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.

P370 INNOVATIVE TELEMONITORED MODEL OF PHYSICAL EXERCISE PRESCRIPTION IN SECONDARY PREVENTION DURING THE QUARANTINE

Introduction

COVID–19 pandemic induced the emanation of extraordinary measures like quarantine, that can be considered a risk factor for both physical and mental health in the population. In particular, gym’s closure and the need to stay home didn’t allow people to perform physical activity easily, with a consequent worsening of cardiovascular risk factors. During quarantine some general recommendations have been disseminated, but little is known about specific guidelines for home–based exercise prescription in patients with cardiovascular disease. Therefore, the purpose of this study is to develop home–based physical exercise programs for cardiac patients referred to the Center for Exercise Science and Sports of University of Ferrara.

Methods

On the basis of exercise capacity obtained from the last functional evaluation, performed in presence before the closure, three structured workouts were realized following the guidelines. They are composed as follows: warm–up, strenght and balance exercises alternate to indoor walking, cool–down. Patients received an explicative iconographic via e–mail or smartphone. Some domiciliary sessions were supervised by an operator through video connection.

Results

All patients showed excellent compliance with the proposed program. Adherence has been verified through biweekly recalls. No adverse events occurred.

Conclusions

Telemonitored exercise prescription in cardiac outpatients was effective and safe, helping to prevent negative consequences of the abrupt cessation of physical activity due to COVID–19 pandemic. These evidence could be useful even after the end of pandemic, for all those patients that are less likely to participate in traditional cardiovascular rehabilitation programs because of difficulties in reaching facilities or leaving home.

P401 REMOTE COUNSELING ROLE DURING COVID–19 PANDEMIC IN SECONDARY PREVENTION AFTER ACUTE CORONARY SYNDROME

Introduction

Patients affected by acute coronary syndrome are usually referred to center–based secondary prevention programs where they are enrolled in physical activity programs and received indications about cardiovascular risk factors control. COVID–19 pandemic induced the emanation of restrictions in people’s mobility, ban on gathering and the obligation of social distancing. This made it difficult to maintain such group meetings in presence.

Methods

After hospitalization for acute coronary syndrome in Cardiology Unit of the AUSL of Ferrara, patients equipped with electronic devices were allowed to participate to remote counseling meetings on the digital platform LifesizeC. To improve participation, meetings were organized monthly (in order to gradually include new discharged patients) and involving caregivers (if patients weren’t able to access the web app). Information on regular physical activity benefits were provided. In particular, the F.I.T.T. principle (Frequency, Intensity, Type, Time) has been explained and Borg’s exertion scale was illustrated to be used in autonomy. Furthermore, there were provided recommendations about the need of a proper warm– up/cool–down, the possibility to wear a heart rate monitor and the early recognition of symptoms and warning signs. To complete health education, there were given information about correct nutrition, risk factors control and correct assumption of pharmacological therapy.

Results

All patients showed interest in the topics analyzed, asking various questions during the meetings. They also stated that they were strongly motivated to undertake regular physical activity having received convincing explanations on its usefulness and safety.

Conclusions

Remote counseling meetings obtained a high approval rating and the moments of discussion with the speakers were particularly well attended. The prescription of physical exercise in secondary prevention can follow innovative telemonitored approaches, which could be maintained even after COVID–19.

Ablation of typical atrial flutter: a prospective study of cooled-tip versus 8-mm-tip catheters

AIM

Both ablation catheters with irrigated system and 8mm tip-catheters have shown to be more effective for typical atrial flutter radiofrequency (RF) ablation when compared to conventional 4 mm tip catheter. The purpose of this prospective study was to compare the efficiency of radiofrequency catheter ablation (RFA) of the cavotricuspid isthmus using a new type of open irrigation-tip catheter versus 8 mm tip-catheters to eliminate atrial flutter (AFL).

METHODS

Sixty consecutive patients, matched for age, presence of cardiopathy, atrial dimensions and comorbidity, underwent RF ablation of cavotricuspid isthmus (CTI) for the treatment of typical atrial flutter, using an open irrigated tip catheter - Surround Flow™ - (N.=30) or an 8-mm-tip catheter (N.=30). The RF pulses were applied point-by-point for 30 seconds, with power limited at 35 w for the irrigated catheter and by temperature control (60/70 w) for the 8-mm catheter.

RESULTS

The CTI block was successfully performed in 100% of cases. There was no significant difference with regard to ablation parameters, such as total time of RF ablation (608±324 vs. 556±244 s, P=0.79), number of RF applications (12±8 vs. 10±5, P=0.56), total procedure duration (86.4±23.6 vs. 78.1±22.5 min, P=0.58) and time of fluoroscopy (12±6 vs. 14±6 min, P=0.25) and periprocedural complications (1 groin hematoma in the 8 mm group). During follow-up of 11.6 months on average, one patient in the 8 mm group had recurrence of typical atrial flutter.

CONCLUSION

Efficacy and safety of CTI ablation was comparable between both techniques (open irrigated catheter and 8mm tip catheter). The ablation parameters were comparable and homogeneous between the two groups.

Pacemaker-induced mitral regurgitation: prominent role of abnormal ventricular activation sequence versus altered atrioventricular synchrony

BACKGROUND

Functional mitral regurgitation is a hemodynamic adverse consequence of right ventricular apical pacing that profoundly modifies the contraction and relaxation of the left ventricle by inverting and delaying its activation sequence. The aim of this study was to analyze by Doppler echocardiography in the acute setting the true incidence and the mechanism responsible for the right ventricular apical pacing-induced mitral regurgitation.

METHODS

We studied 27 consecutive patients submitted to pacemaker implantation (VVI n = 9; DDD n = 18) because of bradyarrhythmias. The exclusion criteria were structural cardiac disease and permanent atrioventricular block. Patients underwent Doppler echocardiographic examination during both spontaneous rhythm (pacemaker off) as well as during programmed pacing at a rate of 70 b/min. In case of a double chamber pacemaker, a non-optimized atrioventricular delay of 150 ms was chosen.

RESULTS

Two groups were identified: 11 patients with (Group 1, mean age 71 +/- 7 years) and 16 patients without (Group 2, mean age 71 +/- 4 years) new-onset pacing-induced mitral regurgitation. The incidence of mitral regurgitation was found to be higher during DDD (33%) than during VVI (24%) pacing mode. The relationship between gender and the occurrence of pacing-induced mitral regurgitation was striking: 10/13 women (77%) presented with mitral regurgitation during acute right ventricular apical pacing while this complication occurred in only 1/14 men (7%). Moreover, analysis of variance (ANOVA) and post-hoc pairwise multiple comparison showed an increased size of the mitral apparatus, as defined by the enlargement of the annulus (long axis 28 +/- 3 vs 23 +/- 2 mm; short axis 25 +/- 3 vs 20 +/- 3 mm, p = 0.05) and the lengthening of the anterior mitral leaflet (23 +/- 4 vs 18 +/- 2 mm, p = 0.05) and chordae tendineae (16 +/- 3 vs 13 +/- 2 mm, p = 0.05). This was probably related to the high female prevalence (91%) in Group 1 as compared to the control group (50 healthy subjects; 17 men, 33 women; mean age 71 +/- 8 years). No significant differences were observed between Group 2 and controls.

CONCLUSIONS

Our study confirmed that functional mitral regurgitation is a frequent consequence of right ventricular apical pacing. Despite the maintenance of normal atrioventricular synchrony, we found that the pathway for ventricular depolarization was the critical determinant of normal mitral valve function. Such data show the importance of the preservation of a normal ventricular activation sequence during permanent cardiac pacing where it is technically feasible. Female patients seemed to be exposed to a higher risk of pacing-induced mitral regurgitation due to an anatomic predisposing condition of the mitral apparatus and to the left ventricular dyssynchronous contraction secondary to right ventricular apical pacing.

[Platelet antiaggregants or anticoagulants in the secondary prevention after myocardial infarct]

Aspirin and oral anticoagulants are effective treatments in the secondary prevention after myocardial infarction. Aspirin at the dosage of 160-325 mg per day accomplishes a 21% reduction of the recurrences of vascular events (INR: 3-4). Oral anticoagulants are likely to be more effective; this therapy however is more demanding for the patient and the referring physician and is associated with a higher risk of hemorrhage. According to the available information from the literature, aspirin should be recommended for the majority of patients surviving after myocardial infarction. Oral anticoagulants should be reserved for post-infarction patients at high risk of thromboembolism and for those patients who present either intolerance to aspirin or recurrence of vascular events during aspirin treatment.

Prognostic significance of silent myocardial ischemia in variant angina pectoris

The present study investigates the prognostic significance of silent myocardial ischemia in variant angina. Forty-eight-hour Holter monitoring and coronary angiography were performed in 54 patients with transient ST elevation and no history of myocardial infarction admitted to the coronary care unit for worsening of symptoms. Coronary artery spasm was documented in most of these patients. Over the subsequent month, 20 patients (group 1) had a major coronary event (2 died, 6 had nonfatal myocardial infarction and 12 had urgent coronary revascularization), and the remaining 34 patients (group 2) had a good clinical outcome. From 2,578 hours of recording, 547 ischemic episodes were identified of which only 9% were associated with angina. The mean daily number of ST elevation in group 1 was similar to that in group 2 (4.8 +/- 5.1 vs 4.1 +/- 4.6; p = not significant). Conversely, the mean daily duration of such ischemic episodes was consistently greater in group 1 than in 2 (79 +/- 36 vs 37 +/- 25 minutes; p less than 0.005). The occurrence of greater than or equal to 1 long-lasting (greater than or equal to 10 minutes) episode of ST elevation was observed in 18 of 20 patients in group 1 (sensitivity 90%), but only in 4 of 34 in group 2 (specificity 88%). Significant coronary atherosclerosis (greater than 50% stenoses) was found at angiography in 18 of 20 patients in group 1, and in 18 of 34 in group 2.(ABSTRACT TRUNCATED AT 250 WORDS)