A previous randomized study demonstrated that the subcutaneous implantable cardioverter defibrillator (S-ICD) was noninferior to transvenous ICD with respect to device-related complications and inappropriate shocks. However, that was performed prior to the widespread adoption of pulse generator implantation in the intermuscular (IM) space instead of the traditional subcutaneous (SC) pocket. The aim of this analysis was to compare survival from device-related complications and inappropriate shocks between patients who underwent S-ICD implantation with the generator positioned in an IM position in comparison with an SC pocket. We analysed 1577 consecutive patients who had undergone S-ICD implantation from 2013 to 2021 and were followed up until December 2021. Subcutaneous patients (n = 290) were propensity matched with patients of the IM group (n = 290), and their outcomes were compared. : During a median follow-up of 28 months, device-related complications were reported in 28 (4.8%) patients and inappropriate shocks were reported in 37 (6.4%) patients. The risk of complication was lower in the matched IM group than in the SC group [hazard ratio 0.41, 95% confidence interval (CI) 0.17–0.99, P = 0.041], as well as the composite of complications and inappropriate shocks (hazard ratio 0.50, 95% CI 0.30–0.86, P = 0.013). The risk of appropriate shocks was similar between groups (hazard ratio 0.90, 95% CI 0.50–1.61, P = 0.721). There was no significant interaction between generator positioning and variables such as gender, age, body mass index, and ejection fraction. Our data showed the superiority of the IM S-ICD generator positioning in reducing device-related complications and inappropriate shocks. Clinical Trial Registration: ClinicalTrials.gov; NCT02275637.

Aims: The subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to traditional ICDs. The PRAETORIAN score, based on chest radiographs, has been validated to predict the probability of successful S-ICD defibrillation testing by assessing factors like fat thickness between the coil and sternum and generator placement. This study evaluated the correlation between the PRAETORIAN score and clinical characteristics, as well as implantation variables. Methods and results: We retrospectively analysed data from 1253 patients who had undergone implantation of an S-ICD across 33 centres. The intermuscular positioning of the pulse generator was adopted in all patients. Post-implantation posterior–anterior and lateral chest radiographs were analysed to calculate the PRAETORIAN score. A total of 95.7% of patients had a PRAETORIAN score < 90, indicative of a low risk of conversion failure. Body mass index (BMI) was the only independent predictor of a score ≥ 90, and all patients with BMI < 25 kg/m2 (normal weight or underweight) had a score < 90. The intermuscular positioning technique resulted in optimal posterior placement of the device in all patients and significant sub-generator fat in only 3% of cases. A shock impedance value > 88 Ohm enabled to detect a PRAETORIAN score ≥ 90 with 98% (95% CI 97–99%) negative predictive value. Conclusion: In contemporary practice, the PRAETORIAN score can be simplified. By adopting an intermuscular approach, two of the three steps of the score—evaluating the adequate posterior positioning of the generator and measuring the sub-generator fat—become superfluous, and impedance may serve as a reliable surrogate of sub-coil fat thickness. Furthermore, our data suggest that for non-obese patients, a favourable PRAETORIAN score is assured, making the score evaluation potentially unnecessary. Clinical trial registration: URL: http://clinicaltrials.gov/ Identifier: NCT02275637.

Pectus excavatum (PE) can be associated with either congenital or acquired heart disease. This study highlights the importance of PE surgical repair in cases of severe chest depression on the heart in underlying cardiac diseases exacerbating cardiopulmonary impairment. From January 2023 to March 2024, four male patients underwent PE repair, having heart disease including pericarditis, mitral valve prolapse, ventricular fibrillation arrest and type 1 second-degree atrioventricular block. PE severity was determined by the Haller index (HI). Preoperative assessment included a pulmonary function test, chest computed tomography and cardiac evaluation. The Nuss procedure was performed in three patients, whereas, in one patient, it was performed in combination with a modified Ravitch procedure. The median HI was five. The median time of chest tube removal was 6.5 days. Postoperative complications were prolonged air leak, atrial fibrillation and atelectasis. The median length of hospital stay was 19.5 days, and no 30-day postoperative mortality was recorded. In all patients, surgical repair helped to resolve the underlying cardiological issues, and surgical follow-ups were deemed regular. PE is generally an isolated congenital chest wall abnormality, and, when associated with a heart disease, it can have severe life-threatening hemodynamic consequences due to mechanical compression on the heart for which surgical corrections should be considered.

Artificial Intelligence (AI) applications and Machine Learning (ML) methods have gained much attention in recent years for their ability to automatically detect patterns in data without being explicitly taught rules. Specific features characterise the ECGs of patients with Brugada Syndrome (BrS); however, there is still ambiguity regarding the correct diagnosis of BrS and its differentiation from other pathologies.

BACKGROUND: The safety of subcutaneous implantable cardioverter defibrillator (S-ICD) recipients who lead active lifestyles and engage in recreational sports is unknown. We aimed to evaluate the association between lifestyle and recreational sports and the occurrence of arrhythmia- and device-related complications, appropriate and inappropriate shocks in S-ICD recipients. METHODS: We assessed a cohort of young-adult (15–65 years) S-ICD patients, evaluated their physical activity with IPAQ (International Physical Activity Questionnaire), and assessed the association between lifestyle and recreational sports on S-ICD safety and shocks. RESULTS: We enrolled 602 S-ICD recipients (77% men; age, 46±14 years). According to the IPAQ, patients were categorized as inactive subjects (26.4%), moderately active subjects (45.2%), or highly active subjects (28.4%). Among moderately/highly active subjects, 163 (27.1%) were recreational athletes. During follow-up (47.3 [interquartile range, 27.0–67.6] months), 23 patients (3.8%) reached the safety end point of arrhythmia- or device-related complications, with moderately and highly active subjects showing in multivariate analysis similar incidence compared with inactive subjects ( P =0.59 and P =0.83, respectively). Forty-four patients had 87 appropriate shocks. In multivariate analysis, moderately and highly active subjects showed a nonsignificantly lower incidence of appropriate shocks compared with inactive subjects ( P =0.12 and P =0.11, respectively). Consistently, there was a nonsignificant lower incidence of appropriate shocks in athletes versus nonathletes ( P =0.06). Thirty-nine patients had 46 inappropriate shocks. Moderately and highly active subjects had similar incidence of inappropriate shocks compared with inactive subjects ( P =0.92 and P =0.88, respectively). CONCLUSIONS: Young S-ICD patients often lead active lifestyles and participate in sports. Higher activity levels were not associated with increased implantable cardioverter defibrillator–related complications or increased risk of implantable cardioverter defibrillator shocks.

Purpose of the study: Previous studies investigated the role of intrinsic conduction for cardiac resynchronization therapy (CRT) optimization. We investigated the role of the fusion between pacing-induced activation and intrinsic conduction in CRT, by evaluating the acute hemodynamic effects of simultaneous His bundle and left ventricular (LV) pacing. Method used: We studied 11 patients with systolic heart failure and left bundle-branch block scheduled for implantation of a CRT device. At implantation, LV pressure and volume data were determined via conductance catheter. Standard leads were placed in the right atrium, at the apex of the right ventricle (RVA) and in a lateral or posterior-lateral coronary vein. An additional electrode was temporarily positioned in His bundle. Following pacing configurations were systematically assessed: standard biventricular pacing (RVA + LV), LV only pacing (LV-only), His bundle pacing (HIS), simultaneous His bundle and LV pacing (HIS + LV). Each configuration was compared with the AAI mode at multiple atrioventricular intervals. Summary of results: In comparison with AAI mode, RVA + LV and LV-only pacing resulted in improved stroke volume (85 ± 32ml and 86 ± 33ml versus 58 ± 23ml), stroke work, maximum pressure-derivative and systolic dyssynchrony at individual optimal interval. The optimal atrioventricular delay was close to the P-H interval in the majority of patients. By contrast, HIS-LV pacing improved hemodynamic indexes at all atrioventricular intervals (stroke volume >76ml at all fixed intervals and 88 ± 31ml at optimal interval). Conclusion: The original simultaneous HIS + LV pacing enhanced systolic function and LV synchrony regardless of the atrioventricular interval setting, whereas standard RVA + LV and LV-only pacing yielded improvements at individual optimal atrioventricular intervals, close to the measured intrinsic P-H interval. These findings support the hypothesis of the crucial role of intrinsic right ventricular conduction for optimal CRT delivery.