Background: Heart rate (HR) reduction may be useful in treatment of patients with heart failure (HF). There are no data on the haemodynamic effects of ivabradine (a selective I f current inhibitor) in advanced HF patients. Aims: To assess the haemodynamic effects of ivabradine in patients with advanced HF and markedly depressed left ventricular (LV) function. Methods and results: Ten NYHA class III patients (50 ± 12 years, LV ejection fraction 21 ± 7%) underwent 24-h haemodynamic monitoring. Ivabradine 0.1 mg/kg was infused over 90′, followed by 0.05-0.075 mg/kg in the subsequent 90′. Baseline HR was 93 ± 8 bpm, cardiac index (CI) 2.2 ± 0.6 l/min ⁎ m 2 ; LV stroke volume 44 ± 11 ml and systolic work 39 ± 13 g. Ivabradine significantly reduced HR, by a maximum of 27% (to 68 ± 9 bpm) at 4 h, without decreasing CI. Ivabradine increased stroke volume and LV systolic work by a maximum of 51% (to 66 ± 17 ml) and 53% (to 58 ± 20 g) at 4 h. No serious adverse events occurred. Conclusion: In patients with advanced HF and markedly depressed LV function, the acute administration of ivabradine is well tolerated, effectively reduces HR, markedly increases stroke volume and preserves cardiac output. Ivabradine appears a promising approach for the treatment of patients with moderate and advanced heart failure.

Background: A two-incision technique, in association with inter-muscular positioning of the subcutaneous defibrillator (S-ICD), is now the most frequently adopted implantation approach in Europe. Ultrasound-guided serratus anterior plane block (SAPB) has been proposed to provide anesthesia/analgesia during S-ICD implantation.Objective: We performed a case-control analysis in which a standardized SAPB approach was compared with the typical local anesthesia and sedation approach.Methods: Ninety-one consecutive patients underwent implantation of an S-ICD with the SAPB approach for anesthesia/analgesia at 10 centers. The control group consisted of 55 consecutive patients who underwent S-ICD implantation with a standard local approach.Results: The mean procedure duration was 59 ± 15 minutes in the SAPB group and 76 ± 23 minutes in the control group (P < .001). No operative complications were reported in either group. During the procedure, 79 (87%) patients in the SAPB group and 25 (46%) patients in the control group (P < .001) remained awake. Lower values of pain intensity at the device pocket (P = .005) and the lateral tunneling site (P = .046) were reported in the SAPB group. The difference in static (P = .002) and dynamic (P = .007) pain intensity between the groups persisted at 1 hour, while no differences were observed 6 hours after the end of the procedure.Conclusions: SAPB is feasible and effective in providing anesthesia/analgesia during S-ICD implantation. The procedures were successfully accomplished and no complications occurred in either group. However, SAPB was associated with lower Correspondence

An elite mountaineer reported severe acute mountain sickness and ataxia during an 8000-m expedition and concomitant use of transdermal nitroglycerin patches aimed to prevent frostbites. Use of nitroglycerin for this purpose is off-label, and its safety has not been assessed. Moreover, a relation between nitrate-induced cerebral vasodilation and high altitude cerebral edema is theoretically possible on a pathophysiological basis. It is our opinion that nitroglycerin use at high altitude should be discouraged, as efficacy in the prevention of frostbites is questionable and safety has not been assessed.

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