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.

Potent integrin antagonists from a small library of RGD-including cyclic pseudopeptides

[structure: see text]. A small library of cyclic RGD pseudopentapeptides incorporating stereoisomeric 6,5- and 7,5-fused bicyclic lactams was synthesized with the aim of developing active and selective integrin antagonists. The solid-phase synthesis and activity of these RGD derivatives is described. The approach led to two of the most active known inhibitors of alpha(V)beta3 receptor.

First human experience with pulmonary vein isolation using a through-the-balloon circumferential ultrasound ablation system for recurrent atrial fibrillation

BACKGROUND

Standard mapping and ablation of focal sources of atrial fibrillation are associated with very long procedure times and low efficacy. An anatomic approach to complete pulmonary vein isolation could overcome these limitations.

METHODS AND RESULTS

Fifteen patients with atrial fibrillation refractory to medication underwent circumferential isolation of the pulmonary veins by using a novel catheter, with an ultrasound transducer (8-MHz) mounted near the tip, in a saline-filled balloon. Twelve atrial foci and/or atrial fibrillation triggers were identified in 9 patients (pulmonary vein locations: left upper, 3; right upper, 6; right middle, 1; right lower, 1; and left inferior, 1). In 5 patients, lesions were placed in the absence of any mapped triggers. Irrespective of trigger mapping, circumferential isolation of both upper pulmonary veins was attempted in all patients. The lower pulmonary veins were ablated when sinus rhythm activation mapping revealed evidence of a sleeve of atrial muscle in the vein. The median number of lesions per patient required to isolate 1 pulmonary vein was 4 (range, 1 to 29). After ablation, no evidence of narrowing was seen with repeat venography or follow-up computed tomography scan. After a mean follow-up of 35+/-6 weeks, 5 patients had recurrence of atrial fibrillation. Three responded to drugs that were previously ineffective, and 2 remained in atrial fibrillation.

CONCLUSIONS

This novel ultrasound ablation system can successfully isolate multiple pulmonary veins. At early follow-up, this approach seems to be effective in preventing recurrent atrial fibrillation in a significant number of patients.

Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter

BACKGROUND

Despite the high success rate of radiofrequency (RF) ablation, pharmacologic therapy is still considered the standard initial therapeutic approach for atrial flutter.

OBJECTIVE

We prospectively compared the outcome at follow-up of patients with atrial flutter randomly assigned to drug therapy or RF ablation.

METHODS

Patients with at least two episodes of symptomatic atrial flutter in the last four months were randomized to regimens of either antiarrhythmic drug therapy or first-line RF ablation. After institution of therapy, end points included recurrence of atrial flutter, rehospitalization and quality of life.

RESULTS

A total of 61 patients entered the study, 30 of whom were randomized to drug therapy and 31 to RF ablation. After a mean follow-up of 21 +/- 11 months, 11 of 30 (36%) patients receiving drugs were in sinus rhythm, versus 25 of 31 (80%) patients who underwent RF ablation (p < 0.01). Of the patients receiving drugs, 63% required one or more rehospitalizations, whereas post-RF ablation, only 22% of patients were rehospitalized (p < 0.01). Following RF ablation, 29% of patients developed atrial fibrillation which was seen in 53% of patients receiving medications (p < 0.05). Sense of well being (pre-RF 2.0 +/- 0.3 vs. post-RF 3.8 +/- 0.5, p < 0.01) and function in daily life (pre-RF 2.3 +/- 0.4 vs. post-RF 3.6 +/- 0.6, p < 0.01) improved after ablation, but did not change significantly in patients treated with drugs.

CONCLUSION

In a selected group of patients with atrial flutter, RF ablation could be considered a first-line therapy due to the better success rate and impact on quality of life, the lower occurrence of atrial fibrillation and the lower need for rehospitalization at follow-up.

A new isoflavone from Genista corsica

A new isoflavone (1), dihydroisoderrondiol [(3' 'S,4' 'R)-5,7,3' ', 4' '-tetrahydroxy-2' ',2' '-dimethyl-3' ',4' '-dihydropyrano(5' ',6' ';3' ',4' ')isoflavone], was isolated from aerial parts of Genista corsica, together with 11 previously known compounds [daidzein, isoprunetin, isoderrone (2), ficuisoflavone (3), luteolin, luteolin 4'-O-beta-glucoside, luteolin 7-O-beta-glucoside, taxifolin, 5-methoxytaxifolin, sucrose, and D-pinitol]. The structure of 1 was elucidated by spectroscopic methods.

Recovery-oriented psychopharmacology: redefining the goals of antipsychotic treatment

The traditional goals of psychopharmacology stem from the medical model. Rehabilitation interventions attempt to improve aspects of functioning in patients with chronic illnesses that are not responsive to biological intervention. Recovery is a concept emanating from the consumer self-help movement. It describes a move away from the patient role defined by a diagnostic label toward community membership defined by relationships and responsibilities in the community. Comprehensive care for people with psychotic disorders can include attention to each realm. This article provides an overview of the 3 models of care and describes a role for the psychopharmacologist in each as well as his or her unique potential to incorporate all 3. We outline potential synergistic benefits of integrating recovery-, rehabilitation-, and medical-model thinking into the practice of psychopharmacology and explore implications for the goals and outcomes of treatment for people with psychotic disorders.

Frequency of superior vena cava syndrome following radiofrequency modification of the sinus node and its management

In a series of 35 consecutive patients, the presence of a permanent pacemaker appears to be a strong risk factor for developing superior vena cava syndrome after radiofrequency modification of the sinus node. Treatment of this complication with balloon venoplasty is as effective as surgical repair.

Sodium channel blockers identify risk for sudden death in patients with ST-segment elevation and right bundle branch block but structurally normal hearts

BACKGROUND

A mutation in the cardiac sodium channel gene (SCN5A) has been described in patients with the syndrome of right bundle branch block, ST-segment elevation in leads V1 to V3, and sudden death (Brugada syndrome). These electrocardiographic manifestations are transient in many patients with the syndrome. The present study examined arrhythmic risk in patients with overt and concealed forms of the disease and the effectiveness of sodium channel blockers to unmask the syndrome and, thus, identify patients at risk.

METHODS AND RESULTS

The effect of intravenous ajmaline (1 mg/kg), procainamide (10 mg/kg), or flecainide (2 mg/kg) on the ECG was studied in 34 patients with the syndrome and transient normalization of the ECG (group A), 11 members of 3 families in whom a SCN5A mutation was associated with the syndrome and 8 members in whom it was not (group B), and 53 control subjects (group C). Ajmaline, procainamide, or flecainide administration resulted in ST-segment elevation and right bundle branch block in all patients in group A and in all 11 patients with the mutation in group B. A similar pattern could not be elicited in the 8 patients in group B who lacked the mutation or in any person in group C. The follow-up period (37+/-33 months) revealed no differences in the incidence of arrhythmia between the 34 patients in whom the phenotypic manifestation of the syndrome was transient and the 24 patients in whom it was persistent (log-rank, 0.639).

CONCLUSIONS

The data demonstrated a similar incidence of potentially lethal arrhythmias in patients displaying transient versus persistent ST-segment elevation and right bundle branch block, as well as the effectiveness of sodium channel blockers to unmask the syndrome and, thus, identify patients at risk.

Catheter ablation approach on the right side only for paroxysmal atrial fibrillation therapy: long-term results

We report the long-term follow-up of a right side only catheter ablation approach for paroxysmal AF. Eighteen patients with AF refractory to drugs entered the study. Ablation was attempted in the right atrium only by creating linear lesions based on a specific design including from two to four linear lesions. Induction of AF was attempted before ablation and after placement of the lesions. A septal lesion was performed in nine patients. In ten patients atrial defibrillation thresholds (ADFTs) before ablation and following creation of the linear lesions were compared. After a mean follow-up of 22 +/- 11 months, seven patients had recurrence of AF, and another nine patients experienced atrial flutter or atrial tachycardia. Five patients remained in sinus rhythm without medications and four required the use of drugs. Three patients had sporadic AF and six were in chronic AF. The recurrence rate was similar in patients with and without the septal lesion. However, a cure with right side ablation appeared to be predicted by the presence of disorganized and earlier activity in the high right atrium and crista terminalis. Linear lesions in the right atrium were associated with a lower ADFT (pre 2.6 +/- 04 J vs post 1.7 +/- 0.6 J). In conclusion, in a small number of patients, control of AF can be obtained with a right side only approach. Certain activation patterns may identify patients suitable to this approach. No specific lesion pattern appeared more effective. Right atrial linear lesions resulted in lower ADFT.

Genetic basis and molecular mechanism for idiopathic ventricular fibrillation

Ventricular fibrillation causes more than 300,000 sudden deaths each year in the USA alone. In approximately 5-12% of these cases, there are no demonstrable cardiac or non-cardiac causes to account for the episode, which is therefore classified as idiopathic ventricular fibrillation (IVF). A distinct group of IVF patients has been found to present with a characteristic electrocardiographic pattern. Because of the small size of most pedigrees and the high incidence of sudden death, however, molecular genetic studies of IVF have not yet been done. Because IVF causes cardiac rhythm disturbance, we investigated whether malfunction of ion channels could cause the disorder by studying mutations in the cardiac sodium channel gene SCN5A. We have now identified a missense mutation, a splice-donor mutation, and a frameshift mutation in the coding region of SCN5A in three IVF families. We show that sodium channels with the missense mutation recover from inactivation more rapidly than normal and that the frameshift mutation causes the sodium channel to be non-functional. Our results indicate that mutations in cardiac ion-channel genes contribute to the risk of developing IVF.

Antiphosphatidylserine antibodies in human immunodeficiency virus-1 patients with evidence of T-cell apoptosis and mediate antibody-dependent cellular cytotoxicity

Serum reactivities to a panel of phospholipid antigens, including cardiolipin (CL), phosphatidylserine (PS), sphingomyelin, phosphatidylcholine, and phosphatidylethanolamine, were measured by enzyme-linked immunosorbent assay in 196 human immunodeficiency virus-l+ (HIV-1+) patients with CDC II to IVC clinical disease. Significant levels of IgG to CL, PS, or both were observed in 23 patients lacking evidence of thrombophilic events or any peculiar clinical feature of HIV-1 infection. Fluorescence-activated cell sorting analyses showed that in vitro apoptosis of T cells was increased in patients with high serum anti-PS IgG, whereas the overexpression of Fas/Apo-1 marker was detected in all patients regardless of their antiphospholipid reactivities. Macrophages from patients with significant titers of anti-PS IgG antibodies were not activated by the presence of apoptotic CEM lymphoblasts or by purified anti-PS IgG from the same patients. By contrast, these antibodies greatly improved the effector functions of autologous macrophages in antibody-dependent cellular cytotoxicity (ADCC) assays using 51Cr-labeled CEM cells, whereas polyspecific IgG were unable to induce an equivalent cytotoxicity in all instances. An increasing effect on ADCC was also observed in tests using macrophages from healthy controls to CEM coated with anti-PS IgG. These results support a potential correlation of anti-PS specificity with T-cell apoptosis in HIV-1 infection. Because PS is exteriorized by apoptotic lymphocytes, its persistence may stimulate antibodies which cooperate with macrophages in the clearance of dead cells by an enhanced ADCC mechanism. This interpretation could explain the absence of thrombophilia in HIV-1+ patients with serum elevations of antiphospholipid reactivities.

HTLV-I and HTLV-II infections in subjects at risk for HIV-I infection from southeastern Italy (Apulia region)

To assess the prevalence of HTLV-I and HTLV-II infections in different groups at risk for HIV-I infection, a study on 867 subjects was carried out by means of serological and PCR analyses. Serum specimens were collected from 268 intravenous drug users (IVDU), 66 homosexual men, 248 subjects with sexually transmitted diseases (STD), 105 thalassemics and 180 hemophiliacs. Sera from 3 IVDU and a sample from an STD patient were confirmed as HTLV-II seropositive; a thalassemic patient was seropositive for HTLV-I; a homosexual man, though confirmed as HTLV-I/II-seroreactive, could not be typed by serological methods. No hemophiliac was found to be HTLV-I/II-reactive. All 3 HTLV-II-seroreactive IVDU and the HTLV-I-infected thalassemic were confirmed by PCR; an additional sample from an IVDU, indeterminate by Western blot, was confirmed to be positive for HTLV-II by PCR. Subtyping of HTLV-II samples indicated the presence of II/b subtype in all 4 cases. Up to now, the reservoir for HTLV-II infection in southeastern Italy is mainly represented by IVDU, while HTLV-I infection seems to be sporadic.

Detection of HCV RNA in serum and seminal fluid from HIV-1 co-infected intravenous drug addicts

The presence of hepatitis C virus (HCV) RNA in serum and seminal fluid was investigated in eleven drug addicts coinfected with HIV-1 and HCV. Serum and seminal fluid were taken from each patient at the same time point. HCV RNA was found in ten of the eleven serum samples tested, but only in one of the semen samples. No relationship was observed between CD4 cell counts, the stage of HIV infection, extent of liver damage and the presence of HCV RNA in serum and semen. The results indicate that HCV is not usually present in the semen and provide further evidence against sexual transmission as an important mode of transmission of HCV infection.

Serum beta 2-microglobulin in intravenous drug users and its correlation with human immunodeficiency virus infection

High levels of serum beta 2-microglobulin have been associated with human immunodeficiency virus infection and beta 2-microglobulin has been used with other serological and immunological markers for monitoring disease progression. The usefulness of beta 2-microglobulin as a prognostic marker during human immunodeficiency virus infection has been demonstrated in homosexual men and hemophiliacs; few and contradictory data have been reported in intravenous drug users. We have evaluated a cohort of 160 intravenous drug users (81 seronegative and 79 seropositive for human immunodeficiency virus infection) with normal renal function to assess whether serum beta 2-microglobulin could be used as a serological marker for monitoring infection; 78 healthy subjects were used as controls. Of 79 seropositive drug users, 54 were asymptomatic or had persistent generalized lymphoadenopathy the remaining 25 had the acquired immunodeficiency syndrome. Seropositive patients were tested for CD4+ lymphocyte number, p24 antigen and anti-p24 antibodies. A significant statistical difference was found in mean serum beta 2-microglobulin levels between seronegative and seropositive drug users. Moreover, higher levels of beta 2-microglobulin were observed in acquired immunodeficiency syndrome patients compared with asymptomatic or patients with persistent lymphadenopathy. A significant relationship was also observed between increased concentration of beta 2-microglobulin and the serological and immunological markers which indicate human immunodeficiency virus disease progression.

O6-methylguanine and temozolomide can reverse the resistance to chloroethylnitrosoureas of a mouse L1210 leukemia

Using L1210 and a subline resistance to chloroethylnitrosoureas (L1210/BCNU), we found that the resistance to 1-(2-chloroethyl)-1-nitrosourea (CNU) or to diethyl-1-3-(2-chloroethyl)-3-nitrosoureido ethyl phosphonate (fotemustine) can be reversed by a pretreatment with O6-methyl Guanine (O6-mGua) or temozolomide. In L1210/BCNU but not in L1210 the pretreatment with O6mGua caused an increased peak level of CNU-induced DNA-interstrand crosslinks. We then evaluated whether the resistance to BCNU could be counteracted in vivo by i.p. O6mGua treatment of L1210/BCNU bearing mice. The results were negative due to the fact that O6mGua, which was not toxic when given alone, caused a high toxicity when associated with BCNU.