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Background Drug-related bradycardia (DRB) is a common clinical conundrum and can result in multiple hospital admissions as a result of the increased prescription of rate-limiting medications that can predispose to presyncopal or syncopal episodes. Aim To evaluate the incidence of DRB in elderly hospital inpatients. Methods We conducted a retrospective analysis of all patients admitted to our acute medical unit between November 2018 and February 2019 and identified patients over the age of 70 with more than one diurnal bradycardic episode during their admission. We extracted patient demographics, presenting complaint, admission 12-lead ECG and medications from the hospital electronic database. Results We screened 2312 adults and identified 100 patients over the age of 70 years with two or more episodes of diurnal bradycardia during their hospital admission. This constituted 4.32% of total admissions. Beta blockers were the most commonly prescribed rate-limiting medication (n=54, 87.1%), of which bisoprolol was the most frequently prescribed (n=41) and sinus bradycardia was the most commonly identified rhythm disturbance in our cohort of patients (n=41, 41%). Syncope was the most common presenting symptom and occurred in 23 patients, 14 (60.9%) of which were diagnosed with a DRB. Atrial fibrillation was more common in those with DRB compared with those with bradycardia not caused by medications (35.5% vs 10.5%, p=0.006), and atrial fibrillation was a significant predictor of DRB (OR=10.2, 95% CI 3.3 to 31.6, p Conclusion Bradycardia is a significant cause of hospital admissions in older adults and can be avoided with pharmacovigilance. Caution should be exercised when initiating or changing the dose of rate-limiting agents in these patients; while those with atrial fibrillation should undergo regular review of their heart rate followed by appropriate medication dose adjustments.

Sacubitril/valsartan has been demonstrated to improve prognosis and outcomes in heart failure with reduced ejection fraction (HFrEF) patients. We sought to compare the improvement in cardiac function between non-ischaemic and ischaemic cardiomyopathy for patients receiving sacubitril/valsartan. We conducted a single centre prospective cohort survey of patients reviewed in the Heart Function Clinic between February 2017 and January 2018. Functional evaluation and measurement of biochemical and echocardiographic parameters occurred before the initiation of sacubitril/valsartan, and after 3 months of treatment. We identified 52 patients (26 non-ischaemic and 26 ischaemic cardiomyopathy) suitable for treatment with sacubitril/valsartan. Treatment was followed by a significant decrease in a New York Heart Association (NYHA) class in both patients with non-ischaemic (2.3 ± 0.6 vs. 1.6 ± 0.7, P

The neurocognitive benefits of donepezil are well recognised, but the potential side effects on cardiac conduction remain unclear.To investigate whether long-term donepezil therapy is associated with electrocardiographic (ECG) changes and in particular to assess its effects on the QT interval.We conducted a single centre retrospective analysis of patients admitted to our trust on donepezil therapy over a 12-month period. An admission resting 12-lead ECG was obtained and compared to their ECG prior to commencement of donepezil therapy to assess for any significant difference in ECG parameters.We identified 59 patients suitable for analysis. PR (177.0 ± 29.0 ms vs. 186.1 ± 34.2 ms,Our results clearly demonstrate that long-term use of donepezil is associated with prolongation of the QT interval. We suggest ECG evaluation should take place before and after donepezil initiation, and clinicians should be even more vigilant in those prescribed tricyclic antidepressants.

Εισαγωγή: Η καρδιακή ανεπάρκεια αποτελεί σύνθετο κλινικό σύνδρομο, με ποικίλους παράγοντες να συμμετέχουν στην παθογένεση και εξέλιξη της νόσου όπως η ενεργοποίηση του αυτόνομου νευρικού συστήματος. Η διέγερση του συμπαθητικού συστήματος κατέχει πρωτεύοντα ρόλο και συνεπάγεται σειρά νευροορμονικών μηχανισμών που οδηγούν σε προοδευτική αναδιαμόρφωση και έκπτωση της κοιλιακής λειτουργίας με συνέπεια την επιβαρυμένη πρόγνωση και συμπτωματολογία των ασθενών. Στα πλαίσια της φαρμακευτικής αγωγής ασθενών με καρδιακή ανεπάρκεια, η χορήγηση β-αναστολέα κατέχει θεμελιώδη ρόλο καθώς συνεπάγεται μεταβολή στον αριθμό και τη δραστικότητα των αδρενεργικών υποδοχέων. Προηγούμενες μελέτες υποστήριξαν ότι πολυμορφισμοί των αδρενεργικών υποδοχέων μπορεί να αυξάνουν τον κίνδυνο καρδιακής ανεπάρκειας και την ανταπόκριση των ασθενών στην αγωγή με β-αναστολείς. Παρόλα αυτά η πολυπλοκότητα του φαινομένου που προκύπτει από το συνδυασμό πληθώρας πολυμορφισμών και την αλληλεπίδραση αυτών με άλλους συμβαλλόμενους παράγοντες, καθώς και οι μικροί αριθμοί ασθενών που συνήθως έχουν χρησιμοποιηθεί, καθιστούν δύσκολη την διαπίστωση ασφαλών συμπερασμάτων. Στην παρούσα μελέτη εξετάσαμε τη συχνότητα και την επίδραση των πολυμορφισμών Gln27Glu, Arg16Gly και Arg19Cys των β2 αδρενερεργικών υποδοχέων στον ελληνικό πληθυσμό, σε ασθενείς με καρδιακή ανεπάρκεια ισχαιμικής αιτιολογίας. Μέθοδοι: Συμπεριλήφθηκαν συνολικά 291 άτομα, 136 άτομα ταξινομήθηκαν στην ομάδα ελέγχου και 155 άτομα στην ομάδα καρδιακής ανεπάρκειας (συμπτωματικοί ασθενείς σε NYHA class II-IV, σταθερή στεφανιαία νόσο τεκμηριωμένη στεφανιογραγικά ή με ιστορικό εμφράγματος και με πρόσφατη υπερηχογραφική μελέτη με κλάσμα εξώθησης της αριστερής κοιλίας ≤35%). Από τον πληθυσμό αυτό, κατά την είσοδό του στο πρωτόκολλο και μετά από συγκατάθεση, έγινε λήψη φλεβικού αίματος που ακολουθήθηκε από απομόνωση DNA, αντίδραση αλυσιδωτής πολυμεράσης (PCR) και ανάλυση των γονοτύπων με ανάλυση νουκλεοτιδικής αλληλούχισης (48 ασθενείς και 52 control) ή πέψη με περιοριστικό ένζυμο (107 ασθενείς και 84 control). Aποτελέσματα: Δεν διαπιστώσαμε στατιστικά σημαντική διαφορά στην κατανομή αλληλίων μεταξύ ασθενών ΚΑ και controls σε ότι αφορά στους πολυμορφισμούς Gln27Glu και Arg16Gly. Αρχικά διαπιστώθηκε στατιστικά σημαντική διαφορά στην κατανομή γονοτύπων μεταξύ των δύο ομάδων για τον πολυμορφισμό Arg19Cys (Ρ-value=0.002), μετά όμως από ανάλυση της κατανομής των αλληλίων σε ασθενείς και control δεν διαπιστώνεται στατιστικά σημαντική διαφορά (Ρ-value=0.445). Κατά την επιμέρους ανάλυση των χαρακτηριστικών ασθενών ΚΑ, διαπιστώθηκε στατιστικά σημαντική διαφορά μεταξύ των αλληλίων Gln και Glu (Gln27Gln vs Gln27Glu / Glu27Glu) με προστατευτική δράση του αλληλίου Glu27 στην εμφάνιση εμφράγματος του μυοκαρδίου (P-value=0.02). Σε ότι αφορά στον πολυμορφισμό Arg19Cys, υπήρξε στατιστικά σημαντική διαφορά στην συχνότητα προηγούμενου εμφράγματος (Ρ=0.009) και στην φαρμακευτική αγωγή με β-αναστολέα (Ρ=0.008). Συγκεκριμένα η πλειοψηφία των ασθενών με γονότυπο Αrg19Arg είχαν ιστορικό προηγούμενου εμφράγματος του μυοκαρδίου και συνεπώς η παρουσία του αλληλίου της Cys φαίνεται πως δρα προστατευτικά. Επίσης η χορήγηση β-αναστολέα ήταν υψηλότερη στην κατηγορία των ετεροζυγωτών (όλοι οι ασθενείς υπό β-αναστολέα) και χαμηλότερη στην κατηγορία των Cys19Cys, όπου μόνο το 33% ελάμβανε συστηματικά β-αναστολέα. Σε ότι αφορά στον πολυμορφισμό Arg16Gly παρατηρήθηκε προστατευτική δράση του αλληλίου Gly στην εμφάνιση σακχαρώδη διαβήτη (P-value=0.01). O μικρός αριθμός των ατόμων που μελετήθηκαν ως προς τους πολυμορφισμούς Arg19Cys or Cys19Cys αλλά και η απουσία προοπτικής παρακολούθησης του συνόλου των ασθενών καθιστούν δύσκολη την ανάπτυξη ασφαλών συμπερασμάτων και συσχέτισης των αποτελεσμάτων με την πρόγνωση των ασθενών. Συμπεράσματα: Στην παρούσα μελέτη εξετάσαμε τη συχνότητα και επίπτωση διαφορετικών πολυμορφισμών των β2 αδρενεργικών υποδοχέων στον ελληνικό πληθυσμό και συγκεκριμένα σε ασθενείς με καρδιακή ανεπάρκεια ισχαιμικής αιτιολογίας και σοβαρή συστολική δυσλειτουργία της αριστερής κοιλίας. Διαπιστώθηκε ότι δεν υπάρχει στατιστικά σημαντική διαφορά στη συχνότητα των πολυμορφισμών μεταξύ ασθενών ΚΑ και control, όμως ασθενείς με Gln27Glu / Glu27Glu και φορείς του αλληλίου Cys (Arg19Cys or Cys19Cys) είχαν μειωμένη επίπτωση εμφράγματος του μυοκαρδίου. Βρέθηκε επίσης ότι ασθενείς με γονότυπο Gly16Gly είχαν μειωμένα ποσοστά εμφάνισης σακχαρώδη διαβήτη. Παρόλα αυτά δεν είναι σαφείς οι ακριβείς μηχανισμοί που αφορούν στους πολυμορφισμούς των αδρενεργικών υποδοχέων και συμμετέχουν στην καρδιακή ανεπάρκεια ισχαιμικής αιτιολογίας και άλλες μελέτες χρειάζονται να αποσαφηνίσουν τους μηχανισμούς αυτούς.

Purpose of the study Iron deficiency anaemia (IDA) is associated with increased morbidity and mortality in heart failure patients. The aim of our audit was to evaluate the current practice in diagnosis and assessment of IDA in patients admitted with heart failure. Study design We conducted a retrospective audit of patients admitted to our hospital between January 2017 and June 2017 with a diagnosis of heart failure, and obtained data regarding each patient’s demographics and anaemic status. We also conducted a qualitative survey to assess healthcare professionals’ ability to diagnose IDA, and their knowledge of iron replacement in heart failure patients. Results Our audit identified 218 heart failure patients, nearly two-thirds (n=138, 63.3%) of which were anaemic. Of the 138 anaemic patients, only 40 had a full haematinic screen compared with 98 who had incomplete investigations (29% vs 71%, p=0.007). Iron studies were the most commonly performed haematinic investigation (n=87, 63%), and over half of these patients were iron deficient (n=49, 56.3%). Only 12 (24.5%) iron deficient patients were prescribed oral iron therapy, while 37 (75.5%) were left without iron replacement (X2=12.8, p=0.0003). Our survey demonstrated a lack of awareness among healthcare professionals with only 19.7% of participants being able to correctly define anaemia and 9.1% being aware of guidelines regarding treatment of IDA. Conclusion Many patients admitted to hospital with heart failure also have a concomitant diagnosis of anaemia. The aetiology of the underlying anaemia is often poorly investigated, and where IDA is identified it is poorly treated.

We have observed hypernatraemia and hypokalaemia with normal serum urea and creatinine associated with new‐onset hypertension among COVID‐19 patients. We assessed the renin‐angiotensin‐aldosterone system (RAAS) of 2 patients during the pandemic and found elevated urinary potassium (without causal medications) and hyporeninaemic hypoaldosteronism in both.

BACKGROUND: Early studies have reported various electrolyte abnormalities at admission in patients who progress to the severe form of coronavirus disease 2019 (COVID-19). As electrolyte imbalance may not only impact patient care, but provide insight into the pathophysiology of COVID-19, we aimed to analyze all early data reported on electrolytes in COVID-19 patients with and without severe form. METHODS: An electronic search of Medline (PubMed interface), Scopus, and Web of Science was performed for articles comparing electrolytes (sodium, potassium, chloride, and calcium) between COVID-19 patients with and without severe disease. A pooled analysis was performed to estimate the weighted mean difference (WMD) with 95% confidence interval. RESULTS: Five studies with a total sample size of 1415 COVID-19 patients. Sodium was significantly lower in patients with severe COVID-19 (WMD: −0.91 mmol/L [95% CI: −1.33 to −0.50 mmol/L]). Similarly, potassium was also significantly lower in COVID-19 patients with severe disease (WMD: −0.12 mmol/L [95%CI: −0.18 to −0.07 mmol/L], I(2)=33%). For chloride, no statistical differences were observed between patients with severe and non-severe COVID-19 (WMD: 0.30 mmol/L [95%CI: −0.41 to 1.01 mmol/L]). For calcium, a statistically significant lower concentration was noted in patients with severe COVID-19 (WMD: −0.20 mmol/L [95% CI: −0.25 to −0.20 mmol/L]). CONCLUSIONS: This pooled analysis confirms that COVID-19 severity is associated with lower serum concentrations of sodium, potassium, and calcium. We recommend electrolytes be measured at initial presentation and serially monitored during hospitalization in order to establish timely and appropriate corrective actions.

The review by Sotirakos et al. provides a comprehensive overview of new pharmacotherapies that have emerged for the treatment of heart failure with reduced ejection fraction (HFrEF). The review foc...

Background Heart failure is a prevalent condition associated with frequent and costly hospital admissions. Hospitalizations are primarily related to worsening fluid retention and often require admission for decongestion with intravenous diuretics. Objective To assess the safety of an outpatient intravenous diuresis service for heart failure patients, and its impact on emergency admissions and the cost of treatment. Methods We conducted a prospective observational cohort registry study on patients referred to the diuretic lounge at our acute hospital between May 2017 and April 2018. Results We analysed 245 patients treated in the diuretic lounge, of which 190 (77.6%) avoided hospitalization or any adverse events during the 60 days of follow up (77.6% vs. 22.4%; P Conclusion Ambulatory administration of intravenous diuretics reduces emergency admissions and is a safe and cost-effective alternative to treat acute decomposition in heart failure patients.

Atrial fibrillation is the most common arrhythmia worldwide, and carries a significantly increased risk of thromboembolic stroke. Initially, vitamin K antagonists were used as stroke prophylaxis; but more recently, a group of drugs known as novel oral anticoagulants have been developed. Apixaban belongs to this group of drugs, and is a factor Xa inhibitor that has emerged as a popular pharmacological agent worldwide. In this review, we will provide an overview of the pivotal trials in the development of apixaban, while also critically evaluating the new emerging real-world data, and discussing the effectiveness, safety, economic viability and future prospects of apixaban and how it impacts on patient outcomes in those with non-valvular atrial fibrillation.

Severe calcific aortic stenosis is relatively common, and unless treated with valve replacement it carries an adverse prognosis. A large number of patients, however, are denied surgery due to their advanced age or coexistent medical conditions that increase perioperative cardiovascular risks. Transcatheter aortic valve implantation (TAVI), a technique in which a bioprosthetic valve is inserted via a catheter and implanted within the diseased native aortic valve, is a new therapeutic modality for treatment of older patients with severe symptomatic aortic stenosis and other comorbidities, who have an inherently high surgical risk. This review will provide an overview of the pivotal trials in the development of TAVI; while also investigating important complications and limitations of the procedure and evaluating how new valves are being designed and clinically evaluated, with the ultimate goal of reducing potential complications and expanding the use of TAVI to lower-risk patient cohorts.

Mann et al. ([1][1]) recently published the protocol for the LIFE (LCZ696 in Hospitalized Advanced Heart Failure) study. In this multicenter prospective trial, the investigators aimed to assess whether 24 weeks of sacubitril/valsartan therapy led to a significant reduction in N-terminal pro−B

Objective: Our aim was to assess whether the recommendations and guidelines for thromboprophylaxis in patients with atrial fibrillation (AF) have been adopted in general practice (GP). Methods: We conducted a retrospective study using the GP computer database (Hatfield, UK) on all 9400 patients to assess the quality of anticoagulation in patients with a recorded diagnosis of AF. Results: Of the 180 patients with a diagnosis of AF, 107 (59.4%) were treated with warfarin, 19 (10.6%) with a novel oral anticoagulant (NOAC), 31 (17.2%) with aspirin or clopidogrel, and 23 (12.8%) received none. Thirty-seven patients (34.6%) who were taking warfarin had a time in the therapeutic range (TTR) of less than 65%. Forty-five (27.6%) of the 163 patients who had a CHA2DS2VASc score of two or more were not prescribed a vitamin K antagonist (VKA) or a NOAC. None had a HAS-BLED greater than the CHA2DS2VASc score. Conclusion: Our study demonstrates that one in four patients with non-valvular AF, at risk of a stroke, is not being adequately treated with an oral anticoagulant in primary care. The majority were treated with warfarin, a third of which had a low TTR. A high proportion of patients are prescribed antiplatelet therapy instead. This is despite overwhelming evidence that VKAs and NOACs, and not aspirin or clopidogrel, improve outcome in patients with non-valvular AF. We suggest that a review of GP practice databases should be considered to identify patients with non-valvular AF, at risk of a disabling or fatal event, and measures taken to initiate anticoagulant therapy.

BACKGROUND Polymorphisms of the Adrenergic Receptors (ARs) might affect the development and progression of Heart Failure (HF) and the response to treatment with β-blockade therapy. OBJECTIVE To examine the role of the Gln27Glu polymorphism of β2-AR in HF development and to assess the hypothesis that Gln27Glu is associated with coronary artery disease in patients with ischaemic HF. METHODS In this case control study we enrolled 155 consecutive patients with symptomatic HF of ischaemic aetiology with impaired Left Ventricular Ejection Fraction (LVEF) ≤35%. The control group consisted of 133 patients with no obstructive coronary artery disease and or evidence of HF. RESULTS Concerning HF and control subjects there was no significant differences in the prevalence of Gln27Gln homozygotes (46 vs. 44%, p=0.82). In HF patients concerning the differences in patient characteristics between allele categories (Gln27Gln vs. Gln27Glu/Glu27Glu) there was no difference in risk factors, LVEF, treatment, the clinical status and NYHA categorization of patients, and in the prevalence of multi-vessel coronary artery disease. Interestingly, participants homozygous for Gln had significant higher prevalence of previous myocardial infarction (Gln27Gln vs. Gln27Glu/Glu27Glu: 77 vs. 23%, p=0.02). CONCLUSION The present study shows that the Gln27Gln genotype of β2-AR is the most predominant while the Glu27Glu is the least prevalent in our HF population. There was no difference in the prevalence of polymorphism Gln27Glu between HF patients and control subjects. However, the presence of Glu allele was associated with lower myocardial infarction rate.

Objective We have previously reported our successful approach for percutaneous cardiac implantable electronic device (CIED) lead extraction using inexpensive tools, which we have continued over the years. Herein we report the results of the systematic use of a unique stylet, the lead-locking device (LLD), which securely locks the entire lead lumen, aided with non-powered telescoping sheaths in 54 patients to extract 98 CIED leads. Methods This prospective observational clinical study included 38 men and 16 women aged 68.9±13.1 years undergoing lead extraction for device infection (n=46), lead malfunction (n=5), or prior to defibrillator implant (n=3). Leads were in place for 6.7±4.3 years. Infections were more commonly due to Staphylococcus species (n=40). There were 78 pacing (31 ventricular, 37 atrial, 4 VDD, and 6 coronary sinus leads) and 20 defibrillating leads. Results Using simple traction (6 leads) and the LLD stylets (92 leads) aided with telescoping sheaths (15 patients), 96 (98%) leads in 52 (96.3%) patients were successfully removed, with all but one leads removed using a subclavian approach; in 1 patient, the right femoral approach was also required. In 2 patients, distal fragments from one ventricular pacing and one defibrillating lead could not be removed. Finally, lead removal was completely (52/54) (96.3%) or partially (2/54) (3.7%) successful in 54 patients for 96 of 98 leads (98%) without major complications. Conclusion Percutaneous lead extraction can be successful with mechanical tools using the LLD locking stylet aided with non-powered telescoping sheaths through a simplified, safe, and inexpensive procedure using local anesthesia.

Varicella-zoster virus (VZV) infection can rarely lead to serious cardiac complications and life-threatening arrhythmias. We present a case of a 46-year-old male patient who developed VZV myocarditis and presented with recurrent syncopal episodes followed by a cardiac arrest. He had a further collapse eight years later, and cardiac magnetic resonance imaging (MRI) demonstrated mild mid-wall basal and inferolateral wall fibrosis. He was treated with an implantable cardioverter defibrillator (ICD) and represented two years later with ICD shocks, and interrogation of the device revealed ventricular fibrillation episodes. This case demonstrates the life-threatening long-term sequelae of VZV myocarditis in adults. We suggest that VZV myocarditis should be considered in all patients who present with a syncopal event after VZV infection. In these patients, ICD implantation is a potentially life-saving procedure.

Introduction Dasatinib is an oral Bcr-Abl and Src family tyrosine kinase inhibitor approved for use in patients with chronic myelogenous leukaemia (CML) and Philadelphia chromosome positive acute lymphoblastic leukaemia (ALL). Its common side effects include myelosuppression, oedema, diarrhea and nausea. It has also been associated with the formation of pleural and pericardial effusions. As a result, Dasatinib is to be avoided in patients with pre-existing effusions or predisposition to respiratory or cardiovascular disease. Case description A fit 62-year-old pilot with no relevant medical history was diagnosed with CML in 2014, and commenced on Dasatinib therapy (100mg OD). A subsequent trans-thoracic echocardiogram (TTE) revealed normal ventricles and cardiac valves. There was however a mild to moderate global pericardial effusion, without haemodynamic compromise. This was regularly monitored with TTEs and remained stable until May 2016, where it measured 2.1cm posteriorly around the LV and 1.0 cm around the RV. Due restrictions imposed by the Civil Aviation Authority in the UK, the patient was referred for pericardial window procedure, prior to being considered fit for flying. Conclusions Dasatinib is known to cause pleural and pericardial effusions. This has been reported in patients without any predisposing factors.(1) The link with pericardial effusions has been proven with robust statistical analysis.(2) No specific mechanism has been proposed but an immune mediated reaction or off target inhibition of growth factors may be involved.(3) Management includes dose interruption or reduction, and/or treatment with steroids.(3) Our case report re-enforces that Dasatinib is an important cause of pericardial effusion and TTE is the modality of choice for follow-up. Pericardial window and drainage may be needed in patients where this prohibits them from undertaking employment. Take-home message Dasatinib related pericardial effusions are a documented side effect of therapy. One should be vigilant in monitoring patients on the drug as effusions may progress over time and require intervention. TTE is the monitoring modality of choice. As far as we are aware this is the first case report for surgical intervention in a patient with Dasatinib induced pericardial effusion.

Electrical storm (ES) is defined as three or more sustained episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate implantable cardioverter-defibrillator (ICD) therapies during a period of 24 h. Electrical storm is a life-threatening situation presenting during the acute phase of myocardial infarction or in patients with various forms of ischemic or nonischemic cardiomyopathy. It requires hospitalization to ensure management of hemodynamically unstable patients and optimization of pharmacologic or non-pharmacologic therapy. Certain triggers or risk factors have been identified for patients presenting with ES, and, in general, ES has been associated with increased mortality and might be an independent risk factor for cardiac death.

The transvenous insertion of implantable pacemaker (PM) and implantable cardioverter defibrillator (ICD) leads was a major milestone in antiarrhythmic therapy with the use of cardiac devices. Indeed, based on data published over the last decade the indications for ICD therapy have further expanded [1,2] while cardiac resynchronization therapy (CRT) through bi-ventricular pacing has significantly improved mortality and quality of life in patients with heart failure and ventricular dyssynchrony [3,4,5]. Unfortunately, this exponential increase in the implantation rate of cardiac devices has been accompanied by a parallel increase in the need for explanting some of those [6]. This has been mainly attributed to the so called “increased total lead exposure time” resulting from the expanding indications for device treatments, the implantation of more leads per patient and the longer average life expectancy of device-recipients [7]. Lead removal has been performed only in limited centers from physicians with some expertise in this subject. The volume of procedures in these centers has also been increasing in a continuous manner and the techniques applied have become more and more sophisticated and effective. Indeed, the options for lead extraction were initially very limited and dedicated tools were not available. Life threatening situations such as infection with sepsis were the only reason to attempt a lead removal with these highly morbid and often ineffective techniques [8]. As a necessity to overcome these limitations a significant evolution in lead extraction technology occurred over the past 30 years. More simple, safe and efficacious techniques are nowadays widely used in clinical practice [9].