Adairgram0431

Accidental lead misplacement in the left ventricle is a rare complication, which should be diagnosed early and treated with lead removal. In case of late diagnosis, chronic anticoagulant therapy or, if the patient needs cardiac surgery for other reasons, surgical lead removal are recommended. In the present case, lead misplacement occurred at the time of a traditional pacemaker implantation due to bradycardia.

The service strategy (same-day transfer between the spoke hospital and the hub center with catheterization laboratory facility to perform invasive procedures) has been shown to improve the management of patients with non-ST-elevation acute coronary syndrome admitted to spoke hospitals. However, few data exist about the safety of this strategy and, in particular, the safety of retransferring patients to spoke centers immediately after successful percutaneous coronary intervention.

We used data from a prospective registry to retrospectively describe the application, performance and outcome of the service strategy in the daily clinical practice in our province, organized in 5 spoke hospitals and a hub center in Reggio Emilia, Italy.

From January 2013 to December 2017, 1183 consecutive patients were admitted to the cath-lab in the hub center from spoke hospitals with a diagnosis of non-ST-elevation acute coronary syndrome. Mean age was 68 ± 12 years, with a mean GRACE risk score of 137 ± 3. Overall, 1063 pae strategy in our provincial network in patients with non-ST-elevation acute coronary syndrome admitted to spoke centers allowed an early access to the cath-lab as recommended by international guidelines. The safety of the service strategy is confirmed in our experience, with no major adverse events occurring during the back transfer.Inappropriate prescribing of diagnostic procedures and treatments should be avoided for good medical practice. Furthermore, the therapeutic plan of each patient should be regularly revised, activating deprescription procedures to reduce the dosage or to discontinue unnecessary drugs. It has widely been reported that the number of drugs taken by each patient increases over the years and adverse events caused by polypharmacy therapy are increasingly reported. Polypharmacy is due to multimorbidity related to longer life expectancy, but it is also induced by drug manufacturers' pressures, the practice of prescribing one product to counteract the adverse effects of another, the division into subspecialties inducing clinicians to solve the specific problem regardless of the patient therapeutic profile, and the uncritical implementation of current guidelines. The recommendations published by scientific societies for the international Choosing Wisely project allow to identify practices at risk of inappropriateness, and programs are available to help evaluating the risks of several drug associations, taking into consideration different aspects of pharmacology, drug interactions, potentially inappropriate in the elderly, according to different criteria from the scientific literature. The safety of reducing or withdrawing under strict medical supervision some cardiovascular treatments has been demonstrated, with documented benefits for the patients.In elderly patients with heart failure and an indication for implantable cardioverter defibrillator (ICD) implantation, the incidence of sudden cardiac death (SCD) increases progressively with age, up to 80-85 years. ICD implantation is a recognized therapy, included in the guidelines for the prevention of SCD in the general population, which is also applied to elderly patients, albeit in an uneven manner, given the lack of robust data in the literature. this website In fact, the average age of patients included in the main randomized trials on ICDs is about 60 years. All this brings to a series of doubts in this regard, compounded by recent studies that have raised the suspicion of therapeutic futility in the implantation of ICDs in primary prevention in subjects aged ≥70 years, especially in the absence of ischemic heart disease. In the elderly, although the risk of SCD does not vary, the mortality rate for other causes tends progressively to increase with age, as the main consequence of the simultaneous presence of situations such as frailty syndrome and comorbidity. In order to avoid an ageistic attitude, it is therefore necessary to promote randomized controlled trials aimed at a multidimensional evaluation of the elderly patients with an indication for ICD implantation, from which more robust data can be obtained to allow the heart team a selectively targeted evaluation of elderly patients.The rapid increase in cardiac implantable electronic device (CIED) implants and their ability to monitor atrial activity significantly contributed to a parallel increase in the occasional detection of atrial tachyarrhythmias, termed as atrial high-rate episodes (AHREs). These episodes of atrial tachyarrhythmia are usually asymptomatic and they are often diagnosed incidentally during the regular follow-up of patients with CIEDs or during the diagnostic work-up for patients affected by cryptogenic stroke. Over the past 20 years, numerous studies attempted to demonstrate the clinical significance and prognostic impact of these episodes, but their clinical management remains unclear. However, AHREs are not only significantly associated with a greater risk of developing clinical atrial fibrillation over time, but are also associated with an increased risk of cerebral and/or systemic thromboembolic events. Therefore, if deemed favorable, the use of oral anticoagulant therapy may be reasonable. The purpose of this review is to perform a state of the art analysis focusing on the clinical management of AHREs, their prognostic impact, the risks and benefits of anticoagulation and the critical issues that have emerged in the last years of studies.Electrical storm (ES) is defined as three or more episodes of sustained ventricular tachycardia (VT) or fibrillation (VF) within 24 h, or an incessant VT/VF lasting more than 12 h. It usually occurs in implantable cardioverter-defibrillator (ICD) recipients, and three or more device interventions are typically used for the diagnosis. ES incidence is particularly high in case of ICD implanted in secondary prevention (10-30%), with recurrences occurring in up to 80% of patients. A comprehensive evaluation of triggers, predictive factors of high-risk patients and an appropriate management of the acute/subacute and chronic phases are pivotal to reduce mortality and recurrences. Medical therapy with antiarrhythmic and anesthetic drugs, with appropriate device reprogramming and neuroaxial modulation if needed, are used to cool down the ES, which should ultimately be treated with ablation therapy or, less often, with an alternative treatment, such as denervation or stereotactic radiosurgery. An optimization of the clinical pathway in a network modeling is crucial to achieve the best treatment, eventually addressing patients to centers with VT ablation programs, and identifying the most challenging procedures and the most critical patients that should be treated only in high-volume tertiary centers.