Spinal gunshot wounds: A retrospective, multicenter, cohort study

INTRODUCTION AND OBJECTIVE

To describe the demographic and clinical characteristics and treatment of patients with spinal gunshot wounds across Latin America.

MATERIAL AND METHODS

Retrospective, multicenter cohort study of patients treated for gunshot wounds to the spine spanning 12 institutions across Latin America between January 2015 and January 2022. Demographic and clinical data were recorded, including the time of injury, initial assessment, characteristics of the vertebral gunshot injury, and treatment.

RESULTS

Data on 423 patients with spinal gunshot injuries were extracted from institutions in Mexico (82%), Argentina, Brazil, Colombia, and Venezuela. Patients were predominantly male civilians in low-risk-of-violence professions, and of lower/middle social status, and a sizeable majority of gunshots were from low-energy firearms. Vertebral injuries mainly affected the thoracic and lumbar spine. Neurological injury was documented in 320 (76%) patients, with spinal cord injuries in 269 (63%). Treatment was largely conservative, with just 90 (21%) patients treated surgically, principally using posterior open midline approach to the spine (79; 87%). Injury features distinguishing surgical from non-surgical cases were neurological compromise (P = 0.004), canal compromise (P < 0.001), dirty wounds (P < 0.001), bullet or bone fragment remains in the spinal canal (P < 0.001) and injury pattern (P < 0.001). After a multivariate analysis through a binary logistic regression model, the aforementioned variables remained statistically significant except neurological compromise.

CONCLUSIONS

In this multicenter study of spinal gunshot victims, most were treated non-surgically, despite neurological injury in 76% and spinal injury in 63% of patients.

Spinal gunshot wounds: A retrospective, multicenter, cohort study

INTRODUCTION AND OBJECTIVE

To describe the demographic and clinical characteristics and treatment of patients with spinal gunshot wounds across Latin America.

MATERIAL AND METHODS

Retrospective, multicenter cohort study of patients treated for gunshot wounds to the spine spanning 12 institutions across Latin America between January 2015 and January 2022. Demographic and clinical data were recorded, including the time of injury, initial assessment, characteristics of the vertebral gunshot injury, and treatment.

RESULTS

Data on 423 patients with spinal gunshot injuries were extracted from institutions in Mexico (82%), Argentina, Brazil, Colombia, and Venezuela. Patients were predominantly male civilians in low-risk-of-violence professions, and of lower/middle social status, and a sizeable majority of gunshots were from low-energy firearms. Vertebral injuries mainly affected the thoracic and lumbar spine. Neurological injury was documented in n=320 (76%) patients, with spinal cord injuries in 269 (63%). Treatment was largely conservative, with just 90 (21%) patients treated surgically, principally using posterior open midline approach to the spine (n=79; 87%). Injury features distinguishing surgical from non-surgical cases were neurological compromise (p=0.004), canal compromise (p<0.001), dirty wounds (p<0.001), bullet or bone fragment remains in the spinal canal (p<0.001) and injury pattern (p<0.001). After a multivariate analysis through a binary logistic regression model, the aforementioned variables remained statistically significant except neurological compromise.

CONCLUSIONS

In this multicenter study of spinal gunshot victims, most were treated non-surgically, despite neurological injury in 76% and spinal injury in 63% of patients.

Real-world survival of model-3501 subcutaneous implantable defibrillator lead

Funding Acknowledgements

Type of funding sources: None.

Background

In December 2020, the subcutaneous implantable cardioverter-defibrillator (S-ICD) lead model-3501 was subject to a safety notification because of increased risk of fracture at a location just distal to the proximal sense ring. The manufacturer’s product performance report currently reports a lead survival probability of 98.8% at 45 months. However, no multicenter long-term performance information exists for this lead.

Purpose

Our aim was to assess the longevity of model-3501 leads and to compare it with that of the previous model-3401.

Methods

This analysis included consecutive patients who received an S-ICD with a model-3501 or a model-3401 lead at 66 Italian participating centers of the Rhythm Detect registry. A lead failed if it required extraction/replacement because of abnormalities suggestive of a structural defect, e.g. out-of-range impedance, nonphysiological electrical noise or ineffective therapy.

Results

From January 2013 to July 2021, 2403 patients were implanted and followed up (78% male, age 49±15years, ejection fraction 45±16%, body mass index 26±4Kg/m2). A 3501-model lead was used in 1697 patients and a 3401-model in 706 patients. During a median follow-up of 38 months [25th–75th percentile: 24-55], we detected 4 malfunctioning model-3501 leads and 2 model-3401 leads. After analysis of the returned leads by the manufacturer’s technical services, a single model-3501 lead failure was a fracture distal to the proximal ring electrode, as described in the manufacturer’s advisory letter. No deaths or permanent injuries occurred as a result of lead failures. The survival of 3501-model leads at 4 years was 99.5% (95% confidence interval, 99.0 to 99.9) compared with 99.9% (95% confidence interval, 99.6 to 100.0) of 3401-model leads (p=0.110). The cumulative occurrence rate of the 3501-model safety notification fracture was 0.1% (95% confidence interval, 0.0 to 0.3).

Conclusions

In this large multicenter analysis, the survival probability of model-3501 S-ICD leads was in line with that reported by the manufacturer, was not significantly lower than that of 3401-model leads (not affected by a safety notification), and still higher than that reported with transvenous leads. Although an enhanced electrode is now available, which addresses the potential for electrode body fracture, the present findings are reassuring and may have significant implications for the management of patients who have affected leads.

Local impedance characteristics and advanced mapping capabilities to better understand pulmonary veins reconnections during repeat AF ablation procedures: insight from the CHARISMA registry

Background

Detailed characterization of pulmonary veins (PV) reconnection during repeat AF ablation through high-density mapping (HDM) and local impedance (LI) algorithm is still lacking.

Purpose

We aimed to characterize PV gaps and underlying electrical activity during and after ablation of PVs in AF patients (pts).

Methods

Consecutive patients (pts) undergoing redo AF ablation from the CHARISMA registry with complete characterization of PV gaps (PVG) at 8 Italian centers were included. Rhythmia mapping system was used to map the left atrium and PVs before and after ablation. LI characteristics were collected through a RF ablation catheter equipped with a dedicated LI algorithm (DirectSense). A novel map analysis tool (Lumipoint) that automatically identifies split potentials and continuous activation was used sequentially on each PV component, in order to better assess PVG. Each PVG was characterized in terms of LI and its variations during the procedure. Ablation endpoint was PVI as assessed by entrance and exit block.

Results

Fifty PVGs were automatically identified through the Lumipoint tool in 23 cases, mostly at anterior sites (21, 42%), followed by posterior (15, 30%) and carina (10, 20%) sites. One PVG was identified in 7 (28%) pts, 2 gaps in 10 (43.5%) pts and &gt;2 gaps in 6 (26.1%) pts. The mean LI at PVG sites was 111.3±12Ω prior to ablation: it was significantly higher than LI at scar tissue closer to PVG (99.3±8Ω, p&lt;0.0001) but was significantly lower than LI at healthy tissue (120.8±11Ω, p=0.0015). The mean linear extension of PVGs detected through Lumipoint was significantly lower than the one recognized through voltage map (11.5±8 mm vs 13.3±9 mm, p=0.01) whereas was comparable to the one identified through conventional activation map (11.8±7 mm, p=0.1161 vs Lumipoint). Complete identification of the whole area of PVG was achieved in 31 (62%) and 42 (84%) cases through voltage and activation map, respectively whereas the identification was only partial in 18 (36%) and 7 (14%) cases, respectively. In 1 case both voltage and activation map failed to identify a PVG. No complications during the procedures were reported. All PVs were successfully isolated in all study pts.

Conclusion

Advanced mapping capabilities were useful to pinpoint the search for PVGs, enabling a more targeted ablation approach vs relying on voltage mapping. LI values correlated well with PVGs characteristics and they significantly differ from both scar and healthy tissue.

Funding Acknowledgement

Type of funding sources: None.

Are Dynamic Arterial Spin-Labeling MRA and Time-Resolved Contrast-Enhanced MRA Suited for Confirmation of Obliteration following Gamma Knife Radiosurgery of Brain Arteriovenous Malformations?

BACKGROUND AND PURPOSE

Intra-arterial DSA has been traditionally used for confirmation of cure following gamma knife radiosurgery for AVMs. Our aim was to evaluate whether 4D arterial spin-labeling MRA and contrast-enhanced time-resolved MRA in combination can be an alternative to DSA for confirmation of AVM obliteration following gamma knife radiosurgery.

MATERIALS AND METHODS

In this prospective study, 30 patients undergoing DSA for confirmation of obliteration following gamma knife radiosurgery for AVMs (criterion standard) also underwent MRA, including arterial spin-labeling MRA and contrast-enhanced time-resolved MRA. One dataset was technically unsatisfactory, and the case was excluded. The DSA and MRA datasets of 29 patients were independently and blindly evaluated by 2 observers regarding the presence/absence of residual AVMs.

RESULTS

The mean time between gamma knife radiosurgery and follow-up DSA/MRA was 53 months (95% CI, 42-64 months; range, 22-168 months). MRA total scanning time was 9 minutes and 17 seconds. Residual AVMs were detected on DSA in 9 subjects (obliteration rate = 69%). All residual AVMs were detected on at least 1 MRA sequence. Arterial spin-labeling MRA and contrast-enhanced time-resolved MRA showed excellent specificity and positive predictive values individually (100%). However, their sensitivity and negative predictive values were suboptimal due to 1 false-negative with arterial spin-labeling MRA and 2 with contrast-enhanced time-resolved MRA (sensitivity = 88% and 77%, negative predictive values = 95% and 90%, respectively). Both sensitivity and negative predictive values increased to 100% if a composite assessment of both MRA sequences was performed. Diagnostic accuracy (receiver operating characteristic) and agreement (κ) are maximized using arterial spin-labeling MRA and contrast-enhanced time-resolved MRA in combination (area under receiver operating characteristic curve = 1, P < .001; κ = 1, P < .001, respectively).

CONCLUSIONS

Combining arterial spin-labeling MRA with contrast-enhanced time-resolved MRA holds promise as an alternative to DSA for confirmation of obliteration following gamma knife radiosurgery for brain AVMs, having provided 100% sensitivity and specificity in the study. Their combined use also enables reliable characterization of residual lesions.

Are body mass index and age independent risk factors for new-onset atrial fibrillation after cardiac surgery regardless of left atrial size and left ventricular ejection fraction value?

Background

Obesity, advanced age and left atrium dimensions have been linked to atrial fibrillation (AF).

Purpose

This study aimed at evidencing if the above mentioned risk factors have a role among the others in conditioning the onset of post operative AF (PoAF) in patients undergoing cardiac surgery without previous AF.

Methods

This study evaluated 249 consecutive patients undergoing coronary artery by-pass surgery either isolated or in combination with aortic or mitral valve repair/replacement, or isolated valve repair/replacement. Prior to surgery, in all patients the following data were collected: age (yrs), body mass index (BMI, kg/m2), left atrium (LA) diameter (cm), LA area (cm2), left ventricular ejection fraction (LVEF, %), the presence/absence of arterial hypertension (AH) and diabetes, creatinine (mg/dL). To detect the presence of PoAF, cardiac rhythm was continouosly recorded during the first seven postoperative days.

Results

PoAF occurred in 127 patients (51%). We compared patients with and without PoAF. Mean values (±1 SD) of continuous variables and the frequency of dicothomic ones are reported in the table. No difference was observed for sex, LA diameter, LA area, LVEF and diabetes. Instead, patients with PoAF had higher values of age, BMI, creatinine and a greater prevalence of AH. According to multivariable binary logistic analysis the independent predictors of PoAF were: age (OR = 1.05, CI 95%: 1.026–1.074, p=0.018) and BMI (OR = 1.09, CI 95%: 1.015–1.171, p=0.0001).

Conclusions

Results suggest that advanced age and a higher value of BMI could be strong risk factors for PoAF in patients who undergo cardiac surgery without previous AF. This considering that in the present population the values of LA diameter, LA area and LVEF showed no statistically significant difference between patients with and without PoAF.

Funding Acknowledgement

Type of funding source: None

New competences to manage Urban Health: Health City Manager core curriculum

Health as a common good is a prior essential objective to be pursued by an alliance including citizens and local administrations. Role of cities in health promotion is emphasized by urbanization, entailing 70% of the global population living in urban areas. Cities are therefore perfect laboratories within which to act: studying and monitoring dimensions that determine the level of quality of life in cities, improving their sustainability and capacity for growth, is fundamental for a new governance model able of managing this complexity. Under the premises, the Health City Manager (HCM) has been launched, a professional gaining skills in PH management, sociology of communities, urban design and control in reducing health inequalities. A course lasting 80 hours gives then the opportunity to put into practice, at municipal level, knowledge, competences and abilities achieved. In the background, both the former EU Commissioner for Health and the Committee of the Regions warmly supported the establishment of HCMs, who would coordinate a process ensuring alignment of policies on a macro and micro scale. During G7 in 2017, Ministry for Health and Presidency of Italian Municipalities signed the Urban Health Rome Declaration, underlining the need for a stronger synergy facilitated by HCMs. In 2019, Ministry of Youth and Sport approved and financed the project. On the basis of a core curriculum, validated by a group of experts, the course is starting in 2020 for the first 120 HCMs. Innovation lies in the holistic approach, a multidisciplinary project managing method overcoming silos logic. Customization of public policies and participatory process make the figure ideal to be applied in all countries. Sustainability is ensured by a relatively high return on investment. Main impact relates to improvement of the quality of life through a full involvement and accountability of local administrations; contrast of climate change identifying strategies of urban resilience.

Key messages

Improvement of the quality of life through a full involvement and accountability of local administrations. Contrast of climate change identifying strategies of urban resilience.

P1149Subcutaneous implantable cardioverter-defibrillator when Transvenous ICD is not a viable option

Funding Acknowledgements

NO FUNDING

OnBehalf

RHYTHM DETECT Registry

Background

The class of recommendation for S-ICD implantation in patients who have inadequate vascular access is I according to AHA-ACC-HRS Guidelines and IIb according to ESC Guidelines. Data are lacking about the use of S-ICD for patients in which a transvenous ICD is not a viable option because of the inability to deploy a transvenous lead.

Purpose

To describe current practice and to measure outcomes associated with S-ICD use in patients in which a transvenous ICD is not a viable option.

Methods

942 consecutive patients underwent S-ICD implantation at 22 Italian centers from 2014 to 2019. We identified 101 (11%) patients who received S-ICD because of the reported impossibility of deploying a transvenous lead.

Results

21 patients presented with inadequate vascular access but no previous device in place. One patient had a mechanical prosthesis in tricuspid position. The remaining 79 patients received the S-ICD after removal of a prior system implanted, and venous occlusion was diagnosed after lead extraction, or partially or completely failed lead removal. In 24 of these patients a functional transvenous pacing system was left in place for persisting pacing needs. Patients were 60 ± 15 years old, 85% were male, 77% had ischemic or non-ischemic dilated cardiomyopathy, ejection fraction was 36 ± 13%. At implantation, acute conversion test was performed in 64 patients and shock energy of ≤65J was successful in 62 (96.9%) patients. During a median follow-up of 18 months, 6 patients died for non-device related reasons and 1 patient underwent heart transplantation. One patient underwent device replacement for battery depletion and one patient underwent leadless pacemaker implantation. Minor complications (hematomas not requiring system revision) were reported in 2 patients. Appropriate therapies were delivered in 4 patients and 8 patients experienced inappropriate therapies (in 3 patients due to double counting during pacing); all resolved with device reprogramming. Conclusions: In current clinical practice, a minority of S-ICD patients receive the device because of inadequate vascular access. The profile of these patients is similar to that of the typical ICD population in the context of primary sudden death prevention, but many of them present with pacing indications. Acute and mid-term efficacy of S-ICD seemed high. Few complications occurred during follow-up. Particular attention must be paid to device programming for those patients with concomitant pacing systems, in order to prevent inappropriate therapies.

67Atrial fibrillation and depressive symptoms in the elderly: an association with age, CHA2DS2-VASc score and physical performance

Background. Atrial fibrillation (AF) is the most frequent sustained arrhythmia found in clinical practice. Its prevalence significantly grows with age. The proportion of elderly individuals with depression varies between 4.2 and 10.6% according to the different criteria used for diagnosis. Interestingly, AF and depression synergistically act to increase mortality.

Purpose. Aim of this study was to identify the clinical variables associated with depressive symptoms in elderly individuals with persistent AF.

Methods. All patients consecutively admitted in a Day-Hospital setting to undergo electrical cardioversion of AF were enrolled in the study. No exclusion criteria were specified. Population was studied with instruments exploring neurocognitive performance (Mini-Mental State Examination - MMSE; range: 0-30; abnormal values &lt;27) and functional status (Short Physical Performance Battery; range: 0-12; abnormal values &lt;10). With these tools, a better condition is expressed by higher scores. The presence of depressive symptoms was assessed with the Geriatric Depression Scale (GDS; 15-item form; abnormal values &gt;5). In this case, lower scores identified a healthier emotional profile.

Results. Between January 2018 and August 2019, 111 patients were evaluated (age: 77 ± 9 years; women: 39.6%; weight: 78 ± 15 Kg; height: 171 ± 11 cm). Lone AF and brady- tachy- syndrome were diagnosed in 12.6% of cases. Hypertension and structural heart disease (coronary artery disease, heart failure, valvular heart disease) were responsible of the arrhythmia in 30.6% and 56.8% of patients, respectively. Left ventricular ejection fraction was 60 ± 12%, with a heart rate equal to 78 ± 17 bpm. MMSE and SPPB score were 28 ± 3 and 8.7 ± 2.9. An abnormal GDS score was observed in 19.8% of cases (mean: 3.0 ± 2.7). Interestingly, in univariate analysis, depressive symptoms increased with age (p = 0.002) and the CHA2DS2-VASc score (&lt; =2: 1.3 ± 1.7; 3: 1.9 ± 2.3; 4: 3.9 ± 3.2; 5: 4.0 ± 2.4; &gt; =6: 4.4 ± 2.8; p &lt; 0.001), and were inversely related to MMSE (p = 0.004) and SPPB (p &lt; 0.001). The type of oral anticoagulation (NOACs: 64.0%) did not exert any effect on GDS score (VKA: 3.2 ± 2.2 vs. NOACs: 3.0 ± 3.0; p = 0.717). In multivariate analysis (R = 0.711; p &lt; 0.001), depressive symptoms were higher in those who lived alone (+1.35 ± 0.48; p = 0.007) and were taking a renin-angiotensin system blocker (+0.93 ± 0.43; p = 0.032). Age (-0.07 ± 0.03 per year; p = 0.026), height (-0.09 ± 0.03 per cm; p = 0.001), glomerular filtration rate (-0.03 ± 0.01 per mL/min; p = 0.013) and SPPB (-0.39 ± 0.09 per each point; p &lt; 0.001) were inversely associated with GDS.

Conclusions. In a population of elderly patients with persistent AF, the prevalence of depression is not negligible. Importantly, depressive symptoms are significantly associated with the CHA2DS2-VASs score, and, at multivariate analysis, with renal function, to live alone and physical performance. Paradoxically, after adjustment for these factors, GDS score decreases with age per se.

P1765 Cardiac myxomas: echocardiographic findings and clinical correlation, a 15-years single-center experience

Background

Cardiac myxomas, the most frequent primary benign cardiac tumours, are in some cases lethal due to impaired cardiac dynamics and thromboembolic potential. When tumors are diagnosed and surgically resected in a timely manner, they lose their deleterious potential and patients are cured, except for rare cases of recurrence.

Purpose

We sought to describe the association of clinical presentation, course and echocardiographic findings, dividing myxomas on the basis of location, morphology, size, mobility, echocardiographic appearance.

Methods

We reviewed the medical records and retrospectively analyzed the transthoracic echocardiograms of 51 patients (31female, aged 63 ± 14), who underwent cardiac surgery and were diagnosed at histology with myxoma, between 2004 and 2019. Myxomas were classified according to their location (typical when attached to the interatrial septum in the left side, or atypical), diameters, shape (solid and round shape, or irregular and multilobulated), echocardiographic appearance (homogeneous or heterogeneous), mobility (high mobile pedunculated, or nonmobile), obstruction (no or impaired mitral/ tricuspid dynamics). Depending on symptoms patients were referred to emergency or elective surgery.

Results

In 28 patients (55%) myxomas were incidental echocardiographic findings (Figure 1 A), 23 patients (45%) reported symptoms at presentation (dyspnea in 15 cases, embolic symptoms in 5 cases, syncope in 3 cases) (Figure1 B). A total of 41 myxomas (80%) were tipically located on the interatrial septum in the left side, followed by the left atrium (5 patients,10%), the right atrium (4 patients, 8%) and the tricuspid valve (1 patient).

Symptoms were associated with large size (41 ± 15 mm vs 29 ± 15 mm, p = 0.004 ), high mobility (76% vs 24%, p&lt; 0.001, ), obstruction (75% vs 25%, p = 0.004), heterogeneous aspect (75% vs 25%, p = 0.006) and were not related to location and shape. A maximum diameter &gt; 39 mm distinguished patients with or without symptoms.

In patients with symptoms surgery was based only on echo. In the other cases cardiac CT (20 cases) or MRI (8 cases) was performed.

All patients received a complete surgical resection, recurrency was observed in one case.

Conclusions

Clinical presentation relates to the ultrasound characteristics of myxomas: small, non mobile, homogeneous lesions probably benefit of elective surgery. Large size, high mobility, heterogeneous aspect and impaired valves dynamics correlate with symptoms at presentation and emergency surgery is mandatory.

Abstract P1765 Figure 1

Healthcare costs and outcomes: a value-based assessment tool for Clinical Governance

Issue/problem

Health systems sustainability is a critical public health issue. A value-based approach is essential to improve patient-centeredness, appropriateness, quality and funding allocation in healthcare.

Description of the problem

This project was aimed to develop an innovative transferable tool to assess value-based activities in Hospital by monitoring care pathways costs and outcomes. Main questions were to: assess cost and outcome variance in homogeneous groups of patients; evaluate clinical activities contribution to the hospital budget; identify and monitor critical points. In 2018 a Business Intelligence system fed by different Hospital datasets was developed and tested in a Teaching Hospital in Rome to quantify and integrate data on pathways efficacy and costs. It was based on an algorithm of 20 indicators related to Women and Child Care Pathways.

Results

Preliminary results showed a great variance for the same intervention/procedure concerning length of stay (3-8 days), waiting times (1-4 days), innovative technologies costs (2000-6000€) and obsolete reimbursement rates (2000-5000€) that do not guarantee adequate economic contribution margins. Improvement actions were defined concerning pathways’ workflow and organizational appropriateness. The need for negotiations with Ministry of Health was highlighted, aimed to update reimbursement rates.

Lessons

The tool, built on a value-based process view, allowed analyzing online outcomes and costs data aggregated by path, benchmarking results, identifying critical issues and providing improvement solutions. It turned out to be an innovative methodology - also applicable in other settings/countries - to trigger changes in health management and pursue quality and efficiency in healthcare.

Key messages

Value-based healthcare is the new public health paradigm. Assessing simultaneously Hospital costs and outcomes is a valuable way to derive overall healthcare value, improve quality and rationalize resources allocation.

P6556Prevention of long-lasting atrial fibrillation through device therapy in dual-chamber pacemakers: analysis on 1384 patients of the role of Reactive ATP and atrial preventive pacing

Background

Atrial fibrillation (AF) is the most prevalent heart rhythm disorder in clinical practice and it is associated with poor quality of life and increased risks of heart failure, dementia, stroke, and death. Moreover AF management is a huge cost for healthcare systems. AF is irregular, typically originates from the pulmonary veins, and as such, requires cardioversion to terminate persistent episodes. AF is not susceptible to pace-termination, however, the MINERVA trial has shown that AF may transform in slower organized rhythms such as atrial flutter or atrial tachycardia, which can often be terminated by atrial anticahycardia pacing (ATP); in particular by Reactive ATP, a specific ATP feature which can be re-armed when atrial arrhythmias get slower or more regular. The MINERVA trial showed that the combination of ATP, preventive atrial pacing algorithms and minimal ventricular pacing (MVP) was associated with lower progression to persistent and permanent AF, compared with standard DDD pacing mode and to MVP mode, in pacemaker patients with clinical history of AF.

Purpose

We aimed to confirm MINERVA trial results in real-world clinical practice and to evaluate whether AF prevention was associated with preventive atrial pacing or solely with ATP. Indeed in our project atrial preventive pacing algorithms were not enabled and the pacing mode (DDD or MVP) was chosen according to patients' AV conduction characteristics.

Methods

Consecutive dual-chamber pacemaker patients with sinus node disease and device detected AT/AF were prospectively followed by 30 Italian cardiologic centers in an observational research. Clinical and device data were collected and reviewed by expert cardiologists to assess AT/AF occurrence through in clinic visit and/or remote transmissions of device data.

Results

A total of 239 patients (73 years old, 56% male) wearing a dual-chamber pacemaker with Reactive ATP were included in the project, followed for a median observation period of 13 months and compared with 1145 patients included in the MINERVA trial followed for a median observation period of 34 months and programmed with DDD pacing mode (383 patients), MVP (389 patients) and MVP+Reactive ATP+preventive algorithms (373 patients). As shown in the following figure incidence of 7 consecutive days of AF in the patients treated by DDD/MVP+Reactive ATP in real-world clinical practice was very similar to that found in the MINERVA trial arm programmed with MVP+Reactive ATP+preventive algorithms.

Incidence of AF longer than 7 days

Conclusions

Our analysis performed in a population of sinus node disease patients with dual-chamber pacemakers confirmed MINERVA trial results in terms of prevention of long-lasting AF episodes. In particular these results confirm the benefit associated with the use of Reactive ATP, rather than preventive atrial pacing algorithms.

P3746Temporal patterns of premature atrial contractions predict atrial fibrillation occurrence in bradycardia patients continuously monitored through pacemaker diagnostics

Background

The frequency of premature atrial complexes (PACs) has been indirectly related with atrial fibrillation (AF) occurrence and adverse outcomes.

Objective

To evaluate whether temporal patterns of PACs are directly associated with AF onset in pacemaker patients with continuous monitoring of the atrial rhythm.

Methods

Overall, 193 pacemaker patients (49% female, 72±9 years old), enrolled in a national registry, were analyzed. Frequency of daily PACs was measured in a 14-day initial observation period, during which patients were in sinus rhythm. In the following period, temporal occurrence and frequency of daily PACs and eventual onset of AF were derived by pacemaker diagnostics.

Results

In the run-in period, median PACs frequency was 614 PACs/day (interquartile range=70–3056). Subsequently, in a median follow-up of 6 months, AF occurred in 109 patients, in particular in 37/96 (38.5%) patients with a PAC rate<614 PACs/day and in 72/97 (74.2%) patients with PAC rate≥614 PACs/day (p<0.001). In patients with AF occurrence, the number of daily PACs, normalized by dividing for the average of PACs in 10 preceding days, progressively increased in the 5–6 days preceding AF (Figure). Cox Model predictive analysis showed that the risk of AF was significantly higher in patients with a relative increase of the daily PACs higher than 30% compared with PACs average number in 10 preceding days (hazard ratio (95% confidence interval) = 3.67 (2.40–5.59), p<0.001).

PACs changes daily trend before AF

Conclusion

PACs frequency increases in the 5–6 days preceding AF onset. A relative increase of the daily PACs is significantly associated with the risk of AF occurrence.

P5688Is renal dysfunction associated with the outcome of CRT patients?

Background

The benefit of cardiac resynchronization therapy (CRT) in patients (pts) with chronic kidney disease (CKD) remains controversial despite frequent use. Pts with impaired renal function have systematically been excluded from randomized clinical trials and therefore specific recommendations for the use of CRT in these pts are still lacking.

Purpose

Study objectives were to assess long-term outcomes and clinical/echocardiographic response in a large population of patients with moderate-to-severe impaired renal function implanted with a CRT device in accordance with the current standard of care.

Methods

We prospectively analyzed clinical, instrumental data and survival of pts with CKD who received a CRT device in the CRT-MORE registry from 2011 to 2014. Adverse events for the analysis of clinical outcome comprised death from any cause and nonfatal HF events requiring hospitalization after CRT implantation. LV reverse remodeling and Clinical Response (CR) were also evaluated at 12-month follow-up. Patients were stratified according to current definition of CKD stage: low-moderate CKD with a GFR = 45–59 mL/min (stage 3A); moderate CKD with a GFR = 30–44 mL/min (stage 3B) and severe CKD with a GFR = 15–29 mL/min (stage 4).

Results

Of the 922 consecutive patients enrolled in the registry, 416 (45%) pts had a moderate-to-severe impaired renal function (43% Stage 3A, 43% Stage 3B and 14% Stage 4). The mean follow-up was 935±506 days. By the end of the study, 85 pts had died and 47 pts had been hospitalized for HF. The combined end-point of death or HF hospitalization was reached by 121 (29%) pts. After 12 months the absolute LVEF improvement was greater than 10% in 37% of pts and 58% of pts displayed a positive clinical response. The percentage of pts who died was higher in the group of pts with severe CKD (32.8% vs 18.4%; p=0.012, compared to the group of pts with moderate CKD). On the contrary the percentage of pts who had at least one HF hospitalization was lower in the group with more severe CKD (2% vs 13%; p=0.011). According to CKD stage both LV remodeling (LVEF improvement ranging from 43.7% - 3A - to 30.8% - 4) and CR (positive response ranging from 63.9% - 3A - to 50% - 4) were higher in low-moderate stage and decreased with CKD severity. At multivariate Cox regression analysis adjusted for baseline confounders, CKD class at implantation [HR=1.5; 95% CI: 1.06–2.14; p=0.0219], chronic obstructive pulmonary disease [HR=1.89; 1.18–3.01; p=0.0077], persistent/permanent AF [HR=1.86; 1.15–3.01; p=0.0115] and male gender [HR=1.92; 1.07–3.46; p=0.0301] remained associated with death.

Conclusions

Among CKD patients in the CRT-MORE registry, severity of renal dysfunction at the time of CRT implantation was associated with worse prognosis, lower clinical response and LV reverse remodeling.

Acknowledgement/Funding

None

Evaluation of pain, swelling and trismus after extraction of impacted third molars relative to the use of betamethasone in submucusal infiltration

The aim of this study was to evaluate the anti-inflammatory effect of a single 4 mg injection of submucosal betamethasone after extraction of impacted third molars. Single-centre, single-blinded, parallel group study; Forty-three patients were submitted to impacted third molar extraction. In this study, 4 mg single-dose submucosal betamethasone was injected in the interventional group, while in the control group nothing was injected. Postoperative measurement included pain via the VAS scale, swelling and trismus with facial measurements and maximum mouth openings, and finally nerve sensitivity. There was a significant difference between the two groups regarding trismic pain and edema. The use of a single 4 mg submucosal betamethasone injection leads to a reduction of oedema, trismus and pain in patients undergoing impacted third molar extraction. .

Efficacy of the Andresen activator before peak growth in class II patients

Andresen activator (AA) is a functional appliance used to correct Class II malocclusion in growing patients. It corrects the malocclusion stimulating mandibular growth and determining a palatoversion of the upper incisors and a vestibularization of the lower incisors. The aim of this study was to analyze the treatment efficacy of class II malocclusion due to mandibular hypodevelopment before peak growth. Fourteen subjects with class II relationship of the skeletal bases and cervical vertebrae maturation stage 1 or 2 were enrolled in the study. Cephalometric analyses were carried out using landmarks derived from the analyses of Pancherz, Ricketts, Tweed and Steiner. A significant decrease (P less than 0.05) in ANB angle was found (-2.29±3.05°) after treatment, which was expression of an improvement in maxillo-mandibular sagittal skeletal relationships. There was also a significant reduction of OJ after treatment (-4.44±2.36 mm; P less than 0.001), indicating a vestibularization of the mandibular incisors and a palatoversion of the maxillary incisors, and a correction of the molar relationship. The favorable effects of the Andresen activator for the correction of the mandibular defect can be found even prior to peak growth; the achieved class I relationship maintains a correct mandible position in time, ensuring a proper skeletal growth. .

Tooth agenesis: part 2. Orthodontic treatment and prosthetic possibilities

Dental agenesis has a great clinical significance due to its frequency during daily practice and the therapeutic problems that can arise from it. This paper will explore all the aspects to consider in order creating a proper multidisciplinary treatment plan: in particular, orthodontic, prosthetic and implantologic therapeutic alternatives are described for the rehabilitation of the different areas of the dental arches. In fact, dental agenesis is a problem that often requires the intervention of specialists from the different fields of dentistry and its treatment must meet aesthetics needs, stomatognathic function and patient satisfaction.

Tooth agenesis: part 1. Incidence and diagnosis in orthodontics

Dental agenesis has a great clinical significance due to its frequency during daily practice and the therapeutic problems that can arise from it. This paper will explore the incidence of dental agenesis, its diagnosis and how this anomaly affects the teeth differently. The second subsequent paper will look at its treatment and management.

Piezoelectric surgery inserts vs conventional burst: a clinical investigation

Piezosurgery is a new technique that can be used to cut mineralized structures without damaging adjacent soft tissues. This device has a lot of advantages: reduced surgical time, blood loss, and inferior alveolar nerve injury in bimaxillary osteotomy. Fifty patients underwent different surgical operations (orthognathic surgery, traumatic surgery, reconstructive surgery, aesthetic procedures) with 7 different kind of piezosurgery inserts in a period of 8 months. The same two surgeons performed all the procedures. All the procedures were carried out in order to improve the precision of the osteotomy and the comfort of the surgeon. Piezoelectric devices provide an innovative ultrasonic technique for safe and effective osteotomy compared with methods that use rotating instruments. Different inserts have been developed in order to achieve the utmost advantages.

Iatrogenic traumatic optic neuropathy: report of an injury occurring during a choanal atresia correction surgery treatment

We report the case of a 36-year-old adult male patient who came to our attention for the evaluation of a possible iatrogenic injury suffered during the surgical correction of congenital choanal atresia. This case report retraces the patient's medical history and the events lapsed in the peri-operative time analyzing if any malpractice has occurred in causing the amaurosis.

Epidemiology of essential hypertension: the role of genetic polymorphism

Over the past 20 years, the interest of the scientific community was increasingly placed in the field of genetic epidemiology and molecular genetics of blood pressure control. This paper explores references related to essential hypertension, gene and genetic epidemiology indexed in the MedLine health science database during the period 1980-2001. A systematic literature search was performed using selected keywords, such as 'genetic', 'genome' or a combination of words. We considered the study heading and evaluated the time profile of published articles. A total number of 3116 publications was collected and analyzed. Allelic distribution for the most studied polymorphisms of the renin-angiotensin system in different world populations was reviewed and reported together with a detection of their frequency in Italy: essential hypertensive patients (n = 90), healthy unrelated subjects (n = 300). Molecular variants at angiotensinogen (M and T), angiotensin II type 1 receptor (A and C) and angiotensin-converting enzyme (D and I) genes were analyzed by amplified fragment length polymorphism. A significant association was detected by chi2 analysis for angiotensinogen and angiotensin II-type I receptor allele distribution in hypertensive patients, in accordance with previous reports. Genetic data and methods are contributing more and more to epidemiological studies of complex diseases, and their application is influenced by information availability and Genome Project results.

Speed and accuracy in nest-mate recognition: a hover wasp prioritizes face recognition over colony odour cues to minimize intrusion by outsiders

Social insects have evolved sophisticated recognition systems enabling them to accept nest-mates but reject alien conspecifics. In the social wasp, Liostenogaster flavolineata (Stenogastrinae), individuals differ in their cuticular hydrocarbon profiles according to colony membership; each female also possesses a unique (visual) facial pattern. This species represents a unique model to understand how vision and olfaction are integrated and the extent to which wasps prioritize one channel over the other to discriminate aliens and nest-mates. Liostenogaster flavolineata females are able to discriminate between alien and nest-mate females using facial patterns or chemical cues in isolation. However, the two sensory modalities are not equally efficient in the discrimination of 'friend' from 'foe'. Visual cues induce an increased number of erroneous attacks on nest-mates (false alarms), but such attacks are quickly aborted and never result in serious injury. Odour cues, presented in isolation, result in an increased number of misses: erroneous acceptances of outsiders. Interestingly, wasps take the relative efficiencies of the two sensory modalities into account when making rapid decisions about colony membership of an individual: chemical profiles are entirely ignored when the visual and chemical stimuli are presented together. Thus, wasps adopt a strategy to 'err on the safe side' by memorizing individual faces to recognize colony members, and disregarding odour cues to minimize the risk of intrusion from colony outsiders.

QCD and strongly coupled gauge theories: challenges and perspectives

We highlight the progress, current status, and open challenges of QCD-driven physics, in theory and in experiment. We discuss how the strong interaction is intimately connected to a broad sweep of physical problems, in settings ranging from astrophysics and cosmology to strongly coupled, complex systems in particle and condensed-matter physics, as well as to searches for physics beyond the Standard Model. We also discuss how success in describing the strong interaction impacts other fields, and, in turn, how such subjects can impact studies of the strong interaction. In the course of the work we offer a perspective on the many research streams which flow into and out of QCD, as well as a vision for future developments.