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.

C6 IN VIVO CHIARI NETWORK REMOVAL. COMPLICATION OR INNOCENT SURPRISE

A 78 years old man was admitted to our hospital because of a syncope and evidence of complete AV– block, low ventricular rate and suitable for definitive PM implantation. He had no other pathologies or previous surgical interventions. A transthoracic echocardiography was performed and any particular structural anomaly was detected and the left ventricular ejection fraction was normal. In the electrophysiology laboratory, a vascular access through the left axillary vein was used to insert a passive fixation catheter for the right ventricular using a 9 F sheath. When the ventricular lead reached the right atrium it was impossible to advance it farther into the right ventricle; the lead was blocked near tricuspid anulus without any possibility to move it towards any direction despite many and vigorous manual traction maneuvers were attempted. Immediately, a transesophageal echocardiography was performed and it showed the lead entrapment into a mobile structure, likely a Chiari network.The patient needed a PM implantation as soon as possible and also a temporary PM could further complicate the procedure. Since the hospital did not have a cardiac surgery department and our crew was not familiar with lead extractions, an expert hemodynamist, who suggested to remove the lead by using a snare, was consulted. The tip of the lead was stuck in the atrial wall so it was impossible to capture it as expected. So, from right femoral vein access, a 6F pig–tail catheter was inserted through a a 45 cm– 8 F Terumo Destination sheath in order to give more stability to the pig–tail catheter until it hooked the lead. A 0.035 mm normal hydrophilic Terumo wire was later passed into the pig–tail catheter, snared and externalized with an AndraSnare 25 catheter inserted through another 6F introducer. A vigorous traction was performed simultaneously pulling both the ends of the wire from the bottom and the lead from the top. After a few seconds, the lead was unstuck and removed from the axillary vein [Fig. 1a,b]. At the external examination, the tines of the lead were found attached to a net–like structure that was actually the Chiari network that had been completely removed from the atrium [Fig 2–3]. A transthoracic echocardiogram ruled out any pericardial effusion. The anatomical finding was sent to tissue analysis and was confirmed to be the tendon material. After that the patient was immediately implanted with a VDD PM without any complications, and dismissed after 2 days.

P2882Sustainable organization of a management model for CIED remote control: data from a single tertiary center

Introduction

The remote control (RC) of CIED has become necessary, though the human resources and technical facilities needed are limited. In most of Centers, the ratio of RC CIED /CIED with in-office follow up, is continuously increasing and is expected to reach the 100% of CIED remotely controlled.

We sought assess an organizational model based on available facilities and a long-term projection of RC data burden. Pacemakers, ICD and implantable loop recorders were considered.

Methods

The total population served by the Hospital area has been obtained (271.260 citizens), timed at December 31st 2014. By checking our Hospital data files, the total number of followed up CIED patients timed at January 1st 2011 (3995; 1.47% of all population), was compared with the same data timed at January 1st 2015 (3902; 1.43% of all population), in order to the check for the “stability” of that data over time.

At the analyzed time 1582/3902 (40,5%) of CIED were followed by RC.

We have then considered an yearly average of 465 CIEDs implanted/replaced (yearly implants 2012 to 2015) and excluded a roughly 10% of them because not provided of RC facilities (unwilling patients or CIED not RC “ready”); all the other patients were provided with RC. On these basis, we can assume a ratio of RC CIEDs /non-RC CIED, deemed to increase by 10 to 11% per year, to reach the break-even of 100% of RC CIEDs, in 2021 (projection).

The number of RC transmissions (Tx) have been gathered in 5 types of events (Fig. left upper).

The timing of RC patient managing from opening the CIED web site to complete patient file assessment (RC file analysis) performed by expert nurses, was arbitrarily calculated over a sample of 10 Tx per day in 3 different days.

Results

Of 3902 CIED patient, 1582 (40.5%) were RC followed up (3261 pacemakers, 594 ICDs and 47 implantable loop recorder); the CIED brands were represented as follows: Medtronic 685 (43.3%); St. Jude 180 (11.4%), Boston Sc. 330 (20.8%), Biotronik 318 (20.1%) and Livanova (previously SorinGroup) 69 (4.4%).

During the year 2015 we received a total number of 10396 Tx: 128 (1.2%) red alert; 1944 (18.6%) yellow alert, 141 (1.3%) atrial fibrillation; 403 (3.9%) lost Tx (disconnected transmitters or un-compliant patients for remote interrogation) and 7780 (75%) Tx “OK” with NO events. (Fig. right upper).

The projection model at 2021 with 100% RC patients (break-even) shows a total 25990 Tx: 320 red alert; 1944 yellow alert, 352 atrial fibrillation; 1007 lost Tx and 19459 Tx “OK”. The 2021 monthly Tx would be 2320 (26 red alert; 405 yellow alert, 29 atrial fibrillation; 91 lost Tx and 1769 (75%) Tx “OK”) (Fig. both lower panels)

The RC file analysis was roughly calculated around 3 minutes (116 hours/month); 5.8 hours/business day (Monday–Friday).

Conclusion

The rate of RC followed up CIEDs will inexorably increase by time. The projection management model presented could help to build a sustainable organization.

Activation mapping to determine the mechanism of atrial tachycardia when pacing techniques are not feasible

AIM

Atrial tachycardia/flutter (ATAF) could be sustained by a focus or a reentry circuit, which mapping differs significantly. Entrainment mapping is widely used to detect reentry, but it is not always feasible. We evaluated an activation mapping protocol to differentiate macro, micro-reentrant and focal ATAFs.

METHODS

Among 454 patients who underwent ablation for supraventricular tachycardia (SVT) between December, 2004 and August, 2008, 52 ATAF patients were selected and assessed by means of activation mapping (study mapping protocol). The remaining 402 cases (AVNRT, AVRT, and common atrial flutter) were excluded.

RESULTS

Fifty-eight ATAF morphologies were mapped (mean CL 297.2±98 ms). The protocol identified the ATAF mechanism in 53/58 (91%, 52 successfully ablated) morphologies, while the mapping technique failed in 5/58 (9%) cases/patients. Among the 53 ATAF diagnoses, 25/53 (47%) were macroreentrant ATAFs (MATs), whereas 12/53 (23%) were focal ATAFs (FATs) or microreentrant ATAFs (MIATs) (16/53, 30%). Ablation was successful in 25/25 cases of the MAT group, in 11/12 (91.7%) cases of the FAT group, and in 16/16 cases of the MIAT group. At the end of the procedure, no ATAF was inducible in 44/52 (85%) patients. The study protocol was successfully validated in 20 patients (10 with AVNRT, and 10 with common atrial flutter) of the control group. After a mean follow-up of 21.5±12.5 months, 36/52 (70%) pts resulted free from ATAF. Non-inducibility predicted long-term freedom from ATAF (92.1 % vs. 60 %, P=0.005, OR 0.09; 95% CI 0.18-0.51, P=0.006).

CONCLUSION

Activation mapping alone may be reliable to determine the ATAF mechanism, especially when pacing techniques are not feasible.

Long term follow up of radiofrequency catheter ablation of atrial flutter: clinical course and predictors of atrial fibrillation occurrence

OBJECTIVES

To evaluate the time to onset and the predictors of atrial fibrillation (AF) during long term follow up of patients with typical atrial flutter (AFL) treated with transisthmic ablation.

DESIGN

Prospective multicentre study.

METHODS AND RESULTS

383 patients (75.4% men, mean (SD) age 61.7 (11.1) years) who underwent transisthmic ablation for typical AFL were investigated. In 239 patients (62.4%) AF was present before ablation. Ablation proved successful in 367 patients (95.8%). During a mean (SD) follow up of 20.5 (12.4) months, 41.5% of patients reported AF. The cumulative probability of postablation AF increased continuously as time passed: it was 22% at six months, 36% at one year, 50% at two years, 58% at three years, and 63% at four years.

CONCLUSIONS

AF occurred in a large proportion of patients after transisthmic catheter ablation of typical AFL. The occurrence of AF was progressive during follow up. Preablation AF, age < 65 years, and left atrial size > 50 mm are associated with postablation AF occurrence.

Success of serial external electrical cardioversion of persistent atrial fibrillation in maintaining sinus rhythm. A randomized study

AIMS

The aim of this prospective, randomized study was to determine the efficacy of a serial external electrical cardioversion strategy in maintaining sinus rhythm after 12 months in patients with recurrent persistent atrial fibrillation.

METHODS AND RESULTS

Ninety patients with persistent atrial fibrillation lasting more than 72 h but less than 1 year were randomized in a one to one fashion to repetition of up to two electrical cardioversions in the event of relapse of atrial fibrillation detected within 1 month of the previous electrical cardioversion (Group AGG), or to non-treatment of atrial fibrillation relapse (Group CTL). ECGs were scheduled at 6 h, 7 days, and 1 month. Clinical examination and ECGs were repeated during the 6-month and 12-month follow-up examinations. Echocardiography was repeated during the 6-month follow-up examination. Clinical and echocardiographic characteristics were similar in the two groups. All patients were treated with antiarrhythmic drugs before electrical cardioversion and throughout follow-up. After 12 months, sinus rhythm was maintained in 53% of Group AGG patients and in 29% of Group CTL patients (P<0.03). After 6 months, left ventricular ejection fraction had recovered significantly only in Group AGG (56.8 +/- 9.0% at enrollment vs 60.4 +/- 9.4% at 6 months,P <0.001).

CONCLUSION

These results demonstrate that an aggressive policy towards persistent atrial fibrillation by means of repetition of electrical cardioversion after early atrial fibrillation recurrence is useful in maintaining sinus rhythm after 12 months.

Transient complete atrioventricular block during transcatheter ablation of a left inferoparaseptal anomalous pathway in a patient with a history of previous surgical repair of ventricular septal defect

This case describes a young woman with a manifest left inferoparaseptal accessory pathway and previous history of surgical repair of a defect of the ventricular inlet septum in whom a transient complete AV block occurred during radiofrequency ablation performed from the coronary sinus. The presence of a preexisting surgery related AV block unmasked by anomalous pathway ablation is the more reliable explanation for this case.

Liver transplantation. A summary of our surgical practice

At the turn of the new century, liver transplant procedures can finally be considered an efficient treatment option. Technology has helped transplant intervention become a preferred treatment for patients with progressive and irreversible liver failure. New immuno-suppressive drugs have been introduced which reduce the patient's immunological reaction to the implanted organ, entail minimal side effects and improve practical applications of liver transplantation. As a result of these technological advanced and proper disease management, liver transplant procedures are no longer thought of as an elite therapy, reserved for selected patients with end stage liver disease. In our opinion, it is now a sound and valid surgical option with strictly defined characteristics, indications and well-understood limits. Throughout the past decade, we have studied and applied this type of intervention and have come to terms with its rapid expansion at both the theoretical and practical levels. The most significant obstacle remaining today is the discrepancy between the ever increasing demand and limited supply of organs. The future of liver transplant lies in overcoming this obstacle. Liver transplant practice began at our Institute on 23 November 1990 with the first surgical intervention to replace an organ. In the past 10 years, we have exceeded 200 liver transplant procedures.

Urinary NO2- and NO3- evaluation by an ion chromatography system

We describe an ion chromatography system using a Dionex AS4A-SC column with carbonate-bicarbonate buffer (1.8-1.7 mM) as eluent for the evaluation of urinary NO2- and NO3-. This chromatographic system gives an accurate measurement of NO2- and NO3- in the urine as an index of NO production in vivo, making also possible to evaluate their relative proportion and providing useful tools to investigate the NO system.

Evidence of myocardial dysfunction in Bartter's syndrome

Bartter's syndrome (BS) is characterized by arterial normohypotension despite biochemical and hormonal abnormalities generally associated with hypertension. An abnormal intracellular calcium homeostasis due to a reduced capacity to increase intracellular calcium has been demonstrated by us in BS and proposed as the main pathophysiological factor of the vascular hyporeactivity in BS. The present study was designed to assess whether this altered intracellular calcium homeostasis could also impair contractile recruitment at the myocyte level. Left-ventricular function of patients with BS and normal subjects (C) were studied by quantitative 2-D echocardiography at rest and by postextrasystolic potentiation (PESP), an inotropic stimulus able to recruit the maximal contractile reserve. A group of patients with hypokalemia other than BS (PB) was also included in the study to evaluate the effect of hypokalemia on myocardial contractile recruitment. Baseline left-ventricular end-diastolic volume (EDV) and ejection fraction (EF) did not differ in the 3 groups: EDV: 62 +/- 6 vs. 64 +/- 9 and 60 +/- 12 ml/m2; EF: 64 +/- 9 vs. 67 +/- 8 and 64 +/- 8%. PESP determines an increase of EF in C and PB: 82 +/- 5%, p < 0.01 and 76 +/- 6%, p < 0.01, while in BS it is unchanged: 69 +/- 9% and is reduced in comparison with the increment of myocardial function shown by C and PB (p < 0.01). This study is the first demonstration in BS of a depressed inotropic recruitment causing an exercise-induced left-ventricular dysfunction likely due to an abnormal intracellular calcium homeostasis in the myocytes.

[Contribution of magnetic resonance imaging to the diagnosis of 2 cases of cardiomyopathy]

Two cases of cardiomyopathy were studied by echocardiography, endomyocardial biopsy carried out during cardiac catheterization and magnetic resonance imaging. In accordance with echocardiogram, magnetic resonance imaging showed global thickening of the free and septal wall in the first case and apical thickening in the second case. The alteration of the tissue component described by magnetic resonance imaging is in agreement with the histologic description of endomyocardial biopsy. Magnetic resonance imaging is a useful method for the diagnosis of cardiomyopathy.