[Leadless pacemakers: results of a survey from implanter centers in the Lombardy region]

BACKGROUND

Transvenous pacing is nowadays the cornerstone of interventional management of bradyarrhythmias. It is still associated, however, with significant complications, mostly related to indwelling transvenous leads or device pocket. In order to reduce these complications, leadless pacemakers have been recently introduced into clinical practice, but no guidelines are yet available to indicate who are those patients that might benefit the most and whether leadless pacing should be preferred in the old or young population. This survey aims to describe the use of leadless pacemaker devices in a real-world setting.

METHODS

Eleven arrhythmia centers in the Lombardy region (out of a total of 17 participating centers) responded to the proposed questionnaire regarding patient characteristics and indications to leadless pacing.

RESULTS

Out of a total of 411 patients undergoing leadless pacing during 4.2 ± 0.98 years, the median age was 77 years, with 0.18% of patients having less than 18 years, 29.9% 18-65 years, 34.3% 65-80 years and 35.6% >80 years. The most common indication was slow atrial fibrillation (49% of patients), followed by atrioventricular block and sinoatrial dysfunction. Two centers reported in-hospital complications.

CONCLUSIONS

Leadless pacemakers proved to be a safe pacing strategy actually destined mostly to elderly patients.

Impact of COVID-19 on birth rate trends in the Italian Metropolitan Cities of Milan, Genoa and Turin

Objectives

The COVID-19 pandemic has led to major changes in the lives of people worldwide, including changes in personal and social habits. Faced with this global health emergency, governments have imposed strict mitigation measures. Within this context, and considering data from previous epidemics, it has been proposed that birth rates may have been negatively impacted. This study aimed to assess the trends in birth rates in three main industrial cities in Northern Italy during the COVID-19 pandemic.

Study design

This was a retrospective and observational study.

Methods

Data on birth rates were collected and compared for the cities of Milan, Genoa and Turin from November 2019 to January 2020 (i.e. before the COVID-19 pandemic) and during the same period of the following year (i.e. during the COVID-19 pandemic).

Results

Birth rates in the cities of Milan, Genoa and Turin decreased by 55%, 12% and 33%, respectively.

Conclusions

The decrease in birth rates during the COVID-19 pandemic in these three industrialised cities is in line with the demographic effects of previous pandemics. The negative impact of COVID-19 on conception may be a result of various underlying factors. Further studies are required to verify how social and demographic factors may influence birth rates during pandemics.

Immediate psychological effects of COVID-2019 in people sheltered in place living in New York state

Introduction

The epidemic caused by the SARS-CoV-2, which began in Wuhan city in December 2019, quickly spread to various countries around the world. The first case in New York State was confirmed on March 1; three weeks later (on March 22, 8 p.m.) the entire population was sheltered in place (SIP). By March 27, the USA had already become the first country in the world for the number of infections. 56% of known domestic cases were confined to New York State.

Objectives

The study aims to evaluate the immediate psychological effects on sheltered in place persons aged between 18 and 70 years old and living in New York State (USA).

Methods

This study is based on a cross-sectional online survey conducted anonymously in the period between the tenth and twenty-third day of SIP. Zung Anxiety Self-Assessment Scale (ZAS scale), Insomnia Severity Index (ISI) and Perceived Stress Scale 4 (PSS4) were used to evaluate anxiety, insomnia and stress respectively.

Results

We collected data on 354 individuals (189 females, 34.9 years). MANOVA evidenced that anxiety was significantly related to marital status (higher for divorced/widow participants as compared to married/civil partnership and single), it decreased significantly with age, it was higher for females and for persons having an history of psychiatric disorders and sleeping problems.

Conclusions

Our results could be used as a “psychological baseline” meanwhile the outbreak of COVID-19 is still ongoing. Despite the few days of shelter in place, we found the presence of a significant incidence and pervasive prevalence of psychological distress.

Disclosure

No significant relationships.

Immediate psychological effects of COVID-2019 in Emilia Romagna, Italy

Introduction

The epidemic caused by the SARS-CoV-2, which began in Wuhan city in December 2019, quickly spread to various countries around the world. On march Italy had already become the second country after China in terms of number of infections and deaths and Emilia Romagna was the second region in Italy by number of cases after Lombardy. On 11th of March 2020 through the “Stay at home” decree, the entire nation was sheltered-in-place (SIP).

Objectives

Main objective is to understand immediate psychological effects on sheltered in place persons living in Emilia Romagna.

Methods

This study is based on a cross-sectional online survey conducted anonymously in the period between the tenth and seventeenth day of SIP. We used Zung Anxiety Self-Assessment Scale, Insomnia Severity Index and Perceived Stress Scale 4. SPSS 21.0 was used for data analysis.

Results

We collected data on 651 individuals. About 38% of the sample reported having sleep problems; 31% of the population has a minimal-moderate level of anxiety while 4% marked-severe; finally, 54% of the interviewees perceive a moderate level of stress while 31% high. The MANOVAs showed that anxiety is influenced by gender, age, level of education and occupational status. Greater levels of stress are shown by individuals who declared the fear of contracting the virus and the concern of financial loss.

Conclusions

Our results could be used as a “psychological baseline” meanwhile the outbreak of COVID-19 is still ongoing. Despite the few days of SIP, we found the presence of a significant incidence and pervasive prevalence of psychological distress.

TV or not TV? health information, anxiety and stress during the initial stage of COVID-19 epidemic in Italy

Introduction

With the spread of the coronavirus pandemic, there has been the dissemination of an enormous amount of information, through multiple channels, from different sources and with an often unverifiable basis (infodemic). In recent years, there has been debate in the literature about the possibility that different information channels (social media vs traditional media) can determine a more or less extensive emotional contagion regardless of the severity and direct exposure to the stressful event and more precisely through a ‘secondhand’ exposure to events.

Objectives

We want to investigate whether the information channel or the amount of time dedicated to the update is associated with greater psychological sequelae.

Methods

This study is based on a cross-sectional online survey conducted anonymously in the period between the tenth and seventeenth day of shelter in place in Italy. We used Zung Anxiety Self-Assessment Scale and Perceived Stress Scale 4. SPSS 21.0 was used for data analysis.

Results

We collected data on 1047 individuals. In our sample, the Internet was the primary health information channel (55%) followed by TV (36%). Most TV and internet users spend about 1-3 hours a day for the update. There was no correlation between the time spent or the information channel used and higher levels of stress and anxiety.

Conclusions

In our opinion, this relationship between the time spent receiving information or the most widely used information channel and psychological disorders is not clear. Is it the news channel causing an emotional contagion or are the most anxious people looking for news anywhere and anytime?

Neuropsychological profile and correlation with outcomes in patients admitted to spdc

Introduction

Literature showed that patients suffering from disorders belonging to the schizophrenic (SZ) and bipolar (DB) spectrum have a qualitatively similar but quantitatively different neurocognitive impairment that correlates with the outcomes. However, the majority of former studies are conducted on patients in remission phase.

Objectives

This study aims to compare cognitive functions between SZ and DB in the acute phase and their possible correlations with treatment outcomes.

Methods

In a prospective longitudinal study conducted at the SPDC Ausl unit of Romagna - Cesena, 57 SZ and 82 DB took part in the study. The diagnosis was based on the SCID5 CV and SCID5 DP. Symptom severity was assessed with BPRS and HONOS both at the beginning and at the end of hospitalization. Executive functions were measured with Tower of London (ToL) and Modified Wisconsin Card Sorting Test (MCST), attention with Attentive Matrices (MA) and Stroop Test (ST), non-verbal logic skills with Colored Matrices by Raven (PM47). The statistical analyzes applied are ANOVA and logistic regression.

Results

The cognitive tests did not reveal significant differences between SZ and DB. The logistic regression analysis showed that the scores obtained at the MCST and MA positively correlate with the efficacy of the treatment for both groups.

Conclusions

Cognition in DB and SZ patients was similarly impaired, supporting recent theories that placed diagnoses on a continuum of severity. Moreover, the results indicated that also in the acute phase the best predictors of the outcome were flexibility in problem solving strategies and visuospatial attention.

Disclosure

No significant relationships.

P951Autonomic nervous function and excitability of the accessory pathway in pediatric patients with Wolff-Parkinson-White ECG

Abrupt loss of preexcitation identifies low-risk Wolff-Parkinson-White (WPW). We hypothesize that the autonomous nervous system (ANS) modulates the conduction of the accessory pathway (AP).

PURPOSE

To compare heart rate variability (HRV) in children with (WPWi) and without (WPWp) intermittent preexcitation. 

METHODS

The study conforms to the Declaration of Helsinki. 

18 WPW children and controls performed ECG Holter for HRV analysis. Intermittent preexcitation was defined as abrupt loss of WPW pattern. Kolmogorov-Smirnov test confirmed normal distribution of data. T-test and Fisher"s exact test were used for continuous and categorical variables. Multivariate regression excluded the effect of potential confounders (figure 1 shows correlation between HRV and HR). 

RESULTS

WPWi (11/18, 61.1%) have higher HRV as compared with WPWp. Despite WPWp patients are younger, with higher HR, corrected multivariate analysis confirmed significant differences (table 1), also between WPW patients and controls. 

CONCLUSIONS

WPW patients have lower HRV. WPWp may have worst autonomic control to the excitability of AP.

Table 1 WPW (n = 18)A WPWi (n = 11)B WPWp (n = 7)C Controls (n = 18)D P value A vs. D P value B vs. C P value B vs. D P valueC vs. D Age 7.6 ± 4 10.1 ± 4.2 4.1 ± 2.9 7.8 ± 4.7 0.9 <0.01 0.1 0.03 24 hours mean HR 92.8 ± 15.9 81.1 ± 11.2 104.9 ± 12.6 90.3 ± 16.5 0.7 <0.01 0.03 0.07 pNN50 20 ± 11.4 30.5 ± 11.8 14.7 ± 9.9 24.3 ± 13.4 <0.001 <0.001 <0.001 <0.001 RMSSD 53 ± 19.1 68.8 ± 21.4 44.6 ± 14.7 59.4 ± 22.2 <0.001 <0.001 <0.001 <0.01 ASDNN 64.9 ± 21.1 78.4 ± 20.7 48.8 ± 11.8 66.9 ± 22.9 <0.001 <0.001 <0.001 <0.001 SDANN 108.2 ± 39.8 127.9 ± 36 77.5 ± 16.9 108.3 ± 38.8 <0.001 <0.01 <0.001 <0.01 VLF 7.4 ± 0.8 7.8 ± 0.4 6.9 ± 0.5 7.5 ± 0.6 <0.001 <0.001 <0.001 <0.001 LF 6.8 ± 0.8 7.3 ± 0.4 6.4 ± 0.4 6.9 ± 0.6 <0.001 <0.001 <0.001 <0.001 HF 6.6 ± 0.8 7.1 ± 0.7 6.2 ± 0.6 6.7 ± 0.8 <0.001 <0.01 <0.001 <0.01 LF/HF 1.4 ± 0.8 1.4 ± 0.7 1.4 ± 0.6 1.4 ± 0.6 0.2 0.3 0.05 0.7 VarIndex% 4.8 ± 1.4 5.8 ± 1.2 4.4 ± 1.4 5.3 ± 1.4 <0.001 <0.01 <0.01 <0.01 Total Power 8.2 ± 0.7 8.6 ± 0.4 7.8 ± 0.4 8.3 ± 0.6 <0.001 <0.001 <0.001 <0.001 Frequent SVB 2 (11%) 1 (9.1%) 1 (14%) 0 0.5 1.0 0.4 0.3 SVT 1 (5.6%) 1 (9.1%) 0 0 n.a. n.a. n.a. n.a. P values from multivariate analysis and t-test for age and HR. HR: heart rate; WPWi: intermittent preexcitation; WPWp: persistent preexcitation; VarIndex%: variability index (%); SVB: supraventricular beats; SVT: supra ventricular tachycardia. Values are expressed as mean ± SD for age, HR and time domain variables (ms). Variables in the frequency domain are expressed as ln. P <0.05: significant.

Abstract Figure 1

Two-step Cluster Analysis Application to a Sample of Psychiatric Inpatients at Psychiatric Service of Diagnosis and Care

Introduction

Recent findings demonstrated significant overlaps among major psychiatric disorders on multiple neurocognitive domains. However, it is not clear which are the cognitive functions that contribute to this phenomenon.

Objectives

To find the optimal clustering solution using the two-step cluster analysis on a sample of psychiatric patients.

Aims

To classify into subgroups a cross-diagnostic sample of psychiatric inpatients on the basis of their neurocognitive profiles.

Methods

Seventy-one patients with psychotic, bipolar, depressive and personality disorders hospitalised at Psychiatric Diagnosis and Care Service of Bufalini Hospital of Cesena participated in the study. The symptomatology was assessed using Health of the Nation Outcome Scales-Roma and Brief Psychiatric Rating Scale. Cognitive functions were evaluated using Tower of London, Modified Wisconsin Card Sorting Test, Judgment and Verbal Abstract Tasks test, Raven matrices, Attentional Matrices, Stroop Test and Mini Mental State Examination. Two-step cluster analysis was conducted using the standardized scores of each neurocognitive test.

Results

Two groups were obtained:– group 1, with good cognitive performances;– group 2, with almost all subjects having impaired cognitive performances.

Executive functions and attention are the major determinants of the cluster solution. The clusters did not differ on socio-demographic correlates. Different diagnoses were equally distributed amongst the clusters.

Conclusions

Two-step cluster analysis was useful in identifying subgroups of psychiatric inpatients with different cognitive functioning, overcoming other cluster techniques limitations. According to former literature, these results confirm a continuum of severity in cognitive impairment across different psychiatric disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Bion's Group Psychotherapy for Dramatic Personality Disorders: An Empirical Study in a Public Mental Health

Educational objectives

Psychotherapy is the most preferable intervention for personality disorder patients and group psychotherapy offers the possibility to increase the self-perception through resonance and mirroring processes. When a group is disorganized and emotionally tensioned generates regressive movements, which make it a basic assumption group.

Purpose

To highlight the change of a group of patients after the inclusion of a new patient named Margherita.

Methods

The patients were included within the group run by two psychotherapists after a cluster B personality disorder's clinical diagnosis (except for antisocial personality disorder), confirmed by SCID II and by a set of individual interviews aimed to prepare the patient to the inclusion within the group.

Results

Margherita, from the first sessions, showed the tendency to coercively polarize the attention on herself through themes of discouragement and helplessness, posing a threat for the members’ identity and resulting in a disorganization of the work group, which became a basic assumption group.

Conclusions

The temporary disorganization of the group with the consequent regression to a worse functioning condition has subsequently allowed to revitalize the group and to avoid its dissolution. After the temporary regression, indeed, the work group was restored and started again to function even based on the new patient's problems.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Smooth pursuit eye movements in psychiatric inpatients

Introduction

Eye movements are used in several studies as a biomarker in order to evaluate cortical alterations in psychiatric disorders. Pursuit eye movements’ deficits were found both in schizophrenia and in affective disorder patients. Nevertheless, these findings are still controversial.

Objectives

Set up a system to record and evaluate the eye movements in psychiatric patients.

Aims

To verify the applicability of a smooth pursuit task in a sample of psychiatric inpatients and to prove its efficiency in discriminating patient and control group performance.

Methods

A sample of psychiatric inpatients was tested at psychiatric service of diagnosis and care of AUSL Romagna-Cesena. Eye movement measures were collected at a sampling rate of 60 Hz using the eye tribe tracker, a bar plugged into a PC, placed below the screen and containing both webcam and infrared illumination. Subjects underwent to a smooth pursuit eye movement task. They had to visually follow a white dot target moving horizontally on a black background with a sinusoidal velocity. At the end of the task, a chart of the eye movements done is shown on the screen. Data are off-line analyzed to calculate several eye movement parameters: gain, eye movement delay with respect to the movement of the target, maximum speed and number of saccades exhibited during pursuit.

Results

Patients compared to controls showed higher delay and lower gain values.

Conclusions

Findings confirm the adequacy of this method in order to detect eye movement differences between psychiatric patients and controls in a smooth pursuit task.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Holter Monitoring and Loop Recorders: From Research to Clinical Practice

Holter monitors are tools of proven efficacy in diagnosing and monitoring cardiac arrhythmias. Despite the fact their use is widely prescribed by general practitioners, little is known about their evolving role in the management of patients with cryptogenic stroke, paroxysmal atrial fibrillation, unexplained recurrent syncope and risk stratification in implantable cardioverter defibrillator or pacemaker candidates. New Holter monitoring technologies and loop recorders allow prolonged monitoring of heart rhythm for periods from a few days to several months, making it possible to detect infrequent arrhythmias in patients of all ages. This review discusses the advances in this area of arrhythmology and how Holter monitors have improved the clinical management of patients with suspected cardiac rhythm diseases.

Prevalence of deep vein thrombosis and pulmonary embolism in patients with superficial vein thrombosis: a systematic review and meta-analysis

Essentials The association of superficial vein thrombosis (SVT) with venous thromboembolism (VTE) is variable. We performed a meta-analysis to assess the prevalence of concomitant VTE in patients with SVT. Deep vein thrombosis was found in 18.1%, and pulmonary embolism in 6.9%, of SVT patients. Screening for VTE may be worthy in some SVT patients to plan adequate anticoagulant treatment.

SUMMARY

Background Some studies have suggested that patients with superficial vein thrombosis (SVT) have a non-negligible risk of concomitant deep vein thrombosis (DVT) or pulmonary embolism (PE) at the time of SVT diagnosis. Unfortunately, the available data on this association are widely variable. Objectives To perform a systematic review and meta-analysis of the literature in order to evaluate the prevalence of concomitant DVT/PE in patients with SVT of the lower limbs. Methods Studies reporting on the presence of DVT/PE in SVT patients were systematically searched for in the PubMed, Web of Science, Scopus and EMBASE databases. The weighted mean prevalence (WMP) of DVT and PE was calculated by use of the random effect model. Results Twenty-one studies (4358 patients) evaluated the prevalence of DVT and 11 studies (2484 patients) evaluated the prevalence of PE in patients with SVT. The WMP of DVT at SVT diagnosis was 18.1% (95%CI: 13.9%, 23.3%) and the WMP of PE was 6.9% (95%CI: 3.9%, 11.8%). Heterogeneity among the studies was substantial. Selection of studies including outpatients only gave similar results (WMP of DVT, 18.2%, 95% CI 12.2-26.3%; and WMP of PE, 8.2%, 95% CI 3.3-18.9%). Younger age, female gender, recent trauma and pregnancy were inversely associated with the presence of DVT/PE in SVT patients. Conclusions The results of our large meta-analysis suggest that the prevalence of DVT and PE in patients presenting with SVT is not negligible. Screening for a major thromboembolic event may be worthwhile in some SVT patients, in order to allow adequate anticoagulant treatment to be planned. Other high-quality studies are warranted to confirm our findings.

Infection and excretion of Salmonella Enteritidis in two different chicken lines with concurrent Ascaridia galli infection

Studies on the impact of interaction of Salmonella enterica serovar Enteritidis and the parasitic nematode Ascaridia galli with the avian host were undertaken with particular emphasis on infection and excretion of these pathogens in two different layer lines. A total of 148 salmonella-free 1-day-old chickens (73 Hellevad and 75 Lohmann Brown) were randomly divided into five groups for each line. Group 1 served as an uninoculated control group. Groups 2 and 3 were infected with A. galli and S. Enteritidis, respectively. Group 4 was first infected with S. Enteritidis and subsequently with A. galli, and vice versa for group 5. The number of chickens excreting S. Enteritidis was significantly higher (P < 0.001) in the groups infected with both S. Enteritidis and A. galli compared with those only infected with S. Enteritidis over time. Furthermore, excretion of S. Enteritidis over time was significantly higher (P < 0.001) in the group first infected with S. Enteritidis and subsequently with A. galli compared with the group infected in the reverse order. No significant differences were observed between the two lines concerning excretion of S. Enteritidis over time in any group (P = 0.61 (group 3), P = 0.73 (group 4), P = 0.31 (group 5)). A. galli established itself significantly better (P = 0.02) in the group first infected with A. galli and subsequently with S. Enteritidis compared with the group infected in the reverse order. Furthermore, the A. galli infection rate was significantly higher (P = 0.02) in Hellevad chickens compared with Lohmann Brown chickens at the end of the experiment.

Atrial fibrillation and antithrombotic treatment in Italian hospitalized patients: a prospective, observational study

BACKGROUND

We studied the prevalence of atrial fibrillation within a large Italian inpatient population, and evaluated the use of antithrombotic therapy among these individuals.

METHODS

A prospective cross sectional study (Phase 1) with a 1-year follow-up period (Phase 2) was conducted at a single Italian centre. During Phase 1, we conducted a chart review of all inpatients on 5 separate days, each 1 month apart, between January and May 1999. During Phase 2, at 1-year of follow-up, patients or their families were contacted to document the occurrence of new clinical events, as well as current antithrombotic therapy use.

RESULTS

A total of 3121 patient charts were reviewed. The prevalence of atrial fibrillation was 7.2%. Of these 224 patients, 21.3% were on oral anticoagulants, 29.7% on antiplatelets, while 49% received neither. Patients on oral anticoagulants were significantly younger (mean age 72.3 years) than those on antiplatelets (mean age 80.6 years; p<0.001) or neither therapy (mean age 80.7 years; p<0.001). At 1 year follow up, an acute ischaemic stroke occurred among 7.4% of the 121 contacted patients. Among patients with chronic atrial fibrillation [98], 25.5% were receiving an oral anticoagulant.

CONCLUSIONS

Despite clear evidence from clinical trials, oral anticoagulants are significantly underused among patients with chronic atrial fibrillation. Methods should be developed to improve both physician and patient knowledge about the overall benefits of anti-thrombotic therapy among these individuals.

Comparison of a daily fixed 2.5-mg warfarin dose with a 5-mg, international normalized ratio adjusted, warfarin dose initially following heart valve replacement

Patients starting oral anticoagulant therapy after heart valve replacement initially require a lower target international normalized ratio (INR) (2.0, range 1.5 to 2.6) because of a higher risk of bleeding until pericardial wires are removed. In a previous retrospective analysis, we observed a higher sensitivity to warfarin in these patients compared with nonsurgical patients. In a randomized clinical trial, we compared a fixed, lower dose of warfarin (2.5 mg) with the standard treatment consisting of a 5-mg loading dose, then adjusted to the target INR during the first 5 days of anticoagulation. INRs were measured daily, but the fixed dose was only modified on day 3 if the INR was <1.5 or >3.0. One hundred ninety-seven patients were considered eligible for the study. The 2 groups were well matched according to age, gender, body mass index, concomitant treatments, and type of valves implanted. The proportion of INRs >2.6 during the study period was 42.5% in the 5-mg group and 26.2% in the 2.5-mg group (p <0.05), and the proportion of INRs >3.0 on day 3 was 23.9% and 9.5% (p <0.05), respectively. In the 2.5-mg group, 35.7% of patients had an INR <1.5 on day 3 and had the dose increased (vs 3.5%, p <0.001); however, in the 5-mg group, 95.6% had the initial dose reduced, 49.6% had the dose withheld for at least 1 day, and the mean dose during the 5 days of study was 3.08 mg. Average time to achieve therapeutic range was higher in the 2.5-mg group (2.72 vs 1.98 days, p <0.0001), but the approach to the targeted INR was more regular, and the gap between target and mean INR on day 5 was smaller. There were no bleeding or thromboembolic complications in either group. Thus, a lower loading dose of warfarin in patients after heart valve replacement reduces excessive anticoagulation and offers a more regular achievement of the therapeutic target by reducing the number of dose adjustments. Daily monitoring of the INR is still recommended.

Neuropsychological deficits in asymptomatic atrial fibrillation

OBJECTIVE

To assess the preclinical effects on cognitive functions of nonrheumatic atrial fibrillation (NRAF) in patients with negative history for cerebrovascular disease.

MATERIALS AND METHODS

The study included 37 consecutive patients with chronic (n=16, mean age 65.3+/-6.6 years) or paroxysmal (n=21, mean age 58.3+/-9.5 years) NRAF and an equal number of control subjects in sinus rhythm, who were matched for age, education and presence of hypertension. A comprehensive neuropsychological battery including tests of attention, memory, language and visuospatial skills was administered.

RESULTS

Patients with chronic NRAF showed significantly poorer performances in tasks exploring attention and verbal memory functions, while the paroxysmal group was significantly impaired in a long-term memory task. The neuropsychological findings were confirmed excluding from both groups patients with CT evidence of cerebrovascular damage. A small subgroup of patients was also submitted to cerebral MRI.

CONCLUSION

Neurologically asymptomatic NRAF is related to a subclinical but significant impairment in attention and memory. These deficits could be produced by minor ischemic lesions due to microembolization, or by diffuse hypoxic damage due to hypoperfusion.

[Use of esophageal atrial electrogram and an external Thera VDD pacemaker in atrial-triggered ventricular pacing in acute myocardial infarction complicated by total AV block and low cardiac output]

Aim of this short report is to present a simple and fast technique to pace in VDD mode patients with acute myocardial infarction associated with third degree AV block and haemodynamic deterioration. VDD pacing was obtained using atrial electrogram recorded by trans-oesophageal catheter and a Medtronic Thera VDD pace-maker as temporary pace-maker.

[Ventricular stimulation triggered by esophageal atriogram: a new technique of temporary physiologic stimulation in the course of acute myocardial infarct complicated by atrioventricular block and low cardiac output]

Advanced atrio-ventricular (AV) block during acute myocardial infarction (AMI) is considered a complicating dysrhythmia as the well as mechanism responsible for occurrence of life-threatening hemodynamic changes. Often, simple VVI pacing can result insufficient in improving the decreased cardiac output. VDD pacing, which preserves atrial contribution, should represent the most effective electrical approach; therefore, it requires intracavitary placement of 2 catheters. In 10 pts (6M, 4F, mean age of 63.8 +/- 6.6 years) with advanced AV block due to AMI (4 inferior, 6 anterior) and without sinus node dysfunction, we performed stable VDD stimulation (mean 16.6 +/- 20.6 hours) using only one catheter positioned in the right ventricle while the atrial impulse, filtered (50-70 Hz) and amplified through a special device, was derived from the esophagus. Such technique is rapid and reliable, avoiding problems associated with atrial sensing and catheterization.

[Therapy and prevention of atrial fibrillation]

In the last decade, broader insights into the mechanisms and clinico-prognostic significance of atrial fibrillation have prompted a dramatic shift in the clinician's decision making process in terms of treatment and prevention of this common rhythm disturbance. In fact, evidence of short- or long-term untoward effects on cardiac function and the risk of cerebrovascular accidents, together with a much wider therapeutic armamentarium, form the rationale for the present far more aggressive attitude, aiming at restoring sinus rhythm in all patients in whom an even weak chance exists. The newer class IC (flecainide, propafenone) and class III (amiodarone, sotalol) antiarrhythmic agents are widely and successfully utilized to restore and to maintain sinus rhythm, with significant advantages in comparison with classic quinidine derivatives in terms of efficacy and patient compliance, as demonstrated in clinical controlled trials. Moreover, calcium channels blocking agents as verapamil and diltiazem have been demonstrated more effective than digitalis in the limitation of ventricular rate in patients with chronic atrial fibrillation. Although the advantages of long-term anticoagulation and/or antiaggregation in patients with atrial fibrillation are still being widely investigated at the present time, data obtained in the last years favoured a wider use of this treatment. Many non-pharmacologic interventions have been shown as dramatically effective in particular aspects of atrial fibrillation. Permanent atrial or atrioventricular pacing, alone or in association with antiarrhythmic drugs, has come out as first choice option in patients with bradycardia-tachycardia syndrome. Transcatheter ablation and antiarrhythmic surgical techniques are more and more widely utilized with increasing success in cases refractory to conventional approaches.

[Early and late prognosis in acute myocardial infarct. A retrospective study in patients admitted to the coronary care unit in the past 10 years]

The prognostic evaluation of the patient with an acute myocardial infarction is one of the most interesting unanswered problems. This is both because of its complexity and its implications in terms of secondary prevention. Several clinical studies have emphasized the reliability of the prognostic evaluation based on data collected during the first 24 hours. We therefore evaluated the prognostic relevance of 26 variables measured in the coronary care unit in 1914 patients admitted to our Unit as a result of acute myocardial infarction during the past 10 years. Twenty-four patients were lost to follow-up so that the evaluation refers to 1,890 patients, 1,506 of whom are males aged between 22 and 99 years (mean 58.1) and 384 are females aged between 29 and 88 years (mean 67.1); thus there is a greater prevalence of males. The sex-related difference in the age distribution is statistically significant. In-hospital mortality was analyzed using univariate and multivariate statistical methods (chi-squared test, multiple logistic regression analysis). The prognostic relevance of the considered variables in relation to the survival was analysed using the logrank test and using Cox's model. The variables associated with a greater risk of in-hospital death were found to be: age, presence of diabetes, anterior location of the infarct, arterial hypotension at admission, Killip class III and IV and the presence of ventricular tachyarrhithmias. In contrast, smokers had a lower in-hospital death risk. As to mortality during the follow-up, there was an association with age, female sex, pre-existent coronary disease, presence of high heart rate on admission, low peripheral tissue perfusion, x-ray documented pulmonary congestion, supraventricular tachiarrhythmias and intraventricular block. In contrast, the presence of obesity was associated with a reduced death risk during the follow-up. During the follow-up the most frequent cause of death was re-infarction, followed by sudden death, death from non-cardiac causes and heart failure.

[The Italian Group for the Study of Streptokinase in Myocardial Infarct: Changes in surface cardiac potentials. Study with chest electromaps]

The electrocardiographic changes during and after the thrombolytic treatment with streptokinase (SK) were assessed by means of body surface potential mapping. The aim of the study was to identify potential patterns suggesting reperfusion and revealing possible short-term effects on the infarct size of the recanalization. We studied 23 patients enrolled in the G.I.S.S.I. trial; 11 had an anterior and 12 had an inferior myocardial infarction; 14 were treated with SK and 9 were controls. Body surface maps were recorded from 105 lead points located on the anterior thoracic surface using an automated instrument. The maps were obtained immediately before the SK infusion (or at the time of randomization in the control patients), 30, 60, 120 minutes thereafter and then 24 hours and 7 days after the onset of the infarct symptoms. In each patient the surface potential distribution at 100 msec after the end of QRS was considered and the sum of all the positive potential values was calculated (sigma ST). In addition, the potential time integrals relating to two intervals of the cardiac cycle (first 100 msec of ST and first 40 msec of QRS) were calculated at each lead point and transferred to diagrams representing the chest surface explored (isointegral map). With respect to Q-40 maps, deviation index maps were calculated as follows: the mean Q-40 map (obtained from 30 normal subjects) was subtracted from the map of each patient; the value obtained at each lead point was then divided by the standard deviation of the normal values for that point. An area where the integral values were at least 2 SD lower than normal was considered a reliable index of infarct. By considering as index of reperfusion an early peak of CPK (less than 12 hours from the onset of infarct symptoms), we divided the patients into 2 subsets: reperfused (R) and not reperfused (NR). The mean values of sigma ST at 100 msec progressively decreased in all patients from the baseline to the subsequent recordings in both control and SK groups, without significant differences; nevertheless, the highest percent reductions of sigma ST were observed only in some R patients. The maximum on the ST-100 isointegral maps also showed a similar behaviour.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term prognostic significance and electrophysiological evolution of intraventricular conduction disturbances complicating acute myocardial infarction

Fifty-nine patients with post-infarctional, isolated intraventricular conduction disturbances (IVCD) who survived the acute stage of myocardial infarction were followed up after hospital discharge for a mean period of 11.4 +/- 4.8 months. Fourteen patients (24%) had HV interval prolongation (greater than 55 ms) during AMI (group A), and 45 patients had normal HV intervals (76%, group B). His bundle recordings were repeated during follow-up in 48 survivors after a mean period of 7.2 +/- 0.7 months. Infranodal conduction delay in the acute stage of infarction was correlated with a higher incidence of heart failure during AMI (78% of patients in group A vs 22% in group B, p less than 0.001), and with higher rate of cardiac mortality during follow-up (50% in group A vs 13% in group B, p less than 0.01). Survivors of group A showed a higher functional NYHA class, a higher incidence of CHF, and a higher prevalence of complex ventricular arrhythmias at Holter monitoring. No statistically significant difference in late sudden death was evident between the two groups of patients, and the global incidence of late AV block was 2%. At repeat His bundle recording no significant change (greater than 5 ms) in HV interval could be demonstrated in comparison to the acute phase recording, neither in patients with prolonged nor in patients with normal HV time. We conclude that HV prolongation in patients with isolated, post-infarctional IVCD is correlated with a worse prognosis, both during acute infarction and during the follow-up period, which presumably reflects wider anatomic damage in comparison to patients with normal HV time. The low incidence of late AV block and the electrophysiological demonstration of the stability of infranodal conduction several months after AMI indicate that these patients do not require permanent prophylactic pacing after acute myocardial infarction.

Hemodynamic effects of antiarrhythmic drugs in acute myocardial infarction

The hemodynamic effects induced by an i.v. administration of Amiodarone (5 mg/Kg in 10 min + continuous infusion of 0.6 mg/min for 4-40 hrs), Propafenone (1-2 mg/Kg in 5 min + continuous infusion of 10-15 mcg/Kg/min for 24 hrs) and Mexiletine (250 mg in 15 min + 250 mg in 1 hr) have been evaluated in patients with acute myocardial infarction complicated by sinus tachycardia and hyperdynamic pattern, ventricular or supraventricular arrhythmias. The hemodynamic serial determinations have been comprehensive of: heart rate; systolic, diastolic and mean pressure; central venous pressure; arterial and wedge pulmonary pressure; cardiac output and cardiac index; vascular systemic resistences; left ventricular stroke work index; left ventricular mean ejection rate; double and triple product. In all of the three groups we observed: a reduction of cardiac index associated with an increase of left and right ventricular filling pressure and a reduction either of left ventricular stroke work index and left ventricular mean ejection rate; these hemodynamic changes were less significant after Mexiletine than after Amiodarone or Propafenone. These data confirm the negative inotropic effect of the three drugs; anyhow, these changes are usually well tolerated by patients affected by AMI with a sufficiently preserved ventricular function. The authors, however, reccommend an accurate hemodynamic monitoring of the effects of the drugs also to identify patients with a not overt ventricular failure which may become manifest after drug administration.

[Hemodynamic effects of propafenone in acute myocardial infarct]

The hemodynamic effects of Propafenon were evaluated in 11 patients with acute myocardial infarction complicated by atrial and/or ventricular arrhythmias (atrial fibrillation in 4 cases, atrial premature beats in 3 cases, ventricular premature beats Class II-IVa in 4 and rapid sustained ventricular tachycardia in one case). Drug was administered as a bolus of 1-2 mg/kg in 5 min, followed by a 10-15 gamma/kg/min infusion for 24 hours in 7 patients. Serial measurements were taken of heart rate, systemic blood pressure, right atrial, pulmonary and capillary wedge pressure, cardiac output, cardiac index, total systemic resistances, left ventricular stroke work index, left ventricular ejection time and left ventricular mean ejection rate (LVMER) (8 cases) and PEP/LVET ratio (5 cases). After the intravenous bolus, a significant reduction of cardiac index (p less than 0.01) and LVMER (p less than 0.05) parallel to an increase of total systemic resistances and PEP/LVET ratio (p less than 0.01 and p less than 0.05 respectively); was observed no other parameter varied significantly. The peak hemodynamic effect was observed after 10 minutes and return to normal required from 30 minutes to 3-6 hours in the more severely affected patients. No late negative inotropic action was evident in 6 out of 7 patients who received long term infusion. Suppression or greater than 80% reduction of premature beats was evident in 9/12 cases. Sinus node function, atrioventricular and intraventricular conduction, and the QTc interval did not vary significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

[Usefulness of morphoscillography for the prognosis of the duration of aorta-femoral bypass in complex ilio-femoral arteriopathies]

The work has the purpose to draw some prognostic indications and therapeutical directions in the aorto-iliac arteriosclerotic disease, with reference to the preoperative arteriographic and morphoscillographic reports. In the 94 patients, corresponding to 140 limbs operated on, it was possible to remark the progression in worsening of the sphygmic activity in the limbs segments goes along with a deterioration of the surgical results, and the prognosis is particularly severe when the minimum values of total vascular caliber are remarked at thighs.