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The right ventricular apex (RVA) has always been the most used pacing site, because it is easily accessible and provides a stable lead position with a low dislodgment rate. However, it is well-known that long-term right ventricular apical pacing may have deleterious effects on left ventricular function by inducing a iatrogenic left bundle branch block, which can have strong influences on the left ventricle hemodynamic performances. More specifically, RVA pacing causes abnormal contraction patterns and the consequent dyssynchrony may cause myocardial perfusion defects, histopathological alterations, left ventricular dilation and both systolic and diastolic left ventricular dysfunction. All these long-term changes could account for the higher morbidity and mortality rates observe in patients with chronic RVA pacing compared with atrial pacing. This observation led to the reassessment of traditional approaches and to the research of alternative pacing sites, in order to get to more physiological pattern of ventricular activation and to avoid deleterious effects. Then, attempts were made with: right ventricular outflow tract (RVOT) pacing, direct His bundle pacing (DHBP), parahisian pacing (PHP) and bifocal (RVA + RVOT) pacing. For example, RVOT pacing, especially in its septal portion, is superior to the RVA pacing and it would determine a contraction pattern very similar to the spontaneous one, not only because the septal portions are the first parts to became depolarized, but also for the proximity to the normal conduction system. RVOT is preferable in terms of safety too. DHBP is an attractive alternative to RVA pacing because it leads to a synchronous depolarization of myocardial cells and, therefore, to an efficient ventricular contraction. So it would be the best technique, however the procedure requires longer average implant times and dedicated instruments and it cannot be carried out in patients affected by His bundle pathologies; furthermore, due to the His bundle fibrous area, higher pacing thresholds are required, causing accelerated battery depletion. For all these reasons, PHP could be considered an important alternative to DHBP, to be used on a large scale. Finally, bifocal pacing in CRT candidates, provides better acute hemodynamic performance than RVA pacing, derived from a minor intra-and interventricular dyssynchrony, expressed also by the QRS shortening. Then, bifocal pacing could be taken into account when RVA pacing is likely to be the origin of serious mechanical and electrical dyssynchrony or when CRT is contraindicated or technically impossible. So, whatever chosen as selective pacing site, you must look also at safety, effectiveness and necessary equipment for an optimal pacing site.

Coronary ectasia is a dilation of coronary arteries, angiographically defined if the diameter of the artery is ≥ 1.5 times greater than that of the intact adjacent vascular segment. An association has been found between coronary artery ectasia and a broad spectrum of different diseases, first of all atherosclerotic coronary artery disease. The mechanisms that determine the abnormal dilatation of the vascular lumen and the etiology of coronary artery ectasia are still poorly understood. Various hypotheses have been formulated over the time, the most accredited between these recognizes as main responsible an uncontrolled activity of a particular family of enzymes that degrade the extracellular matrix, the metalloproteinases. This exaggerated activity can be due to an increase in the absolute sense of these enzymes and/or a reduction in the levels of their natural specific inhibitors. Coronary ectasia may have a variable clinical presentation. It is often an occasional finding detected at coronary angiography or following the occurrence of atypical chest pain, stable angina or even acute coronary syndrome. The frequent coexistence of coronary artery ectasia and atherosclerotic coronary artery disease and their common histopathological features have led to hypothesize that coronary ectasia may represent a variant of atherosclerosis. However, some significant differences between these two diseases leave open the hypothesis that coronary artery ectasia may be a pathological entity per se.

IMIN11. Cytokine Polymorphism in Takotsubo Cardiomyopathy P. Di Gangi1, L. Scola1, S. Giambanco1, M. Bova1, G. Santini1, L. Vaccarino1, C. R. Balistreri1, D. Lio1, P. Assennato1, S. Novo1, G. Novo1 1University of Palermo, Palermo, Italy Background: Takotsubo (TT) cardiomyopathy is characterised by an acute left ventricular dysfunction triggered by emotional or physical stresses. Clinically, the syndrome is characterised by acute symptoms mimicking acute infarction without relevant electrocardiographic and biochemical markers of myocardial damage changes. Stressful events inducing an excess catecholamine release and myocardial β-adrenergic receptors (β-AR) seem to play a major role in TT. Accordingly, we have reported that the L41Q polymorphism of the G protein-coupled receptor kinase 5 (GRK5), which, leads to β-arrestin recruitment and mediates β- AR desensitisation might play a role in TT susceptibility. Extended sympathetic activation may influence the pro-inflammatory cytokine secretion triggering b-adrenergic receptors of the immuno system cells. In turn, IL-1, IL-6, TNF-α stimulating the synthesis and release of CRH and norepinephrine might magnify the activation of the sympathetic system. In this view, we have analyzed the role that polymorphisms of inflammatory cytokines might play in the pathogenesis of TT. Methods: We analysed ADRB-1 (rs1801253), IL–1A (rs1800587), IL-1B (rs16944), (rs1143634), IL-6 (rs1800795), TNF-α(rs1800629), TGF- β(rs1800471), IL-10 (rs1800872), (rs1800871), (rs1800896), MAL (rs8177374) and TLR-4 polymorphisms in 25 TT patients and 100 controls using KASPar SNP genotyping method. Statistical analysis of data was performed using dominant, codominant, and recessive models. Results: Analysis of the genotypic and allelic frequencies does not allow the detection of relevant differences in polymorphism frequencies in TT patients. Conclusions: Because of the low number of patients, further studies are necessary to understand the role of cytokine polymorphisms in Takotsubo cardiomyopathy. Work is in progress to recruit and analyse a larger group of patients.

The increased survival after acute myocardial infarction induced an increase in heart failure with left ventricular systolic dysfunction. Early detection and treatment of asymptomatic left ventricular systolic dysfunction give the chance to improve outcomes and to reduce costs due to the management of patients with overt heart failure.

The term metabolic syndrome defines a cluster of risk factors for cardiovascular diseases and diabetes. This syndrome is very frequent in general population. However, despite the efforts to define the diagnostic criteria, nowadays its clinical utility is object of a lively debate.

Objective: the aim of our study was to evaluate the role of stressful events, lifestyles and various socio-environmental factors in the beginning of ischemic cardiac diseases, together with cardiovascular factors. Materials and methods: 64 patients with recent cardiac ischemia and 64 controls matched 1:1, according to their sex and age, have been evaluated. The study required the filling in of clinico-anamnestic reports and the evaluation of stressful events, using the Holmes Rahe scale. Results: in the 44% of the patients who had a heart ischemia, an emotional striking event occurred few day before, with a 28% incidence of work and family problems. The mean score of the Holmes Social Readjustment Rating Scale was statistically significantly higher among cases (p

INCREASED MACROPHAGE COLONY STIMULATING FACTOR CONCENTRATIONS ARE ASSOCIATED WITH LEFT VENTRICLE SYSTOLIC DYSFUNCTION IN PATIENTS WITH ACUTE CORONARY SYNDROMES

BACKGROUND: The natural history of atherosclerosis has not clearly been elucidated yet. Some works reported that flogosis plays a role in plaque instability. Why does this inflammatory process start? We investigated the correlation between Chlamydia pneumoniae acute infection and plaque rupture. METHODS: We compared blood concentrations of IgM anti-Chlamydia pneumoniae in patients affected by acute myocardial infarction (AMI) and in patients affected by stable angina. RESULTS: Our results showed a minimal statistical difference, with a more positive value in patients with AMI. Subsequently, the group affected by AMI was divided into two subgroups with and without plaque rupture: the subgroup with plaque rupture showed a higher blood concentration of Chlamydia antibodies. This subgroup was also divided into two other subgroups according to blood white cell concentration: the subgroup with normal concentration of white blood cells showed the highest value of Chlamydia antibodies. CONCLUSIONS: Chlamydia pneumoniae could play an important role in atherosclerotic plaque instability