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.

P21 AGE–RELATED DIFFERENCES AND ASSOCIATED OUTCOMES OF S–ICD: INSIGHTS FROM A LARGE, EUROPEAN, MULTICENTER REGISTRY

Background

The subcutaneous implantable cardioverter defibrillator (S–ICD) has become an alternative to transvenous ICDs (TV–ICD) in patients who do not need pacing. To date, there is little evidence directly comparing the rates of inappropriate shocks (IAS) in young vs old S–ICD recipients.

Purpose

Aim of our study was to assess differences in device–related complications and inappropriate shocks (IS) between teenagers/young adults and adult recipients of a subcutabeous implantable cardioverter defibrillator (S–ICD) device.

Methods

Two propensity–matched cohorts of teenagers + young adults (≤ 30–year–old) and adults (> 30–year–old) were retrieved from the ELISIR registry. The primary outcome was the comparison of the inappropriate shock (IAS) rate; complications, freedom from sustained ventricular arrhythmic events, overall and cardiovascular mortality were deemed secondary outcomes.

Results

A total of 1491 patients were extracted from the ELISIR project. Teenagers + young adults represented 11.0% of the entire cohort. Two propensity–matched groups of 161 patients each were used for the analysis (Figure 1); median follow–up was 23.1 [13.2–40.5] months. 15.2% patients experienced inappropriate S–ICD shocks and 9.3% device related complications were observed with no age–related differences in IAS (16.1% vs 14.3%; p = 0.642) and complication rates (9.9% vs 8.7%; p = 0.701); Figure 2 shows a survival analysis from inappropriate shocks in the teen–ager/young adult cohort (red) and in the adult cohort (blue). At univariate analysis, young age was not associated with increased rates of IAS (HR 1.204 [0.675–2.148]: p = 0.529). At multivariate analysis (Figure 3), the use of SMART pass algorithm was associated to a strong reduction in IAS (aHR 0.292 [0.161–0.525]; p < 0.001), while ARVC was associated with higher rates of IAS (aHR 2.380 [1.205–4.697]; p = 0.012).

Conclusion

In a large multicentered European registry of patients with S–ICD, 11.0% of all recipients were teenagers or young adults. The use of S–ICD in teenagers/young adults resulted safe and effective, and the rates of complications and IAS between teenagers/young adults and adults were not significantly different. The only predictor of increased IAS was a diagnosis of ARVC.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Left atrial function after standalone totally thoracoscopic left atrial appendage exclusion in af patients with absolute contraindication to oral anticoagulation therapy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left atrial appendage (LAA) is the source of more than 90% of thrombi in patients with atrial fibrillation (AF).  The Totally Thoracoscopic (TT) LAA exclusion with epicardial clip has become a safe and effective procedure, but the effect on left atrial (LA) function remains unknown.

Purpose

The aim of this study was to assess the effect of TT LAA exclusion on LA function.

Methods

20 patients (15 males) with non-valvular AF and contraindication to oral anticoagulation therapy (OAT) or antiplatelet therapy underwent standalone TT LAA exclusion with the Atriclip Pro II device. All patients were screened preoperatively with 3D CT scan, trans-esophageal echocardiography, spirometry and cerebrovascular doppler ultrasound. Intraoperative Atriclip Pro II positioning and LAA exclusion were guided and confirmed by trans-esophageal echo. To objectify LA function, transthoracic echocardiography with 2D Speckle tracking was performed before surgery, at discharge and at 3-month follow-up. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit.

Results

Baseline characteristics are reported in Table I. There were no major complications during the procedures. One non cardiovascular death, one minor stroke and 4 hospitalizations occur at 1-year follow up. The reservoir LA function considering the strain measurements dramatically decreased few days after the procedure and it recovered at 3-month follow-up compared to baseline, even though the LA volume is augmented (Table II). Furthermore, NT pro-BNP increased and ventricular strain decreased significantly after the procedure recovering over time.

Conclusion

TT LAA exclusion with Atriclip Pro II device is a safe and effective procedure in preventing AF related stroke in patients with contraindication to OAT. Our findings suggest that the LAA epicardial clip impairs immediately the reservoir LA function that recovers over time. Abstract Table I  Abstract Table II

An heart team stroke prevention decision-making process comparing percutaneous endocardial and thoracoscopic epicardial left atrial appendage occlusion

Introduction

Left atrial appendage occlusion (LAAO) is a validated therapeutic option in patients with atrial fibrillation (AF) at high thrombo-embolic risk and contraindication to oral anticoagulation. Large clinical trials have demonstrated excellent efficacy of percutaneous LAAO, but also stand-alone thoracoscopic LAAO has shown promising results with the advantage of absence of antiplatelet therapy. No direct comparison of both strategies has been published yet.

Purpose

To evaluate an Atrial Fibrillation Heart Team guided approach to percutaneous or thoracoscopic left appendage exclusion in patients with non valvular atrial fibrillation (NVAF).

Methods

Forty patients with a contraindication to oral anticoagulation (OAC) were evaluated in the AF Heart Team for LAA exclusion. Contraindication for OAC was based upon a history of cerebral hemorrhages (n=17), non-cerebral life-threatening hemorrhages (n=9), repetitive bleeding (n=8) and having underlying diseases associated to high bleeding risk (n=6). The 20 patients included in the LAAO-Percutaneous group (LAAO-P) were on low molecular weight heparin pre-procedure, whereas in the LAAO-thoracoscopic group (LAAO-TT) none were on low molecular weight heparin nor antiplatelet therapy since the bleeding risk was estimated too high. The LAAO-P group were 70% male, with a mean age of 72.3±7.5 (range 57–82), mean CHA2DS2VASc 4.2 (range 1–6) and a mean HASBLED 3.5 (range 1–5) with an expected risk of bleeding between 3.7–8.7% per year. The LAAO-TT were 72.5% male, with a mean age of 74.9±8 (range 53–87 years), mean CHA2DS2-VASc 6.05 (range 4–8), HASBLED mean 5.4 (range3–8) expected risk of bleeding &gt;12.5% per year. Variables considered were CHA2DS2VASc, HASBLED, documented blood transfusions, comorbidities related risk of bleeding, anatomy of the LAA, lung function, patient quality of life. LAAO-P patients were on dual antiplatelet therapy (DAT) at discharge for the first three months and aspirine 100mg/day thereafter, whereas the LAAO-TT patients were not. Follow up included TEE at 1 months and CT scan at 3 months.

Results

Mean duration of procedures for LAAO-P was 54.4 minutes, for LAAO-TT 52.01 minutes, mean post procedural ventilation time was respectively 11.2±6.4 and 15.8±16.4 minutes. No major complications occurred in both groups. One patient in the LAAO-P crossed over because of an unsuitable anatomy which became apparent intra-operatively. Mean hospital stay were comparable in both groups, 3.4±0.7 and 3.8±0.9 days respectively. At mean follow up of 24.3±10.1 months (range 5–36) all patients had complete exclusion of the appendage, no neurological events were reported.

Conclusions

The Heart Team can improve decision making in complex stroke prevention where LAAO is a therapeutic option, percutaneous and thoracoscopic occlusion seem to be comparably safe and effective. An epicardial LAAO could be advised in patients were the bleeding risk is estimated too high for AP therapy.

Funding Acknowledgement

Type of funding sources: None. Appendage closure: CT scan viewAppendage closure: surgical view

Standalone totally thoracoscopic left appendage exclusion for stroke prevention and absolute contraindication to anticoagulation: a referral centre experience

Introduction

Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). ESC guidelines state as class IIB indication left appendage exclusion in patients with contraindication to oral anticoagulation. Here we give our contribute to the issue of safety and efficacy of standalone totally thoracoscopic left appendage exclusion (TT-LAE) for stroke prevention in patients with contraindication to oral anticoagulant or at risk of life threatening hemorrhage on antiplatelet therapy: a large single Centre experience.

Materials and methods

60 patients with non valvular AF and contraindication to oral anticoagulation (25 cerebral hemorrhages,8 GI bleeding, 18 non cerebral/Gi bleeding requiring multiple transfusions, 2 myelodysplastic syndrome, 7 anatomy unsuitable for percutaneous closure, 75%male, patients age ranged 53–87 years,mean CHAD-VASC 6.4,mean HASBLED range 4.7, type of AF permanent 76.6%, 23.4% longstanding persistent), underwent stand alone totally thoracoscopic appendage exclusion. All patinets enrolled after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography, spirometry and cerebrovascuar doppler ultrasound. Intraoperative appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit. Follow up (range 35–1 months) included outpatient visit and CT scan or TEE at 3–6-12 month in all patients to document LAA exclusion. Perioperative mortality and early and late morbidity in addition to freedom from neurological events at follow up were analyzed by chart evaluation and full outpatient neurological examination including including the Questionnaire for Verifying Stroke Free Status (QVSFS) as validated screening tool.

Results

Mean duration of surgery “skin to skin” was 52.4 minutes; all patients were extubated shortly after the procedure. There were no deaths nor need for blood transfusion or pulmonary procedure related morbidities, only three casea of pericarditis treated with colchicine till complete resolution was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with minimal residual stumps and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit and questionnaire filling.

Conclusion

Standalone totally thoracoscopic left appendage clipping is a safe and effective procedure for stroke prevention in patients with permanent and longstanding persistent atrial fibrillation with contraindication to oral anticoagulation. Longer follow up and an European registry are needed to, possibly, confirm this preliminary results.

Funding Acknowledgement

Type of funding source: None

The addition of strict stability criteria does not reduce recurrences after atrial fibrillation ablation using ablation index and can impact on procedure efficiency

Background

Ablation Index (AI) is a proprietary lesion quality marker that combines power, contact force and time. Recent studies showed that radiofrequency (RF) pulmonary vein isolation (PVI) using AI can deliver high arrhythmia-free survival rates at mid-term follow-up in patients with paroxysmal atrial fibrillation.

Purpose

The aim of this multicenter study was to compare the outcome of three different strategies of PVI using AI (group 1 and 2) or VISITAG module with average force and strict criteria of stability as target parameters (group 3).

Methods

We enrolled 132 consecutive naive patients (97 males, mean age 61,03±9,42) affected by paroxysmal atrial fibrillation who underwent PVI at two high volume centres between January 2017 and February 2019. AI target was set at ≥380 at the posterior wall and ≥500 at the anterior wall. A strict stability criteria (VISITALY criteria: 3 mm for a time of 15 s and a FOT &gt;5 g for 60% of the time) was set for Group 1 procedures (65 patients), whereas Group 2 procedures (67 patients) were carried out with standard stability criteria (VISTAX criteria: 3 mm for a time of 3 s and FOT &gt;3 g for 25% of the time). We then compared those strategies with a historical cohort of 72 patients (40 males, mean age 60,74±8,53) treated at our centres with RF PVI using the VISITAG module with average force and strict stability criteria as target parameters. An interlesion distance ≤6 mm was a target parameter for all procedures. Recurrence was defined as any AF, atrial tachycardia (AT) or atrial flutter (AFL) during the 12 months after ablation, excluding a blanking period of 90 days.

Results

There were no significant differences in terms of age (Group 1 59,2±8,97; Group 2 62,81±9,58; Group 3 60,74±8,53 years) and left atrial area (Group 1 24,16±20,46; Group 2 22,55±12,32; Group 3 20,74±3,84 cm2). Group 1 showed a slightly higher number of males (Group 1 78,46%; Group 2 68,66%; Group 3 55,56%; p=0,004). Procedure duration was significantly lower in Group 2 compared to Groups 1 and 3 (176,67±50,88 vs 224,05±47,21 min, p&lt;0,001; 176,67±50,88 vs 203,96±52,38 min p=0,02). Fluoroscopy time was significantly higher in Group 1 compared with Group 2 (11,85±4,38 vs 10,39±6,4 min; p=0,014). There was a slight trend to have a higher freedom from AF/AT/AFL at 12 months in group 2 compared to the others (Group 1 86,15% vs Group 2 91,04% vs Group 3 84,72%; p=0,2).

Conclusion

A strategy of PVI using AI with standard stability criteria performed the best in terms of procedure efficiency, with a significant benefit in terms of procedure duration, delivering a 12 months arrhythmia-free survival rate comparable with other strategies. Combination of AI with strict stability criteria provided no benefit, at a cost of a higher fluoroscopy time and longer procedure duration.

Funding Acknowledgement

Type of funding source: None

3050Non valvular atrial fibrillation, contraindication to anticoagulation or antiplatelet therapy and heart team approach: a single centre experience

Introduction

Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). Protect-AF and Prevail trials have tested the non inferiority of left appendage percutaneous closure to warfarin for stroke prevention but contraindication to anticoagulation was an exclusion criteria for enrollment. On the surgical side recent studies have shown the efficacy of left appendage exclusion concomitant to open chest cardiac surgery or totally thoracoscopic Maze. In these studies all patients were on anticoagulation or antiplatelet regime at discharge and follow up. Here we give our contribute to the issue of safety and efficacy of stand alone totally thoracoscopic left appendage clipping for non valvular AF related stroke prevention in patients with contraindication to oral anticoagulant or antiplatelet therapy.

Materials and methods

20 patients with non valvular AF and cerebral hemorrhages (16 males, patients age range 53–87, CHAD-VASC range 4–8, HASBLED range 4–7), underwent stand alone totally thoracoscopic appendage exclusion with a clipping device. All patients, after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography and cerebrovascular doppler ultrasound. Intraoperative device positioning and atrial appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy from the time of surgery to the control visit. Follow up (range 6–21 months) included outpatient visit, CT scan or TEE. Perioperative mortality and early and late morbidity were analyzed by chart evaluation and full outpatient neurological examination including the Questionnaire for Verifying Stroke Free Status.

Results

Mean duration of surgery “skin to skin” was 62 minutes; all patients were extubated shortly after the procedure. There were no deaths or pulmonary procedure related morbidities, only one case of pericarditis treated with colchicine was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with residual stumps less than 1 cm and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit.

Conclusion

Totally thoracoscopic left appendage exclusion is a safe, expeditous and effective procedure in preventing non valvular AF related strokes in patients with contraindication to oral anticoagulation or antiplatelet therapy. The efficacy of the procedure is comparable to open chest surgery and this procedure may be considered as valid therapeutic option in patients at high risk of hemorrhage if on anticoagulant or antiplatelet therapy. Clearly further data, longer follow up and possibly an European registry are needed to confirm this preliminary results.