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A 55-years old sporty man, without any cardiovascular risk factors nor previously known cardiological history, presented for a cardiological evaluation due to extra-systolic palpitations and dyspnea. The ECG documented a new onset of right bundle branch block, left anterior fascicular block and first degree of atrio-ventricular block. Echocardiography revealed severe left ventricular (LV) systolic dysfunction (LV ejection fraction -EF- 34%), showing also right ventricular (RV) dilatation and disfunction. A 24-hour Holter monitoring did not show any significant arrhythmias and maximal stress test did not reveal any ECG changes nor arrhythmias. Cardiac magnetic resonance (CMR) confirmed the presence of severe biventricular dysfunction; multiple areas of edema and late gadolinium enhancement (LGE) were observed, with ischemic and nonischemic pattern and extensive involvement of the RV and the interventricular septum. In the suspicion of cardiac sarcoidosis a 18-fluorodeoxyglucose positron emission tomography (PET) was performed, confirming the presence of an inflammatory cardiomyopathy in an active phase. A subsequent endomyocardial biopsy was performed, which demonstrated the presence of non-caseating granulomas, signs of inflammation and fibrosis, consistent with the diagnosis of cardiac sarcoidosis. No signs of extra-cardiac involvement were present. The patient started anti-inflammatory therapy with Prednisone and Metotrexate, along with anti-neurohormonal therapy. However, due to a significant increase in ventricular arrhythmic burden, an implantable cardioverter defibrillator was placed during early follow-up, and Amiodarone therapy was started. After 5 months of medical therapy, PET scan showed a marked reduction of cardiac inflammation and echocardiography showed a significant LVEF improvement (from 34% to 43%). After slow tapering of steroid therapy Prednisone was stopped, whereas Metotrexate, Amiodarone and anti-neurohormonal therapy were maintained. Follow-up is still ongoing without clinical events. Sarcoidosis is a systemic inflammatory disease characterized by the presence of non-caseating granulomas in multiple organs. Cardiac involvement is associated with higher incidence of heart failure, ventricular arrhythmias and all-cause mortality. Isolated cardiac involvement is rare but associated with worse prognosis. Multimodality imaging is of paramount importance for the diagnosis and monitoring therapy.

A 60-year-old man with a previous myocardial infarction was admitted to our ICU for acute pulmonary edema in the context of an acute antero-lateral non-ST elevation myocardial infarction. Echocardiography showed severe left ventricular (LV) dilatation with extensive wall motion abnormalities, large apical aneurysm and severe systolic dysfunction. Coronary angiography showed a triple-vessel disease with proximal occlusion of the left anterior descending artery. During the hospitalization, multiple episodes of drug-resistant monomorphic ventricular tachycardias occurred, requiring repeated DC Shock. After Heart Team discussion, the patient underwent coronary artery bypass grafting, LV restoration according to the procedure described by Guilmet and surgical cryoablation. The Guilmet septoexclusion is indicated when the interventricular septum is more involved than the free wall. After aneurysm incision, cryolesions were applied at the septum and at the transitional zone of the scar and viable tissue. Thus, the anterior free wall was sewn obliquely to the septum. Finally, the edges of the incision, anterior and septal, were sewn together to assure a definitive hemostasis (overcoat technique). After surgery, an implantable cardioverter-defibrillator was implanted in secondary prevention. The postoperative course and subsequent cardiological follow-up were characterized by a gradual clinical improvement with mild increasing in LV function and reduction in ventricular arrhythmias. Nowadays, combined aneurysmectomy and endocardial ablation are rarely performed, but should be considered in patients with LV aneurysm who manifest drug-resistant ventricular arrhythmias. Encircling cryoablation in a remodelled ventricle is safe and effective in reducing ventricular arrhythmias which are a negative prognostic factor.

Aims Although increasingly recognized as a distinct pathological entity, left bundle branch block‐induced cardiomyopathy (LBBB‐ICMP) is not included among the possible aetiologies of acquired dilated cardiomyopathies (DCM). While diagnostic criteria have been proposed, its recognition remains principally retrospective, in the presence of clinical and instrumental red flags. We aimed to assess the prevalence and clinical and instrumental features of LBBB‐ICMP in a large cohort of patients with DCM. Methods and results We analysed a cohort of 242 DCM patients from a two‐centre registry. Inclusion criteria were age > 18, non‐ischaemic or non‐valvular DCM, and LBBB on electrocardiogram. LBBB‐ICMP was defined according to previously proposed diagnostic criteria: (i) neither family history nor clinically identifiable potential causes for DCM; (ii) negative genetic testing; (iii) echocardiographic features including non‐severe chamber dilation, normal absolute and relative wall thickness, marked dyssynchrony, and normal right ventricular function; and (iv) absence of late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR). From the entire cohort, we identified 30 subjects (similar in terms of New York Heart Association class I or II in 80% vs. 75%, P = 0.56; QRS width of 150 ± 22 vs. 151 ± 24 ms, P = 0.82; and cardiac remodelling of baseline end‐diastolic diameter 66 ± 8 vs. 65 ± 10 mm, P = 0.53) with a comprehensive dataset including CMR and genetic testing, required to verify the presence of the diagnostic criteria proposed for LBBB‐ICMP. The main characteristics of this subgroup were 73% males, age 45 ± 13 years, left ventricular ejection fraction (LVEF) 30 ± 10%, LGE in 38% of patients, and QRS complex of 150 ± 22 ms. Patients were under guideline‐directed medical therapy, and 57% of them were treated with cardiac resynchronization therapy (CRT). Two patients (6.67%, 50% males, age 53 ± 13 years) fulfilled the diagnostic criteria proposed for LBBB‐ICMP. After a follow‐up of 44 (12–76) months, LVEF was normal and QRS width significantly reduced (from 154 ± 25 to 116 ± 52 ms) in patients with LBBB‐ICMP. Both patients were under optimal medical treatment, and one was implanted with CRT‐D. Neither of the two patients experienced death, malignant ventricular arrhythmia, or heart failure hospitalization at follow‐up. Conclusions Left bundle branch block‐induced cardiomyopathy emerges as a distinct pathological entity, promptly identifiable in a minority but not negligible proportion of patients with newly diagnosed DCM and LBBB, using a series of diagnostic criteria including CMR and genetic testing. Further studies are needed to better elucidate the clinical course of LBBB‐ICMP.

The number of patients with cardiac implantable electronic devices (CIEDs) undergoing radiotherapy (RT) for cancer treatment is growing. At present, prevalence and predictors of RT-induced CIEDs malfunctions are not defined.Systematic review and meta-analysis conducted following the PRISMA recommendations. PubMed, Scopus and Google Scholar were searched from inception to 31/01/2022 for studies reporting RT-induced malfunctions in CIEDs patients. Aim was to assess the prevalence of RT-induced CIEDs malfunctions and identify potential predictors.Thirty-two out of 3962 records matched the inclusion criteria and were included in the meta-analysis. A total of 135 CIEDs malfunctions were detected among 3121 patients (6.6%, 95% confidence interval [CI]: 5.1%-8.4%). The pooled prevalence increased moving from pacemaker (PM) to implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy and defibrillator (CRT-D) groups (4.1%, 95% CI: 2.9-5.8; 8.2% 95% CI: 5.9-11.3; and 19.8%, 95% CI: 11.4-32.2 respectively). A higher risk ratio (RR) of malfunctions was found when neutron-producing energies were used as compared to non-neutron-producing energies (RR 9.98, 95% CI: 5.09-19.60) and in patients with ICD/CRT-D as compared to patients with PM/CRT-P (RR 2.07, 95% CI: 1.40-3.06). On the contrary, no association was found between maximal radiation dose at CIED2 Gy and CIEDs malfunctions (RR 0.93; 95% CI: 0.31-2.76).Radiotherapy related CIEDs malfunction had a prevalence ranging from 4% to 20%. The use of neutron-producing energies and more complex devices (ICD/CRT-D) were associated with higher risk of device malfunction, while the radiation dose at CIED did not significantly impact on the risk unless higher doses (10 Gy) were used.

The design of critical facilities needs a targeted computation of the expected ground motion levels. The Trans Adriatic Pipeline (TAP) is the pipeline that transports natural gas from the Greek-Turkish border, through Greece and Albania, to Italy. We present here the probabilistic seismic hazard analysis (PSHA) that we performed for this facility, and the deaggregation of the results, aiming to identify the dominant seismic sources for a selected site along the Albanian coast, where one of the two main compressor stations is located. PSHA is based on an articulated logic tree of twenty branches, consisting of two models for source, seismicity, estimation of the maximum magnitude, and ground motion. The area with the highest hazard occurs along the Adriatic coast of Albania (PGA between 0.8 and 0.9 g on rock for a return period of 2475 years), while strong ground motions are also expected to the north of Thessaloniki, Kavala, in the southern Alexandroupolis area, as well as at the border between Greece and Turkey. The earthquakes contributing most to the hazard of the test site at high and low frequencies (1 and 5 Hz) and the corresponding design events for the TAP infrastructure have been identified as local quakes with MW 6.6 and 6.0, respectively.

Aims: To analyze temporal trends (2001 -2017) of Pacemakers (PM) and Implantable Cardioverter-Defibrillators (ICD) procedures in Italy, according to the national Hospital Discharge Database (HDD). Methods: Frequency and implant rate (IR) in the Italian population were analyzed by age groups (

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.

Since about 20,000 years ago, the geography of the Earth has been profoundly modified by the gradual sea-level rise caused by the melting of continental ice sheets. Flat areas and regions characterized by very low gradients experienced, more than others, rapid flooding, with the progressive disappearance of vast coastal territories. Here we present a recon- struction of the late Quaternary coastline evolution of the north-western sector of the Sicilian Channel, constrained by high-resolution seismic profiles where the marker of the post-Last Glacial Maximum (LGM) marine transgression has been clearly identified and mapped. The locations of the post-LGM seismic horizon have been compared with predictions of a Glacial Isostatic Adjustment (GIA) model, which accounts for the migration of the shorelines in response to sea-level rise and for Earth’s rotational and deformational effects associated with deglaciation. We have verified that most of the points mapped through seismic data interpretation fall along the palaeo-coastline that the GIA model predicts for the 21 kyrs B.P. time frame. However, the model shows a misfit in the marine sector between Mazara del Vallo and Sciacca, where the available data indicate a Quaternary tectonic uplift. The analy- sis of the seismic profiles provides useful constraints to current GIA models. These add on existing histories of relative sea level in the Mediterranean Sea, allowing to gain new insight into the evolution of the palaeo-geography of the region of study and of the whole Sicilian Channel since the LGM, even in areas where direct geophysical observations are not avail- able yet. In this respect, one of the most attractive implications of the ancient coastline evo- lution is linked with the underwater archaeology. The sea-level rise heavily impacted the distribution of human settlements, possibly forcing site abandonment and migrations, and this is particularly relevant in the Mediterranean basin, the cradle of the western civilization. The underwater traces left by these ancient populations represent the fundamental proofs to reconstruct the early history of our precursors.

The Plio-Quaternary tectonic evolution of the central sector of the Sicilian Channel and the resulting morphostructural setting have been analyzed using a large geophysical dataset consisting of multichannel seismic profiles, which some of them never published, and available bathymetric data. This area hosts two regional-scale tectonic domains that registered the complex pattern of deformation occurred since the Early Pliocene: (1) the Sicilian Channel Rift Zone (SCRZ), which can be divided into a western sector formed by the Pantelleria graben (PG) and in a eastern one represented by the Linosa and Malta grabens (LG and MG) and (2) the Capo Granitola-Sciacca Fault Zone (CGSFZ), a NNE-oriented lithospheric transfer zone that crosses the Sicilian Channel from the Sicily coast to the Linosa Island, of which only its northern part has been studied to date. Data interpretation has allowed achieving the following outcomes: (i) the presence of an alternation of basins and structural highs forming a NNE-oriented separation belt between the western and eastern sectors of the SCRZ, and interpreted as the shallow expression of the southern part of the CGSFZ; (ii) a NE-oriented tectonic lineament separating the MG in a northern and southern part, and interpreted as the southern prosecution of the Scicli-Ragusa Fault System; (iii) the presence of syn-rift deposits in the Plio-Quaternary fill of the grabens, suggesting that the opening of the grabens of the SCRZ was coeval, and started since Early Pliocene in the framework of a NW-oriented right-lateral transtensional mega-shear zone; (iv) continental rifting ended around the Early Calabrian, during which extensional tectonics dominated along the separation belt; (v) the CGSFZ conditioned the SCRZ configuration at a regional scale, leading to the development of the PG in the western sector and of the LG and MG in the eastern one; and (vi) after the Early Calabrian, the PG and the southern MG followed a different tectonic evolution with respect to the LG and northern MG. The syn-rift deposits of the PG and southern MG were sealed by an undeformed post-rift succession, while the LG and the northern MG suffered a basin inversion that ended around the Latest Calabrian time. During this stage, the separation belt was affected by a transpressional tectonics. At present, the grabens of the Sicilian Channel seem to be tectonically inactive, while the CGSFZ represents an active tectonic domain.

Background Sleep apnea, as measured by polysomnography, is associated with adverse outcomes in heart failure. The DASAP-HF (Diagnosis and Treatment of Sleep Apnea in Patient With Heart Failure) study previously demonstrated that the respiratory disturbance index (RDI) computed by the ApneaScan algorithm (Boston Scientific) accurately identifies severe sleep apnea in implantable cardioverter-defibrillator (ICD) patients. Objective The purpose of the long-term study phase was to assess the incidence of clinical events after 24 months and investigate the association with RDI values. Methods Patients with left ventricular ejection fraction ≤35% implanted with an ICD were enrolled and followed-up for 24 months. The RDI calculated at 1 month after implantation was used to stratify patients (below or above 30 episodes/h). The endpoints were all-cause death and a combination of all-cause death or cardiovascular hospitalization. Results Of the 265 enrolled patients, 224 had usable RDI values. Severe sleep apnea (RDI ≥30 episodes/h) was diagnosed in 115 patients (51%). These patients were more frequently male (84% vs 72%; P = .030) and had higher creatinine levels. During median follow-up of 25 months, 19 patients (8%) died. Cardiovascular hospitalizations were reported in 19 patients (8%). The risk of all-cause death was higher in patients with RDI ≥30 episodes/h (hazard ratio [HR] 3.33; 95% confidence interval [CI] 1.35–8.21; P = .023), as well as the risk of all-cause death or cardiovascular hospitalization (HR 1.94; 95% CI 1.01–3.76; P = .048). At multivariate analysis, independent predictors of death were RDI ≥30 episodes/h (HR 4.02; 95% CI 1.16–13.97; P = .029) and creatinine levels (HR 2.36; 95% CI 1.26–4.42; P = .008). Conclusion In heart failure patients implanted with an ICD, higher RDI values are associated with death and cardiovascular hospitalizations. Device-detected severe sleep apnea independently predicts death.

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 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.

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.

Funding Acknowledgements This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Background/Introduction: Parameters routinely measured during cardiac devices implantation also depend on bioelectrical properties of the myocardial tissue. Purpose To explore the potential association of electrical parameters with clinical outcomes in implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy defibrillators (CRT-D) recipients. Methods In the framework of the Home Monitoring Expert Alliance, baseline electrical parameters for all implanted leads were compared by occurrence of all-cause mortality, adjudicated ventricular arrhythmia (VA) and atrial high rate episode lasting ≥7 days (7day-AHRE). Results In a cohort of 2,976 patients (58.1% ICD) with a median follow-up of 25 months, events rates were 3.1/100 patient-years for all-cause mortality, 18.1/100 patient-years for VA and 8.9/100 patient-years for 7day-AHRE. At univariate analysis baseline shock impedance was consistently lower in groups with events than in those without, with a 40 Ohm cut-off better identifying patients at high risk, but at multivariable analysis the adjusted-hazard ratios (HRs) lost statistical significance for any endpoint. Baseline atrial sensing amplitude during sinus rhythm was lower in patients with 7-day AHRE as compared to those without (2.40 [IQ: 1.62-3.71] Vs 3.50 [IQ: 2.35-4.66] mV, p 1.5 mV versus those with values ≤1.5 mV was 0.44 (95% CI:0.27-0.72), p = 0.001. Conclusion Despite in patients with events a lower baseline shock impedance was observed at univariate analysis, the association lost statistical significance at multivariable analysis. Conversely, low sinus rhythm atrial sensing (≤1.5 mV) measured with standard transvenous leads could identify subjects at high risk of long-lasting atrial arrhythmia. Abstract Figure. AHRE occurrence by atrial sensing

Background: Little is known about the role of different types of atrial fibrillation (AF) in dilated cardiomyopathy (DCM). We investigated the epidemiological and prognostic impact of different types of AF in DCM during long-term follow-up. Method: We evaluated consecutive DCM patients enrolled in the Trieste Muscle Heart Disease Registry. Uni- and multivariable, extended Kaplan-Meier and propensity score-matching analyses were performed for a composite outcome including death/heart transplantation/ventricular-assist device implantation. Results: Out of 1181 DCM patients (71% males, age 49 ± 15 years, left ventricular ejection fraction 33 ± 11%), 46 (3.9%) had baseline permanent AF (permAF), while 66 (5.6%) had a history of paroxysmal/persistent AF. Compared with sinus rhythm (SR) patients, permAF patients were older (48 ± 15 vs. 61 ± 11 respectively, p = 0.001), were more frequently in NYHA class III-IV (18% vs. 30%, p = 0.002) and had larger left atrium diameter (40 ± 8 vs. 50 ± 10 mm, respectively). Paroxysmal/persistent AF patients had intermediate characteristics between permAF and SR. During a median follow-up of 135 (75–210) months, 63 patients developed permAF (0.45 new cases/100patients/year). At multivariable analysis, permAF as a time-dependent variable was an independent outcome predictor (HR 2.45; 95% C.I. 2.61–3.63, p < 0.001), together with creatinine, NYHA class, restrictive filling pattern and moderate-severe mitral regurgitation, while paroxysmal/persistent AF was neutral. Propensity score-matching analysis confirmed the higher rate of primary outcome events in patients with baseline or incident permAF versus patients without permAF during a very long-term follow-up (70% vs. 20%, p < 0.001). Conclusions: PermAF in a large DCM cohort had low prevalence and incidence but had a relevant. prognostic role on hard outcomes.

Aim: Contemporary survival trends in dilated cardiomyopathy (DCM) are largely unknown. The aim of this study is to investigate clinical descriptors, survival trends and the prognostic impact of aetiological characterization in DCM patients. Methods and results: Dilated cardiomyopathy patients were consecutively enrolled and divided into four groups according to the period of enrolment (1978-1984; 1985-1994; 1995-2004; and 2005-2015). A subset of patients with DCM of specific aetiology, enrolled from 2005 to 2015, was also analysed. Over a mean follow-up of 12 ± 8 years, 1284 DCM patients (52 in the 1978-1984 group, 326 in the 1985-1994 group, 379 in the 1995-2004 group, and 527 in the 2005-2015 group) were evaluated. Despite older age (mean age 51 ± 15, 43 ± 15, 45 ± 14, and 52 ± 15 years for the 1978-1984, 1985-1994, 1995-2004, and 2005-2015 groups, respectively; P < 0.001), most of the baseline clinical characteristics improved in the 2005-2015 group, suggesting a less advanced disease stage at diagnosis. Similarly, at competing risk analysis, the annual incidence of all outcome parameters progressively decreased over time (global P < 0.001). At multivariable analysis, the last period of enrolment emerged as independently associated with a reduction in all-cause mortality/heart transplantation (HTx)/ventricular assist device (VAD) implantation (1.46 events/100 patients/year), cardiovascular death/HTx/VAD implantation (0.82 events/100 patients/year) and sudden cardiac death (0.15 events/100 patients/year). Lastly, in 287 patients with DCM of specific aetiology, patients with environmental, toxic, or removable factors appeared to have different phenotypes and prognosis compared to those with genetic, post-myocarditis, or idiopathic DCM (P < 0.001). Conclusions: Contemporary survival trends in DCM significantly improved, mainly due to a reduction of cardiovascular events. Appropriate aetiological characterization might help in prognostication of DCM patients.

The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2018 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers.The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards.PM Registry: data about 23 912 PM implantations were collected (20 084 first implants and 3828 replacements). The number of collaborating centers was 180. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 34.5% of first PM implants, sick sinus syndrome in 18.3%, atrial fibrillation plus bradycardia in 13.0%, other in 34.2%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (19.2% of first implants). Use of single-chamber PMs was reported in 24.9% of first implants, of dual-chamber PMs in 67.6%, of PMs with cardiac resynchronization therapy (CRT) in 1.6%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 5.9%. ICD Registry: data about 18 353 ICD implantations were collected (13 944 first implants and 4359 replacements). The number of collaborating centers was 433. Median age of treated patients was 71 years (63 quartile I; 78 quartile III). Primary prevention indication was reported in 84.3% of first implants, secondary prevention in 15.7% (cardiac arrest in 5.3%). A single-chamber ICD was used in 27.9% of first implants, dual-chamber ICD in 31.9% and biventricular ICD in 40.2%.The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice. In order to increase and optimize the cooperation of Italian implanting centers, online data entry (http://www.aiac.it/riprid) should be adopted at large scale.

Background Parameters measured during implantable cardioverter defibrillator (ICD) implant also depend on bioelectrical properties of the myocardium. We aimed to explore their potential association with clinical outcomes in patients with single/dual‐chamber ICD and cardiac resynchronization therapy defibrillator (CRT‐D). Methods In the framework of the Home Monitoring Expert Alliance, baseline electrical parameters for all implanted leads were compared by the occurrence of all‐cause mortality, adjudicated ventricular arrhythmia (VA), and atrial high‐rate episode lasting ≥24 hours (24 h AHRE). Results In a cohort of 2976 patients (58.1% ICD) with a median follow‐up of 25 months, event rates were 3.1/100 patient‐years for all‐cause mortality, 18.1/100 patient‐years for VA, and 9.3/100 patient‐years for 24 h AHRE. At univariate analysis, baseline shock impedance was consistently lower in groups with events than without, with a 40 Ω cutoff that better identified high‐risk patients. However, at multivariable analysis, the adjusted‐hazard ratios (HRs) lost statistical significance for any endpoint. Baseline atrial sensing amplitude during sinus rhythm was lower in patients with 24 h AHRE than in those without (2.45 [IQR: 1.65‐3.85] vs 3.51 [IQR: 2.37‐4.67] mV, P 1.5 mV vs those with values ≤1.5 mV was 0.52 (95% CI: 0.33‐0.83), P = .006. Conclusions Although lower baseline shock impedance was observed in patients with events, the association lost statistical significance at multivariable analysis. Conversely, low sinus rhythm atrial sensing (≤1.5 mV) measured with standard transvenous leads could identify subjects at high risk of atrial arrhythmia., Some of the electrical parameters routinely measured at ICD/CRT‐D implant differed according to long‐term clinical outcome. Shock impedance values were lower in patients who experienced death and both atrial and ventricular arrhythmias during follow‐up. Subjects with atrial signal amplitude below 1.5 mV showed a significant higher risk of atrial arrhythmias as compared to those with >1.5 mV, potentially revealing the presence of a more impaired atrial tissue.

Large-scale submarine gravitational land movements involving even more than 1,000 m thick sedimentary successions are known as megalandslides. We prove the existence of large-scale gravitational phenomena off the Crotone Basin, a forearc basin located on the Ionian side of Calabria (southern Italy), by seismic, morpho-bathymetric and well data. Our study reveals that the Crotone Megalandslide started moving between Late Zanclean and Early Piacenzian and was triggered by a contractional tectonic event leading to the basin inversion. Seaward gliding of the megalandslide continued until roughly Late Gelasian, and then resumed since Middle Pleistocene with a modest rate. Interestingly, the onshore part of the basin does not show a gravity-driven deformation comparable to that observed in the marine area, and this peculiar evidence allows some speculations on the origin of the megalandslide.

Background The traditional technique for subcutaneous implantable cardioverter defibrillator (S-ICD) implantation, which involves three incisions and a subcutaneous pocket, is associated with possible complications, including inappropriate interventions. The aim of this prospective multicenter study was to evaluate the efficacy and safety of an alternative intermuscular two-incision technique for S-ICD implantation. Methods The study population included 36 consecutive patients (75% male, mean age 44 ± 12 years [range 20–69]) who underwent S-ICD implantation using the intermuscular two-incision technique. This technique avoids the superior parasternal incision for the lead placement and consists of creating an intermuscular pocket between the anterior surface of the serratus anterior and the posterior surface of the latissimus dorsi muscles instead of a subcutaneous pocket. Results All patients were successfully implanted in the absence of any procedure-related complications with a successful 65-J standard polarity defibrillation threshold testing, except in one, who received a second successful shock after pocket revision. During a mean follow-up of 10 months (range 3–30), no complications requiring surgical revision were observed. At device interrogation, stable sensing without interferences was observed in all patients. Two patients (5.5%) experienced appropriate and successful shock on ventricular fibrillation and in four patients (11%), a total of seven nonsustained self-terminated ventricular tachycardias were correctly detected. No inappropriate interventions were observed. Conclusions Our experience suggests that the two-incision intermuscular technique is a safe and efficacious alternative to the current technique for S-ICD implantation that may help reducing complications including inappropriate interventions and offer a better cosmetic outcome, especially in thin individuals.

Device interrogation and management are time consuming, representing a relevant burden for pacing centers. In several situations, patients' management requires additional follow up visits.Remote Monitoring (RM) allows an optimal recall management and a rapid diagnosis of device or lead failure, without the need of additional in office visits. Further it allows a significant delay reduction between the adverse event and the reaction to the alarm, shortening the time needed to make a clinical decision. A role in risk-predicting patient-related outcomes has also been shown. RM permits detection of the arrhythmia from 1 to 5 months in advance compared to in-office visits. Importantly, by using specific algorithms with multiparametric analysis, RM has been studied as a potential instrument to identify early patients on risk of worsening HF using specific algorithms. Although the use of RM in HF setting remains controversial, it has been proposed to improve HF clinical outcomes and survival in clinical trials. In this sense, RM success could require a standardization of process within a management model, that may involve different health care professionals. In this review, we examine recent advances of RM providing an update of this tool through different clinical scenarios. Keywords: Implantable devices, Heart failure, Atrial fibrillation, Remote telemonitoring

In patients with dilated cardiomyopathy (DCM), it is possible to find a broad range of bradyrhythmias and tachyarrhythmias. Bradyrhythmias and supraventricular arrhythmias can frequently occur in some familial forms such as lamin A/C mutations. Nonsustained ventricular arrhythmias (VA) are observed in about 40% of patients with DCM, but their prognostic role is not clear, and conflicting data have been published in the last 30 years. Multiple mechanisms can explain atrial and ventricular tachyarrhythmias in DCM. Reentry is associated with slow conduction across surviving muscle bundles within regions of interstitial fibrosis, but other mechanisms can be involved, as nonuniform anisotropy of impulse propagation, ion channel dysfunction, and reduced gap junction function.

Background Implantable cardioverter‐defibrillators ( ICDs ) are widely employed for the prevention of sudden cardiac death. Despite technological improvements, patients often need to undergo generator replacement, which entails the risk of periprocedural complications. Our aim was to estimate the service life of ICD s over a 10‐year interval and to assess the main causes of replacement on the basis of data from the National ICD Registry of the Italian Society of Arrhythmology and Cardiac Pacing (AIAC). Methods and Results The registry includes data from over 400 hospitals in Italy. We included all patients who underwent device replacement from calendar years 2007 to 2016. The median service life of the ICD s and its trend over the years was estimated across the 3 types of devices (single‐chamber, dual‐chamber, cardiac resynchronization therapy defibrillator) and the indication to implantation. The causes of replacement were also analyzed. We included 29 158 records from 27 676 patients (80.9% men; mean age at device replacement 65.8±12.0 years). The median service life was 57.3 months (interquartile range 27.8 months). Over the years, service life showed an increasing trend. The majority of patients underwent elective replacement because of battery end of life, and over the years there was a significant reduction of replacement for recalls, erosion/infections, and cardiac resynchronization therapy upgrading. Conclusions Our data from a large single‐nation population showed that the trend of ICD service life, independently from ICD type, indication, and settings, significantly improved over time. Moreover, there was a striking reduction of interventions for upgrading and infection/erosion. This favorable trend has important clinical, organizational, and financial implications.

Aims: Despite continuous efforts in improving the selection process, the rate of non-responders to cardiac resynchronization therapy (CRT) remains high. Recent studies on intraventricular blood flow suggested that the alignment of hemodynamic forces (HDFs) may be a reproducible biomarker of mechanical dyssynchrony. We aimed to explore the relationship between pacing-induced realignment of HDFs and positive response to CRT. Methods and results: We retrospectively analyzed 38 patients from the CRT database of our institution fulfilling the inclusion criteria for HDFs-related echocardiographic assessment early pre and post CRT implantation, with available mid-term follow-up (≥ 6 months) evaluation. Standard echocardiographic and deformation parameters early pre and post CRT implantation were integrated with the measurement of HFDs through novel methods based on speckle-tracking analysis. At midterm follow-up 71% of patients were classified as responders (reduction of Left Ventricular Systolic Volume Indexed ≥ 15%). Patients did not display significant changes between close evaluations pre and post-implant in terms of ejection fraction and strain metrics. A significant reduction of the ratio between the amplitudes of transversal and longitudinal force components was found. The variation of this ratio strongly correlates (R2 =0.60) with Left Ventricular (LV) end-systolic volume variation at mid-term follow up. Conclusion: Pacing-induced realignment of HDFs is associated with CRT efficacy at follow up. These preliminary results claim for dedicated prospective clinical studies testing the potential impact of HDFs study for patient selection and pacing optimization in CRT.

Introduction The recently developed second‐generation subcutaneous implantable cardioverter defibrillator (S‐ICD) and the intermuscular two‐incision implantation technique demonstrate potential favorable features that reduce inappropriate shocks and complications. However, data concerning large patient populations are lacking. The aim of this multicentre prospective study was to evaluate the safety and outcome of second‐generation S‐ICD using the intermuscular two‐incision technique in a large population study. Methods and Results The study population included 101 consecutive patients (75% male; mean age, 45 ± 13 years) who received second‐generation S‐ICD (EMBLEM; Boston Scientific, Marlborough, MA) implantation using the intermuscular two‐incision technique as an alternative to the standard implantation technique. Twenty nine (29%) patients were implanted for secondary prevention. Twenty four (24%) patients had a previously implanted transvenous ICD. All patients were implanted without any procedure‐related complications. Defibrillation testing was performed in 80 (79%) patients, and ventricular tachycardia was successfully converted at less than or equal to 65 J in 98.75% (79/80) of patients without pulse generator adjustments. During a median follow‐up of 21 ± 10 months, no complications requiring surgical revision or local or systemic device‐related infections were observed. Ten patients (9.9%) received appropriate and successful shocks for ventricular arrhythmias. Three (2.9%) patients experienced inappropriate shocks due to oversensing the cardiac signal (n = 1), noncardiac signal (n = 1), and a combination of both cardiac and noncardiac signals (n = 1), with one patient requiring device explantation. No patients required device explantation due to antitachycardia pacing indications. Conclusions According to our multicentre study, second‐generation S‐ICD implanted with the intermuscular two‐incision technique is an available safe combination and appears to be associated with a low risk of complications, such as inappropriate shocks.

Background Sleep apnea (SA) is a relevant issue in the management of patients with heart failure for risk stratification and for implementing treatment strategies. Objective The purpose of this study was to evaluate in patients with implantable cardioverter-defibrillators (ICDs) the performance of the respiratory disturbance index (RDI) computed by the ApneaScan algorithm (Boston Scientific Inc., Natick, MA) as a discriminator of severe SA. Methods ICD-indicated patients with left ventricular ejection fraction ≤35% were enrolled. One month after implantation, patients underwent a polysomnographic study. We evaluated the accuracy of the RDI for the prediction of severe SA (apnea-hypopnea index [AHI] ≥30 episodes/h) and the agreement between RDI and AHI during the sleep study night. Results Two hundred sixty-five patients were enrolled to obtain the required sample of 173 patients with AHI and RDI data for analysis. The mean AHI was 21 ± 15 episodes/h and severe SA was diagnosed in 38 patients (22%), while the mean RDI was 33 ± 13 episodes/h. On the basis of the receiver operating characteristic curve analysis of RDI values, the area under the curve was 0.77 (95% confidence interval [CI] 0.70–0.83; P < .001). At an RDI value of 31 episodes/h, severe SA was detected with 87% (95% CI 72%–96%) sensitivity and 56% (95% CI 48%–66%) specificity. RDI closely correlated with AHI recorded during the same night (r = 0.74; 95% CI 0.57–0.84; P < .001), and the Bland-Altman agreement analysis revealed a bias of 11 episodes/h, with limits of agreement being −10 to 32 episodes/h. Conclusion The RDI accurately identified severe SA and demonstrated good agreement with AHI. Therefore, it may serve as an efficient tool for screening patients at risk of SA.

The lower Pliocene Belvedere Formation, cropping out in the Crotone Basin, southern Italy, exhibits a metre-scale to decametre-scale shallow-marine cyclicity that shares features of both high-frequency sequences linked to shoreline shifts and controlled by minor relative sea-level and/or sediment supply changes, and sedimentological cycles unrelated to shoreline shifts. In order to better understand the high-frequency sequence stratigraphic framework of this succession, an integration of sedimentological, micropalaeontological (micro-foraminifera assemblages) and mineralogical (heavy minerals abundance) data is used. From a sedimentological/stratigraphic point of view, wave-ravinement surfaces bounding high-frequency sequences, and associated substrate-controlled ichnofacies, are prominent in outcrop and document environmental and water-depth changes, whereas bedset boundaries separating sedimentological cycles have a more subtle field appearance and are only associated with changes of environmental energy. Moreover, condensed deposits are present only above wave-ravinement surfaces, and the high-frequency sequences bounded by these surfaces have a thickness that is an order of magnitude greater than that of the bedsets. Micro-foraminifera assemblages may change, and the content of heavy minerals usually increases, across wave-ravinement surfaces, whereas both parameters do not change significantly across bedset boundaries. The abundance of heavy minerals is systematically higher, with respect to the underlying and overlying deposits, in the condensed shell beds that overlie wave-ravinement surfaces. An integrated sedimentological, micropalaeontological and mineralogical approach represents a powerful tool to discriminate between wave-ravinement surfaces bounding high-frequency sequences and bedset boundaries, and in general to investigate at the intra high-frequency sequence scale. This integrated approach is expected to be very useful in the study of potentially all shallow-marine successions composed of small-scale cycles, in order to delineate a detailed sequence stratigraphic framework and understand the factors that controlled the cyclicity. This article is protected by copyright. All rights reserved.

We provide a model for the genesis of Holocene coralligenous buildups occurring in the northwestern Adriatic Sea offshore Venice at 17-24 m depth. High-resolution geophysical surveys and underwater SCUBA diving reconnaissance revealed meandering shaped morphologies underneath bio-concretionned rocky buildups. These morphologies are inferred to have been inherited from Pleistocene fluvial systems reactivated as tidal channels during the post-Last Glacial Maximum transgression, when the study area was a lagoon protected by a sandy barrier. The lithification of the sandy fossil channel-levee systems is estimated to have occurred at ca. 7 cal. ka BP, likely due to the interaction between marine and less saline fluids related to onshore freshwater discharge at sea through a sealed water-table. The carbonate-cemented sandy layers served as nucleus for subsequent coralligenous buildups growth., Contiene material complementario: consultar en https://www.nature.com/articles/s41598-017-01483-z#Sec5, Centro de Investigaciones Geológicas

There has been a significant increase in cancer patients with implanted electronic devices which have been exposed to the risk of malfunction when undergoing radiotherapy in the last few years. In this review, we provide a short summary of radiotherapy principles, later analyzing in vitro and in vivo data and recent recommendations, in order to present the current evidence on predictive factors, risk stratification, and management of patients with implanted electronic devices requiring radiotherapy. The risk of device failure is usually transient, seldom permanent and mainly related to patients' characteristics and cumulative doses administrated during radiotherapy. The strongest predictive factors of implanted electronic device malfunction are higher radiation doses and higher beam energy. Indeed, energy

Aims ACE-inhibitors, β-blockers, implantable cardioverter–defibrillator (ICD) and cardiac resynchronization therapy (CRT) improved prognosis of heart failure. We sought to analyse the long-term prognostic impact of evidence-based integrated therapeutic strategies in patients with idiopathic dilated cardiomyopathy (IDCM). Methods and results From 1978 to 2007, 853 IDCM patients (45 ± 15 years, 72% males) were enrolled and classified as follows: Group 1, 110 patients (12.8%) enrolled during 1978–1987; Group 2, 376 patients (44.1%) enrolled during 1988–1997; Group 3, 367 patients (43.1%) enrolled during 1998–2007. ACE-inhibitors/angiotensin receptor blockers were administered in 34%, 93%, and 93% (P

The upper Messinian to lower Zanclean succession of the Crotone Basin, a forearc basin located along the Ionian side of the Calabrian Arc (southern Italy), consists of a turbidite-bearing succession (the Petilia Policastro Formation) overlying evaporites and abruptly passing upward into coarse-grained continental deposits (the Carvane Conglomerate), which are in turn overlain by distal shelf to slope mudstones (the Cavalieri Marl). The marked environmental changes from subaqueous to continental and vice versa documented by the studied succession are inferred to be the expression of basin-scale tectonics, leading to uplift and exposure, superposed on the Mediterranean-scale base-level rise that followed the acme of the Messinian Salinity Crisis. The upper part of the succession documents a transgressive trend probably initiated within the Carvane Conglomerate, and further testified by the presence of a ravinement surface marked by a transgressive lag at the base of the Zanclean Cavalieri Marl, pointing to a non-catastrophic deepening occurred near the end of the Messinian.

Objectives The study sought to provide an insight into the prevalence, characterization and possible reliable indicators of early sudden cardiac death/malignant ventricular arrhythmias (SCD/MVAs) in a large cohort of dilated cardiomyopathy (DCM). Background DCM generally affects young individuals and is characterized by an unpredictable prognosis with a non-negligible risk of SCD/MVAs, particularly in early stages of disease. Methods From 1988 to 2014, 952 patients with DCM were consecutively included in the Heart Muscle Disease Registry of Trieste. Results Globally, 20 patients (2.1% of the overall population) experienced SCD/MVAs within the first 6 months after enrollment (primary endpoint). At baseline they showed a worse functional class (New York Heart Association functional class III to IV 42% vs. 22%, p = 0.038), a longer QRS complex duration (127 ± 41 ms vs. 108 ± 33 ms; p = 0.013) and a larger indexed left ventricular end-systolic volume (LVESVI) (82 ± 49 ml/m 2 vs. 67 ± 34 ml/m 2 ; p = 0.049), as compared to patients without early SCD/MVAs. Beta-blockers were less tolerated (59% vs. 83% in patients with no early SCD/MVAs; p = 0.008), mostly due to hemodynamic intolerance. At multivariate analysis, LVESVI (odds ratio [OR]: 1.012; 95% confidence interval [CI]: 1.000 to 1.024; p = 0.043) and QRS complex duration (OR: 1.017; 95% CI: 1.003 to 1.030; p = 0.015) were independently associated with the primary endpoint, whereas beta-blockers demonstrated a protective effect (OR: 0.169, CI: 0.048 to 0.593; p = 0.006). Conclusions Patients with DCM present a significant risk of major arrhythmic events in the first phase of the disease. Baseline LVESVI, QRS duration, and intolerance to beta-blocker therapy might be useful tools in the arrhythmic early risk assessment.

The Southern Apennines (SA) are part of the Apennine–Maghrebian chain, a segment of the circum-Mediterranean Alpine orogenic system. It is a NE-verging fold-and-thrust belt with an about N150°-striking axis developed since the late Oligocene-early Miocene. The Geological Map at 1:25,000 scale of the Pergola–Melandro basin area, presents a sector of the axial zone of the SA which represents a key area to reconstruct the tectonic evolution of this chain. The map describes the complex structural and stratigraphic relationships between the three main tectonic units forming this sector of the SA: (1) the carbonate slope succession of the Maddalena Mts Unit, interpreted as the eastern boundary of the Apennine carbonate Platform; (2) the Lagonegro Unit, resulting from the deformation of the homonym pelagic basin; (3) the strongly deformed Argille Variegate Group sandwiched between the two previous units. Three main contractional tectonic stages, occurring from middle Miocene to Pliocene, have been recognized. Since Pliocene times low-angle extensional tectonic contacts and tectono-gravitative detachments affected the tectonic pile.

Benign thyroid nodules are an extremely common occurrence. Radiofrequency ablation (RFA) is gaining ground as an effective technique for their treatment, in case they become symptomatic. Here we review what are the current indications to RFA, its outcomes in terms of efficacy, tolerability, and cost, and also how it compares to the other conventional and experimental treatment modalities for benign thyroid nodules. Moreover, we will also address the issue of treating with this technique patients with cardiac pacemakers (PM) or implantable cardioverter-defibrillators (ICD), as it is a rather frequent occurrence that has never been addressed in detail in the literature.

BACKGROUND: To evaluate the role of nonsustained ventricular tachycardias (NSVT) for the prediction of major ventricular arrhythmias (MVA) in patients with idiopathic dilated cardiomyopathy (DCM) after optimization of medical treatment. METHODS AND RESULTS: Three hundred nineteen consecutive DCM patients were evaluated after adequate stabilization on optimal angiotensin-converting enzyme (ACE) inhibitor (88%) and beta-blocker (82%) therapy. Frequency, length, and rate of NSVT at 24-hour Holter monitoring were analyzed to assess their values in predicting MVA (unexpected sudden death, SVT, ventricular fibrillation, and appropriate implantable cardioverter defibrillator interventions). During follow-up (median 96 months, 1(st)-3(rd) interquartile range 52-130), MVA incidence was low, and not statistically different between patients with and without NSVT (3 and 2 per 100 patient-years, respectively, P = nonsignificant [NS] at log-rank analysis). At multivariable analysis, the number of NSVT was predictive of MVA only if left ventricular ejection fraction (LVEF) was > 0.35 (two NSVT/day vs no NSVT/day: hazard ratio [HR] 5.3, 95% confidence interval [CI] 1.59-17.85 in LVEF > 0.35 vs HR 0.93, 95% CI 0.3-2.81 in LVEF < or = 0.35). Consequently, in patients with LVEF < or = 0.35, MVA incidence rates were similar regardless of NSVT (3.6 and 4.1 patient-years, respectively, in those with and without NSVT, P = NS), while in patients with LVEF > 0.35, MVA incidence (3.1 per 100 patient-years vs 0.9 per 100 patient-years, P = 0.003) was significantly higher when NSVT were present. CONCLUSIONS: After medical stabilization, NSVT did not increase the risk of MVA in patients with DCM and LVEF < or = 0.35. Conversely, the number and length of NSVT runs were significantly related to the occurrence of MVA in the patients with LVEF > 0.35.