Background. Despite advances in therapy, heart failure (HF) remains a syndrome characterized by high morbidity and mortality. The PONTE-HF/ACS registry aims to assess the outcomes of a structured outpatient follow-up between hospital and community care for patients with HF or recently hospitalized for acute coronary syndrome. The purpose of this study is to evaluate one of the main process indicators of the registry for patients with HF, namely the prescribed pharmacological therapy, with particular reference to therapy with angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) or angiotensin receptor-neprilysin inhibitors (ARNi), beta-blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i). Methods. Between January 2024 and September 2025, 1203 patients were enrolled: 496 with HF and reduced ejection fraction (HFrEF), 189 with HF and mildly reduced ejection fraction (HFmrEF), 302 with HF and preserved ejection fraction (HFpEF), and 216 with HF and improved ejection fraction. Results. In HFrEF patients, after enrollment, therapy was prescribed as follows: ACEi/ARB/ARNi in 89% of cases (64% ARNi), beta-blockers in 97%, MRA in 85%, and SGLT2i in 85%. Quadruple therapy with and without ARNi was prescribed in 69% and 51% of cases, respectively. The percentage of patients receiving at least 50% of the recommended dose was 63% for ARNi, 41% for ACEi/ARB, 70% for beta-blockers, and 98% for MRA. Conclusions. The PONTE-HF/ACS registry shows good optimization of therapy in enrolled patients with HFrEF. Achieving this important process indicator highlights the quality of care provided by the HF outpatient network in the Apulia region and confirms the relevance of the registry for the analysis and optimization of diagnostic-therapeutic pathways in patients with HF.

Multifocal ectopic Purkinje-related premature contractions syndrome presents as a rare cardiac disorder characterized by frequent multifocal ectopic ventricular beats with narrow QRS complexes, originating from various ectopic foci along the fascicular-Purkinje system. It is characterized by mutations in the SCN5A gene, inducing a gain-of-function in the human cardiac voltage-gated Na+ channel (Nav1.5), which causes an alteration in the action potentials of the cardiomyocytes. The syndrome was initially delineated in 2012 by Laurent et al in 3 Dutch families, subsequently garnering recognition through several reported cases worldwide. Clinically, it often manifests with a familial predisposition to other arrhythmogenic cardiac diseases, alongside symptoms such as palpitations and syncope. A key diagnostic hallmark is the high daily burden of multifocal premature ventricular contractions observed on 24-hour dynamic ECG, with evidence of repetitive ventricular arrhythmias. This can potentially induce a reversible form of left ventricular dilation with systolic dysfunction, known as premature ventricular contraction-induced cardiomyopathy. Diagnosis may be challenging, requiring exclusion of the most frequent causes of ventricular arrhythmias first. The disappearance of arrhythmias during a stress test and the inefficacy of catheter ablation procedures may serve as additional elements to bolster the suspicion of multifocal ectopic Purkinje-related premature contractions syndrome. Genetic testing and electrophysiological studies are pivotal in confirming the diagnosis. Therapeutic management of this syndrome primarily involves medical therapy with class I antiarrhythmic drugs, such as flecainide and quinidine, which may reduce ventricular arrhythmias and associated symptoms. In this systematic review, our aim was to provide an exhaustive insight into the genetic basis, diagnosis, and treatment strategies for this intriguing yet relatively underexplored syndrome.

Conduction system pacing (CSP) is more and more emerging as a cardiac pacing technique alternative to conventional cardiac resynchronization therapy (CRT) to treat ventricular dyssynchrony. At this very moment, only a few data are available about the implantation of a traditional high voltage (HV) lead to perform left bundle branch area (LBBA) pacing, and follow-up is very short. The aim of our study is to evaluate the electrical performances, pacing, and defibrillator efficiency of traditional HV leads implanted in the LBBA at mid-term follow-up (up to 1 year). 14 patients (10 males, 68.8 ± 10.5 yo), with the indication for ICD/CRT-D (4 secondary prevention, 2 LBBB, 1 3rd degree AV block), were enrolled and implanted with a traditional HV lead (6.8F) in the LBBA (via a preshaped three-dimensional delivery sheath). CSP verification and defibrillation tests were performed at implantation. Patient follow-ups were performed at one week, one month, three months, six months, and twelve months reporting electrical parameters, consistency of CSP, ventricular synchrony (via echocardiographical evaluation), and efficacy of antitachycardia therapy in vivo. All 14 patients reported, at 1-year follow-up, no change in ECG and ventricular synchrony echo parameters (Peak Strain Dispersion <60ms). Electrical parameters were also stable (mean R-wave amplitude 10.8±2.2 mV; pacing impedance 436±44 ohm, shock impedance 70±6 ohm, and pacing threshold 0.72±0.24V@0.4ms) with improving trend of R-wave amplitude and pacing threshold (with effective automatic capture management in 12 of 14 patients) and a significant reduction of pacing impedance, in comparison to acute post-implantation values. We do not report any over/undersensing or noise issues and in two patients we observed in vivo ICD effective ventricular arrhythmias termination both by antitachycardia pacing (ATP) and shock. One patient underwent pocket revision due to significant weight loss, with no further issues. No lead-related complications are reported. Traditional HV leads could not only be safely and effectively implanted in the LBBA but are also showing excellent pacing and defibrillation performances in mid-term (up to 1 year) follow-up. Further investigations are ongoing with prolonged follow-up.

INTRODUCTION:In patients with symptomatic, refractory atrial fibrillation the ablate and pace (A&P) strategy (pacemaker implantation followed by atrio-ventricular junction ablation (AVJA)) is superior to medical therapy in improving quality of life and prognosis. Despite its well-proven benefits, this invasive therapeutic option is still underutilized in clinical practice. The choice of pacing modality (right ventricular pacing, biventricular pacing, BVP, or conduction system pacing, CSP) is crucial and can have significant clinical implications. In particular, in recent years CSP is emerging as an alternative to BVP, showing a good effectiveness and safety profile. Other important aspects are the timing of ablation, the approach used for AVJA, and the correct device programming after AVJA. AREAS COVERED:This article reviews the currently available evidence on this therapeutic strategy with a particular focus on its impact on patient outcome, recognized indications, technical considerations, and future perspectives. EXPERT OPINION:With the availability of more robust evidence confirming the better effectiveness and safety profile of CSP compared to conventional pacing modalities, in the next few years CSP will become the standard pacing modality in candidates for A&P. The routine adoption of this pacing modality could lead to a wider use of A&P in clinical practice.

INTRODUCTION:Thoracic impedance (TI) drops measured by implantable cardioverter-defibrillators (ICDs) have been reported to correlate with ventricular tachycardia/fibrillation (VT/VF). The aim of our study was to assess the temporal association of decreasing TI trends with VT/VF episodes through a longitudinal analysis of daily remote monitoring data from ICDs and cardiac resynchronization therapy defibrillators (CRT-Ds).METHODS AND RESULTS:Retrospective data from 2384 patients were randomized 1:1 into a derivation or validation cohort. The TI decrease rate was defined as the percentage of rolling weeks with a continuously decreasing TI trend. The derivation cohort was used to determine a TI decrease rate threshold for a ≥99% specificity of arrhythmia prediction. The associated risk of VT/VF episodes was estimated in the validation cohort by dividing the available follow-up into 60-day assessment intervals. Analyses were performed separately for 1354 ICD and 1030 CRT-D patients. During a median follow-up of 2.0 years, 727 patients (30.4%) experienced 3298 confirmed VT/VF episodes. In the ICD group, a TI decrease rate of >60% was associated with a higher risk of VT/VF episode in a 60-day assessment interval (stratified hazard ratio, 1.42; 95% confidence interval (CI), 1.05-1.92; p = .023). The TI decrease preceded (40.8%) or followed (59.2%) the VT/VF episodes. In the CRT-D group, no association between TI decrease and VT/VF episodes was observed (p = .84).CONCLUSION:In our longitudinal analysis, TI decrease was associated with VT/VF episodes only in ICD patients. Preventive interventions may be difficult since episodes can occur before or after TI decrease.

We report the case of a 50-year-old female patient with breast cancer who, during preoperative workup, presented repeated wide QRS complex tachycardias, recorded by Holter ECG. She was immediately referred to a hub center for electrophysiological study where she was diagnosed with right ventricular outflow tract ventricular tachycardia and underwent catheter ablation. The chemotherapy with paclitaxel that the patient was receiving combined with psychological stress may have triggered the arrhythmias.

Cancer-associated thrombosis (CAT) is the second main cause of cancer death with high related mortality and morbidity, leading to anticancer agent delays and interruptions. The recommended therapy, low-molecular-weight heparin (LMWH), however, is burdensome for patients and costly for society, as treatment should last until cancer is no longer active, even indefinitely. Tinzaparin is a manageable, efficient, safe, and cost-effective option. Compared to the other LMWHs, advantages are single-daily dose and safety in the elderly and those with renal impairment (RI). The purpose of this review is to critically discuss recent data on its efficacy and safety in CAT.

Abstract Introduction TEV is the second highest cause of death in malignancy with 20% incidence. Platelets is a leading mediator of thrombosis as well as of tumor development. Indeed, thrombocytosis is a predictive biomarker of thrombosis risk and contributes to CAT burden. However, the management of thrombocytopenia in patients with CAT is well investigated, whereas evidence is poor on the management of patients with concomitant occurrence of thrombocytosis and CAT. Case report A 67 y-o woman, in primary thromboprophylaxis with 100 mg/die aspirin for myeloproliferative syndrome (PC: 771 x103/µl), was treated with left mastectomy for infiltrating ductal carcinoma (G3 pT1cN1a Mx Ki67:25%) and adjuvant chemotherapy with anthracyclines and anastrozole. Due to bone metastases, zoledronic acid, fulvestrant and palbociclib were administrated. For liver metastases, she was treated with exemestane, paclitaxel and bevacizumab and for disease progression, started capecitabine and cyclophosphamide, still ongoing. She experienced left jugular vein thrombosis (Fig 1-2) treated with edoxaban 60 mg/die with an almost total DVT regression after 2 months. The multidisciplinary team (oncologist, cardiologist, hematologist) decided to interrupt aspirin, proceeding antithrombotic therapy with edoxaban full dose. Concomitant cytoreductive therapy with hydroxyurea was started concomitantly with edoxaban. PC was reduced (522 x103/µl). After 1-month follow-up duplex ultrasound still documented mild persistence of the DVT (Fig 3-4), the patient was compliant and the anticancer regimens (addressed to both the solid cancer and the hematologic disease) were still administrated without any adverse effects. Conclusions CAT is a frequent and major complication of malignancy, worsening mortality, morbidity and decision-making. Platelets play a central role in promoting the hypercoagulable melieu of cancer as well as the metastases growth. Notably, thrombocytosis occurrence further increases the thrombogenic burden in malignancy; nevertheless, its concomitant development together with CAT is understudied. In the reported case, a solid tumor, together with hematologic cancer and DVT, concurred to a difficult management of a patient admitted to our multidisciplinary team. The use of a DOAC, edoxaban, at full dose, without concomitant therapy with aspirin, was an effective, safe and manageable antithrombotic treatment option, allowing the continuation of anticancer agents with no interruptions or delays. The knowledge of tumor-specific pathways may help to personalize strategies for CAT prevention. Fig 1-2 Fig 3-4

RATIONALE:Venous thromboembolism is a feared frequent complication of cancer with a 2-way relationship. Low molecular weight heparin is the mainstay of treatment. The use of direct oral anticoagulants is supported by established evidence for the treatment of deep vein thrombosis also in active cancer and they are prioritized over low molecular weight heparin for cancer-associated thrombosis according to current guidelines. However, upper limb deep vein thrombosis is poorly studied with scant data on the use of direct oral anticoagulants in noncatheter-related deep vein thrombosis. We report the case of a patient with noncatheter-related deep vein thrombosis and a rare tumor site effectively and safely treated with a direct oral anticoagulant, edoxaban, after lack of efficacy with low molecular weight heparin.PATIENT CONCERNS:A 35-year-old man with primitive mediastinal seminoma presented at our Cardio-Oncology Unit for prechemotherapy assessment.DIAGNOSIS:Persistent brachiocephalic deep vein thrombosis, despite full-dose enoxaparin, was detected at ultrasonography.INTERVENTION:We decided to switch the anticoagulant treatment from enoxaparin to edoxaban.OUTCOME:The 3-month ultrasonography showed almost total regression of the deep vein thrombosis without any adverse effects and a good patient compliance.LESSONS:We conducted a literature review on upper limb deep vein thrombosis, since its management is challenging due to inconsistency of evidence. This report highlights the benefits of direct oral anticoagulants compared to low molecular weight heparins in cancer-associated thrombosis therapy in terms of efficacy, safety and ease of use.

Abstract Introduction Implantable cardioverter defibrillators (ICDs) provide daily values of thoracic impedance (TI) that are inversely correlated with fluid accumulation in the lungs. Since sustained ventricular arrhythmias (SVA) are known to have a short-term relationship with heart failure exacerbations, our objective was to assess TI trends temporally related to SVA episodes. Methods This study analyzed data daily transmitted from patients with ICD or cardiac resynchronization therapy defibrillator (CRT-D) of the nationwide Home Monitoring Expert Alliance network. Device-detected SVAs were adjudicated for appropriateness. Patients were randomly split into a derivation and validation cohort. To identify the most significant TI trend (TI-index), several numerical TI transformations were tested in a cross-sectional analysis of the derivation cohort modelling the odds of first SVA with univariate logistic regressions. In the same cohort, the threshold of the selected transformation was identified to maximize the projected specificity. The relative risk of SVA for TI-index above threshold was estimated in the validation cohort by applying Cox proportional hazard models stratified by individual patients to 60-day duration windows. Analyses were performed separately in the ICD and CRT-D groups. Results The study cohort included 2,384 patients with 69 years of age (interquartile range: 60, 77); 19% were women, 42% had coronary artery disease, and 43% had a CRT-D. After a median follow-up of 2.0 (1.0, 3.4) years, there were 3,298 appropriate SVA episodes in 727 patients (30%). The derived IT-index consisted of the percentage of 6-day intervals of the rolling average of TI values showing monotone decrease in the last 82 days. The increase in the risk of SVA was 3% (p<0.0001) per unit of percentage. The threshold of 60% of intervals with monotone decrease was associated with 99.9% projected specificity and 70.3% accuracy. In the validation cohort, the TI-Index was associated with a 42% increased risk of SVA episodes in the ICD group (hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.05-1.92, p=0.023). The TI-index exceeded the 60% threshold before the episode in 38% of the detected episodes. The association was not significant in the CRT-D group (HR 0.96, 95% CI 0.62-1.47, p=0.84). Conclusions In our analysis of remote monitoring data, a specific monotonic decreasing trend of TI was temporally associated with SVA in patients with ICD. Careful monitoring of TI can identify a period of susceptibility to ventricular arrhythmias that deserves more intensive attention.

The study aimed to evaluate the impact of dalbavancin therapy on both hospital length-of-stay (LOS) and treatment-related costs, as well as to describe the clinical outcome, in a retrospective cohort of patients with diverse Gram-positive bacterial infections, hospitalized in different specialty Units. From July 2017 to July 2019, clinical and sociodemographic data were collected for all hospitalized patients switched to dalbavancin for the treatment of Gram-positive infections. LOS and treatment-related costs were assessed and compared to a hypothetical scenario where the initial standard antimicrobial therapy would have been administered in hospital for the same duration as dalbavancin. A total of 50 patients were enrolled. The observed infections were: acute bacterial skin and skin structure infections (ABSSSIs, 12 patients), complicated ABSSSIs (eight patients), osteoarticular infections (18 patients), vascular graft or cardiovascular implantable electronic devices (CIED) infections (12 patients). After a median of 14 [interquartile range (IQR) 7–28] days, the in-hospital antimicrobial therapy was switched to dalbavancin 1500 mg. When appropriate, considering the site and the clinical course of the infection, 1500 mg doses were repeated every 14 days until recovery. Overall, 49/50 (98%) patients reported clinical success at the end of therapy. No relapses were observed in 37 patients for whom a median follow-up of 150 (IQR 30–180) days was available. By switching to dalbavancin, a median of €8,259 (IQR 5644–17,270) and 14 hospital days (IQR 22–47) per patient were saved. In this experience, the use of dalbavancin contributed to shorten LOS and treatment-related costs, especially in difficult Gram-positive infections requiring prolonged therapy.

Background: A lead-reactive fibrous capsule (FC) identified by ultrasounds as an atrial or ventricular lead thickness of more than 1 mm above the vendor-declared lead diameter (TL) and its local fibrotic attachment to the cardiac wall (FAC) have never been investigated in vivo, so their relationship with post-extraction masses (ghost) is not known. Methods: Intracardiac echocardiography (ICE) was performed twice during the same extraction procedure in 40 consecutive patients: before and immediately after infected lead extraction Results: The ghost detection rate was high: 60% (24/40 patients); ICE could identify both TL and FAC, TL being noted in 25/40 (62%) patients and FAC in 12/40 patients (30%). Both TL and FAC were significantly associated with ghosts (p < 0.001 and p = 0.002, respectively), but TL had a higher prediction power. The specificity was similar: 94% (15/16) and 100% (16/16), respectively, but TL showed a much higher sensitivity: 100%, (24/24) vs 50% (12/24) (p = 0.016). The ghost group did not show a higher event rate in the follow-up (mean follow-up time = 20 ± 17 months). Conclusion: ICE is able to evaluate both TL and FAC in vivo; ghosts are mostly benign remnants of fibrotic lead capsule cut off during extraction and retained inside the heart by FAC.

INTRODUCTION:Little data are available on anticoagulation (AC) management in patients with cardiac resynchronization (CRT) devices who undergo transvenous lead extraction (TLE) procedure. We investigated the impact of AC on periprocedural complications in CRT patients undergoing TLE, enrolled in the ESC-EHRA European Lead Extraction ConTrolled (ELECTRa) registry.METHODS AND RESULTS:All CRT patients treated with TLE enrolled in the registry were considered. Perioperative AC management was left to the discretion of the Center. Major and minor intraprocedural and postprocedural complications were compared between patients without AC (Gp1) and patients with AC (Gp2). Regression analyses were performed to identify predictors of complications for Gp2. Out of 734 CRT pts, 328 (44.7%) were under AC (Gp2). Patients from Gp2 presented lower LVEF (Gp2 32.5 ± 10.9 vs Gp1 34.5 ± 11.9%; P = 0.03), more advanced heart failure disease (NYHA III/IV: Gp2 42.0 vs Gp1 31.5%; P = 0.02), and renal impairment (Gp2 39.0 vs Gp1 24.3%; P < 0.001). Perioperative regimens included AC interruption (Gp2A: n = 169, 51.5%), "bridging" (Gp2B: n = 135, 41.2%), or continued AC (Gp2C: n = 24, 7.3%). TLE complete success rates (98% in both groups) and major complication rates were comparable for both groups; minor bleeding events were more frequent in Gp2 (5.5%) compared to Gp1 (2.5%; P = 0.051). No independent predictors were identified for Gp2, but minor complications were associated with "bridging" approach (Gp2B: 16 events vs Gp2A/C: 9 events; P = 0.020).CONCLUSION:CRT patients treated with TLE under AC were more compromised but did not present more major complications compared to patients without AC. More minor complications were associated with "bridging" AC regimen.

Aims About one-third of patients receiving cardiac resynchronization therapy (CRT) are not responders, due to either patient selection or technical issues. Left ventricular quadripolar passive fixation leads (QPL) and bipolar active fixation (BAF) leads have been designed to ensure a targeted left ventricular stimulation area, minimizing lead dislodgments and phrenic nerve stimulation (PNS). The aim was to compare real-world safety and efficacy of BAF (Attain Stability, Medtronic Plc.) and QPL (Attain Performa, Medtronic Plc.). Methods We performed a retrospective analysis examining procedural and follow-up data of 261 BAF and 124 QPL (programmed to single-site left ventricular pacing), included in the ClinicalService project from 16 Italian hospitals. Results At median follow-up of 12 months, no difference in left ventricular pacing threshold was recorded between BAF and QPL (1.3 ± 0.9 V @0.4 ms vs. 1.3 ± 1.0 V @0.4 ms; P = 0.749). Total left ventricular lead dislodgement rate was 1.43/100 patient-years in BAF vs. 2.9/100 patient-years in QPL ( P = 0.583). However, no dislodgements occurred among BAF after hospital discharge. Events requiring repeated surgery or permanently turning CRT off occurred in 0.8% of BAF, as compared with 4.0% of QPL ( P = 0.025). There was no difference between groups in the echo CRT responders’ rate (70% of BAF and 66% of QPL; P = 0.589) or in the annual rate of heart failure hospitalization ( P = 0.513). Conclusions BAF resulted in noninferior clinical outcome and CRT responders’ rate in comparison to QPL. Moreover, BAF ensured more precise and stable placement in cardiac veins, with comparable electrical performance and less than 1% patients with unsolved PNS.