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Recent clinical trials have shown that selected patients with recurrent vasovagal syncope (VVS) may benefit from permanent cardiac pacing. In a previous study using head-up tilt testing (HUT) the authors demonstrated that the increase in sympathetic activity preceding syncope could be sensed by a microaccelerometer located in the tip of a ventricular pacing lead and used to drive a rate adaptive pacer. They compared in a single blind randomized crossover study, DDDR pacing driven by this system, with conventional DDI pacing in patients with recurrent VVS. Twenty-three patients (age 61.8 +/- 15.2 years, 19 men) with recurrent VVS were enrolled at seven European centers and underwent implantation of a 'MiniLivingD/Best' pacing system. Inclusion criteria were (1) > 6 cumulative syncopal episodes or > or = 1 syncope within 6 months of a positive HUT, and (2) a positive HUT with bradycardia. Using a crossover study design, the pacemakers were randomly programmed for two successive periods of 6 months to DDDR or DDI mode. The numbers of episodes of syncope and presyncope, and quality-of-life (QOL), were assessed at the end of each period. During the 6 months before implant, the mean number of syncopal episodes per patient was 3.2 +/- 9. During pacing in the DDDR mode, 0.09 +/- 0.29 syncope/presyncope per patient was observed, while during the DDI period 0.48 +/- 0.73 episodes per patient were reported (P < 0.05). QOL scores were 77.40 +/- 11.32 in the DDDR mode versus 74.45 +/- 14.59 in the DDI mode (NS). In patients with recurrent VVS, symptomatic recurrences were less frequent during contractility-driven DDDR pacing, than during DDI pacing. QOL was similar in the two pacing modes. [ABSTRACT FROM AUTHOR]

The effectiveness of respiratory-dependent atrial pacing (AAI-RDJ was assessed in 23 patients [11 male, 12 female; 68 ± 10 years) with symptomatic isolated sinus node disease (SND). Follow-up was performed at 3 month intervals and included history taking, physical examination, ECG recording and 24-hour Holter monitoring. An incremental treadmill exercise test was performed in 21/23 patients be/ore pacemaker implantation, in 23/23 patients after implantation (at least two tests with different programmed settings of respiratory rate/paced rate ratio); 21/23 patients underwent treadmill tests during both fixed rate 70 bpm and AAI-RD pacing. Physiological sensitivity of AAI-RD pacing was found excellent in 34 tests (85%) and fair in six (15%). Spontaneous heart rate was significantly higher after pacemaker implantation (bpm 115 ± 20 vs 98 ± 24, P < 0.001). In 10/21 patients paced rate was significantly higher during AAI-RD vs AAI pacing (131 ±9 vs 106 ± 16, P < 0.001) with better total work time (min 9.9 ± 4 AAI-RD vs 6.8 ± 2.6 AAI, P <. 0.002), higher oxygen consumption at anaerobic threshold [ml/min 1137 ± 406 AAI-RD vs 882 ± 268 AAI-RD vs 5.5 ± 2.6 AAI, P = 0.001). No significant difference was found in 7/21 patients (overlap between spontaneous and paced rate during both AAI-RD and AAI programming); 4/21 patients did not reach anaerobic threshold owing to osteomuscular limitations. AV block was detected in 1/23 patients, Biorate circuital failure in 1/23, sporadic undersensing in 5/23, short and symptom-free myopotential inhibitions in 10/23. We concluded that AAI-RD pacing is a reliable, safe and useful modality in pacemaker management of isolated SNA, especially in patients with abnormal rate response to exercise. [ABSTRACT FROM AUTHOR]

A study was carried out to determine whether variations in the respiration rate during physical exercise could be used as a physiological variable in controlling the rate of an implanted pacemaker. The relation between respiration rate and heart rate was significantly correlated in 73 patients (19 with normal lung function, four with restrictive pulmonary disease, and 50 with obstructive airways disease) during repeated calibrated ergometric tests; no significant differences were found between the subgroups. An external computerised programmable system with algorithm control activated by a radio frequency system was used to vary the cardiac stimulation rate in relation to respiration rate in 11 patients implanted with ventricular inhibited pacemakers. In addition, a prototype programmable pacemaker dependent on respiration rate was implanted in two patients. Maximum values of oxygen uptake, minute ventilation, and work time were increased during the exercise stress tests when the variable cardiac pacing rate was used. Thus respiration rate appears to be a valid and stable physiological variable for controlling the cardiac stimulation rate in order to improve cardiac output in patients dependent on pacemakers. [ABSTRACT FROM PUBLISHER]

Aim of the study is to evaluate if BNP and TWA can better identify, in patients needing CRT, those who must receive ICD.Eight pts. suffering for refractory CHF were evaluated (NYHA III-IV, ischaemic or idiopathic DCM, average EF=22%, with inter/intraventricular asyncronisms).BNP was measured before, 3 and every six months after implantation. Five patients underwent TWA analysis, with a positive result. All pts. received ICD plus CRT.All pts. underwent: clinical and echocardiographyc evaluation, device controls, BNP and HRV analysis.Results all pts. improved their functional class, EF, BNP (reduced) and HRV (increased) due to the favourable effect of CRT. Nowadays (average follow-up: 8 months) no malignant arrhythmias conditioning ICD discharges occurred. Conclusions CRT significantly improves symptoms and haemodinamyc conditions in severe CHF. The dramatic reduction of basal BNP values well correlates with haemodinamyc restoration. The shortness of follow-up doesn't allow, at the moment, to foresee a relation between arrhythmic risk and BNP and basal TWA. Nevertheless we hope that the data of follow-up can support the property of a more selective stratification of the arrhythmic risk (and consequently of ICD implantation) based not only on EF. [ABSTRACT FROM PUBLISHER]

Background: In standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH 2 O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation., Methods: This multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH 2 O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization., Discussion: We aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients., Trial Registration: The Research Ethics Committee (CEIm) of the Fundació Unió Catalana d'Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053., (© 2024. The Author(s).)

Background: High red blood cell distribution width (RDW) is associated with worse outcome in diverse scenarios, including in critical illness. The Sabadell score (SS) predicts in-hospital survival after ICU discharge. We aimed to determine RDW's association with survival after ICU discharge and whether RDW can improve the accuracy of the SS., Design: Retrospective cohort study. Setting: general ICU at a university hospital., Patients: We included all patients discharged to wards from January 2010 to October 2016., Methods: We analyzed associations between RDW and variables recorded on admission (age, comorbidities, severity score), during the ICU stay (treatments, complications, length of stay (LOS)), and at ICU discharge (SS). The primary outcome was hospital mortality. Statistical analysis included multivariable logistic regression and receiver operating characteristic curve (ROC) analyses., Results: We discharged 3366 patients to wards; median ward LOS was 7 [4-13] days; ward mortality was 5.2%. Mean RDW at ICU discharge was 15.4 ± 2.5%. Ward mortality was higher at each quartile of RDW (0.7%, 2.9%, 7.5%, 10.3%; area under ROC 0.81). A logistic regression model with Sabadell score obtained an excellent accuracy for ward mortality (area under ROC 0.863), and the addition of RDW slightly improved accuracy (AUROC 0.890, p  < 0.05). Recursive partitioning demonstrated higher mortality in patients with high RDW at each SS level (1.6% vs. 0.3% in SS0, 9.7% vs. 1.1% in SS1, 21.9% vs. 9.7% in SS2), but not in SS3., Conclusion: High RDW is a marker of severity at ICU discharge and improves the accuracy of Sabadell score in predicting ward mortality except in the more extreme SS3., Competing Interests: This study was approved by the ethical committee of the Unió Catalana d’Hospitals, and informed consent was waived.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Levosimendan is one of the documented pharmacological agents used in the management and treatment of acute and chronic heart failure; it is a novel inodilator agent which enhanced myocardial performance without changes in oxygen consumption. The combination of positive inotropic and vasodilator effects of levosimendan relates to its Ca(2+) - sensitizing and K(+) channels opening effects. Levosimendan has been proposed, in the recent past, to be non-inferior and may have some advantages to standard inotropes; further possible indications for levosimendan have been described, in some observational studies, such as a perioperative use, cardioprotection, cardiogenic shock, sepsis and right ventricular dysfunction. The ability of levosimendan to improve myocardial function without substantially increasing oxygen consumption may appear paradoxical but is possible via improved efficacy not only with regard to the effects on the contractile apparatus of the cardiomyocytes. The aim of this review is to describe the pharmacological characteristics of levosimendan and its clinical applications. The patent review data regarding the use of levosimendan are also discussed in this review article.

The no - reflow phenomenon occurs in one third of the patients treated with primary percutanous intervention for acute ST segment elevation myocardial infarction. In addition of the effect of prolonged ischaemia, also reperfusion injury contributes significantly to the microvascular damage in the perfusion territory of the infarct - related coronary artery. In the recent years there has been an increasing interest in the concept of adjunctive mechanical thrombectomy to improve outcomes in primary percutaneous coronary intervention. In the literature randomized trials of thrombectomy have provided conflicting results with no definitive evidence for efficacy. The recently published Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction Study (the largest randomized study of a thrombectomy device) demonstrates that adjunctive treatment with aspiration and manual thrombectomy improves clinical end - point. The aim of the report is to review the evidence to our date on the role of mechanical thrombectomy during primary percutaneous intervention in the setting of acute myocardial infarction.

Purpose: To confirm the central role of antenatal echocardiography and necropsy in the prenatal diagnosis of rare congenital heart defects., Methods: A 33-year-old woman undergoing second trimester scan using 2D transabdominal and Doppler sonography., Results: The echocardiographic examination showed, at the level of the four-chamber view, a predominant left ventricle with a rudimental right ventricle and a single artery emerging with failed visualization of the pulmonary trunk: a diagnosis of truncus arteriosus communis associated with tricuspid atresia and hypoplastic right heart was made. No other ultrasound-associated anomalies were seen. Fetal karyotype and 22q11.2 microdeletion for Di George syndrome were sought using cordocentesis performed at 21 weeks and both the results were normal. After extensive counselling, the couple opted for termination of pregnancy at 22 weeks gestation. Necroscopy confirmed the prenatal ultrasound diagnosis. Necroscopy of the heart was performed in a manner that resembled the fetal echocardiographic examination and revealed two atria, two atrio-ventricular valves with recognizable mitral and tricuspid morphology, a prevalent ventricle of left-type and a rudimental ventricle of right type and a ventricular septal defect. The common truncus was seen coming out above the ventricular septum, whilst the pulmonary arteries arise separated from the truncus communis. No other structural thoraco-abdominal anomalies were found., Conclusions: A combined diagnostic strategy based on second trimester fetal echocardiography, genetic analysis and necroscopy has made identification of a rare congenital heart disease possible.

Flecainide is a class Ic anti - arrhythmic drug with sodium channel blocking activities. We report a case of a 57 year - old woman who attempted a suicide by ingesting approximately 1,8 gr of flecainide. On the surface electrocardiogram this results in a large QRS complex and in prolongation of the QTc interval. Overdose with a class Ic drug is very uncommon, its management is difficult and the mortality high.Because of a hemodynamic instability and in addition to supportive care and antidysrhythmics, she was treated with a high dose of sodium bicarbonate in hypertonic solution; after this infusion the patient's QRS progressive narrowed.In conclusion, sodium bicarbonate may be useful in the treatment of widened QRS and to stabilize a overdose of class Ic anti - arrhythmic drugs.

Anagrelide is a phosphodiesterase III inhibitor utilized in the treatment of essential thrombocythemia. Anagrelide can be responsible for positive inotropic and chonotropic activity of the cardiovascular system. Moreover, it can induce vasospam directly on the epicardial coronary arteries. In the literature, it is well reported that this inhibitor can determine serious cardiovascular side effects, including congestive heart failure, arrhythmia and acute coronary syndrome. We describe the case of a 75-year-old woman who developed a mid-ventricular Takotsubo syndrome while on anagrelide therapy. Takotsubo cardiomyopathy, also known as left ventricular ballooning syndrome, is characterized by a reversible ventricular contractile dysfunction with akinesis and expansion of apical segments and hyperkinesis of the basal segments. Recently, atypical cases with akinesia and dilation of mid-ventricular segment and hypercontraction of the apical segments, also called mid-ventricular and inverted Takotsubo syndrome, have been described. Even though the pathogenesis of Takotsubo syndrome is poorly understood, several mechanisms have been proposed, including catecholamine-induced myocardial stunning, and ischemia-mediated stunning due to multivessel epicardial or microvascular spasm. We think that in our case, the adverse response of anagrelide therapy was determined, by accumulated dosage of the drug, through an intensive inotropic stimulation and a sympathetic hyperactivation in a vulnerable myocardium. To our knowledge, this is one of the first reports of an association between anagrelide therapy and Takotsubo cardiomyopathy.

Background: Tako - tsubo like syndrome (also named left ventricular apical ballooning) is an unusual cardiomyopathy with an high incidence in Japanese population of female sex, following an emotional stress. The clinical features (typical chest pain), and the electrocardiographic changes (negative T wave and persistent ST elevation in anterior leads), are suggestive of an acute myocardial infarction; nevertheless the coronary angiography show coronary arteries without lesions and the ventriculography show specific segmental dysfunction. In the literature there are many reports of typical left ventricular ballooning (apical); due to the rarity of the atypical localizations (such as mid, basal, anterior or inferior left ventricular wall) many authors think they are different physiopatologic entity., Case Report: We report a case of 50 - years old woman, with a family history of ischeamic cardiomyopathy but with no additional cardiovascular risk factors, who arrived to emergency department with a recent episode of chest pain (about 30 minutes) with electrocardiographic and echocardiographic features suggested of a inferior ST elevation myocardial infarction. Coronary angiography showed coronary arteries without atherosclerotic lesions; ventriculography showed an inferior dysfunction., Conclusion: This data can suggest for an atypical form (in term of clinical presentation and localization) of left ventricular ballooning involving the inferior wall (never described in the literature), not preceded by any emotional or physical stress. The follow - up performed by transthoracic echocardiography (2 months later) revealed a complete regression of wall motions abnormalities.

Ivabradine (a compound of the benzocyclobutane) is a highly selective I(f) current inhibitor acting directly on the sino-atrial node, induces a rapid, sustained and dose-dependent reduction of heart rate at rest and during exercise without a significant effect on atrio-ventricular conduction, left ventricular contraction/relaxation or vascular tissues. These properties associated with an improvement in left ventricular loading related to bradycardia resulted in an increase in stroke volume and preservation in cardiac output even during exercise. Various experimental and clinical studies showed the efficacy of ivabradine in patients with chronic stable angina, on heart rate reduction, on ventricular remodelling after acute myocardial infarction and on coronary blood flow. The safety of ivabradine has been documented in several studies and clinical trials, in contrast to beta-blockers, no significant side effects were expressed in the literature. The aim of our review is to describe ivabradine and its cardiovascular effects and outline some recent patents and the results of the most important trials.

Objective: Pericentric inversion carriers are predisposed to produce unbalanced gametes that result in conceptuses having either a partial trisomy for one distal segment and a partial monosomy for the other or vice versa. Larger inversions result in smaller unbalanced distal segments and a higher likelihood of a viable fetus. In these cases the structure of the recombinant chromosome is similar to the original balanced inverted or normal ones despite the (unbalanced) genetic content. Such cases may not be detected prenatally by conventional cytogenetic analysis., Methods: In all prenatal samples from the pericentric inversion carriers we applied subtelomeric FISH probes specific for the chromosome involved in order to detect parental meiotic recombinants resulting from a single cross-over event. Confirmatory MLPA was also applied in unbalanced fetuses., Results: The occurrence of a duplication deficiency unbalance from pericentric inversion carriers was successfully detected in all three fetuses by FISH. MLPA assays applied in two cases confirmed these results., Conclusions: The application of commercial FISH subtelomeric probes is a reliable method that could be routinely applied for the detection of single cross-over meiotic recombinants. MLPA is a sound alternative technique.

Objectives: To evaluate uterine artery resistance during multiovulation induction in relation to the implantation rate in patients attending in vitro fertilization (IVF) cycles., Patients: Multiovulation induction for IVF was monitored by daily determination of the pulsatility index (PI) of the uterine arteries, obtained by a transvaginal probe (6.5 MHz) implemented with color-flow imaging. Doppler data were obtained from 5 days before hCG administration to the day of follicular aspiration. One IVF cycle was monitored in 70 patients. In 17 patients, 41 IVF cycles were monitored until a successful attempt occurred., Results: In the 70 patients studied during one IVF attempt, the PI of the uterine arteries significantly varied (P < 0.001) in the different phases of the cycle. In the 24 patients who conceived, a significantly lower PI (P < 0.03) was found throughout the cycle. This result was mainly due to a highly significant difference of PI values observed the day after hCG administration (P < 0.005). In the 17 patients who conceived after 1 to 4 negative in vitro fertilizations, no significant difference in PI was observed in the uterine artery resistance in cycles in which implantation was or was not successful., Conclusions: Uterine artery resistance varies significantly during phases of the induction therapy. Uterine artery resistance is lower throughout the course of multiovulation induction in patients with higher pregnancy rates. The PI on the day after hCG administration was the best index of pregnancy rate. Low uterine artery resistance was present even in negative attempts in patients who eventually achieved a successful implantation. PI values < or = 3 can be considered a favorable prognostic factor for future IVF cycles.

Pathologic studies have shown that atherosclerosis may already be present in childhood as reversible fatty streaks in the aortic intima. These findings are directly related to total serum cholesterol and inversely related to serum HDL cholesterol. This study was aimed at screening children and young adolescents of Novara for cardiovascular risk factors and achieving a specific health educational program. We screened a sample of 2560 children and young adolescents aged 10 to 16 years (mean 12) for known family history of cardiovascular diseases and hyperlipidemia, blood pressure values, serum cholesterol fractions and triglycerides. Of the 2560 children, 786 were considered at risk according to pre-defined cutoff points for systolic BP (> 120 mmHg) 10.6%, diastolic BP (> 80 mmHg) 3.4%, total serum cholesterol (= > 160 mg/dl) 18.7%, serum HDL cholesterol (< 40 mg/dl) 49.5%, total serum cholesterol/HDL ratio (> 4) 28.0%, and triglycerides (> 150 mg/dl) 3.7%. Parents were invited to change family lifestyle according to a specific health educational program, which included advice about diet and physical activity. All children at risk were re-examined 1 year later. Mean values of total serum cholesterol (129 +/- 26 vs 143 +/- 30, p < 0.001), triglycerides (86 +/- 28 vs 91 +/- 32, p < 0.01) and total serum cholesterol/HDL ratio (3.7 vs 3.8, p NS) were found to be lower than at index evaluation. The distribution of total cholesterol curve shifted to the left, and the high risk cases (total serum cholesterol > 200 mg/dl) lowered from 56 to 24 at the follow-up evaluation.(ABSTRACT TRUNCATED AT 250 WORDS)

Objectives: In order to assess possible functional and hemodynamic benefits of different programming of atrioventricular (AV) delay--156 ms fixed vs 156 to 63 adaptive--two maximal exercise tests (cyclette) were performed in 8 patients (6 males, 2 females; 69 +/- 6 years) implanted with Chorus 6003 (Ela Medical, France) DDD pacemakers for complete AV block with normal sinus node function., Methods: The measured parameters were: pacing rate, cardiac output (thermodilution method), oxygen consumption (2001 gas-exchange analyser), arterial-venous difference (derived from pulmonary oxygen saturation, through an optical-fibers Swan-Ganz catheter coupled to an Oximetric3-Abbott oximeter), human atrial natriuretic factor and lactate plasmatic levels, anaerobic threshold., Results: A better cardiac output (11.4 +/- 1.7 vs 10.1 +/- 1.8 l/min) and oxygen consumption (1521 +/- 425 vs 1408 +/- 465 ml/min) were observed at maximal exercise with adaptive rather than with fixed AV delay programming (p < 0.05); moreover anaerobic threshold point was reached later during exercise test with adaptive AV delay (242 +/- 92 vs 216 +/- 109 sec, p = 0.05). On the contrary, with adaptive and fixed AV delay, there were not statistically different values of maximal heart rate (139 +/- 9 vs 139 +/- 9), levels at maximal exercise of arterial-venous difference (12.5 +/- 2 vs 12.8 +/- 1.4 Vol%O2), human atrial natriuretic factor (63 +/- 17 vs 78 +/- 48 pg/ml), lactate (29 +/- 15 vs 29 +/- 18 mg/dl), and oxygen consumption at anaerobic threshold point (772 +/- 164 vs 786 +/- 229 ml/min)., Conclusions: In DDD pacing adaptive AV delay causes aerobic and hemodynamic benefits.

A procedure is described to isolate DNA probes from the bovine genome that are enriched in sites for the so-called rare cutter restriction endonucleases. A collection of SacII (CvCGCGG)-Hin-dIII fragments from bovine sperm was established in the plasmid Bluescript. 180 clones were picked at random and analysed for the presence of inserts with sites for the following rare cutters: EagI, BsshII, NarI, MluI, NruI, NaeI: 70% of the clones contained at least 1 site and 5% contained four different such sites. 22.8% had multiple sites for one or more of the rare cutters tested. Sequence analysis for 16 clones confirmed the cloning of DNA with a G+C content and a proportion of CpG vs GpCs indicative of CpG islands.

Endless loop tachycardia (ELT) is a possible complication in dual chamber pacing; it is usually prevented by programming the atrial refractory period (PVARP) longer than the retrograde ventriculoatrial (VA) conduction interval; this in some patients limits the upper rate. In 15 patients with a DDD (nine patients) or a single-pass lead VDD pacemaker (six patients) and retrograde atrial activation, telemetric recording documented a significant difference in amplitude of antegrade, and retrograde atrial potentials (VDD 1.21 +/- 0.32 mV vs 0.56 +/- 0.23 mV, P = 0.008; DDD 2.7 +/- 1 vs 1.8 +/- 1 mV, P = 0.038; Student's t-test for paired data). In 3/15 patients ELT stopped after programming of atrial sensitivity to a value greater than the retrograde P wave amplitude; in 11/15 patients this occurred at a sensing value lower than or equal to retrograde P wave amplitude with a high pass band filter operating. One patient required PVARP lengthening. Holter monitoring showed no more ELTs. In most patients with a DDD or single-pass lead VDD pacemaker with widely programmable sensing amplitude and Hi/Low bandpass filters, individual programming of atrial channel sensitivity prevents ELT without affecting the PVARP and, consequently, upper rate limit.