Introduction: Cardiac stimulation evolved from life-saving devices to prevent asystole to the treatment of heart rhythm disorders and heart failure, capable of remote patient and disease-progression monitoring. Cardiac stimulation nowadays aims to correct the electrophysiologic roots of mechanical inefficiency in different structural heart diseases. Areas covered: Clinical experience, as per available literature, has led to awareness of the concealed risks of customary cardiac pacing, that can inadvertently cause atrio-ventricular and inter/intra-ventricular dyssynchrony. New pacing modalities have emerged, leading to a new concept of what truly represents ‘physiologic pacing’ beyond maintenance of atrio-ventricular coupling. In this article we will analyze the emerging evidence in favor of the available strategies to achieve an individualized physiologic setting in bradycardia pacing, and the hints of future developments. Expert opinion: ‘physiologic stimulation’ technologies should evolve to enable an effective and widespread adoption. In one way new guiding catheters and the adoption of electrophysiologic guidance and non-fluoroscopic lead implantation are needed to make His-Purkinje pacing successful and effective at long term in a shorter procedure time; in the other way leadless stimulation needs to upgrade to a superior physiologic setting to mimic customary DDD pacing and possibly His-Purkinje pacing.

The aim of this work is to present a preliminary study for the design of a digital auscultation system, i.e., a novel wearable device for patient chest auscultation and a digital stethoscope. The development and testing of the electronic stethoscope prototype is reported with an emphasis on the description and selection of sound transduction systems and analog electronic processing. The focus on various microphone technologies, such as micro-electro-mechanical systems (MEMSs), electret condensers, and piezoelectronic diaphragms, intends to emphasize the most suitable transducer for auscultation. In addition, we report on the design and development of a digital acquisition system for the human body for sound recording by using a modular device approach in order to fit the chosen analog and digital mics. Tests were performed on a designed phantom setup, and a qualitative comparison between the sounds recorded with the newly developed acquisition device and those recorded with two commercial digital stethoscopes is reported.

Background/Objectives: Right ventricular pacing (RVP), leadless pacing (LL), and conduction system pacing (CSP) are treatment options for atrioventricular block (AVB), each with distinct characteristics. However, the long-term outcomes of these pacing strategies remain insufficiently compared. This study evaluates clinical and echocardiographic outcomes of patients with AVB treated with dual chamber RVP, His bundle pacing (HBP), or LL. Methods: This single-center observational registry study included 22 consecutive patients receiving LL with atrioventricular resynchronization functionality (October 2020 to October 2022), matched with 66 control patients receiving either RVP (33 patients) or HBP (33 patients) using propensity score matching (2:3:3 ratio). Primary and secondary endpoints included all-cause mortality, cardiovascular mortality, heart failure, and echocardiographic outcomes. Atrioventricular synchrony in the LL group was assessed. Results: At two years, all-cause mortality was significantly higher in the LL group compared to RVP (36.4% vs. 6.1%, p = 0.002) and HBP (36.4% vs. 12.1%, p = 0.03), but LL had a more severe clinical profile. Cardiovascular mortality and heart failure incidence showed no significant differences. Patients receiving RVP showed a significant decrease in left ventricular ejection fraction and an increase in ventricular volumes. In contrast, HBP patients exhibited favorable cardiac remodeling. Stratification based on atrial sensing showed that LL patients with >66% AV synchrony had a lower mortality (p = 0.02). Conclusions: CSP offers superior results compared to other pacing methods in terms of ventricular function owing to a physiological ventricular activation and maintenance of AV synchrony. However, LL may be a viable alternative for frail and high-risk patients, as the suboptimal AV synchrony is traded off with lesser ventricular dyssynchrony.

A significant portion of embolic strokes occurs without documented atrial fibrillation (AF), challenging the traditional paradigm of cardioembolism. This review addresses the emerging concept of “atrial cardiopathy” as a distinct clinical entity—an underlying atrial substrate abnormality, characterized by fibrosis and dysfunction, that promotes thromboembolism independent of AF. We posit that AF is often a late-stage manifestation of atrial cardiopathy, not the sole trigger for thrombosis. This paper synthesizes the growing evidence linking biomarkers of atrial cardiopathy to Embolic Stroke of Undetermined Source (ESUS). This new framework has profound clinical implications, suggesting a shift from arrhythmia detection to assessing atrial substrate health for stroke risk stratification. Recognizing atrial cardiopathy is fundamental for developing novel “upstream” therapies, such as targeted anticoagulation, aimed at preventing both AF and its devastating thromboembolic consequences. This review critically evaluates the evidence and translational gaps in the field, synthesizing the emerging role of advanced computational modeling as a key future tool for personalized risk stratification.

Atrial fibrillation (AF) is a multifaceted disease requiring personalised treatment. The aim of our study was to explore the prognostic impact of a patient-specific therapy (PT) for rate control, including the use of non-dihydropyridine calcium channel blockers (NDDC) in patients with heart failure (HF) or in combination with beta-blockers (BB), compared to standard rate control therapy (ST), as defined by previous ESC guidelines. This is a single-centre prospective observational registry on AF patients who were followed by our University Hospital. We included 1112 patients on an exclusive rate control treatment. The PT group consisted of 125 (11.2%) patients, 93/125 (74.4%) of whom were prescribed BB + NDCC (±digoxin), while 85/125 (68.0%) were HF patients who were prescribed NDCC, which was diltiazem in all cases. The patients treated with a PT showed no difference in one-year overall survival compared to those with an ST. Notably, the patients with HF in ST had a worse prognosis (p < 0.001). To better define this finding, we performed three sensitivity analyses by matching each patient in the PT subgroups with three subjects from the ST cohort, showing an improved one-year survival of the HF patients treated with PT (p = 0.039). Our results suggest a potential outcome benefit of NDCC for rate control in AF patients, either alone or in combination with BB and in selected patients with HF.