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Survival and exercise performance are key targets of heart transplantation (HT). We designed this study to help in identifying (1) patients with chronic heart failure (CHF) at risk of poor exercise capacity after HT and (2) HT recipients presenting risk factors modifiable with exercise showing a potential impact on outcome. We enrolled 49 HT recipients (age 52 ± 12 years, 84% males) who underwent a cardiopulmonary exercise test before (9 ± 6 months) and after (20 ± 14 months) HT. In the CHF phase, lower peak oxygen consumption (V̇O 2) (odds ratio 0.69, P=0.017) independently predicted peak V̇O 2 improvement after HT. In the post-HT phase, body mass index (BMI) [adjusted hazard ratio (HR) 1.16, P=0.034] and V̇E (ventilation)/V̇CO 2 (carbon dioxide production) slope (adjusted HR 1.07, P=0.031) independently predicted mortality. In conclusion, CHF patients with only a moderate impairment of peak V̇O 2 are at a risk of failing to achieve a significant improvement of exercise performance after HT. In the post-HT phase, a BMI≥28 and/or a V̇E/V̇CO 2 slope ≥47 represent risk factors for death, which are potentially modifiable with exercise. Prospective randomized studies are needed to analyze the effects of training on functional capacity and outcome in the different subsets of HT recipients.

At present the approach to atrial fibrillation treatment is based on the electrophysiological patterns of atrial fibrillation (on the basis of multiple intra-atrial recordings or sophisticated new mapping techniques) only in a restricted minority of patients, those who are candidate to ablation of the substrate and/or of the triggers. Atrial fibrillation has a broad spectrum of clinical presentations and a heterogeneous electrophysiological pattern. The treatment of this arrhythmia, both with drugs and non pharmacological treatments, has been based, classically, on empirical basis and on a clinically-guided staged-approach. The limitations of pharmacological treatment led in recent years to the development of a wide spectrum of non pharmacological treatments. This implies a change in the approach to atrial fibrillation and the need to identify potentially ideal candidates to complex and expensive treatments. In this view it is currently under investigation the possibility to identify potential responders to a definitive treatment or a combination of treatments (both pharmacological and non-pharmacological) on the basis of the electrophysiological pattern.

In this paper a technical solution to the problem of performing spectral analysis of roentgendiagnostic X-ray beams - and its constraints - will be described. With this method, X-ray spectra are reconstructed starting from the beam scattered, by a suitable target, inside a miniaturized Compton Selection Chamber (CSC). Experimental results will be shown and compared with the spectra acquired in a more direct (but not practical for on-field measurements) way.

To prospectively evaluate right atrial refractoriness and sustained atrial fibrillation (AF) inducibility at programmed electrical stimulation in two groups of patient: a series of patients with chronic persistent AF, studied immediately after successful low energy internal atrial cardioversion, and a group of control patients without history of supraventricular arrhythmias.Nineteen patients with chronic persistent AF (mean AF duration 11 +/- 10 months, range 2-61 months) submitted to successful internal low energy atrial cardioversion in fully conscious state and 11 control patients without history of supraventricular arrhythmias.An electrophysiological evaluation was performed to measure atrial refractoriness and AF inducibility, by delivering single atrial extrastimuli in high right atrium, at decremental coupling, during spontaneous sinus rhythm and after 8 beats at 600, 500, 400 and 330 ms cycle length. If sustained AF was induced the protocol was terminated.During programmed atrial stimulation sustained AF was induced in 8 out of 19 (42%) of the AF patients but in none of the control group. Atrial effective refractory period was significantly shorter in AF patients compared to controls both at basic cycle length, at 600 ms, 500 ms and 400 ms cycle length, meanwhile no statistically significant differences were found at 330 ms cycle length. An altered relationship between atrial effective refractory period and cycle length was found in AF patients compared to controls: the slope of linear correlation slope was significantly lower in AF group than in controls (0.04 +/- 0.07 vs 0.17 +/- 0.10, p0.002).Marked abnormalities of atrial refractoriness and of its heart rate relationship are observed after internal cardioversion of chronic persistent AF in humans and these abnormalities are associated with an high vulnerability to AF. These observations may explain the high risk of AF recurrences in the early phases following successful cardioversion. In this scenario antiarrhythmic drug therapy seems to be mandatory for reducing arrhythmia relapses.

Sir,—In a recent article, Biffi et al concluded that treatment guided by head up tilting is a reliable method of treating severely symptomatic and high risk patients with malignant vasovagal syndrome.1 They also found metoprolol to be superior to clonidine treatment according to their protocol. Their “pharmacological test” comprised isoprenaline infusion in five progressive steps, from 1–5 μg/min at 80° head up tilt. The specificity of isoprenaline challenge with steep angles of head up testing has been questioned. Natale et al investigated the effects of both differing degrees of head up tilt and progressive rates of isoprenaline infusion in normal volunteers with no history of syncope or presyncope.2 Testing at a 70° angle with a low dose isoprenaline infusion provided an adequate specificity of 88%, this fell to 60% during 80° head up testing. Limiting test duration at 80° to 10 minutes would have reduced the false positive rate to 16%. Furthermore, increasing the dose of isoprenaline to …

Aim. The new REHAL platform manages home-based cardiac rehabilitation programmes without most of the drawbacks of an earlier E-Remedy EC proposal . The proposal is based on the awareness that safe home rehabilitation is only possible in the post-hospital phase when the patient no longer needs direct control by medical staff and has become accustomed to the technological set-up. Methods The platform is composed of a web-based database and client software (Ergomonitor), which allows health staff to manage the sessions without a real-time connection and legal liability. Ergomonitor permits the complete management of a bike (training session settings, web transmission and data recording) by a serial connection to a PC. Patients own their data and may approve the access of health personnel to evaluate the results and introduce longitudinal ambulatory information together with updated physical activity protocols. The health service does not bear the cost of the technological set-up. Ergomonitor acquires and records heart rate, loads, pedalling speed and other parameters of interest (i.e. arterial pressure) and forwards data to a remote database. Health personnel can modify time by time the scheduled exercise settings, analyse the results of each session and compare session by session. Results The platform is actually used in hospital, gymnasium and home context. More than 1000 subjects have been enrolled in the protocol, with a very good appreciation. A representative case study is reported. Conclusions The first experience of REHAL (six months, more than 1000 enrolled patients) highlights the positive aspects of the solution: the patients are very satisfied with the continuity of the rehabilitation programme and the clinicians are very satisfied they can follow their patient population longitudinally and with a personalized protocol.

The mismatch between the left ventricle and the aorta in heart failure (HF) patients progressively reduces the energy transfer efficiency between the pump and the load. To evaluate the evolution in time of the mechanical coupling between ventricle and aorta, the aorto-ventricular mechanical matching index (Iav) is calculated as the ratio between the ventricular end systolic elastance and the mean aortic elastance during ejection. Iav was tested on eight HF patients submitted to cardiac resynchronisation therapy, during the standard clinical follow-up. Moreover, three healthy control subjects were investigated. Pressure values were measured by arm cuff arterial closure. End systolic ventricular volume was measured by echocardiography. Stroke volume was measured by transthoracic impedance. End systo lic ventricular pressure was assumed equal to arterial systolic pressure. In the normal subjects, the Iav index presented a long-term dispersion less than 0.2. In the group of patients, the Iav index showed dispersion from 0.49 to 2.57, much larger than the resolution limit. The proposed Iav demonstrated a good sensitivity for monitoring the evolution of HF patients. As it is non-invasive, this approach could be an alternative or adjunct method transforming the traditional “subjective” clinical evaluation of HF patients into to a “scientific” instrumental approach.