Cardiac resynchronization therapy determined clinical and functional benefit that was similar in patients with wide or "narrow" QRS. Cardiac resynchronization therapy may be helpful in patients with echocardiographic evidence of interventricular and intraventricular asynchrony and incomplete left bundle branch block.

COVID-19 outbreak had a major impact on the organization of care in Italy, and a survey to evaluate provision of for arrhythmia during COVID-19 outbreak (March-April 2020) was launched. A total of 104 physicians from 84 Italian arrhythmia centres took part in the survey. The vast majority of participating centres (95.2%) reported a significant reduction in the number of elective pacemaker implantations during the outbreak period compared to the corresponding two months of year 2019 (50.0% of centres reported a reduction of > 50%). Similarly, 92.9% of participating centres reported a significant reduction in the number of implantable cardioverter-defibrillator (ICD) implantations for primary prevention, and 72.6% a significant reduction of ICD implantations for secondary prevention (> 50% in 65.5 and 44.0% of the centres, respectively). The majority of participating centres (77.4%) reported a significant reduction in the number of elective ablations (> 50% in 65.5% of the centres). Also the interventional procedures performed in an emergency setting, as well as acute management of atrial fibrillation had a marked reduction, thus leading to the conclusion that the impact of COVID-19 was disrupting the entire organization of health care, with a massive impact on the activities and procedures related to arrhythmia management in Italy.

The typical ECG phenotype of BS disclosed by a febrile illness confirms the in vitro experimental data that previously established a correlation between ECG pattern of BS and temperature variations. The clinical and therapeutic implications of these findings are discussed.

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To investigate the electrophysiological significance of QRS alternans during narrow QRS tachycardia, transesophageal atrial pacing and recording was performed in 24 patients with a history of paroxysmal supraventricular tachycardia. Standard electrocardiograms showed ventricular preexcitation in 15 patients and normal QRS pattern in nine patients. The ventriculoatrial interval during tachycardia, as defined by means of transesophageal electrogram, allowed tentative diagnosis of the tachycardia mechanism. A 12-lead ECG was recorded either during spontaneous or induced tachycardia, as well as during transesophageal atrial pacing at increasing rates. Electrical alternans occurred spontaneously in eight patients (33%, group A): five with accessory pathway reentry (mean VA: 136 +/- 43 msec), and three with AV nodal reentry (mean VA: 48.3 +/- 12 msec). Tachycardia rate ranged between 170 and 230 beats/min (mean 200.7 +/- 16). In two patients, alternation of the QRS occurred only in the presence of a heart rate exceeding 180 and 190 beats/min, respectively. The amplitude of QRS remained stable during tachycardia in 16 patients (67%, group B): 14 had accessory pathway reentry (mean VA: 137.5 +/- 32 msec), and two had AV nodal reentry (mean VA: 45 +/- 7 msec). In this group, the tachycardia rate ranged from 150 to 210 beats/min (mean 175 +/- 12). Incremental transesophageal atrial pacing up to rates equal to that of tachycardia was performed in five patients from group A and in five patients from group B. Electrical alternans could not be induced in both groups with pacing at progressively increasing rates.(ABSTRACT TRUNCATED AT 250 WORDS)

We appreciate the contribution from Marquez et al. 1 and we think that some issues should be commented in order to shed light on the quite intriguing disease association of Brugada syndrome (BS) and vasovagal syncope (VVS).The association of BS and VVS has been recently described, and only four cases have been reported in the literature; moreover, a common diagnostic and therapeutic approach is lacking. Samniah et al., 2 reported on a young man with a family history of sudden death, recurrent near syncope spells, tilt-table-test induced syncope, and electrocardiographic (ECG) features of BS disclosed by procainamide. In this case, the absence of inducible arrhythmias at electrophysiological study (EPS) guided the authors toward a conservative therapeutic approach, and excluded automatic defibrillator (ICD) implantation.Belhassen et al., 3 in a series of high-risk patients with BS treated with quinidine, described one patient with documented VVS and positive EPS. The authors did not perform ICD implantation, due to quinidine efficacy in preventing inducibility at EPS, and during follow-up the patient showed recurrent syncopal episodes with typical vasovagal features.The case described by Marquez et al., 1 is very intriguing and stresses the difficulty to perform a standard diagnostic and therapeutic approach in patients with BS and VVS. They report on a young man with a family history of sudden death, two VVS at the time of childhood, and typical ECG pattern of BS. The patient had a positive tilt-test and a negative EPS, which eventually happened to be a false negative result. In this case, the risk of sudden death has been clearly overlooked and an ICD was implanted only 2 years later, after three syncopal episodes during sleep. Furthermore, it would be interesting to focus on the diagnostic strategies of the authors for the evaluation of an arrhythmic syncope during sleep.We report on a young man with suspected VVS, "coved" ECG pattern, positive tilt-test, and induction of a life-threatening arrhythmia at EPS. 4 In this setting the differential diagnosis of sponta-neous syncope is very difficult; however, it may be reasonable to favor and treat the cause that is most life-threatening, such as an arrhythmic one, and therefore the patient received an ICD. This option was proven correct at the follow-up, since the patient experienced an episode of VF, during sleep at night that was correctly identified and treated by the device.The occurrence of syncope in individuals with BS ECG abnormalities has a strong unfavorable prognostic impact and ICD is recommended, regardless of the EPS. When another possible cause of syncope is identified, EPS may be valuable for risk stratification, even if the clear discordance on the predictive value of inducibility in the literature mandates a consideration of EPS as an investigatory tool (class IIB). 5 Therefore, in patient with BS, associated VVS and negative EPS, as in the case reported by Marquez et al., 1 we suggest, as an alternative to a close follow-up, a loop recorder im...