibrillators (ICD) were analysed. No malfunctions were detected before radiation. After radiation a software malfunction was evident in 13 (52%) ICD and 6 (18%) PM; no significant electromagnetic field or photon radiations were detected in the thoracic region. Neutron capture was demonstrated by the presence of the (198)Au((197)Au + n) or (192)Ir((191)Ir + n) isotope activation; it was significantly greater in ICD than in PM and non-significantly greater in damaged devices. A greater effect in St Jude PM (2/2 damaged), Boston (9/11), and St Jude ICD (3/6) and in older ICD models was observed; the year of production was not relevant in PM., Conclusion: High-energy radiation can cause different malfunctions on CIED, particularly ICD, even without direct exposure to ionizing radiation due to scattered radiation of neutrons produced by the linear accelerator., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Aims: Left bundle branch block (LBBB) is commonly associated with heart failure. We evaluated the prevalence, incidence, and impact of LBBB on long-term outcome in young patients with heart failure affected by idiopathic dilated cardiomyopathy (DCM)., Methods and Results: We included 608 patients with DCM from the Heart Muscle Disease Registry of Trieste in this retrospective analysis. At baseline electrocardiogram (ECG), 189 patients (31.1%) had LBBB. The patients with baseline LBBB had a significantly higher mortality rate than the patients without LBBB (38.6 vs. 27.9%, P = 0.002) at the univariate analysis. After a multiple covariate adjustment, the baseline LBBB was not associated with a significantly increased risk of death [hazard ratio (HR) 1.27, 95% confidence interval (CI): 0.88-1.81, P = 0.2]. Forty-seven (11.2%) patients without LBBB at baseline ECG developed LBBB during follow-up. Among these, the mortality rate was 49 vs. 25% in patients without new-onset LBBB (P = 0.001). New-onset LBBB was a strong and independent predictor of all-cause mortality (HR 3.18, 95% CI: 1.90-5.31, P < 0.001) at multivariate analysis., Conclusion: After correcting for potential confounders, new-onset LBBB was found to be associated with an increased risk of all-cause mortality. The management of patients with new-onset LBBB may need to be more aggressive, possibly including early cardiac resynchronization therapy/implantable cardioverter-defibrillator therapy., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

Aims: To evaluate the long-term changes of clinical and echocardiographic parameters, the incidence of cardiac events and parameters associated with late cardiac events in 'super-responders' to cardiac resynchronization therapy (CRT) with [CRT defibrillator (CRT-D)] or without defibrillator back-up., Methods and Results: In all consecutive patients treated with CRT in two Italian centres (Trieste and Udine) with left ventricular ejection fraction (LVEF) ≤0.35 at implantation (Timp) and LVEF > 0.50 1 and/or 2 years (Tnorm) after implantation, the long-term outcome and the evolution of echocardiographic parameters were assessed; factors associated with a higher risk of cardiac events, defined as hospitalization or death for heart failure (HF), sudden death, or CRT-D appropriate interventions, were also analysed. Among the 259 patients evaluated, 62 (24%) had LVEF ≥ 0.50 at Tnorm (n = 44 with at 1 year, n = 18 at 2 years). During a mean follow-up of 68 ± 30 months, one cardiac death (for HF) and eight cardiovascular events (two hospitalization for HF and six appropriate CRT-D interventions) occurred. At the last echo evaluation (Tfup) performed 51 ± 26 months after Timp, LVEF was <0.50 in five patients (>0.45 in four of them). At univariable analysis, only LV end-systolic volume evaluated at Tfup was associated with a higher risk of cardiac events during follow-up., Conclusion: In 'super-responders' to CRT long-term outcome is excellent. However, cardiac events, mainly CRT-D appropriate interventions, can occur despite the persistence of LVEF > 0.50. Early identification of these patients is still an unsolved issue.

Aim: To analyse the characteristics and outcome of patients with idiopathic dilated cardiomyopathy (DC) considered at high risk of sudden death (SD) and treated with implantable cardioverter defibrillators (ICD) for primary prevention (Group A) in comparison with patients treated with ICDs because of previous sustained ventricular tachyarrhythmias or syncope (Group B)., Methods: Group A consisted of 27 patients with at least two of the following criteria: left ventricular end-diastolic diameter (LVEDD) > or =70 mm (74%), LV ejection fraction (LVEF) < or =30% (78%), non-sustained ventricular tachycardia (VT) (56%), long history of disease (> or =48 months since diagnosis, 85%) and family history of SD (11%). Group B consisted of 27 patients treated with ICDs because of sustained VT/fibrillation (n=18) or syncope (n=9)., Results: NYHA class, LVEF, LVEDD and amiodarone treatment were similar in the two groups. Patients in group A were younger (46+/-15 vs 59+/-17 years, P=0.0008), were more often treated with beta-blockers (89% vs 62%; P=0.02) and had a longer interval since diagnosis (86+/-60 vs 40+/-50 months; P=0.004). Twelve month rates of appropriate intervention (AI) were 41% in Group A and 57% in group B (P NS). In group A, after a mean follow-up of 21+/-14 months, patients showing the combination of LVEF < or =30% and LVEDD > or =70 mm had the highest frequency of AI (76% vs 10%, P=0.005). In group B, after a mean follow-up of 33+/-23 months, 78% of patients with syncope had AI. Total and sudden deaths were 11% and 4% in group A and 19% and 4% in group B (P NS)., Conclusions: Patients with idiopathic DC treated with ICD for primary prevention because they were considered at high risk of SD according to clinical criteria showed a high rate of AI, similar to that of patients treated for secondary prevention. The highest rate of AI was seen in patients with both severe dysfunction and dilatation and in those with previous syncope.

Aim: This retrospective four-centre study assessed the current indications for dual-chamber implantable cardioverter defibrillators (ICDs) at implant and during a medium-term follow-up period in a group of patients treated by single-chamber ICD in the pre dual-chamber ICD era., Methods and Results: The study population consisted of 153 consecutive patients (127 males, mean age 58 +/- 6 years) treated by single-chamber ICD for ventricular tachycardia and/or ventricular fibrillation. Definite indications for having a dual-chamber ICD included the presence of sinus node dysfunction and of second- or third-degree atrioventricular (AV) block, while possible indications were represented by paroxysmal atrial fibrillation or flutter and first-degree AV block. At implant, dual-chamber ICD would appear definitely indicated in 10.5% of cases, and possibly indicated in an additional 17.5% of cases. During 12 +/- 10 months follow-up, such percentages remained stable (11 and 19.5%, respectively). Inappropriate ICD intervention was documented in five of 13 patients (38%), with episodes of paroxysmal atrial fibrillation or flutter., Conclusion: In this non-selected study population, a dual-chamber ICD would have potentially benefited approximately 30% of the patients. During medium-term follow-up, there was no progression towards increasing dual-chamber ICD indications. The 15% cumulative incidence of paroxysmal atrial tachyarrhythmias justifies the activation of dedicated detection algorithms.