Long-term clinical outcomes of patients with drug-induced type 1 Brugada electrocardiographic pattern: A nationwide cohort registry study

BACKGROUND

There are limited real-world data on the extended prognosis of patients with drug-induced type 1 Brugada electrocardiogram (ECG).

OBJECTIVE

We assessed the clinical outcomes and predictors of life-threatening arrhythmias in patients with drug-induced type 1 Brugada ECG.

METHODS

This multicenter retrospective study, conducted at 21 Italian and Swiss hospitals from July 1997 to May 2021, included consecutive patients with drug-induced type 1 ECG. The primary outcome, a composite of appropriate ICD therapies and sudden cardiac death, was assessed along with the clinical predictors of these events.

RESULTS

A total of 606 patients (mean age 49.7 ± 14.7 years; 423 [69.8%] men) were followed for a median of 60.3 months (interquartile range 23.0-122.4 months). Nineteen patients (3.1%) experienced life-threatening arrhythmias, with a median annual event rate of 0.5% over 5 years and 0.25% over 10 years. The SCN5A mutation was the only predictor of the primary outcome (hazard ratio 4.54; P = .002), whereas a trend was observed for unexplained syncope (hazard ratio 3.85; P = .05). In patients who were asymptomatic at presentation, the median annual rate of life-threatening arrhythmias is 0.24% over 5 years and increases to 1.2% if they have inducible ventricular fibrillation during programmed ventricular stimulation.

CONCLUSION

In patients with drug-induced type 1 Brugada ECG, the annual risk of life-threatening arrhythmias is low, with the SCN5A mutation as the only independent predictor. Unexplained syncope correlated with worse clinical outcomes. Ventricular fibrillation inducibility at programmed ventricular stimulation significantly increases the median annual rate of life-threatening arrhythmias from 0.24% to 1.2% over 5 years.

Novel Medical Treatments and Devices for the Management of Heart Failure with Reduced Ejection Fraction

Heart failure (HF) is a growing issue in developed countries; it is often the result of underlying processes such as ischemia, hypertension, infiltrative diseases or even genetic abnormalities. The great majority of the affected patients present a reduced ejection fraction (≤40%), thereby falling under the name of "heart failure with reduced ejection fraction" (HFrEF). This condition represents a major threat for patients: it significantly affects life quality and carries an enormous burden on the whole healthcare system due to its high management costs. In the last decade, new medical treatments and devices have been developed in order to reduce HF hospitalizations and improve prognosis while reducing the overall mortality rate. Pharmacological therapy has significantly changed our perspective of this disease thanks to its ability of restoring ventricular function and reducing symptom severity, even in some dramatic contexts with an extensively diseased myocardium. Notably, medical therapy can sometimes be ineffective, and a tailored integration with device technologies is of pivotal importance. Not by chance, in recent years, cardiac implantable devices witnessed a significant improvement, thereby providing an irreplaceable resource for the management of HF. Some devices have the ability of assessing (CardioMEMS) or treating (ultrafiltration) fluid retention, while others recognize and treat life-threatening arrhythmias, even for a limited time frame (wearable cardioverter defibrillator). The present review article gives a comprehensive overview of the most recent and important findings that need to be considered in patients affected by HFrEF. Both novel medical treatments and devices are presented and discussed.

A Novel Approach to Cardiac Magnetic Resonance Scar Characterization in Patients Affected by Cardiac Amyloidosis: A Pilot Study

Background and Objectives: Cardiac magnetic resonance (CMR) imaging has become an essential instrument in the study of cardiomyopathies; it has recently been integrated into the diagnostic workflow for cardiac amyloidosis (CA) with remarkable results. An additional emerging role is the stratification of the arrhythmogenic risk by scar analysis and the possibility of merging these data with electro-anatomical maps. This is made possible by using a software (ADAS 3D, Galgo Medical, Barcelona, Spain) able to provide 3D heart models by detecting fibrosis along the whole thickness of the myocardial walls. Little is known regarding the applications of this software in the wide spectrum of cardiomyopathies and the potential benefits have yet to be discovered. In this study, we tried to apply the ADAS 3D in the context of CA. Materials and Methods: This study was a retrospectively analysis of consecutive CMR imaging of patients affected by CA that were treated in our center (Marche University Hospital). Wherever possible, the data were processed with the ADAS 3D software and analyzed for a correlation between the morphometric parameters and follow-up events. The outcome was a composite of all-cause mortality, unplanned cardiovascular hospitalizations, sustained ventricular arrhythmias (VAs), permanent reduction in left ventricular ejection fraction, and pacemaker implantation. The secondary outcomes were the need for a pacemaker implantation and sustained VAs. Results: A total of 14 patients were deemed eligible for the software analysis: 8 patients with wild type transthyretin CA, 5 with light chain CA, and 1 with transthyretin hereditary CA. The vast majority of imaging features was not related to the composite outcome, but atrial wall thickening displayed a significant association with both the primary (p = 0.003) and the secondary outcome of pacemaker implantation (p = 0.003). The software was able to differentiate between core zones and border zones of scars, with the latter being the most extensively represented in all patients. Interestingly, in a huge percentage of CMR images, the software identified the highest degree of core zone fibrosis among the epicardial layers and, in those patients, we found a higher incidence of the primary outcome, without reaching statistical significance (p = 0.18). Channels were found in the scar zones in a substantial percentage of patients without a clear correlation with follow-up events. Conclusions: CMR imaging plays a pivotal role in cardiovascular diagnostics. Our analysis shows the feasibility and applicability of such instrument for all types of CA. We could not only differentiate between different layers of scars, but we were also able to identify the presence of fibrosis channels among the different scar zones. None of the data derived from the ADAS 3D software seemed to be related to cardiac events in the follow-up, but this might be imputable to the restricted number of patients enrolled in the study.

High-power short-duration catheter ablation of atrial fibrillation: is it really a new era? Comparison between new and old radiofrequency contact force-sensing catheters

BACKGROUND

The clinical performance of high-power, short-duration (HPSD) pulmonary vein isolation (PVI) with the novel flexible tip TactiFlex™ (TFSE) catheter, as compared to standard-power, long-duration (SPLD) PVI using the TactiCath™ (TCSE) catheter among patients undergoing catheter ablation (CA) of atrial fibrillation (AF) is currently unknown.

METHODS

We conducted a prospective, observational, single-centre study including 40 consecutive patients undergoing PVI for paroxysmal/persistent AF, using HPSD ablation with the novel TFSE catheter (HPSD/TFSE group). Based on propensity score-matching, forty patients undergoing SPLD PVI with the TCSE catheter were identified (SPLD/TCSE group). In the HPSD/TFSE group, RF lesions were performed by delivering 40-50 W for 10-20 s, while in the SPLD/TCSE group, RF power was 30-35 W, targeting a lesion size index (LSI) of 4.0-5.5. The co-primary study outcomes were time required to complete PVI and first pass isolation (FPI).

RESULTS

PVI was achieved in 100% of patients in both groups, and no major adverse events were observed. Remarkably, PVI time was shorter in the HPSD/TFSE, compared to the SPLD/TCSE group(9 [7-9] min vs. 50 [37-54] min; p < 0.001), while FPI rate was non-significantly higher in the former group(91% [146/160] vs 83% [134/160]; p = 0.063). Shorter procedural (108 [91-120] min vs. 173 [139-187] min, p < 0.001), total RF (9 [7-11] min vs. 43 [32-53] min, p < 0.001), fluoroscopy times(15 [10-19] min vs. 18 [13-26] min, p = 0.014), and lower DAP (1461 [860-2181] vs. 7200 [3400-20,800], p < 0.001) were recorded in the HPSD/TFSE group. A higher average impedance drop was obtained with HPSD/TFSE CA(17[17-18]Ω vs. 16 [15-17] Ω, p < 0.001).

CONCLUSIONS

In our initial clinical experience, HPSD PVI with the TFSE catheter proved faster than SPLD PVI with the TCSE catheter, at least equally effective in terms of FPI, and it was associated with greater impedance drop.

Conduction system disease management in patients candidate and/or treated for the aortic valve disease: an Italian Survey promoted by Italian Association of Arrhythmology and Cardiac Pacing (AIAC)

BACKGROUND

Conduction system disorders represent a frequent complication in patients undergoing surgical (surgical aortic valve replacement, SAVR) or percutaneous (transcatheter aortic valve implantation, TAVI) aortic valve replacement. The purpose of this survey was to evaluate experienced operators approach in this clinical condition.

METHODS

This survey was independently conducted by the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) and it consisted of 24 questions regarding the respondents' profile, the characteristics of participating centres, and conduction disease management in different scenarios.

RESULTS

Fifty-five physicians from 55 Italian arrhythmia centres took part in the survey. Prophylactic pacemaker implantation is rare. In case of persistent complete atrioventricular block (AVB), 49% and 73% respondents wait less than one week before implanting a definitive pacemaker after SAVR and TAVI, respectively. In case of second degree AVB, the respondents wait some days more for definitive implantation. Respondents consider bundle branch blocks, in particular pre-existing left bundle branch block (LBBB), the worst prognostic factors for pacemaker implantation after TAVI. The implanted valve type is considered a relevant element to evaluate. In patients with new-onset LBBB and severe/moderate left ventricular systolic dysfunction, respondents would implant a biventricular pacemaker in 100/55% of cases, respectively.

CONCLUSIONS

Waiting time before a definitive pacemaker implantation after aortic valve replacement has reduced compared to the past, and it is anticipated in TAVI vs. SAVR. Bundle branch blocks are considered the worse prognostic factor for pacemaker implantation after TAVI. The type of pacemaker implanted in new-onset LBBB patients without severe left ventricular systolic dysfunction is heterogeneous.

Giant aneurysm of the left atrial appendage: a case report

Background

Left atrial appendage aneurysm (LAAA) is a rare condition mostly due to congenital malformations or secondary causes (i.e. mitral regurgitation).

Case summary

We present a case of a 47-year-old male with a history of atrial fibrillation treated with propafenone presented to our emergency department for palpitation and epigastric pain. The electrocardiogram showed atrial fibrillation at high ventricular rate and a new-onset left bundle branch block. Urgent coronary angiogram excluded coronary artery disease. Echocardiography and cardiac magnetic resonance revealed a giant LAAA. The electrocardiogram alterations were deemed secondary to aberrancy and treatment with class IC antiarrhythmic. The patient was discussed in the heart team, and considering his will to avoid surgery, he was managed conservatively with closed follow-up, anticoagulant and antiarrhythmic therapy, and internal loop recorder. At 1-year follow-up, he showed asymptomatic and without arrhythmias.

Discussion

Few cases are described in the literature; therefore, there is uncertainty in treatment and prognosis. Diagnosis is achieved with multimodality imaging. Treatment can be surgical with aneurysmectomy or conservative with regular follow-up by imaging examinations and pharmacological therapy aimed to prevent complications such as thrombosis and arrhythmias. Since high-quality scientific data are lacking, shared decision-making is essential for the management of patients affected by LAAA. In our clinical case, our patient's will to not undergo surgery was considered, and therefore, a conservative management with strict follow-up and medications was chosen.

Speckle-tracking global longitudinal strain predicts death and cardiovascular events in patients with systemic sclerosis

Aims

Albeit often asymptomatic, heart involvement in systemic sclerosis (SSc) represents a negative prognostic factor, accounting for nearly one-fourth of all deaths. Global longitudinal strain (GLS) is accurate in detecting heart involvement in patients with SSc and no overt cardiac disease and allows early detection and longitudinal monitoring, but its association with clinical endpoints has not been tested so far. The primary outcome was the association between left and right GLS and mortality for all causes. The secondary outcome was the association between left and right GLS and hospitalizations.

Methods and results

A prospective longitudinal study enrolling all consecutive patients with SSc without structural heart disease or previous cardiovascular event.A total of 164 patients were enrolled, of whom 19 (11.5%) died during follow-up and 48 (29.3%) were hospitalized. Both left (LV) and right ventricle (RV) GLS at enrolment were independently associated with an increased risk of death for all causes and hospitalizations. Patients with biventricular GLS impairment, respectively, had a 4.2-, 4.9-, and 13.9-fold increased risk of death when compared with patients with only LV, only RV, or no impairment (P < 0.001). The incidence of hospitalization in patients with biventricular GLS impairment was nearly four times higher when compared with patients with only LV or only RV impairment, and nine times higher when compared with normal biventricular GLS (P < 0.001).

Conclusion

Biventricular GLS is associated with an increased risk of death and hospitalization in patients with SSc during a median of 3-year follow-up, acting as a reliable and accurate prognostic tool in everyday practice.

Characteristics and Clinical Value of Electroanatomic Voltage Mapping in Cardiac Amyloidosis

BACKGROUND

Cardiac amyloidoses (CAs) are an increasingly recognised group of infiltrative cardiomyopathies associated with high risk of adverse cardiac events. We sought to characterise the characteristics and clinical value of right ventricular (RV) electroanatomic voltage mapping (EVM) in CA.

METHODS

Fifteen consecutive patients undergoing endomyocardial biopsy (EMB) for suspected CA (median age 75 years, 1st-3rd quartiles 64-78 years], 67% male) were enrolled in an observational prospective study. Each patient underwent RV high-density EVM using a multipolar catheter and EMB. The primary outcome was death or heart failure hospitalisation at 1-year follow-up. We recorded electrographic features at EMB sampling sites and electroanatomic data in the overall RV, and explored their correlations with histopathologic findings and primary outcomes events.

RESULTS

A final EMB-proven diagnosis of immunoglobulin light chain or transthyretin CA was formulated in 6 and 9 patients, respectively. Electrogram amplitudes in the bipolar and unipolar configurations averaged 1.55 ± 0.44 mV and 5.14 ± 1.50 mV, respectively, in the overall RV, with lower values in AL CA patients. We found a significant inverse correlation between both bipolar and unipolar electrogram amplitude and amyloid burden according to EMB (P = 0.001 and P = 0.025, respectively). At 1-year follow-up, 7 patients (47%) experienced a primary outcome event; the extent of bipolar dense scar area at RV EVM was an independent predictor of primary outcome events at multivariable analysis (odds ratio 2.40; P = 0.037).

CONCLUSIONS

In CA, electrogram amplitudes are around the lower limit of normal yet disproportionately low compared with the increased wall thickness. Out data suggest that RV electrogram amplitude may be a quantitative marker of amyloid burden, and that RV EVM may have prognostic value.

Complications of left bundle branch area pacing compared with biventricular pacing in candidates for resynchronization therapy: Results of a propensity score-matched analysis from a multicenter registry

BACKGROUND

Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is a well-established therapy in patients with reduced left ventricular ejection fraction, heart failure, and left bundle branch block. Left bundle branch area pacing (LBBAP) has recently been shown to be a feasible and effective alternative to BVP. Comparative data on the risk of complications between LBBAP and BVP among patients undergoing CRT are lacking.

OBJECTIVE

The aim of this study was to compare the long-term risk of procedure-related complications between LBBAP and BVP in a cohort of patients undergoing CRT.

METHODS

This prospective, multicenter, observational study enrolled 668 consecutive patients (mean age 71.2 ± 10.0 years; 52.2% male; 59.4% with New York Heart Association class III-IV heart failure symptoms) with left ventricular ejection fraction 33.4% ± 4.3% who underwent BVP (n = 561) or LBBAP (n = 107) for a class I or II indication for CRT. Propensity score matching for baseline characteristics yielded 93 matched pairs. The rate and nature of intraprocedural and long-term post-procedural complications occurring during follow-up were prospectively collected and compared between the 2 groups.

RESULTS

During a mean follow-up of 18 months, procedure-related complications were observed in 16 patients: 12 in BVP (12.9%) and 4 in LBBAP (4.3%) (P = .036). Compared with patients who underwent LBBAP, those who underwent BVP showed a lower complication-free survival (P = .032). In multivariate analysis, BVP resulted an independent predictive factor associated with a higher risk of complications (hazard ratio 3.234; P = .042). Complications related to the coronary sinus lead were most frequently observed in patients who underwent BVP (50.0% of all complications).

CONCLUSION

LBBAP was associated with a lower long-term risk of device-related complications compared with BVP in patients with an indication for CRT.

Neurological Disorders in Takotsubo Syndrome: Clinical Phenotypes and Outcomes

BACKGROUND

Neurological disorders as a risk factor for Takotsubo syndrome (TTS) are not well characterized. The aim of the study was to evaluate TTS-associated neurological phenotypes and outcome.

METHODS AND RESULTS

Patients with TTS enrolled in the international multicenter GEIST (German Italian Spanish Takotsubo) registry were analyzed. Prevalence, clinical characteristics, and short- and long-term outcomes of patients with TTS were recorded. A subgroup analysis of the 5 most represented neurological disorders was performed. In total, 400 (17%) of 2301 patients had neurological disorders. The most represented neurological conditions were previous cerebrovascular events (39%), followed by neurodegenerative disorders (30.7%), migraine (10%), epilepsy (9.5%), and brain tumors (5%). During hospitalization, patients with neurological disorders had longer in-hospital stay (8 [interquartile range, 5-12] versus 6 [interquartile range, 5-9] days; P<0.01) and more often experienced in-hospital complications (27% versus 16%; P=0.01) mainly driven by cardiogenic shock and in-hospital death (12% versus 7.6% and 6.5% versus 2.8%, respectively; both P<0.01). Survival analysis showed a higher mortality rate in neurological patients both at 60 days and long-term (8.8% versus 3.4% and 23.5% versus 10.1%, respectively; both P<0.01). Neurological disorder was an independent predictor of both the 60-day and long-term mortality rate (odds ratio, 1.78 [95% CI, 1.07-2.97]; P=0.02; hazard ratio, 1.72 [95% CI, 1.33-2.22]; both P<0.001). Patients with neurodegenerative disorders had the worst prognosis among the neurological disease subgroups, whereas patients with TTS with migraine had a favorable prognosis (long-term mortality rates, 29.2% and 9.7%, respectively).

CONCLUSIONS

Neurological disorders identify a high-risk TTS subgroup for enhanced short- and long-term mortality rate. Careful recognition of neurological disorders and phenotype is therefore needed.

Age-Related Differences in Takotsubo Syndrome: Results From the Multicenter GEIST Registry

BACKGROUND

The role of age in the short- and long-term prognosis of takotsubo syndrome (TTS) is controversial. The aim of the present study was to evaluate age-related differences and prognostic implications among patients with TTS.

METHODS AND RESULTS

In total, 2492 consecutive patients with TTS enrolled in an international registry were stratified into 4 groups (<45, 45-64, 65-74, and ≥75 years). The median long-term follow-up was 480 days (interquartile range, 83-1510 days). The primary outcome was all-cause mortality (in-hospital and out-of-hospital mortality). The secondary end point was TTS-related in-hospital complications. Among the 2479 patients, 58 (2.3%) were aged <45 years, 625 (25.1%) were aged 45 to 64 years, 733 (29.4%) were aged 65 to 74 years, and 1063 (42.6%) were aged ≥75 years. Young patients (<45 years) had a higher prevalence of men (from youngest to oldest, 24.1% versus 12.6% versus 9.7% versus 11.4%; P<0.01), physical triggers (46.6% versus 27.5%, 33.9%, and 38.4%; P<0.01), and non-apical forms of TTS (25.9% versus 23.7%, 12.7%, and 9%; P<0.01) than those aged 45 to 64, 65 to 74, and ≥75 years. During hospitalization, young patients experienced a higher rate of in-hospital complications (32.8% versus 23.4%, 27.4%, and 31.9%; P=0.01), but in-hospital mortality was higher in the older group (0%, 1.6%, 2.9%, and 5%; P=0.001). Long-term all-cause mortality was significantly higher in the older cohort (5.6%, 6.4%, 11.3%, and 22.3%; log-rank P<0.001), as was long-term cardiovascular mortality (0%, 0.9%, 1.9%, and 3.2%; log-rank P=0.01).

CONCLUSIONS

Young patients with TTS have a typical phenotype characterized by a higher prevalence of male sex, non-apical ballooning patterns, and in-hospital complications. However, in-hospital and long-term mortality are significantly lower in young patients with TTS.

REGISTRATION

URL: https://classic.clinicaltrials.gov/ct2/show/NCT04361994. Unique identifier: NCT04361994.

Statin therapy and outcome in Takotsubo syndrome patients: Results from the multicenter international GEIST registry

BACKGROUND AND AIMS

Several studies have shown that endothelial dysfunction plays a role in the pathogenesis of Takotsubo syndrome (TTS). Given the potential benefit of statin therapy on endothelial dysfunction, we hypothesized that such treatment could improve outcome. Aim of our study was to evaluate clinical characteristics and outcome of TTS patients treated with statin therapy.

METHODS

Patients were enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry. Demographic data, clinical features and drug therapy at discharge were recorded. Primary study outcome was the occurrence of all-cause death at follow-up.

RESULTS

Study population included 2429 consecutive TTS patients: 1293 (53.2%) discharged on statin and 1136 (46.8%) without statin. Patients with statin were older (age 72 ± 11 vs 69 ± 13 years, p < 0.001), with higher prevalence of hypertension (74.3% vs 60.3%, p < 0.001), diabetes (21.1% vs 14.7%, p < 0.001), dyslipidemia (56.1% vs 23.3%, p < 0.001), history of coronary artery disease (13.3% vs 6.3%, p < 0.001) and lower rates of in-hospital complications (14.7% vs 19.3%, p = 0.003). Survival analysis showed similar mortality rates between groups (log rank p = 0.803). At univariable analysis, statin therapy at discharge was not associated with lower mortality (HR: 0.97, 95% CI 0.74-1.26, p = 0.803). At multivariable analysis age (HR: 1.06 95% CI 1.04-1.08, p < 0.001), male sex (HR: 1.83, 95% CI 1.20-2.80, p = 0.005), diabetes (HR: 2.55, 95% CI 1.83-3.54 p < 0.001), malignancies (HR: 2.41, 95% CI 1.68-3.44, p < 0.001) and physical trigger (HR: 2.24, 95% CI 1.62-3.10, p < 0.001) were associated with increased mortality.

CONCLUSIONS

Statin therapy after a TTS event was not associated with better prognosis at follow-up.

Cardiac Masses and Pseudomasses: An Overview about Diagnostic Imaging and Clinical Background

A cardiac lesion detected at ultrasonography might turn out to be a normal structure, a benign tumor or rarely a malignancy, and lesion characterization is very important to appropriately manage the lesion itself. The exact relationship of the mass with coronary arteries and the knowledge of possible concomitant coronary artery disease are necessary preoperative information. Moreover, the increasingly performed coronary CT angiography to evaluate non-invasively coronary artery disease leads to a rising number of incidental findings. Therefore, CT and MRI are frequently performed imaging modalities when echocardiography is deemed insufficient to evaluate a lesion. A brief comprehensive overview about diagnostic radiological imaging and the clinical background of cardiac masses and pseudomasses is reported.

Smoking influence in Takotsubo syndrome: insights from an international cohort

Aims

To assess the influence of tobacco on acute and long-term outcomes in Takotsubo syndrome (TTS).

Methods

Patients with TTS from the international multicenter German Italian Spanish Takotsubo registry (GEIST) were analyzed. Comparisons between groups were performed within the overall cohort, and an adjusted analysis with 1:1 propensity score matching was conducted.

Results

Out of 3,152 patients with TTS, 534 (17%) were current smokers. Smoker TTS patients were younger (63 ± 11 vs. 72 ± 11 years, p < 0.001), less frequently women (78% vs. 90%, p < 0.001), and had a lower prevalence of hypertension (59% vs. 69%, p < 0.01) and diabetes mellitus (16% vs. 20%, p = 0.04), but had a higher prevalence of pulmonary (21% vs. 15%, p < 0.01) and/or psychiatric diseases (17% vs. 12%, p < 0.01). On multivariable analysis, age less than 65 years [OR 3.85, 95% CI (2.86-5)], male gender [OR 2.52, 95% CI (1.75-3.64)], history of pulmonary disease [OR 2.56, 95% CI (1.81-3.61)], coronary artery disease [OR 2.35, 95% CI (1.60-3.46)], and non-apical ballooning form [OR 1.47, 95% CI (1.02-2.13)] were associated with smoking status. Propensity score matching (PSM) 1:1 yielded 329 patients from each group. Smokers had a similar rate of in-hospital complications but longer in-hospital stays (10 vs. 9 days, p = 0.01). During long-term follow-up, there were no differences in mortality rates between smokers and non-smokers (5.6% vs. 6.9% yearly in the overall, p = 0.02, and 6.6%, vs. 7.2% yearly in the matched cohort, p = 0.97).

Conclusions

Our findings suggest that smoking may influence the clinical presentation and course of TTS with longer in-hospital stays, but does not independently impact mortality.

Non-B DNA structures as a booster of genome instability

Non-canonical secondary structures (NCSs) are alternative nucleic acid structures that differ from the canonical B-DNA conformation. NCSs often occur in repetitive DNA sequences and can adopt different conformations depending on the sequence. The majority of these structures form in the context of physiological processes, such as transcription-associated R-loops, G4s, as well as hairpins and slipped-strand DNA, whose formation can be dependent on DNA replication. It is therefore not surprising that NCSs play important roles in the regulation of key biological processes. In the last years, increasing published data have supported their biological role thanks to genome-wide studies and the development of bioinformatic prediction tools. Data have also highlighted the pathological role of these secondary structures. Indeed, the alteration or stabilization of NCSs can cause the impairment of transcription and DNA replication, modification in chromatin structure and DNA damage. These events lead to a wide range of recombination events, deletions, mutations and chromosomal aberrations, well-known hallmarks of genome instability which are strongly associated with human diseases. In this review, we summarize molecular processes through which NCSs trigger genome instability, with a focus on G-quadruplex, i-motif, R-loop, Z-DNA, hairpin, cruciform and multi-stranded structures known as triplexes.

Characteristics of patients with recurrent acute myocardial infarction after MINOCA

BACKGROUND

Myocardial infarction (MI) with non-obstructed coronary arteries (MINOCA) is an increasingly recognized condition with challenging management. Some MINOCA patients ultimately experience recurrent acute MI (re-AMI) during follow-up; however, clinical and angiographic factors predisposing to re-AMI are still poorly defined.

METHODS

In this retrospective multicenter cohort study we enrolled consecutive patients fulfilling diagnostic criteria of MINOCA according to the IV universal definition of myocardial infarction; characteristics of patients experiencing re-AMI during the follow-up were compared to a group of MINOCA patients without re-AMI.

RESULTS

54 patients (mean age 66 ± 13) experienced a subsequent re-AMI after MINOCA and follow-up was available in 44 (81%). Compared to MINOCA patients without re-AMI (n = 695), on first invasive coronary angiography (ICA) MINOCA patients with re-AMI showed less frequent angiographically normal coronaries (37 versus 53%, p = 0.032) and had a higher prevalence of atherosclerosis involving 3 vessels or left main stem (17% versus 8%, p = 0.049). Twenty-four patients (44%) with re-AMI underwent a new ICA: 25% had normal coronary arteries, 12.5% had mild luminal irregularities (<30%), 20.8% had moderate coronary atherosclerosis (30-49%), and 41.7% showed obstructive coronary atherosclerosis (≥50% stenosis). Among patients undergoing new ICA, atherosclerosis progression was observed in 11 (45.8%), 37.5% received revascularization, only 4.5% had low-density lipoprotein cholesterol (LDL_C) under 55 mg/dL and 33% experienced a new cardiovascular disease (CVD) event (death, AMI, heart failure, stroke) at subsequent follow-up.

CONCLUSIONS

In the present study, only a minority of MINOCA patients with re-AMI underwent a repeated ICA, nearly one out of two showed atherosclerosis progression, often requiring revascularization. Recommended LDL-C levels were achieved only in a minority of the cases, indicating a possible underestimation of CVD risk in this population.

Electrophysiology fellowship experience and requirements: an EHRA survey

AIMS

This study aims to survey current educational experience and the individual requirements for electrophysiologists in training.

METHODS AND RESULTS

The European Heart Rhythm Association (EHRA) e-Communication Committee and the Scientific Initiatives Committee prepared a questionnaire and distributed it via newsletters, Twitter, LinkedIn, and Facebook. The survey consisted of 22 questions collected on an individual basis anonymously. Two hundred and forty-three responders from 35 countries (32% female, age 38 ± 6 years old) completed the survey. This EHRA electrophysiology (EP) fellowship survey showed that (i) hands-on participation and observation of EP procedures are very important; (ii) the main motivations to choose the EP fellowship institution are centre reputation and volume as well as the availability of a structured EP fellowship programme; (iii) 59% passed the EHRA exam and 46% took a national certification exam; (iv) respondents are overall satisfied with their own fellowships, but there are areas of less confidence such as conduction system pacing implantation and cardiac resynchronization therapy implantation; (v) 78% of respondents performed research during their fellowship, (vi) the optimal duration of an EP fellowship should be at least 2 years; and (viii) doing fellowships abroad is beneficial, but significant obstacles exist.

CONCLUSION

The results of this EHRA survey may help to refine current EP fellowship programmes to improve the quality of EP training and early career building of young electrophysiologists.

Trigger-Associated Clinical Implications and Outcomes in Takotsubo Syndrome: Results From the Multicenter GEIST Registry

Background Takotsubo syndrome is usually triggered by a stressful event. The type of trigger seems to influence the outcome and should therefore be considered separately. Methods and Results Patients included in the GEIST (German-Italian-Spanish Takotsubo) registry were categorized according to physical trigger (PT), emotional trigger (ET), and no trigger (NT) of Takotsubo syndrome. Clinical characteristics as well as outcome predictors were analyzed. Overall, 2482 patients were included. ET was detected in 910 patients (36.7%), PT in 885 patients (34.4%), and NT was observed in 717 patients (28.9%). Compared with patients with PT or NT, patients with ET were younger, less frequently men, and had a lower prevalence of comorbidities. Adverse in-hospital events (NT: 18.8% versus PT: 27.1% versus ET: 12.1%, P<0.001) and long-term mortality rates (NT: 14.4% versus PT: 21.6% versus ET: 8.5%, P<0.001) were significantly lower in patients with ET. Increasing age (P<0.001), male sex (P=0.007), diabetes (P<0.001), malignancy (P=0.002), and a neurological disorder (P<0.001) were associated with a higher risk of long-term mortality, while chest pain (P=0.035) and treatment with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (P=0.027) were confirmed as independent predictors for a lower risk of long-term mortality. Conclusions Patients with ET have better clinical conditions and a lower mortality rate. Increasing age, male sex, malignancy, a neurological disorder, chest pain, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and diabetes were confirmed as predictors of long-term mortality.

Anti-arrhythmic drugs in atrial fibrillation: tailor-made treatments

During the last decades, many improvements have been made regarding the treatment of atrial fibrillation in terms of risk prevention, anti-coagulation strategies, and gain in quality of life. Among those, anti-arrhythmic drugs (AADs) have progressively fallen behind and overtaken by technological aspects as devices as procedures are now the standards of care for many patients. But is this it? Are AADs doomed to be relegated to an obscure and rarely read paragraph of the European recommendations? Or could they be still employed safely and effectively? In the present paper, we will discuss contemporary evidence in order to define where AADs still play a pivotal role, how should AADs be used, and whether a tailored approach can be the way to propose the right treatment to the right patient.

Implantable Defibrillator-Detected Heart Failure Status Predicts Ventricular Tachyarrhythmias

BACKGROUND AND AIMS

the prediction of ventricular tachyarrhythmias among patients with implantable cardioverter defibrillators is difficult with available clinical tools. We sought to assess whether in patients with heart failure and reduced ejection fraction with defibrillators, physiological sensor-based heart failure status, as summarized by the HeartLogic index, could predict appropriate device therapies.

METHODS

568 consecutive HF patients with defibrillators (n=158, 28%) or cardiac resynchronization therapy-defibrillators (n=410, 72%) were included in this prospective observational multicenter analysis. The association of both HeartLogic index and its physiological components with defibrillator shocks and overall appropriate therapies was assessed in regression and time-dependent Cox models.

RESULTS

Over a follow-up of 25 [15-35] months, 122 (21%) patients received an appropriate device therapy (shock, n=74, 13%), while the HeartLogic index crossed the threshold value (alert, HeartLogic ≥16) 1200 times (0.71 alerts/patient-year) in 370 (65%) subjects. The occurrence of ≥1 HeartLogic alert was significantly associated with both appropriate shocks (HR: 2.44, 95% CI: 1.49-3.97, p=0.003), and any appropriate defibrillator therapies. In multivariable time-dependent Cox models, weekly IN-alert state was the strongest predictor of appropriate defibrillator shocks (HR: 2.94, 95%CI: 1.73-5.01, p<0.001) and overall therapies. Compared to stable patients, patients with appropriate shocks had significantly higher values of HeartLogic index, third heart sound amplitude, and resting heart rate 30-60 days prior to device therapy.

CONCLUSIONS

The HeartLogic index is an independent dynamic predictor of appropriate defibrillator therapies. The combined index and its individual physiological components change before the arrhythmic event occurs. This article is protected by copyright. All rights reserved.

Characteristics and Prognosis of a Contemporary Cohort with Myocardial Infarction with Non-Obstructed Coronary Arteries (MINOCA) Presenting Different Patterns of Late Gadolinium Enhancements in Cardiac Magnetic Resonance Imaging

BACKGROUND

To analyze the characteristics and prognosis of a contemporary cohort of patients with myocardial infarction with non-obstructed coronaries (MINOCA) were referred for cardiac magnetic resonance (CMR) imaging, focusing on late gadolinium enhancement (LGE) patterns.

METHODS

We retrospectively examined and prospectively followed up with 135 patients (49 ± 21 years old, 48% female) undergoing CMR imaging due to a MINOCA diagnosis from 2014 to 2016. We grouped and analyzed the sample according to ischemic (focal or transmural) and non-ischemic LGE patterns. The primary outcome was cardiac-related death; the secondary outcome was a composite of cardiac-related rehospitalizations, the new occurrence of acute myocardial infarction (AMI), heart failure (HF), or arrhythmias.

RESULTS

CMR exams were performed after a median of 28 days from the acute event. One-third of the ischemic MINOCA were first managed as myocarditis, while CMR helped to adopt a different therapy regimen in 22% of patients (30/135). After a median follow-up of 2.3 years, more cardiac-related deaths occurred in the ischemic than non-ischemic group (2 vs. 1, p = 0.36), but it was not statistically significant. The ischemic group also experienced more cardiac-related-rehospitalizations (42%, p < 0.001). In a multivariable Cox regression model, dyslipidemia, reduced left ventricular ejection fraction, ST-elevation at the hospitalization, and the LGE transmural pattern were the independent predictors of cardiac-related rehospitalizations.

CONCLUSIONS

In a contemporary cohort of MINOCA patients who underwent CMR, ischemic and non-ischemic patterns had distinct features and outcomes. Among the MINOCA patients, CMR can identify patients at higher risk who require more aggressive therapeutic approached and strict follow-up.

Diagnostic pathways to wild-type transthyretin amyloid cardiomyopathy: a multicentre network study

AIM

Epidemiology of wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) remains poorly defined. A better characterization of pathways leading to ATTRwt-CA diagnosis is of key importance, and potentially informative of disease course and prognosis. The aim of this study was to describe the characteristics of contemporary pathways leading to ATTRwt-CA diagnosis, and their potential association with survival.

METHODS AND RESULTS

This was a retrospective study of patients diagnosed with ATTRwt-CA at 17 Italian referral centres for CA. Patients were categorized into different 'pathways' according to the medical reason that triggered the diagnosis of ATTRwt-CA (hypertrophic cardiomyopathy [HCM] pathway, heart failure [HF] pathway, incidental imaging or incidental clinical pathway). Prognosis was investigated with all-cause mortality as endpoint. Overall, 1281 ATTRwt-CA patients were included in the study. The diagnostic pathway leading to ATTRwt-CA diagnosis was HCM in 7% of patients, HF in 51%, incidental imaging in 23%, incidental clinical in 19%. Patients in the HF pathway, as compared to the others, were older and had a greater prevalence of New York Heart Association (NYHA) class III-IV and chronic kidney disease. Survival was significantly worse in the HF versus other pathways, but similar among the three others. In multivariate model, older age at diagnosis, NYHA class III-IV and some comorbidities but not the HF pathway were independently associated with worse survival.

CONCLUSIONS

Half of contemporary ATTRwt-CA diagnoses occur in a HF setting. These patients had worse clinical profile and outcome than those diagnosed either due to suspected HCM or incidentally, although prognosis remained primarily related to age, NYHA functional class and comorbidities rather than the diagnostic pathway itself.

[2020 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing]

BACKGROUND

This report describes the findings of the 2020 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC).

METHODS

Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers.

RESULTS

A total of 10 378 ablation procedures were performed by 66 institutions. Most centers (70%) have an electrophysiology laboratory, and 23% a hybrid cardiac surgery laboratory. All centers have a 3D mapping system. The median number of electrophysiologists and nurses involved in the electrophysiology laboratory was 3.5 and 3, respectively. An electrophysiology technician was involved in 35% of all centers. In 88.2% of cases, catheter ablation was performed for supraventricular arrhythmias; the most frequently treated arrhythmia was atrial fibrillation (39.4%), followed by atrioventricular nodal reentrant tachycardia (18.6%), and common atrial flutter (10.6%). In 72.9% of patients, catheter ablation was performed using a 3D mapping system, with a "near-zero" fluoroscopic approach in 37.7% of all patients.

CONCLUSIONS

The 2020 Italian Catheter Ablation Registry confirmed that the electrophysiology activity was markedly affected by the COVID-19 pandemic; atrial fibrillation is the most frequently treated arrhythmia with an increasing number of procedures performed with a 3D mapping system and a "near-zero" approach.

Use of instant messaging in electrophysiological clinical practice in Latin America: a LAHRS survey

AIMS

Instant messaging (IM) platforms are a prominent component of telemedicine and a practical tool for sharing clinical data and counselling. Purpose of the survey was to inquire about the use of IM, the platforms used, frequency, recipients, and contents in Latin America region.

METHODS AND RESULTS

An online survey was sent to medical community via newsletter and social media channels. The survey consisted in 22 questions, in Spanish and Portuguese, collected on SurveyMonkey. A total of 125 responders from 13 Latin-American countries (79% male, mean age 46.1 ± 9.7 years) completed the survey. Most of the responders declared that they send (88.8%) and receive (97.6%) clinical data through IM apps. Most senders declare that they anonymize clinical data before sending (71.0 ± 38.3%), but that the data received is anonymized only in 51.4 ± 33.5%. The most common tests shared with other physicians were 12-lead electrocardiograms (99.2%), followed by Holter recordings (68.0%) and tracings from electrophysiological studies (63.2%). The majority (55.2%) said that are unaware of legal data protection rules in their countries.

CONCLUSIONS

IM apps are used by medical professionals worldwide to share and discuss clinical data and are preferred to many other methods of data sharing and are often used to share many different types of clinical data. They are perceived as a fast and easy way of communication, but medical professionals should be aware of the appropriate use of IM to prevent legal and privacy issues.

Impact of intra-aortic balloon counterpulsation on all-cause mortality among patients with Takotsubo syndrome complicated by cardiogenic shock: results from the German-Italian-Spanish (GEIST) registry

Aims

Takotsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction and can be complicated by cardiogenic shock (CS). However, few data are available on optimal care in TTS complicated by CS. Aim of this study was to evaluate short- and long-term impact of intra-aortic balloon pumping (IABP) on mortality in this setting.

Methods and results

In a multi-centre, international registry on TTS, 2248 consecutive patients were enrolled from 38 centres from Germany, Italy, and Spain. Of the 2248 patients, 212 (9.4%) experienced CS. Patients with CS had a higher prevalence of diabetes (27% vs. 19%), male sex (25% vs. 10%), and right ventricular involvement (10% vs. 5%) (P < 0.01 in all cases). Forty-three patients with CS (20% of 212) received IABP within 8 h (interquartile range 4-18) after admission. No differences in terms of age, gender, cardiovascular risk factors, and admission left ventricular ejection fraction were found among patients with and without IABP. There were no significant differences in terms of 30-day mortality (16% vs. 17%, P = 0.98), length of hospitalization (18.9 vs. 16.7 days, P = 0.51), and need of invasive ventilation (35% vs. 41%, P = 0.60) among two groups: 30-day survival was not significantly different even after propensity score adjustment (log-rank P = 0.73). At 42-month follow-up, overall mortality in patients with CS and TTS was 35%, not significantly different between patients receiving IABP and not (37% vs. 35%, P = 0.72).

Conclusions

In a large multi-centre observational registry, the use of IABP was not associated with lower mortality rates at short- and long-term follow-up in patients with TTS and CS.

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.

Data processing pipeline for cardiogenic shock prediction using machine learning

Introduction

Recent advances in machine learning provide new possibilities to process and analyse observational patient data to predict patient outcomes. In this paper, we introduce a data processing pipeline for cardiogenic shock (CS) prediction from the MIMIC III database of intensive cardiac care unit patients with acute coronary syndrome. The ability to identify high-risk patients could possibly allow taking pre-emptive measures and thus prevent the development of CS.

Methods

We mainly focus on techniques for the imputation of missing data by generating a pipeline for imputation and comparing the performance of various multivariate imputation algorithms, including k-nearest neighbours, two singular value decomposition (SVD)-based methods, and Multiple Imputation by Chained Equations. After imputation, we select the final subjects and variables from the imputed dataset and showcase the performance of the gradient-boosted framework that uses a tree-based classifier for cardiogenic shock prediction.

Results

We achieved good classification performance thanks to data cleaning and imputation (cross-validated mean area under the curve 0.805) without hyperparameter optimization.

Conclusion

We believe our pre-processing pipeline would prove helpful also for other classification and regression experiments.

Effectiveness and safety of implantable loop recorder and clinical utility of remote monitoring in patients with unexplained, recurrent, traumatic syncope

BACKGROUND

Implantable loop recorder (ILR) is still underutilized in clinical practice, especially in the setting of elderly patients with recurrent, traumatic, unexplained syncope. Data on the actual risk of traumatic syncopal recurrence during ILR monitoring in this specific patient setting are lacking.

RESEARCH DESIGN AND METHODS

Prospective, multicentre registry enrolling consecutive patients undergoing ILR insertion for unexplained, recurrent, traumatic syncope. In a proportion of enrolled patients, remote monitoring (RM) was used for device follow-up. The risk of traumatic and non-traumatic syncopal recurrences during ILR observation were prospectively assessed.

RESULTS

A total of 483 consecutive patients (68±14 years, 59% male) were enrolled. During a median follow-up of 18 months, a final diagnosis was reached in 270 patients (55.9%). The risk of syncopal and traumatic syncopal recurrence was of 26.5 and 9.3%, respectively. RM significantly reduced the time to diagnosis (19.7±10.3 vs. 22.1±10.8 months; p=0.015) and was associated with a significant reduction in the risk of syncope recurrence of 48% (p<0.001), and of traumatic syncope recurrence of 49% (p=0.018).

CONCLUSIONS

ILR monitoring is effective and safe in patients with unexplained, recurrent, traumatic syncope. RM reduces the time to diagnosis and significantly reduces the risk of traumatic and non-traumatic syncopal relapses.

288 LAY LADY LAY, A TRICKY CASE OF PLATYPNEA ORTHODEOXIA SYNDROME

Platypnea orthodeoxia syndrome (POS) is characterized by dispnoea and a fall in oxygen saturation levels when in the upright position that resolves lying down in the supine position. It is secondary to a right to left shunt (R-L shunt), typically trough a patent foramen ovale (PFO).

Normally, in the presence of a PFO, R-L shunt does not occur unless there is a clinical condition that raises right side pressures like venous thromboembolism, hydrothorax, pneumothorax or chronic pulmunary hypertension. Although its physiopathological mechanisms are not entirely understood, in the POS, R-L shunt mostly occurs due to anatomical alteration of the interatrial septum in the upright position. Venous flow therefore can pass from the inferior vena cava through the PFO or an atrial septal defect (ASD) to the left side of the heart.

We present a case of a 77 y.o. woman with no relevant past medical hystory, that was admitted to hospital care because of a mild pulmonary embolism and deep vein trombosis of the right popliteal vein. She was promptly treated for PE with direct oral anticoagulation achieving the resolution of the embolism. Despite the CT scan showed the complete resolution of the embolism her dysponoea did not improve. Her blood gas analysis showed normocapnic hypoxiemic respiratory insufficiency with a suspicious lowering of oxygen saturation levels when in the upright position which however improved in the supine position. She also had a transient episode of dysarthria and hypostenia to the right upper limb, the negative head CT scan was suggestive of a transient ischaemic attack. A pulmonary scintigraphy showed arterious renal perfusion as in a right to left shunt. She then underwent a transoesophageal echocardiography which showed an hypermobile interatrial septum with evidence of a patent foramen ovale with left to right shunt. The exame was in fact executed in the supine position. Given these findings, we concluded for a diagnosis of POS. Because of this records, the severity of the shunt and the suggestive clinical hystory of ortodeoxya she underwent PFO closure positioning an Amplatzer PFO Occluder 25 mm. The procedure was carried out without complications and led to complete resolution of the symptoms and the signs of platipnoea-ortodeoxya.

975 SIMPLY-DETECTED INFLAMMATORY BLOOD MARKERS PREDICT INDEXED LEFT ATRIAL VOLUME AMONG PATIENTS UNDERGOING ATRIAL FIBRILLATION CATHETER ABLATION

Background

atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. Predisposing factors for priming and maintenance of AF include increased left atrial (LA) size, which correlates with LA disease and is a major risk factor for recurrence after AF catheter ablation (CA). The role of inflammation in the pathogenesis of AF and the associated atrial cardiomyopathy has been ill-defined

Objective

we hypothesized that simply-detected inflammatory blood markers could correlate with left atrial volume, and thus with the severity of AF-associated atrial cardiomyopathy.

Methods

we conducted a retrospective, observational study enrolling 472 consecutive patients (male gender, n= 357, 76%; mean age, 61±11 years) who underwent paroxysmal (n=318) or persistent (n=154) AF CA at our institution. In each patient, widely available laboratory markers of inflammation (C-reactive protein (PCR), uric acid, and red blood cells distribution width [RDW]) were measured prior to CA and correlated to LA volume, using univariable and stepwise multivariable linear regression.

Results

the mean left ventricular ejection fraction (EF) was 57,4±7,6%, whereas the mean indexed LA volume was 35,3±11,9 ml/m2. The mean RDW measured 13,5±1,3, the mean PCR value was 0,5±1 mg/L, and the mean uric acid value was 5,2±1,4 mg/dl. In univariable linear regression analysis, RDW (β 2.65; 95% CI [1.81-3.49]; p=0.0002), PCR (β 1.2; 95% CI [0.02-2.38]; p=0.047), CHA2DS2VASc (β 2,17; 95% CI [1.42-2.94]; p 0.001), uric acid (β 0.85; 95% CI [0.01-1.69]; p=0.05), EF (β -0.37; 95% CI [-0.51-0.23]; p=0.002) and age (β 0.35; 95% CI [0.25-0.45]; p=0.00004) were significantly related to LA volume. In multivariable linear regression model, EF (β -0.24; 95% CI [-0.39- -0.09]; p 0.002), age (β 02; 95% CI [0.08-0.32]; p 0.0017) and RDW (β 1.5; 95% CI [0.62-2.38]; p 0.00093) retained their independent association with LA volume.

Conclusion

RDW, a simple-detected blood marker, proved to be an independent predictor of LA size, suggesting a mechanistic link between inflammation and the severity of atrial cardiomyopathy. These observations may allow a very simple and low-cost identification of AF patients at higher risk of adverse outcomes and recurrences after CA, facilitating treatment plan decisions (e.g., rate vs. rhythm control).

383 TAKOTSUBO SYNDROME AFTER CAR-T CELL INFUSION

Introduction

The mechanisms of cardiotoxicity during CAR-T cell therapy remain unclear to this day. We present the case of a 63-year-old woman with diffuse large B-cell lymphoma, who underwent CAR-T cell therapy. Five days after the infusion, she developed takotsubo cardiomyopathy. This is one of the rare cases of CAR-T cell-induced takotsubo cardiomyopathy.

Case Description

a 63-year-old woman with a diffuse large B-cell lymphoma and without significant cardiovascular history was treated with CAR-T cell therapy. The patient had arterial hypertension, dyslipidemia and history of CAD in the family. Prior to CAR-T cell therapy, she underwent baseline cardiac evaluation with an echocardiogram which showed a normal biventricular function. Within 24 hours of the infusion of CAR-T cells, she developed grade I cytokine release syndrome (CRS) with high-grade fever and sinus tachycardia. On day four, she developed grade three immune effector cell associated neurological syndrome which was treated with tocilizumab and dexamethasone. On day five laboratory testing showed a disproportionate elevation of BNP compared to hs-TnI. An ECG reported diffuse new-onset T wave inversion in all the precordial leads and a prolonged QT interval, and an echocardiogram showed severely reduced left ventricular ejection fraction (EF = 30%) with evidence of apical ballooning and right ventricular systolic dysfunction. Coronary angiography showed significant stenosis of the middle segment of the circumflex artery, which poorly could explain the clinical presentation of the patient. Ventriculography was also performed, which confirmed the ultrasound findings. During the next 48 hours, ECG and left ventricular function improved along with a gradual reduction of BNP and hs-TnI. We concluded that takotsubo syndrome was the most likely diagnosis. The InterTAK score was 89, which corresponded to a probability of takotsubo of 99.4%. The patient's therapy was then optimized with an increase in the dosage of angiotensin receptor antagonists and beta blockers. One month after CAR-T cell infusion, echocardiography showed complete recovery of biventricular function and ECG completely normalized, together with the values of BNP and TnI-hs. Medical treatment was left unmodified.

Conclusions

the pathophysiology of left ventricular systolic dysfunction during CAR-T cell therapy is unclear, but the main hypotheses are IL-6 mediated myocardial depression during CRS, stress-induced or takotsubo cardiomyopathy, and direct toxicity from CAR-T cells.

From the currently available data from retrospective studies, cardiovascular events strongly overlap with CRS and, particularly, with high-grade CRS. Therefore, there is a strong rationale for early treatment with tocilizumab as it has been postulated from retrospective data a lower risk of cardiovascular events with earlier administration of tocilizumab during CRS.

Surveillance for cardiotoxicity in patients receiving CAR-T cell therapy is mandatory for prompt recognition and treatment of cardiovascular complications. Our understanding of CAR-T cell-induced cardiomyopathy is still limited, and data regarding predictive factors for persistent cardiac dysfunction are lacking. It is important to differentiate cardiovascular events related to CAR-T cell therapy from epiphenomenon of CRS and capillary leak, to allow for a broader assessment of cardiac events among future CAR T-cell trials.

509 RECURRENCE OF ACUTE MYOCARDIAL INFARCTION AFTER MINOCA: INSIGHTS FROM A MULTICENTRE NATIONAL REGISTRY

Background

Myocardial infarction with non-obstructed coronary arteries (MINOCA) is an increasingly recognized condition with challenging management. Prognosis of this patients could be of concern, in particular for those who experienced recurrent acute myocardial infarction (re-AMI). Moreover, there are limited data on characteristics of re-AMI among MINOCA patients.

Methods

In this retrospective multicentre cohort study involving seven Hub Hospitals across Italy we enrolled consecutive patients 18 years and older discharged with diagnosis of MINOCA according to the IV universal definition of myocardial infarction who experienced hospitalization for re-AMI during follow-up.

Results

A total of 54 patients were included (mean age 66±13). Compared to MINOCA patients without re-AMI (n=695), on first angiography MINOCA patients with re-AMI showed less frequently angiographically normal coronaries (37 versus 53%, p=0,032) and had higher prevalence of atherosclerosis involving 3 vessels or left main stem (17% versus 8%, p=0,049).

Twenty four patients (44%) with re-AMI underwent a new coronary angiography and 25% had normal coronary arteries, 12% had mild luminal irregularities (&lt;30%), 21% had moderate coronary atherosclerosis (30-49%), and 42% showed obstructive coronary atherosclerosis (≥50%).

Among patients undergoing new angiography, only 4% had LDL cholesterol under 55 mg/dL, atherosclerosis progression was observed in 11 (46%), 38% received revascularization and 33% experienced a new cardiovascular event (death, AMI, heart failure, stroke) at subsequent follow-up.

Conclusions

In the present study near one out of two patients with re-AMI after MINOCA showed angiographic atherosclerosis progression requiring revascularization in the majority of cases. These patients rarely presented with recommended LDL cholesterol levels and are at risk for further cardiovascular events, indicating a possible underestimation of cardiovascular risk in this population.

294 BEYOND BRUGADA SYNDROME: A COMMON ECG PATTERN IN AN UNCOMMON CLINICAL SCENARIO

Propofol infusion syndrome (PRIS) is a rare but potentially lethal side effect of propofol. In most cases it shows various combinations of signs such as unexplained metabolic acidosis, rhabdomyolysis, hepatomegaly, renal failure, hypertriglyceridemia, malignant arrhythmia and rapidly progressive cardiac failure. The development of coved ST elevation in the right precordial leads of the electrocardiogram (ECG), similar to that seen in the type I Brugada syndrome may be the first sign of cardiac instability. There is no specific treatment for PRIS. Successful management consists of an early recognition of its signs followed by a prompt propofol infusion termination.

We present the case of a 35-year-old male affected by mild hypertension. He was found by his wife during a transitory loss of consciousness episode. He had resulted positive to Sars Cov 2 infection a day before and was symptomatic for fever and myalgia. An ambulance was immediately called and the patient was transferred to the emergency department for a suspected out-of-hospital-cardiac arrest. The initial one-lead ECG performed by the emergency physician was unremarkable. On arrival he was in a coma state but with stable hemodynamics. ECG showed only an asymmetric T wave inversion in V4-V6 leads. The cardiac echocardiogram did not show any major alterations. In the meantime, due to worsening of respiratory function, orotracheal intubation was performed and the patient was sedated with propofol, midazolam and fentanyl. Subsequently, an episode of atrial fibrillation was documented. Amiodarone infusion was started and the patient reverted to sinus rhythm after a few hours. The following day two episodes of Torsade de Pointes during prolonged QTc (660 ms) occurred. These arrhythmias were treated successfully with magnesium sulfate infusion. Blood analysis showed severe hypokalemia that was immediately corrected. After the hemodynamic stabilization the ECG showed a pattern highly resembling the Brugada pattern type 1 in the right precordial leads. Moreover CPK, myoglobin, high sensitivity troponin I levels started to rise, along with creatinine, triglycerides and markers of hepatic injury. Propofol had been administered continuously for eight days, so PRIS was suspected as the primum movens of this clinical scenario. Propofol infusion was immediately interrupted. Thereafter, the patient gradually improved and was extubated. As soon as the patient's hemodynamic conditions allowed it, a coronary CT and a cardiac MRI were performed, but were unremarkable. To further evaluate the case, a flecainide challenge test was performed, but no significant ECG change was induced. Nonetheless, given both the history of ventricular arrhythmia, the young age of the patient and the unexplained transitory loss of consciousness a subcutaneous defibrillator was implanted as a form of secondary prevention.

449 HYPERTROPHIC CARDIOMYOPATHY: A CASE OF CHALLENGING ARRHYTHMIC RISK STRATIFICATION

Hypertrophic cardiomyopathy (HCM) is a common disease, mostly inherited, with a prevalence of 1:500. Cornerstone of the clinical management of HCM patients is stratifying the risk of sudden cardiac death (SCD) which is the most frightening complication despite its relatively low incidence (0,9% per year). Although mathematical risk scores, as proposed by ESC, are the most used to assess the probability of arrhythmic complications leading to SCD, they have been associated with low sensitivity, precluding some high-risk patients from prophylactic ICD implantation.

Among the tools at clinicians’ disposal for risk stratification in HCM patients, the latest AHA/ACC guidelines propose an “individual risk markers strategy”, based on the presence of ≥1 clinical feature such as a family history of SCD, extreme left ventricular hypertrophy (LVH), unexplained recent syncope, NSVT, late gadolinium enhancement (LGE) at CMR, systolic dysfunction and LV apical aneurysm.

We present a case that lets us reflect on arrhythmic risk stratification.

P.C. is a 58 y.o. male with a history of septal hypertrophy (19 mm) and T wave inversion but without an established diagnosis of HCM. He did not have any familiar history of syncope or SCD. He came to the emergency department for epistaxis and was admitted to the cardiology unit due to the previously mentioned findings, where he underwent cardiac-CTA and CMR showing myocardial bridge of left anterior descending artery, LVH with apical aneurysm and LGE areas localized on the apex (transmural) and on the interventricular septum (subendocardial). No signs of dynamic LVOT obstruction or atrial enlargement emerged from echocardiography. During the observation, asymptomatic NSVT were recorded on continuous ECG monitoring. According to the ESC risk prediction score (3.7%) ICD was not strictly indicated but considering the CMR high-risk profile (according to the suggestions of AHA/ACC) we proposed an ICD implantation anyways. The patient refused any invasive procedure and was implanted with a loop recorder. At 12 months remote monitoring showed a single episode of self-terminated sustained polymorphic ventricular tachycardia (02:23 mm: ss) symptomatic of pre-syncope. The patient was then immediately reached and admitted for ICD implantation in secondary prevention. According to the patient's will, and the no need for bradycardia therapy, an S-ICD was implanted. Figure 1LV apical aneurysm at CMRFigure 2Remote Monitoring

731 MULTICENTRE OBSERVATIONAL REGISTRY OF PATIENTS HOSPITALIZED FOR HEART FAILURE AND REAL-LIFE ADHERENCE TO INTERNATIONAL GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH ACUTE AND CHRONIC HEART FAILURE. THE REAL-HF REGISTRY

Purpose

The Multicentre observational REgistry of patients hospitalized for heart failure and reAL-life adherence to international guidelines for the management of patients with acute and chronic Heart Failure (REAL-HF) aims to provide a comprehensive overview of hospital management of HF patients in Italy.

Methods

The registry involves 11 cardiology centers from seven Italian regions, including all adult patients hospitalized for HF in the period 2020-2026. Data are derived from hospital discharge letters and electronic records. Patients are included in the registry based on Diagnosis Related Groups codes.

Results

This preliminary analysis included 1600 patients hospitalized for HF in 2020 in two Italian tertiary university hospitals. Males were 851(53%) with a median age of 81(71-87) years. Less than one-third of the patients (n=461[29%]) was hospitalized in a cardiology unit, while almost half of the patients (n=783[49%]) was admitted to an internal medicine ward. Median hospital length of stay was 9(6-14) days. Readmission rates were 9% and 29% at 30 days and within the same year, respectively. In-hospital mortality was 9%, while 28% of the patients died within the same year. According to HF categories, 501(31%) patients were diagnosed as having HFrEF, 193(12%) mildly reduced ejection fraction (HFmrEF) and 689(43%) preserved ejection fraction (HFpEF). Median left ventricular EF was 49%(35-55%) and was significantly lower in patients with HFrEF (30%[25-35%]) compared to those with HFmrEF (45%[43-45%]) and HFpEF (55%[55-60%]) – p&lt;0.001. Coronary artery disease proved to be the leading cause (n=460[29%]) of HF. Atrial fibrillation was highly prevalent (history -13%; during hospitalization -37%). Arterial hypertension was the most prevalent (71%) cardiovascular risk factor. Chronic kidney disease (51%) and chronic obstructive pulmonary disease (27%) were frequent comorbidities. Apparently, COVID-19 had a low impact, being present in only 3% of patients hospitalized for HF in 2020 at both centers. At discharge, 56% of patients were treated with angiotensin-converting enzyme inhibitors–ACEi (n=490[34%]), angiotensin receptor blockers–ARB (n=221[15%]) or angiotensin-neprilysin inhibitors–ARNi (n=100[7%]), 67%(n=964) with beta-blockers, while mineralocorticoid receptor antagonists–MRAs were prescribed for 56%(n=809) of patients. Loop diuretics were frequently prescribed (89%). When we considered patients with HFrEF, we found that only 69% were treated with ACEi/ARB/ARNi, 82% with a beta-blocker, and 67% with MRAs. Only 48% (n=240) were treated with all three of the above-mentioned classes of drugs. Among patients with HFrEF, only 5% had an implantable cardioverter defibrillator, and only 4% were treated with cardiac resynchronization therapy. Patients hospitalized in wards other than cardiology were older (83vs70 years, p&lt;0.0001), more frequently females (52%vs44%, p&lt;0.001), and with HFpEF (51%vs24%, p&lt;0.0001). In-hospital mortality and death within the same year resulted significantly lower in patients hospitalized in cardiology units (5%vs11% - p&lt;0.001, and 17%vs32% - p&lt;0.001). Overall, drugs indicated in HF were less frequently prescribed in patients hospitalized in non-specialist cardiac units.

Conclusions

Preliminary data from the multicentre REAL-HF registry confirm that HF constitutes a clinical issue. Adherence to the guidelines is still inadequate and this may impact on patients’ outcomes. Moreover, the significant differences in terms of patients’ profiles might further increase the gap between highly specialized cardiology units and internal medicine departments.

770 LONG-TERM PROGNOSIS IN LVNC CARDIOMYOPATHY: A SINGLE-CENTRE EXPERIENCE

Background

left ventricular non-compaction (LVNC) cardiomyopathy is an often underdiagnosed and under-classified disease deriving from the incomplete development of ventricular myocardium. Clinical presentations may be variable and uncommon, ranging from an apparent lack of functional anomalies to heart failure, ventricular arrhythmias and, in some cases, even ischemic stroke. Despite great improvements in diagnostic performance there is still a widespread lack of evidence regarding the prognosis and management of affected patients.

Methods

all consecutive patients admitted to our Cardiology Institution from October 2009 to August 2022 fulfilling LVNC criteria by echocardiography or cardiovascular magnetic resonance (CMR) or both, were consecutively enrolled. CMR has been performed wherever possible. All patients underwent a complete cardiological visit, a 12-lead ECG and echocardiography at baseline, whereas at follow-up, if a complete visit was not possible, information regarding patients’ endpoints was acquired through telephonic contact. Additional diagnostic exams or implantation of a cardiac device were also performed if indicated. The primary endpoint was a composite of at least one between: sustained ventricular arrhythmias, an appropriate ICD intervention and sudden cardiac death. Secondary endpoints included supraventricular arrhythmias, unplanned cardiac hospitalizations, acute decompensated, chronic heart failure and ischemic stroke. Risk predictor analyses were not performed as the overall event rates were low and the risk for type II error was high.

Results

forty patients (26 males; age 45±17) were prospectively enrolled and followed up for a median of five years. CMR and echocardiography were overall agreeing on the majority of the diagnoses, with 62.5% of patients meeting the echo criteria and 70% of patients meeting the CMR criteria for LVNC. The incidence of the primary endpoint was 1.8% per years. Male gender and late gadolinium enhancement (LGE) were correlated with an increased incidence of the primary endpoint, while LVEF, NC/C or functional status were not associated with a significantly increased risk of the composite endpoint. HF diagnosis was the most common endpoint (6.1% annual incidence). The annual incidence of supraventricular arrhythmias was 3.0% and the annual incidence of stroke was 0.7%. Twenty-four patients (60%) experienced at least one hospitalization during follow-up. Unplanned hospitalizations represented 20% of all hospitalizations and were mainly HF-related. Planned hospitalizations were performed for elective procedures such as atrial fibrillation cardioversion, ablation, coronary angiography or diagnostic check-ups.

Discussion

in patients with LVNC, there is an increased incidence of cardiac-related outcomes than in the general population; furthermore, male gender and myocardial fibrosis are associated with increased risk of events. This trend highlights the importance of a prompt diagnosis and, obviously, of a correct knowledge of such disease.

434 TAKOTSUBO SYNDROME AFTER PACEMAKER IMPLANTATION

Introduction

Takotsubo syndrome is a clinical syndrome characterized by typical anamnestic features together with typical ECG and echocardiographic findings. Comparing with the available literature not so many cases of takotsubo syndrome after pacemaker implantation can be found. Furthermore, there are only few articles talking about ECG features in these patient. The case we described allows to observe dynamic ECG alterations in a patient with electro-induced ventriculograms

Case Description

A 90-year-old male was admitted to the emergency room for important fatigue associated with severe bradycardia (25/min). His cardiovascular history was silent, and his past medical history was characterized by high blood pressure, chronic pulmonary obstructive disease and anemia due to iron deficiency. The ECG showed second degree AVB type 2, with phases of 2:1 AVB and paroxysmal third degree AVB on continuous monitoring. The routine blood tests showed normal T troponin and BNP was 420 pg/mL. The echocardiogram revealed normal biventricular dimensions and systolic function with moderate aortic valve stenosis. The patient underwent urgent permanent DDD pacemaker implantation without previous isoproterenol administration. During the procedure he referred important pain on the site of the wound, and he became confused and agitated. The procedure was complicated by massive pneumothorax that needed quick decompression. On the 2nd day after pacemaker implantation the ECG revealed electro-induced atrium-guided ventriculograms and began to modify with only mild ST-segment elevation in V2 and initial T-wave inversion from V3 to V6 and in I - II - aVF. On the next days, T-waves became deeper and QTc prolonged to 540 ms. These abnormalities were then gradually resolved on the 11th day. Mild transient attenuation of the amplitude of the QRS complexes in V2 – V3 leads on day 1 could be reported. Another echocardiogram was then performed, which showed new apical akinesis with “apical ballooning” aspect and EF of 40%. TnT and BNP values increased. Coronary angiogram was not performed due to patient rejection, so that coronaropathy could not be excluded with certainty. Nevertheless, the patient had only high blood pressure as cardiovascular risk factor and that the probability of the diagnosis of takotsubo cardiomyopathy was assessed of 76,9% by InterTAK diagnostic score, so that we considered Takotsubo syndrome the most likely diagnosis. Therefore, the patient's therapy was then optimized with an increase in the dosage of ACE inhibitors. At one month follow-up the ECG remained stable, and the echocardiogram showed a preserved ejection fraction (EF = 55%), without alterations of the segmental contractility. BNP and TnT values were normal. Therapy was left unmodified.

Conclusions

Takotsubo syndrome should be consider a rare but possible complication of pacemaker implantation. This is true especially for patients affected by frailty and cognitive impairment. There are no specific ECG criteria for takotsubo syndrome in patients with electro-induced ventriculograms, but anomalies of the repolarization are similar to those in patients with spontaneous ventricular activity. Transient attenuation of the QRS complexes voltages could be seen even just in the precordial leads and it is generally present in the very acute phase.

426 SPECKLE-TRACKING GLOBAL LONGITUDINAL STRAIN AS A PREDICTOR OF CLINICAL OUTCOMES IN SYSTEMIC SCLEROSIS PATIENTS

Introduction

Cardiac involvement in patients affected by systemic sclerosis is frequent, although mostly asymptomatic, and associated with a negative prognosis. It may be secondary to pulmonary hypertension or defined as an actual systemic-sclerosis related cardiomyopathy, a standalone entity affecting the heart primarily and globally. Speckle-tracking derived global longitudinal strain (GLS) has been proven to be a cost-effective tool in the detection of LV and RV dysfunction in patients with SSc and no overt cardiac disease. The aim of our study was to assess whether GLS can predict clinical outcomes in patients with systemic sclerosis.

Methods

We conducted a prospective observational study enrolling all consecutive patients referred to our “cardiology clinic for autoimmune diseases and pulmonary hypertension” between June 2016 and January 2022. All patients had a confirmed diagnosis of SSc according to the EULAR guidelines and no overt cardiac disease, pulmonary hypertension, or atrial fibrillation at the time of enrollment. For each patient, echocardiogram and GLS calculations were performed at baseline and at each follow-up. We also collected all data regarding clinical history, hospitalizations or adverse events and ECGs.

Results

164 patients (148 female, 58±14 years)were enrolled. 19 (11.6%) patients died during a median follow-up of 3.2 years for mainly non-cardiovascular deaths (7.3%) while cardiovascular deaths were lower (3% non-sudden, 1.3% sudden). Left GLS at first visit was associated with all-cause death, with a 1% left GLS worsening associated with a 19% increased risk of death after adjusting for age, gender, and LVEF (adjusted HR 1.19; 95% CI 1.05-1.35; p=0.007).Similarly, right GLS at first visit was associated with all-cause death, with a 1% right GLS worsening associated with a 12% increased risk of death after adjusting for age, gender, and TAPSE (adjusted HR 1.12; 95% CI 1.03-1.21; p=0.005).Patients with a left GLS worse than -20% had a 3.5-fold increased risk of death when compared to patients with better left GLS (HR 3.55; 95% CI 1.28-9.88; p=0.015). Similarly, patients with a right GLS worse than -20% had a 4.5-fold increased risk of death when compared to patients with better left GLS (HR 4.47; 95% CI 1.4-13.74; p=0.009).Both left and right ventricular GLS were not associated with changes in risk of all-cause hospitalizations, cardiovascular hospitalizations or subsequent diagnosis of pulmonary hypertension.

Conclusions

GLS is a reproducible, cost effective echocardiographic based method to assess both primary heart disease and its progression. It has proven to be associated with clinical outcomes in patients with systemic sclerosis, therefore allowing a prompt intervention when needed in order to try and prolong the life expectancy of this cohort of patients.

432 SACUBITRIL/VALSARTAN AND RISK OF SUPRAVENTRICULAR ARRHYTHMIAS AS DETECTED BY REMOTE MONITORING IN HEART FAILURE PATIENTS

Introduction

Sacubitril/valsartan (ARNI) has demonstrated a significant benefit compared to angiotensin inhibitor (enalapril) in decreasing both morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). While. recent studies demonstrated that in HFrEF patients, ARNI decreased ventricular arrhythmias no data is available with regards to the supraventricular arrhythmic burden in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy-defibrillator (CRT-D) and remote monitoring. The aim of out study was to assess if ARNI therapy was able to significantly reduce supraventricular arrhythmias. More specifically the primary endpoint was the incidence of AT/AF episodes, as detected by the device. Secondary endpoints included the total burden of AT/AF, the mean number of premature ventricular contractions (PVC) per hour and the percentage of biventricular pacing per day (in patients with CRT-D).

Methods

We conducted a multicentre, observational, prospective registry : the SAVE THE RHYTHM (SAacubitril Valsartan rEal-world registry evaluating THE arRHYTHMia burden in HFrEF patients with implantable cardioverter defibrillator). We enrolled all patients with HFrEF, ICD or CRT-D actively followed through remote monitoring and starting treatment with sacubitril/valsartan. All patients were followed-up for at least one year.

Results

At the end of enrollment, 265 patients from 5 centres had at least one sacubitril/valsartan prescription (88% males, age 68±10 years). The annual incidence of AT/AF episodes decreased from 16.6% before sacubitril/valsartan to 12.8%, 6.7% and 0.7% according to the maximum tolerated dose (24/26 mg, 49/51 mg and 97/103 mg, respectively; p=0.026). After treatment with sacubitril/valsartan, patients with at least one episode of AT/AF decreased from 32.6% to 26.5% (24/26 mg), 24.3% (49/51 mg) and 6.9% (97/103 mg); p=.041. A significant decrease in the number of PVC (-28 per hour) and in the rate of appropriate shock (-0.8% per year) were seen in patients with a previous diagnosis of paroxysmal or persistent AF. Patients with permanent AF (n=7) experienced no benefits from sacubitril/valsartan therapy in terms of arrhythmic burden reduction. Patients with a CRT device (41%) experienced a significant increase in biventricular pacing time (+3% per day).

Discussion

Therapy with sacubitril/valsartan could decrease arrhythmic burden in patients with non-permanent AF and HFrEF and reduce subclinical supraventricular arrhythmias in patients with no history of AF.

987 VENTRICULAR TACHYCARDIA CATHETER ABLATION: THE ROLE OF ARRHYTHMIA INTERRUPTION DURING RADIOFREQUENCY EROGATION

Background

Due to the complexity of the underlying substrate and to the difficulty in characterizing the arrhythmia mechanism and circuitry, every ventricular tachycardia (VT) catheter ablation (CA) represents a challenge. Nowadays VT CA is an increasingly recommended and used procedure.

Objective

Investigate whether VT interruption during radiofrequency (RF) delivery can be regarded as a marker indicating a lower risk VT recurrence at follow-up.

Methods

We conducted a retrospective cohort study and we enrolled 69 patients with VTs treated with CA using RF energy, from November 2018 to July 2022. First, in all patient substrate and late potential map was performed; than VT induction was attempted. In patients in whom activation mapping could be performed, we first targeted VT interruption, followed by substrate modification (fragmented/late potential elimination and/or dechanneling of the entire pathologic zone) [group1]. In 15 patients, it was not possible to perform activation mapping due to the poor hemodynamic VT tolerance and/or to the absence of VT inducibility with programmed ventricular stimulation. In these cases, substrate CA was performed, aiming to eliminate fragmented and/or late potentials [group2].

Recurrences were assessed with ICD in office interrogations and remote monitoring for a median of 12 (IQR 5-20) months of follow-up.

Results

Sixty-nine patients were included in the study. Respectively for the group1 and for the group2, the mean age at baseline was 60 ± 18,3 and 63 ± 12,3 p &gt; 0,05) and the mean left ventricular ejection fraction was 41,3 ± 12,6% and 38,2 ± 11,8% (p &gt; 0,05). In 41 (59%) patients, the indication for the procedure was electrical storm refractory to pharmacological therapies or multiple ICD shocks due to VT/VF. 12 (17%) patients underwent endo-epicardial CA due to the presumed epicardial VT origin and only 9 (13%) underwent right ventricular CA.

Among the 31 patients in which it was possible to interrupt the arrhythmia through RF delivery, we observed 9 (23%) sustained VT recurrence at follow-up. Among the 38 patients in which VT was not interrupted with RF delivery or the VT had poor hemodynamic tolerance, there were 16 (42%) sustained VT recurrences at follow-up. Risk of recurrence at follow-up was numerically lower in patients in which VT was interrupted with RF delivery during the procedure, but not statistically significant (p value &gt; 0,05).

Conclusions

In patients undergoing CA for VTs, activation mapping is useful to enhance the understanding of the arrhythmia circuitry. Our preliminary results seem to suggest that VT interruption during RF delivery may represent a positive prognostic marker, pointing to better outcomes and lower recurrence rates, even if the results were not statistically significant.

Further investigations with a larger cohort of patients is required to confirm these findings.

396 ARE BLOOD LEVELS OF RETINOL BINDING PROTEIN USEFUL IN DIAGNOSING ATTR-CA? A NEGATIVE STUDY, SO FAR

Introduction

Retinol binding protein (RBP) is a protein synthesized in the liver which forms, along with transthyretin (TTR) the retinol-transport-complex. This complex ligates retinol and thyroxine and transports them in the human plasma. TTR is a protein longer and heavier than RBP. It ligates RBP preventing its renal filtration. Our hypothesis is that the relationship between RBP and TTR is dual: TTR avoids renal filtration of RBP, but also RBP itself, functioning as an endogenous ligand, has an action on TTR by stabilizing and avoiding TTR misfolding.

Misfolded TTR proteins form amyloid fibrils rich in beta-cross-sheets that can infiltrate healthy tissues altering their physiology. The infiltration of these fibrils in the cardiac tissue leads to the well-known condition of TTR cardiac amyloidosis (ATTR CA).

Our hypothesis is that the lack of TTR stabilization that can happen with low blood levels of RBP is a risk factor for developing ATTR CA. The main goal of our study is to understand if high or normal values of RBP can help exclude any pathological condition linked to the accumulation of misfolded TTR proteins.

Methods

All patients referred to our Cardiomyopathy Clinic with a clinical and echographic suspicion of CA were consecutively enrolled. All patients underwent a complete diagnostic workup in order to confirm or exclude CA, comprehending lab tests (including RBP4), SPECT, cardiac MR, genetic testing and cardiac biopsy as recommended by current recommendations. At the end of the diagnostic process, patients with ATTR-wt CA were enrolled as cases, and patients with no CA were considered as controls. Patients with ATTR-mutated CA or AL CA were excluded from the present analysis.

Results

Fifty-nine consecutive patients (42 males, age 77+/-13 years) were enrolled. Of those, 27 had a definitive diagnosis of ATTR-wt CA, while 32 had another diagnosis. Mean levels of RBP4 were not different between patients with and without CA (5.4+/-1.9 vs. 5.0+/-1.8 mg/dl; p=ns) as were Troponin I, BNP and NT-proBNP levels (all p=ns). Among patients with a definitive diagnosis of ATTR-wt CA and a positive SPECT, RBP4 levels were similar between Perugini 2 and 3 scores (5.4+/-2.1 vs. 5.6+/-2.0 mg/dl; p=ns).

Discussion

From our findings, it seems that there is no significant correlation between low levels of RBP and the presence of ATTR CA as we found no difference in the distribution of RBP levels between cases and controls. It also did not seem to be a useful marker to stratify the levels of myocardial infiltration as long as there is no difference in RBP between Perugini score 2 and 3.

507 LONG-TERM SUBCLINICAL HEART INVOLVEMENT IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHIES

Introduction

Global longitudinal strain (GLS) is a validated and reproducible technique for the measurement of LV longitudinal deformation. There is strong evidence of the prognostic value of GLS in patients with HF and is associated with cardiac mortality independent of clinical and cardiac status. In the present study, we aimed to assess whether GLS can reliably predict prognosis in patients diagnosed with idiopathic inflammatory myopathies.

Methods

We conducted a prospective observational study enrolling all consecutive patients referred to our clinic between June 2016 and January 2022 with a confirmed diagnosis of IIM and no overt cardiac disease. For each patient, echocardiogram and GLS calculations were done at baseline and at each follow-up. All patients enrolled have been revalued from two to four times during the median 2.5-year follow-up period.

Results

Forty patients (67% female, mean age 56±12 years) were consecutively enrolled. We detected a significant deterioration of the GLS of the LV (from -19.3±3.6%to -16.8±4.6%; p = 0.006) during the follow-up, while the GLS of the RV was unchanged. We also noticed an increase in the filling pressures as estimated through E/E’, which resulted to be statistically significant (6.5±3.9 to 9.0 ±3.5; p = 0.002), underlying a subclinical diastolic dysfunction of the LV. Traditional markers of systolic dysfunction, such as EF and TAPSE, did not show a significant worsening during the follow-up period. Patients developing a reduction in LV GLS &gt;5% during follow-up experienced an increased incidence of cardiovascular-related death (19% vs 6%; p=0.03).

Discussion

Cardiovascular manifestations constitute a major cause of death in myositis. Although these complications rarely occur clinically, subclinical manifestations such as conduction disturbances, ventricular dysfunction, myocardial infarction and arrhythmias are often observed. This risk appears to increase especially in the first years after diagnosis. There is therefore a problem of the early recognition of patients who may develop heart disease. Several studies propose to use magnetic resonance imaging as a gold standard to select patients at risk, but its high cost and limited availability make it difficult to use as a screening test. The GLS, consistently with the estimated filling pressures, has demonstrated a high predictive power of cardiovascular-related death in our study, without a modification of the traditional systolic function values.

Conclusion

The GLS has a high power predictive, it is low cost and highly repeatable, therefore in our opinion, it could play an important role as a screening test in identifying patients with a diagnosis of IIM at higher risk of developing cardiovascular-related death.

Angina in 2022: Current Perspectives

Angina is the main symptom of ischemic heart disease; mirroring a mismatch between oxygen supply and demand. Epicardial coronary stenoses are only responsible for nearly half of the patients presenting with angina; whereas in several cases; symptoms may underlie coronary vasomotor disorders; such as microvascular dysfunction or epicardial spasm. Various medications have been proven to improve the prognosis and quality of life; representing the treatment of choice in stable angina and leaving revascularization only in particular coronary anatomies or poorly controlled symptoms despite optimal medical therapy. Antianginal medications aim to reduce the oxygen supply-demand mismatch and are generally effective in improving symptoms; quality of life; effort tolerance and time to ischemia onset and may improve prognosis in selected populations. Since antianginal medications have different mechanisms of action and side effects; their use should be tailored according to patient history and potential drug-drug interactions. Angina with non-obstructed coronary arteries patients should be phenotyped with invasive assessment and treated accordingly. Patients with refractory angina represent a higher-risk population in which some therapeutic options are available to reduce symptoms and improve quality of life; but robust data from large randomized controlled trials are still lacking.

Different clinical and pathological profiles of sudden cardiac death victims caused by coronary artery dissection or myocardial infarction with non-obstructed coronary arteries

Background

Spontaneous coronary artery dissection (SCAD) is a potential cause of acute coronary syndrome and sudden cardiac death (SCD). Coronary fibromuscolar dysplasia (FMD) has been correlated to SCAD occurrence.The prevalence of SCAD and FMD among SCD victims are unclear. Myocardial infarction with non-obstructed coronary arteries (MINOCA) could represent a cause of SCD. Since SCAD could clinically manifest as acute myocardial infarction, expert consensus documents have often considered SCAD as a subtype of MINOCA (1,2), but studies which address direct comparison between these two conditions are lacking.

Purpose

To assess characteristics of decedents with SCAD and/or FMD found at autopsy, and to compare their clinical and pathological profile with MINOCA SCD victims.

Methods

We reviewed a database of 5325 consecutive cases of SCDs referred to our cardiac pathology center between 1994 and July 2017.

Results

We identified 21 (0.4%) with SCAD and 37 (0.7%) victims with MINOCA (3), whereas FMD was found only in 2 (0.04%). SCAD decedents were females in 81%, versus 38% of MINOCA (p=0.02).

No signs of coronary FMD were found among SCAD and MINOCA victims. Necrotic myocardium was identified in the totality of MINOCA and only in 8 (38%) of SCAD decedents (p&lt;0.001). Pre-mortem cardiac symptoms were present in 100% of SCAD and 49% of MINOCA victims (p&lt;0.001); illicit drug use was reported in none of SCAD versus 46% of MINOCA decedents (p=0.001).

Conclusions

SCAD is a rare cause of SCD. Compared to MINOCA, SCAD victims are more frequently females, always experienced pre-mortem cardiac symptoms and have no habit of substances abuse. At autopsy coronary FMD is not present among SCAD victims. SCAD and MINOCA shows different clinical and pathological profile. SCAD should not be considered a subtype of MINOCA.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiac Risk in the Young (CRY) and the Charles Wolfson Charitable Trust.

Long-term prognosis in left ventricular non-compaction cardiomyopathy

Introduction

Left ventricular non compaction (LVNC) cardiomyopathy is an often underdiagnosed disease characterized by a thickened myocardium with a two-layered structure. Clinical presentations are very variable, ranging from an apparent lack of functional anomalies to heart failure, ventricular arrhythmias and, in some cases, even ischaemic stroke. Despite great improvements in diagnostic performance, there is still a wide lack of evidence regarding prognosis and management of affected patients.

Purpose

The aim of the present study was to investigate predictors of cardiovascular death or cardiovascular-related hospitalization in patients with LVNC over a long-term follow-up.

Methods

All consecutive patients with a definite diagnosis of LVNC admitted to the Cardiomyopathy Clinic of our institution from Jan 2015 to Dec 2020 were consecutively enrolled. Inclusion criteria were an age ≥18 years old and a diagnosis of LVNC made either by MRI or echocardiography. Exclusion criteria were a life expectancy ≤1 year and the inability to express informed consent for the study. All patients were follwed-up every six months. The primary endpoint was a composite of cardiovascular death and unplanned cardiovascular hospitalization.

Results

Twenty-one patients (14 male, age 40±17 years) meeting the inclusion criteria were prospectively enrolled and followed-up for a median of five years.

LVNC patients with a previous history of supraventricular tachycardia at the time of diagnosis are more likely to meet the primary composite endpoint during follow-up (60% vs. 18%; p=0.048; Figure 1). On the other hand, neither LVEF (measured either with echo or CMR) nor functional status were associated with a significantly increased risk of the composite endpoint (all p=NS). Other significant predictors of increased risk include history of OSAS (z2 = 4.158), active/previous smoking (z2 = 6.279), and ST-segment alterations (z2 = 4.158). NC/C, as measured by either echo or CMR, was not a predictor of cardiovascular events (HR 0.18; 95% CI 0.31–1.08; p=NS).

Conclusions

Our data show how, in patients with LVNC, supraventricular tachycardias are related to worse outcomes and their presence should prompt a closer follow-up in order to detect possible adverse events. ST-segment alterations, OSAS and smoking are also related to a poorer prognosis, but their relevance should be further assessed. Surprisingly, in our sample LVEF and NC/C ratio were not predictors of worse outcomes; the reason might be that in LVNC patients mortality and cardiovascular hospitalizations resemble complex genetic and molecular mechanisms that differentiate them from other cardiomyopathies, but the paucity of the population prevents us from making wider inferences.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of low QRS voltages in patients with cardiac amyloidosis

Introduction

Cardiac amyloidosis (CA) is an underdiagnosed and heterogeneous cardiac disease characterized by the extracellular deposition of misfolded proteins in the cardiac tissue. Clinical manifestations are heterogeneous leading to progressive heart failure, often complicated by arrhythmias and conduction system disease. Among several sign and symptoms that are suspicious for the disease, named “red flags”, disproportionally low QRS voltages on the ECG has been described.

Purpose

The aim of this prospective observational study is to evaluate potential prognostic features of QRS amplitude in AL e ATTR CA patients.

Methods

All consecutive patients admitted to the Cardiomyopathy Clinic of our institution have been enrolled after receiving CA diagnosis, according to the current guidelines. We included all patients ≥18 years with a diagnosis of CA and written informed consent. A complete assessment including a standard 12-lead electrocardiogram (ECG) and echocardiogram was performed at enrollment. Low QRS voltages (LQRSV) was defined as a QRS total amplitude of ≤5 mm in every limb leads and ≤10 mm in every precordial lead. LQRSV was tested as an independent predictor of death from all causes (primary endpoint), hospitalization from cardiovascular causes, ventricular and supraventricular arrhythmias.

Results

Sixty patients (46 males, 77±12 years old) were enrolled, of which 18 (30%) met the criteria for LQRSV. Patients with LQRSV presented more frequently with an history of ventricular arrhythmia (27.8% vs. 6.7%, p=0.04), a lower left ventricular diastolic volume (31±7 vs. 44±18 ml/m2; p=0.04), and higher retinol-binding-protein 4 (9.3±2.2 vs 3.2±1.5 mg/dl; p=0.02). No differences were seen in the primary outcome (46% vs. 50%; p=NS; Figure 1) or in the secondary ones (cardiovascular hospitalization 25% vs. 21%; ventricular arrhythmias 12% vs 4%; supraventricular arrhythmias 29% vs 19%; all p=NS) between the two groups during a median follow up of 1.1 year.

Conclusions

In the present cohort of CA patients LQRSV did not emerge as independent predictor of all-cause mortality at 1 year. Although LQRSV is a recognized diagnostic “red-flag” in the work-up of CA, its role as prognostic marker remains unclear. Further studies with a longer follow-up are needed to better define the prognostic role of LQRSV among CA patients.

Funding Acknowledgement

Type of funding sources: None.

Tachycardiomyopathy: long-term sequelae of arrhythmia-induced acute heart failure

Introduction

The definition of heart failure (HF) is known to include different etiological entities which may lead to the plethora of signs and symptoms characteristic of the syndrome. When it comes to HF with reversible forms of reduced ejection fraction (EF), tachycardiomyopathy (TCM) accounts for around 10% of all hospitalizations for acute HF.

Among the TCM group we can identify situations in which an arrhythmia is the sole cause for the reversible cause of LV (pure TCM), and cases in which LV deterioration is mediated by the arrhythmia, on a substrate of diseased heart.

Purpose

The aim of our study was to investigate the prognosis of patients with pure and impure TCM compared to patients with ischemic HF and idiopathic HF.

Methods

We conducted and observational prospective study enrolling all patients who were admitted with a diagnosis of de novo acute HF with reduced EF between January 2012 and June 2020. All patients were divided into four groups based on guideline-specific definitions: structural HF (encompassing ischemic, valvular, inflammatory, and infiltrative causes, as well as hypertrophic and arrhythmogenic cardiomyopathy), idiopathic HF, pure TCM and impure TCM. Patients presenting with a decline in EF due to any kind of tachyarrhythmia and a subsequent recovery of left ventricular EF after rhythm or rate control were diagnosed with TCM. Further grouping into pure or impure was made according to the presence of absence of underlying heart disease.

Results

456 patients were consecutively enrolled (304 males, 70±13 years). The four groups had significantly different estimates for all-cause death, with pure TCM having the highest survival and structural HF having the lowest over a median 6-year follow-up (pure TCM 22.1%; impure TCM 32.1%; idiopathic HF 26.3%; structural HF 51.9%; log-rank p&lt;0.0001; Figure 1a). Using structural HF as a comparator, HRs for death were significantly lower for all the other three groups (pure TCM HR 0.35; 95% CI 0.21–0.57; impure TCM HR 0.48; 95% CI 0.24–0.96; idiopathic HF HR 0.53; 95% CI 0.31–0.90).

Unplanned hospitalizations showed a different trend, with TCM having the highest rate and non-ischemic HF having the lowest over the same follow-up (pure TCM 58.1%; impure TCM 40.2%; idiopathic HF 15.8%; structural HF 38.4%; log-rank p&lt;0.0001; Figure 1b). The average total number of unplanned hospitalizations also differed significantly between the four groups (pure TCM 0.84; 95% CI 0.65–1.04; impure TCM 0.88; 95% CI 0.53–1.23; idiopathic HF 0.45; 95% CI 0.25–0.65; structural HF 1.02; 95% CI 0.78–1.25; p=0.021).

Conclusions

Among all patients with de novo acute HF, those who present structural heart disease present a lower survival rate over a 6-year follow up. However, patients with pure TCM present the highest rate of unplanned hospitalizations when compared to the other groups. It is therefore important to identify the etiology of HF to start appropriate treatment and prevent new hospitalizations.

Funding Acknowledgement

Type of funding sources: None.