Five waves of COVID-19 pandemic in Italy: results of a national survey evaluating the impact on activities related to arrhythmias, pacing, and electrophysiology promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

BACKGROUND

The subsequent waves of the COVID-19 pandemic in Italy had a major impact on cardiac care.

METHODS

A survey to evaluate the dynamic changes in arrhythmia care during the first five waves of COVID-19 in Italy (first: March-May 2020; second: October 2020-January 2021; third: February-May 2021; fourth: June-October 2021; fifth: November 2021-February 2022) was launched.

RESULTS

A total of 127 physicians from arrhythmia centers (34% of Italian centers) took part in the survey. As compared to 2019, a reduction in 40% of elective pacemaker (PM), defibrillators (ICD), and cardiac resynchronization devices (CRT) implantations, with a 70% reduction for ablations, was reported during the first wave, with a progressive and gradual return to pre-pandemic volumes, generally during the third-fourth waves, slower for ablations. For emergency procedures (PM, ICD, CRT, and ablations), recovery from the initial 10% decline occurred in most cases during the second wave, with some variability. However, acute care for atrial fibrillation, electrical cardioversions, and evaluations for syncope showed a prolonged reduction of activity. The number of patients with devices which started remote monitoring increased by 40% during the first wave, but then the adoption of remote monitoring declined.

CONCLUSIONS

The dramatic and profound derangement in arrhythmia management that characterized the first wave of the COVID-19 pandemic was followed by a progressive return to the volume of activities of the pre-pandemic periods, even if with different temporal dynamics and some heterogeneity. Remote monitoring was largely implemented during the first wave, but full implementation is needed.

P544Evaluation of three-dimensional trajectory of pacing cathode pole in coronary sinus to predict long-term response to cardiac resynchronization therapy

Background

An automated method for 3D reconstruction of coronary sinus (CS) lead’s pacing cathode trajectory (3DTJ) was proposed  to acutely predict long term left ventricular (LV) mechanic response to  cardiac resynchronization therapy (CRT). Preliminary data showed that 3DTJ at biventricular pacing (BIV) start changed  in CRT responders (R) to be,  becoming less eccentric and more multi-directional, as described by the ratio between its two major axes (S1/S2).

Purpose

The TRAJECTORIES study (Trajectory Changes Of Coronary Sinus Lead Tip And Cardiac Resynchronization Therapy Outcome, NCT02340546) is an observational study by seven Italian centers about  the prediction of CRT-induced LV reverse remodeling by means of the acute 3DTJ changes at CRT implant.

Methods

In CRT implants with standard indications, stable CHF and regular ventricular rhythm,  a fluoroscopic sequence in two standard X-rays views of a few seconds was acquired immediately before (T-1) and after the start of BIV (T0). 3DTJ  of CS lead cathode pole throughout the cardiac cycle at T-1 and T0 were reconstructed and analyzed. Changes of the ratio between its two major axes (S1/S2) between T-1 and T0 (ΔS1/S2), were compared with the volumetric response at six-month f.u: the percent negative variation of S1/S2 (ΔS1/S2 < 0), marking a more multi-directional shape of 3DTJ, was assumed to predict the response to CRT. Volumetric response was adjudicated by a core-lab using a cut-off reduction ≥ 15% in echocardiographic LV end-systolic volume at f.u.. 

Results

  Out of 119 patients enrolled in 42 months, 74 pts ended f.u. (55 m; age 69 ± 10) and 30 dropped–out. Patients baseline features were: ischemic heart disease (IHD) 34 /74 pts; sinus rhythm 64/74 pts; upgrade from PM/ICD 13/74 pts; QRS morphology with LBBB 57/74, intraventricular aspecific delay 6 and  RV pace 11 pts;  LV ejection fraction (EF) 30 ± 9%; QRS duration 162 ± 25 ms. At f.u., volumetric R were 45/74 (60%). Concordance between ΔS1/S2 (as either ΔS1/S2 < 0 or ΔS1/S2 > 0) and volumetric response was 77% overall (57/74), 82% in R (37/45), 69% in non-R (20/29). Non-concordant patients were mostly non-R: 52% vs  35% of non-R in concordant group, but no other differences were found. The proposed 3DTJ metric showed sensitivity = 72%, specificity =80%;  positive predictive value = 69%, negative predictive value = 82%.

Conclusions

Metrics of 3DTJ can be useful to acutely predict CS pacing site-specific response to CRT in long-term, above all in R. 3DTJ assessment might highlight aspects of  CRT effects  on LV mechanics.

Cardiac resynchronization therapy: a comparison among left ventricular bipolar, quadripolar and active fixation leads

We evaluated the performance of 3 different left ventricular leads (LV) for resynchronization therapy: bipolar (BL), quadripolar (QL) and active fixation leads (AFL). We enrolled 290 consecutive CRTD candidates implanted with BL (n = 136) or QL (n = 97) or AFL (n = 57). Over a minimum 10 months follow-up, we assessed: (a) composite technical endpoint (TE) (phrenic nerve stimulation at 8 V@0.4 ms, safety margin between myocardial and phrenic threshold <2V, LV dislodgement and failure to achieve the target pacing site), (b) composite clinical endpoint (CE) (death, hospitalization for heart failure, heart transplantation, lead extraction for infection), (c) reverse remodeling (RR) (reduction of end systolic volume >15%). Baseline characteristics of the 3 groups were similar. At follow-up the incidence of TE was 36.3%, 14.3% and 19.9% in BL, AFL and QL, respectively (p < 0.01). Moreover, the incidence of RR was 56%, 64% and 68% in BL, AFL and QL respectively (p = 0.02). There were no significant differences in CE (p = 0.380). On a multivariable analysis, "non-BL leads" was the single predictor of an improved clinical outcome. QL and AFL are superior to conventional BL by enhancing pacing of the target site: AFL through prevention of lead dislodgement while QL through improved management of phrenic nerve stimulation.