Early systemic insults following traumatic brain injury: association with biomarker profiles, therapy for intracranial hypertension, and neurological outcomes-an analysis of CENTER-TBI data

PURPOSE

We analysed the impact of early systemic insults (hypoxemia and hypotension, SIs) on brain injury biomarker profiles, acute care requirements during intensive care unit (ICU) stay, and 6-month outcomes in patients with traumatic brain injury (TBI).

METHODS

From patients recruited to the Collaborative European neurotrauma effectiveness research in TBI (CENTER-TBI) study, we documented the prevalence and risk factors for SIs and analysed their effect on the levels of brain injury biomarkers [S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), neurofilament light (NfL), glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and protein Tau], critical care needs, and 6-month outcomes [Glasgow Outcome Scale Extended (GOSE)].

RESULTS

Among 1695 TBI patients, 24.5% had SIs: 16.1% had hypoxemia, 15.2% had hypotension, and 6.8% had both. Biomarkers differed by SI category, with higher S100B, Tau, UCH-L1, NSE and NfL values in patients with hypotension or both SIs. The ratio of neural to glial injury (quantified as UCH-L1/GFAP and Tau/GFAP ratios) was higher in patients with hypotension than in those with no SIs or hypoxia alone. At 6 months, 380 patients died (22%), and 759 (45%) had GOSE ≤ 4. Patients who experienced at least one SI had higher mortality than those who did not (31.8% vs. 19%, p < 0.001).

CONCLUSION

Though less frequent than previously described, SIs in TBI patients are associated with higher release of neuronal than glial injury biomarkers and with increased requirements for ICU therapies aimed at reducing intracranial hypertension. Hypotension or combined SIs are significantly associated with adverse 6-month outcomes. Current criteria for hypotension may lead to higher biomarker levels and more negative outcomes than those for hypoxemia suggesting a need to revisit pressure targets in the prehospital settings.

Switch to gliflozins and biventricular function improvement in patients with chronic heart failure and diabetes mellitus

BACKGROUND

SGLT2 inhibitors have been shown to reduce hospitalisation in patients with chronic heart failure (CHF). The cardioprotective mechanisms of gliflozins however have not been fully elucidated. The aim of this study was therefore to evaluate the effect of SGLT2 inhibitors on right and left ventricular function in patients with diabetes and HF.

METHODS

Seventy-eight patients with diabetes and CHF were enroled in the study and followed up; 38 started treatment with SGLT2i, while the remaining 40 continued their previous antidiabetic therapy. All patients underwent conventional, TDI and strain echocardiography in an ambulatory setting, at the beginning and after 3 months of therapy with SGLT2i.

RESULTS

After 3 months of therapy with SGLT2i, echocardiographic parameters assessing both left and right ventricular dimensions and function were found as significantly improved in patients switching to SGLT2i than control group: LVEF (45 ± 9% vs. 40 ± 8%, p < 0.001), LVEDD (54 ± 6.5 vs. 56 ± 6.5 mm, p < 0.01), GLS (-13 ± 4% vs. -10 ± 3%, p < 0.001), TAPSE (21 ± 3 vs. 19 ± 3 mm, p < 0.001), RV S' (12.9 ± 2.5 vs 11.0 ± 1.9 cm/sec, p < 0.001) and PAsP (24 ± 8 vs. 31 ± 9 mmHg, p < 0.001). Also mitral (1.0 ± 0.5 vs. 1.3 ± 0.5, p < 0.01) and tricuspid regurgitation (1.0 ± 0.5 vs. 1.3 ± 0.5, p < 0.01) improved after SGLT2i therapy. Changes were not statistically significant in patients not treated with SGLT2i (p n.s. in all cases).

CONCLUSIONS

In a real-world scenario, treatment with SGLT2i in patients with CHF and diabetes is associated with an improvement in both left and right ventricular function assessed at echocardiography. These data may explain potential anti-remodelling effects of gliflozins.

Modeling chronic oil pollution from ships

Stochastic simulations of virtual oil spills from ships were performed for the Adriatic Sea over 2017-2020, applying the European Marine Observation and Data Network vessel densities as a proxy for starting locations of operational spillage. The MEDSLIK-II oil spill model was run using high-resolution currents provided by the Copernicus Marine Service and the European Centre for Medium-Range Weather Forecasts winds. Chronic exposure to operational oil spills was reported in terms of hazard indices for five vessel groups: pleasure and passenger ships, cargo and service vessels, the fishing fleet, tankers, and other ships. The northernmost Adriatic expectedly showed the highest hazard values, including the areas of Trieste and Venice, where cargo and service ships were the dominant polluters. The Croatian coastal waters were more chronically polluted than the Italian coastal waters; the predominant contribution was from coastwise pleasure and passenger ships.

Conduction system pacing with Selectra 3D Sheath: Technical Results

Funding Acknowledgements

Type of funding sources: None.

Background

Conduction system pacing (CSP) allows physiological electrical activation. The Selectra3D sheath is a new tool able to guide the lead implantation on the His Bundle (HBP) or on the left bundle branch (LBBP). It does exist in 3 different shapes (40-S, 55-M, 65-L).

Objective

To evaluate the effectiveness of different Selectra3D introducers for CSP, considering the procedural success, stability of electrical parameters or need for implant revision at medium-term follow-up.

Methods and results

Selectra3D was used in 113 CSP procedures between Nov 2019 and Nov 2021. Mean patients age was 80±6 years, 54% males. Pacing indications were: AV block 52.2%, slow AF 12.4%; SND 12.4%, ablate&pace 5.3%, implant revision 0.9%, cardiomyopathy 16.8%. Mean EF was 40±15%. Single chamber PM was implanted in 4.8% pts, dual chamber PM in 57.1% pts while 26.2% and 11.9% pts received CRT-P and CRT-D devices respectively. Stylet-driven lead was used in 75 pts, fixed screw lead in 38 pts. HBP was obtained in 34% pts, LBBP in 55% pts, HBP+LBBP in 3% pts, while 8% cases were CSP implant failure (7 lead implanted in the septum; 2 in the coronary sinus). Selectra3D was the first delivery used during the procedure in 88% of cases (55-M in 76%; 40-S in 9%; 65-L in 3%), while was the second tool (after failure of the first delivery utilised) in the other pts. The first Selectra3D utilized during each implant was able to complete the procedure in 64% of cases, while in the other pts a second different tool was required to complete the implant. The Selectra3D 55-M was the mostly used and was able to reach the final position in most cases. In dilated atria the 65-L curve was preferred, while when the target point was more proximal the 45-S curve was the best choice. The baseline QRS duration was 135 ± 34 ms and the paced QRS duration was 113 ± 18 ms (P 0.003). The electrical parameters were optimal with sensing 8.7 ± 8 mV; impedance 562 ± 133 ohm; threshold 0.97 ± 0.47 V. During a median follow-up of 178 [34-402] days, 7 lead dislodgement (3 HBP and 4 LBBP) were recorded. All the others showed stability of the electrical parameters.

Conclusion

The Selectra3D introducers effectively supports CSP ensuring procedural success rate&gt;90%. The 55-M curve fits for most of the anatomies, the 45-S curve allows to reach more proximal target, the 65-L curve more distal target in dilated atria. The electrical parameters were optimal at implant and remained stable during follow-up. 6% lead dislodgement were recorded.

Left Bundle Branch Pacing: procedural outcomes using different sheaths

Funding Acknowledgements

Type of funding sources: None.

Background

Left Bundle Branch Pacing (LBBP) ensures physiologic ventricular activation. Growing experiences are rising on its applicability . Different tools available allow successful implant in different cardiac anatomies.

Objective

To analyse implant success rate and acute electrical parameters in LBBP guided by C315 fixed curve sheath or Selectra3D sheath.

Methods

151 patients (mean age 79.8±8.3 years; 51% males) received LBBP. Pacing indication: AV block 50%, SND 12%, slow AF12%, ablate&pace 9%; HF 14%, revision of previous lead 1%. Coronary disease was present in 31%; hypertension in 93%, diabetes in 30%, severe valvular disease in 5%, persistent AF in 31% pts. Average QRS duration was 136±34 ms. Basal mean EF 52±12%. Different criteria for successful LBBP were analyzed (table 1).

Results

The lead was successfully implanted in the left bundle in 97.3% pts. In 60.5% pts guided by the C315 Medtronic fixed curve sheath while in 39.5% pts by the Selectra3D (40-S, 55-M, 65-L) Biotronik sheaths. 93 (63%) pts received 3830 fixed screw lead, 51 (35%) pts received Solia S 60 stylet-driven lead and 3 (2%) patients received Tendril 58 cm stylet-driven lead. All different criteria analysed to define successful LBBP were comparable in the C315 and Selectra 3D group (table 1). In 61% pts LBBP was the first choice, in 39% LBBP was aimed after unsatisfactory HBP (His threshold&gt;2V or paced QRS&gt;140 ms). The LBBP lead was connected to the RV port in 67% DR and 18% SR PMs; to the LV port in the 22 CRT devices. Mean fluoroscopy time was 10±6 min including implant of all leads, without differences between implants. Electrical parameters were highly favourable in all patients (mean threshold 0.73±0.27V and mean sensing 11±5.8 mV) without differences between the 2 sheaths. Pacing impedance was significantly lower in the Selectra 3D group. Paced QRS duration was 114±15 ms (112±14 vs 116±16 ms; P 0.180). Implant failure were 4 (2 due to severe tricuspid regurgitation and 2 to severe dilated atria).

Conclusion

LBBP is highly reliable in clinical practice. The different sheath available lead to successfully perform the implant in different cardiac anatomies. In our experience there was no differences in technical acute outcome between implant guided by C315 Medtronic sheath and Selectra3D Biotronik sheath.

P80 PROGNOSTIC IMPACT OF NEW ONSET ATRIAL FIBRILLATION AFTER SINGLE OR DOUBLE STENT LEFT MAIN BIFURCATION PCI

Objective

Incidence and prognostic value of new onset atrial fibrillation (NOAF) after single versus double stent strategy in bifurcation Left Main (LM) disease has not been yet investigated.

Methods

We retrospectively analysed the procedural and medical data of patients referred to our center for complex LM bifurcation disease, treated using Cross–over provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT) techniques between January 1st, 2008 to May 1st 2018. Multivariate Cox–regression analysis was used to assess the role of different stent strategies, adjusted for confounders, on the risk of NOAF during the follow–up period.

Results

Five hundred and two patients (316 males, mean age 70.3±12.8 years, mean Syntax score 31.6±6.3) were evaluated. At a mean follow–up of 37.1±10.8 months (range 22.1–39.3 moths), Target lesion failure (TLF) rate was 10.1%. Stent thrombosis and Cardiovascular mortality were observed in 1.2% and 3.6% in of cases, respectively. NOAF occurred in 23 out of 502 patients (4.6%). Patients with NOAF resulted more frequently female, older, obese, diabetic and more frequently experienced TLF and cardiovascular death. NOAF free survival favoured single versus double stent technique and among double stent techniques NIT compared to the others. Single stent strategy had a lower risk of NOAF compared to double stent technique on multivariate analysis (HR: 1.14, 95% CI: 1.10–1.19, p &lt; 0.001 vs HR: 1.28, 95% CI: 1.23–1.32, p &lt; 0.0001).

Conclusions

NOAF in distal LM bifurcation disease treated with PCI had a low incidence but resulted more frequent after double than after single stenting technique and associated with worse outcomes.

24 Gliflozins and ventricular function in patients affected by chronic heart failure with diabetes mellitus

Aims

Diabetes is the most common comorbidity of HF patients. SGLT2 inhibitors has been shown to reduce hospitalization in patients with HF. The cardioprotective mechanisms of gliflozines have not been elucidated. The aim of our study was to evaluate the effect of SGLT2 inhibitors on right and left ventricular function in T2DM patients with HF.

Methods and results

One hundred and fifteen consecutive outpatients with CHF and T2DM were screened in the Daunia Heart Failure Registry. Seventy-eight of them were enrolled and followed up between May 2019 and September 2020. All patients underwent conventional, TDI and strain echocardiography in an ambulatory setting, at the beginning and after 3 months of therapy with SGLT2 inhibitors. Seventy-eight consecutive outpatients with CHF and T2DM (mean age 67.4 ± 8.4 years, male: 83%) were enrolled in the study. Thirty-eight of them started the treatment with SGLT2 inhibitors, while the remaining forty continued their original therapy. After 3 months of therapy, LVEF, LVEDD, and LVESD statistically improved (respectively, from 39.68 ± 7.78% to 45.08 ± 9.04%, P: 0.001 and 57.32 ± 9.76 mm to 54.16 ± 6.54 mm, P: 0.01 and from 47.51 ± 1.58 mm to 43.24 ± 8.12, P: 0.0008). Changes in left ventricular function and dimensions were not significant in patients who did not started a therapy with SGLT2 inhibitors. There was a statistically significant reduction of E/E′ (from 16.51 ± 22.55 to 9.73 ± 3.35, P: 0.0007) in patients with treatment with SGLT2i. Moreover, there was an improvement of right ventricular function, due to a statistically significant reduction of PAPs and increase of TAPSE (respectively, from 30.63 ± 8.80 to 24.00 ± 8.35, P: 0.008; from 19.16 ± 2.54 to 21.18 ± 2.84, P: 0.0003) and S′ (10.42 ± 2.09 to 12.91 ± 2.50, P: 0.000) 3 months after the administration of SGLT2 inhibitors therapy vs. the control group.

Conclusions

In a real-world scenario, our results showed that the treatment with SGLT-2 inhibitors in patients with CHF and diabetes is associated with an echocardiographic biventricular function improvement.

3D electro-anatomical mapping to guide conduction system pacing in complex cardiac anatomies

Background

Conduction System Pacing (CSP) includes both His Bundle Pacing (HBP) and Left Bundle Branch Pacing (LBBP). It guarantees physiological cardiac activation and it is essential to avoid pacing-induced dyssynchrony. Markedly dilated atria, up-grading to CRT, and congenital cardiopathies still represent complex anatomical scenarios in which the available tools could often result inadequate and graved by suboptimal results.

Objective

To evaluate the feasibility and effectiveness of 3D electro-anatomical mapping (EAM) to guide CSP (both HBP and LBBP) in patients with characteristics that allows “a priori” classification as complex anatomical scenario with low probability of success using only fluoroscopic guidance and available tools. Left atrium area &gt;40 cm2; post-PICM up-grading and congenital heart disease were considered signs of anatomical complexity.

Methods and results

The study includes 25 patients (19 males, mean age 76–11 years; mean baseline EF 34.2–12.6%; 17 BBB; 5 post-PICM up-grading), candidates for CSP. 16 and 9 were respectively implanted with PM and ICD (13/12 dual/three-chamber devices). CARTO system was used in 6 ptss and EnsiteTM Precision in 19. EAM involved reconstruction of the right atrium and sub-tricuspid septum with the use of a decapolar catheter. Several “tags” have been placed on the His signals, in order to reconstruct the “His Cloud” and distinguish within it the proximal, medium, and distal area (Fig. 1). The sub-tricuspid septum was always reconstructed so that intra-procedurally operator could easily move from HBP to LBBP based on electrical parameters or paced QRS morphology. The mapping catheter was removed after the mapping phase and replaced with the pacing lead. Both exposed fixed screw 3830 leads and standard stylet-driven leads were used. HBP was achieved in 10 pts and LBBP in 13 pts. Three failures were resolved by CS lead implant. The time spend for His cloud mapping was 18±7 min. The mean threshold was 1.1±0.5 V; sensing 11.6±9.3 mV and impedance 786±339 ohm. Baseline QRS 155±19 ms and paced QRS 119±7 ms. In cases of LBBP we were also able to measure on the EAM map the depth of the catheter within the septum, resulting in 11.5±3.1 mm and the distance of the initial screw site from the His of 26.5±10.3 mm.

Conclusions

The electro-anatomical mapping allows the accurate reconstruction of “His cloud” by properly distinguishing proximal, middle, distal His. The sub-tricuspid zone of the interventricular septum is also reconstructed in high definition, so that intra-procedurally it is possible to easily move from HBP to LBBP and vice-versa based on the electrical parameters and paced QRS morphology. This method appears safe and effective even in complex cardiac anatomies possibly saving time and fluoroscopy use. The tags on the His cloud and sub-tricuspid septum can satisfactorily guide lead placement with high reproducibly.

Funding Acknowledgement

Type of funding sources: None. Figure 1. 3D-EAM used to guide HBP implant

Left bundle branch pacing: 2 year single-centre experience

Background

Left Bundle Branch Pacing (LBBP) ensures a physiologic ventricular activation and shows better electrical parameters compared to His bundle pacing (HBP). A growing body of experience is encouraging a large applicability.

Objective

To analyse feasibility and technical outcomes of LBBP in the daily clinical practice.

Methods

During 2019 and 2020, 132 patients (mean age 79±10 years; 72 males) with standard indication for pacing, received the lead deeply intraseptal aiming to pace the left bundle. The indication for pacing were AV block 72 (55%) pts, SND 14 (11%), AF and slow ventricular rate 21 (16%), ablate&pace in 4 (3%); HF in 10 (7.5%), PICM 6 (4%) pts, lead revision in 5 (3.5%). 75% of pts had ischemic cardiopathy; 82% hypertension, 30% diabetes and 21% severe kidney disease. Baseline QRS was 141±38 ms and 68% of pts had bundle branch block. The basal mean EF 49±15%. 91 (69%) of the pts were in sinus rhythm at implant. Criteria for LBBP were: RBB morphology in V1 together with left ventricular activation time (LVAT)&lt;80 ms in V6. Final lead position was always confirmed with injection of 5 ml of dye contrast in left anterior oblique view.

Results

The lead was successfully implanted in the left bundle in 129 (97,7%) patients. In the remaining 3 patients the cathode only penetrated the septum. In 90 cases LBBP was the first choice, in the remaining 42 patients LBBP was aimed after unsatisfactory HBP (His threshold&gt;2V or paced QRS&gt;140 ms). In 107 cases we utilized the 3830 4Fr lumenless lead; in 25 cases the stylet-driven 6 Fr leads. The LBBP lead was connected to the RV port in the 92 dual-chamber PMs; in the LV port in the 22 three-chamber devices as part of cardiac resynchronization therapy; in the only port in 18 single-chamber PM. Mean fluoroscopy time was 10±6 min including implant of all leads. Electrical parameters were highly favourable (R wave sensing 10,5±5 mV; threshold 0,9±0,2 V@0,5 ms; impedance 829±234 ohm). Paced QRS duration was 114±20 ms (P&lt;0.005). The devices were checked 48 hours after implant and 1 month later. Thereafter were remotely monitored. At the 1-month in clinic interrogation all LB lead showed good performance and QRS morphology and duration like the post implant one (115±21 ms). Mean VP% was 81% and mean AP% 28%. VP ≥90% was detected in 42 (32%) of patients. Chronic AF (AT/AF 100%) in 24 (18%) of patients. In 3 cases the LB lead showed early dislodgement requiring lead revision (1 macroscopic dislodgement and 2 rise in threshold), all of them within 7 days after implant.

Conclusion

The new technique of pacing the left bundle of the conduction system (LBBP), is safe and feasible in the clinical practice. It is applicable in all pacing indications including heart failure and resynchronization. In our experience lead dislodgement were 2,2% (3/132, all in the first week after implant) whereas paced QRS duration was significantly shortened and ejection fraction remained normal.

Funding Acknowledgement

Type of funding sources: None.

Selectra 3D- guided conduction system pacing: single-center experience

Background

Conduction system pacing (CSP)is becoming increasingly popular thanks to the ability to both maintain physiological electrical activation in patients with narrow QRS and restore ventricular synchrony in patients with bundle branch block (BBB). The Selectra3D introducer is a new tool able to support the correct positioning and screwing of the catheter on the bundle of His (HBP) or on the left branch (LBBP). It does exist in 3 different shapes: S, M, L (Fig. 1) based on the radius of main curvature. The internal diameter of 7.3 Fr allows it to support both the 3830 lumen-less catheter historically used for CSP, as well as standard 6Fr stylet-driven leads.

Objective

To evaluate the effectiveness of the Selectra3D introducer for CSP (including both HBP and LBBP), considering the procedural success rate and the lead stability (stability of electrical parameters or need for implant revision) in the medium-term follow-up.

Methods and results

The Selectra3D introducer was used in 56 patients' candidates for CSP (mean age 80±6 years). Pacing indications included A-V block in 21 patients, AF with slow ventricular response in 9 patients; SND in 8 patients and HF and severe ventricular dysfunction in 18 patients (of which 4 were PICM). The mean baseline EF was 40±15%. A PM was implanted in 40 patients and an ICD in 16. A standard stylet-driven lead was used in 48 cases, a fixed exposed screw lead was used in 8 patients. HBP was obtained in 21 cases and LBBP in 30 cases, while in 5 cases (8.9%) neither HBP nor LBBP could be obtained. Implants were performed via a left-sided approach in 55 cases and a right-sided approach in 1 case. The baseline QRS duration was 144±38 ms and the paced QRS duration was 118±21 ms. The electrical parameters were optimal with sensing 8.7±8 mV; impedance 625±276 ohm; threshold 1±0.5 V. During follow-up, 2 lead dislodgement (3.9%) (1 HBP and 1 LBBP) were recorded, both within 7 days after implantation. All the others showed stability of the electrical parameters at a mean follow-up of 8.4±4.2 months.

Conclusions

The new Selectra3D introducer supports effectively and safely the lead implant on conduction system catheters (HBP and LBBP), allowing the implant of both exposed fixed screw leads and standard stylet-driven leads, leading to procedural success&gt;90%. The electrical parameters were optimal at implantation and remained stable during follow-up.

Funding Acknowledgement

Type of funding sources: None. Figure 1

A Bibliometric Analysis of 4 Major Foot and Ankle Surgery Journals

Research publication is a central to the scientific process and comprehensive bibliometric analysis is a leading way to better understand trends within research. Currently, there are limited bibliometric analyses of literature pertaining to foot and ankle surgery. This study aims to quantify the volume of research and investigate what may affect publication and citation. Journals associated with the 3 major orthopedic foot and ankle societies (Foot & Ankle International[FAI], Foot and Ankle Surgery, and The Foot) and one podiatric college (Journal of Foot and Ankle Surgery®) were evaluated from January 2009 to December 2018 using Scopus (Elsevier, Amsterdam, the Netherlands). Descriptive statistics were used to summarize article characteristics and regression modeling was used to determine factors associated with a country's current and future productivity and an article's citation rate. A total of 4994 articles were published over the 10-year period, with the largest contributor of publications being the United States of America (USA), who produced 2096 (41.8%) publications. Regression analysis found no association between a country's productivity and gross domestic product or population. There was no significant relationship between a country's baseline publication rate and future publication rate. The variables significantly associated with an increased citation count were; the number of years since publication, the number of authors, publication in FAI and if the article was a review. To our knowledge this is the largest bibliometric analysis of foot and ankle publications. The majority of research is being produced by the USA, but there are numerous complex factors associated with citation and publication rates. Further research is required to fully assess these factors and characterize the state of foot and ankle surgery research.

Electrograms guided his bundle pacing implant: moving from radiology to electrical signals

Background

The standard technique to His Bundle Pacing (HBP) based on a fluoroscopic approach might be challenging and fluoro consuming. The electrical signals could lead to a precise and rapid lead implant, thus reducing the fluoroscopy time (FT) and X-ray dose.

Objective

To evaluate the feasibility, efficacy and safety of the electrogram-guided technique to obtain His Bundle pacing (HBP) with minimal or no fluoroscopy use.

Methods

Between October and December 2018, 41 consecutive patients with indication for pacing underwent HBP with the electrogram-guided approach.

Results

Successful HBP was obtained in 39/41 (95%) pts, which is the study population (mean age 78±10 years). S-HBP and NS-HBP were achieved in 23 (59%) and 16 (41%) pts, respectively. Final HBP lead position was achieved in 31/39 (79.4%) pts with zero fluoroscopy, only guided by the electrical signals. In the remaining 8 pts a minimal dose of fluoro (mean 8 sec) has been required to locate the His. Fluoroscopy has been routinely used to remove the sheath and to ensure the slack. The atrial lead has been implanted in a standard fashion. No difference was observed in the FT for HBP lead placement in patients with S-HBP and NS-HBP (mean 8.1±25 sec vs 7.5±20 sec, p=0.8; median value 0 sec vs 0 sec). Moreover, no significant differences were observed in the FT needed for the entire procedure, total Dose Area Product (DAP) and total procedural time among both S-HBP and NS-HBP. The His lead dislodgement occurred in 1 (2.6%) patient one day after the procedure.

Conclusion

HBP could be performed safely and efficiently using the electrograms, with minimal or no fluoroscopy. Fluoroscopy was required during sheath removal and atrial lead placement.

Funding Acknowledgement

Type of funding source: None

The challenge of education in conduction system pacing: results from single or dual operators

Background

The his bundle pacing (HBP) and Left bundle branch pacing (LBBp) techniques are quickly increasing in the cardiovascular interest being the most physiological mode of pacing. Education in these new conduction system pacing (CSP) is mandatory in the modern EP programs. Achieving acceptable implant success rate, together with electrical parameters adequacy is required.

Objective

The aim of the study was to compare clinical and technical outcomes in 2 groups of patients, those implanted by a single operator with large expertise in CSP and those implanted by two operators (one of them during his learning curve).

Methods

Data from 255 consecutive patients (mean age 78±9 years; 186 males) who underwent successful HBP or LBBp implants were collected and analyzed. The operators were classified as expert after performing more than 50 procedures. Baseline caracteristics were not significantly different between the two groups.

Results

After a mean follow-up of 20±10months, we found that there were no differences between patients implanted by 1 single expert operator and 2 operators (1 beginner during his learning cirve supervised by 1 expert operator) in terms of clinical end point (composite of death or heart failure hospitalizations) and technical end point (need for surgical revision of the implant for reason other than battery replacement). Fluoroscopy time (16±17 min vs 9.8±11 min; p 0.004) and procedural time (113±48 min vs 16±17 min; p 0.003) were significantly prolonged when the implant was performed by 2 operators.

Conclusions

Skill acquisition in physiological pacing (both HBP and LBBp) is a nowadays process which cannot put patient's safety at risk. Our experience shows that clinical and technical outcomes were equivalent when the implant was performed by an expert operator or a beginner operator supervised by 1 expert operator. Fluoroscopy time and duration of the procedure were significantly prolonged by the presence of a trainees.

Kaplan Meyer curves

Funding Acknowledgement

Type of funding source: None

The back-up lead in his bundle pacing: evolution over the years

Background

His bundle pacing (HBP) can be affected by high thresholds and low sensing. Thus, in selected patients including a back-up lead is advisable.

Objective

Single-centre retrospective analysis of a large HBP experience, focusing on the back-up lead utilization over the years.

Methods

677 pts (76±8 years; 433 males) were implanted with HBP from 2004 to 2019 July. The pts received S-HBP (67%) or NS-HBP by the 3830 lead. The pacing indications were AV block 54%, sinus node disease 17%, slow atrial fibrillation 23%, heart failure 6%. Ischemic cardiopathy was found in 26%; hypertension in 83%, diabetes in28% pts. Baseline QRS duration was 123±32 ms and EF 56±12%.

Results

266 (39%) pts received the back-up lead. In sinus rhythm we implanted 3-chamber PM (His lead:LV port; VV delay 80 ms: His pulses and apical pacing during the refractory period). 30 pts (11%) received a particular type of 3-chamber PM which provides back-up pacing only if His capture fails, thus saving energy. In atrial fibrillation 2-chamber PM was implanted (His lead: atrial port, DVI). We recorded a significant decrease of back-up lead use over the years, strictly related to operators/centre experience (&gt;70% during the first years, nearly 10% during the last year). The C315 fixed curve sheath, strongly contributed to the rapid reduction of back-up lead use thanks to better lead fixation and stability.

Conclusion

The back-up lead utilization is progressively decreasing. It is strictly related to the operator/centre experience. The presence of the back-up lead could strengthen the Hisian pacing reliability, potentially impacting pacing indication even in advanced conduction disturbances and saving device longevity.

Funding Acknowledgement

Type of funding source: None

Readability of foot and ankle consent forms in Queensland

BACKGROUND

The aim of this study was to conduct a readability analysis on both patient take-home information and consent forms for common foot and ankle procedures. Our hypothesis was that the objective reading skills required to read and comprehend the documentation currently in use would exceed the recommendations in place by both national and international bodies.

METHODS

The current Queensland Health consent forms are divided into specific subsections. The readability of consent form subsections C and G (sections containing detailed information on risks of the procedure and pertaining to informed patient consent specifically) and patient take-home information (provided as take-home leaflet from the consent form which is procedure specific) was assessed by an online readability software program using five validated methods calculated by application of the algorithms for (i) Flesch-Kincaid grade level, (ii) the SMOG (Simple Measure of Gobbledygook), (iii) Coleman-Liau index, (iv) automated readability index and the (v) Linsear Wriste formula.

RESULTS

The mean ± standard deviation reading grade level of risk (section C), grade level of patient consent (section G) and grade level for procedure-specific take-home patient information were 8.7 ± 0.9, 11.6 ± 1.2 and 7.5 ± 0.2, respectively.

CONCLUSION

The readability of sections C and G of the Queensland Health consent form exceeds the recommendations by national and international bodies, but the patient take-home information appears suitable. Consideration should be given to lower the reading grade level of patient consent forms to better reflect the reading grade of the Australian population.

Switch to direct anticoagulants and improved endothelial function in patients with chronic heart failure and atrial fibrillation

BACKGROUND

Chronic heart failure (CHF) is characterized by higher rates of atrial fibrillation (AF) and endothelial dysfunction (ED). First line anticoagulant therapy in AF is represented by direct oral anticoagulants (DOACs); several patients, however, are still treated with vitamin-K inhibitors. The use of DOACs is associated in previous studies with an improved vascular function. We therefore sought to evaluate possible changes in endothelial function assessed by flow-mediated dilation (FMD) in patients with CHF and AF shifting from warfarin to DOACs.

METHODS

Forty-three consecutive outpatients were enrolled in the study. FMD was assessed at baseline and after 4 months. Patients were compared according to AC therapy.

RESULTS

After the first measurement of FMD, 18 patients "switched" to DOACs because of poor compliance to warfarin therapy or time in therapeutic range, 19 patients continued to use DOACs, 6 warfarin. "Switched" patients to DOACs therapy showed an improved FMD (19.0 ± 6.6% vs 3.8 ± 1.3%, p < 0.0001); C-reactive protein (CRP) levels decreased in "switched" patients from 1.4 ± 0.5 to 1.0 ± 0.7 mg/dl (p < 0.05). FMD and CRP changes were not significant in patients who did not changed anticoagulant therapy. In switched patients, changes in CRP levels were proportional to FMD changes (r = -0.50, p < 0.05). Shifting from warfarin to DOACs was significantly correlated to improved FMD levels even at multivariable analysis (p < 0.05).

CONCLUSIONS

Switch from warfarin to DOACs in patents with CHF and AF was associated in an observational non randomized study with an improved endothelial function. Changes in FMD values were related to changes in CRP levels.

P6547The energy cost of His bundle pacing can be curtailed

Introduction

His bundle pacing (HBP) allows physiological ventricular activation and prevents the electrical and mechanical desynchronization generally induced by myocardial stimulation, which can increase the risk of atrial fibrillation and heart failure. On the other hand, reliable HBP capture often requires higher energy than conventional myocardial pacing. This reduces the expected life of the stimulator and might limit the diffusion of HBP in the clinical practice.

Purpose

Decreasing HBP current drain by careful management of stimulation safety margin and pulse duration.

Methods

In 28 patients undergoing DDD pacing with HBP, a third lead was implanted in RV apex to provide back-up pacing on demand. HBP and apical leads were connected, respectively, to the V1 and V2 channels of a 3-chamber stimulator. When HBP was effective, apical sensing occurred within the VV delay and prevented V2 stimulation. In contrast, in case of HBP failure, V2 sensing was missing and apical back-up pacing was promptly delivered at the end of the VV delay. The availability of a back-up pulse on demand allowed reducing the HBP safety margin with no risk. Furthermore, the individual HBP strength-duration curve was derived in the aim of optimizing the Hisian pulse parameters, which are the major determinants of the device current drain.

Results

Correct back-up inhibition by successful HBP and stimulation in the event of capture loss was achieved in all the patients. The latency from Hisian pacing to apical sensing averaged 96±14 ms. According to the pacemaker counters, no back-up pulse was delivered in daily life in 59% of patients. In the remaining, the prevalence of back-up stimulation never exceeded 15% of paced ventricular cycles. The high HBP threshold was essentially due to an increased rheobase (1.2±0.6 V), while the chronaxie ranged from 0.30 to 0.53 ms in 71% of patients (median 0.44 ms), exceeding 0.6 ms only in 29% of the cases. An average current saving of 5.4±3.0 μA was obtained at the expense of a mild reduction in HBP safety margin (from 1.6±0.2 to 1.4±0.1 times).

HBP and apical back-up

Conclusions

Back-up stimulation on demand is a reliable option to decrease HBP current drain and prolong the stimulator service life with full safety. In most of the cases, significant saving can be achieved by pulse shortening, as the chronaxie time is in the same range as with myocardial stimulation and longer pulses are not required. A pulse duration exceeding 0.6 ms is indicated in less than 1/3 of the implants.

Time Trends in Survival of Children with Acute Lymphocytic Leukemia in Piedmont, Italy: A Report from the Population-Based Cancer Registry

Aims and Background

The Childhood Cancer Registry of Piedmont (RTI) periodically updates the life status of each registered child. Given its size, the RTI is the major (albeit geographically limited) Italian source of population-based survival rates of cancer in children. The present report describes time trends in survival of children with acute lymphocytic leukemia (ALL).

Methods

During 1970-87, 429 residents in Piedmont aged 0-14 were diagnosed as having ALL: they have been followed up until 1991.

Results

Five-year survival rates increased from 21% to 72% for children diagnosed ALL respectively in 1970-72 and 1985-87. Major improvements occurred up to the mid-seventies and again between cases diagnosed in the early and late eighties. Improvement in survival was statistically significant for children belonging to classes comprised between 2 and 10 years of age at diagnosis. Period of diagnosis was unrelated to probability of survival among the 13 cases diagnosed ALL at age 0. Survival was unrelated to sex, even in the early seventies and even after consideration of children dying more than 5 years after diagnosis. Between 1976-81 and 1982-87, an improvement in survival was found in all categories of WBC count at diagnosis: the ratio between the two estimates was somewhat higher for children with more than 50,000 WBC/mm3 at diagnosis than for other children.

Conclusions

Present data are compared with those resulting from other population-based series: this exercise can be useful for an overall evaluation of delivery of cancer therapy at the population basis.

Parental Occupation and Other Environmental Factors in the Etiology of Leukemias and Non-Hodgkin'S Lymphomas in Childhood: A Case-Control Study

We report the results of a hospital-based, case-control study on acute lymphocytic leukemia (ALL), acute non-lympocytic leukemia (AnLL) and non-Hodgkin lymphoma (NHL) in childhood. The study was conducted from 1981 to 1984 in Turin (Italy). One hundred and forty-two children with ALL, 22 with AnLL and 19 with NHL were included, as well as 307 controls. Information on parental smoking habits, parental occupation, ionizing radiation and childhood diseases were collected using a standard questionnaire during a personal interview of the relative attending the child in the hospital. The odds ratios for antenatal diagnostic radiation were 1.1 (NS) for ALL and 2.4 (NS) for AnLL. No association was found with diseases in childhood. Paternal and maternal smoking habits were similar for ALL cases and controls. Both maternal and paternal smoking were associated with NHL: for paternal smoking, odds ratios were around 5, but without a correlation with number of cigarettes. Positive associations observed with maternal employment were: ALL with teacher and cleaner; AnLL and textile worker; NHL and baker. Corresponding association with paternal jobs were: ALL with clerks, farmers and employment in office equipment production; AnLL and workers in building, tire or textile industries; NHL and lorry drivers, workers in the building or in the wood and furniture industry.

Risk Factors for Soft Tissue Sarcomas in Childhood: A Case-Control Study

A hospital-based case-control study on soft tissue sarcomas (STS) was conducted in 1983-84 in Torino and in Padova (Italy). Cases (36 children with rhabdomyosarcoma (RMS) and 16 non RMS-STS) were compared to 326 controls. Histories of parental smoking habits and occupations, parental and children's exposure to ionizing radiation, children's diseases and some other variables were collected through interviews to the relatives attending the child in the hospital. A non statistically significant association was observed with both maternal age above 30 at child's birth (STS: OR = 1.5, C.I. = 0.8-2.9; RMS: OR = 1.9, C.I. = 0.9-4.0) and « in utero » exposure to diagnostic radiation (STS: OR = 1.9, C.I. = 0.5-6.5, based on 4 cases). No association was found with children's previous diseases. Paternal and maternal smoking habits were similar for RMS and STS cases and controls. Some positive associations with either maternal or paternal occupational histories were identified. They are difficult to interpret in view of the large number of comparisons and small absolute figures. They included maternal employment as medical doctor and nurse, farmer, textile worker and machine tool operator. An association was also observed with paternal occupation as butcher, building worker or employment in the production of domestic appliances. One case and no controls reported a maternal aunt affected by breast cancer.

Ataxia Telangiectasia and Acute Lymphoblastic Leukemia: Report of a Case

We report a new case of ataxia-telangiectasia (AT) and acute lymphoblastic leukemia (ALL) and review all 21 known cases of AT and ALL. Leukemia in these patients is associated with a male predominance, age older than 10 years at diagnosis, a white blood cell count higher than 50,000 mm3, and a fatal course. Four patients have been reported who developed T-cell leukemia, 3 null-cell leukemia and 1 B-cell leukemia. The AT-ALL patients appear to be at risk for infections related to their immunodeficient status and ALL chemotherapy. In addition, neurologic deterioration has been noted during the early phase of therapy.

Neurofibromatosis and Malignant Childhood Cancers: A Survey in Italy, 1970–83

Neural tumors, Wilms’ tumor, rhabdomyosarcoma and several types of leukemia have been previously described in association with neurofibromatosis (NF). In a nation-wide collection of cases in Italy, 15 children (0–14 years of age) with NF and cancer or leukemia were identified; 13 of them had been diagnosed with cancer between 1976–83. The expected number of children with cancer and NF in 1976–83 was 4.48. The distribution of tumor types was different from that found in the general population, with a higher proportion of tumors of neural crest origin as well as soft tissue sarcomas. In 7/15 the family history was positive for NF; in 5/7 the individuals affected included the mother and/or a maternal relative.

Mortality of Parents of Children with Cancer: A Population-based Study in Turin, Italy

Aims and Background

A cohort study was conducted in order to measure cause-specific mortality among parents of children recorded in the Childhood Cancer Registry of Piedmont. It is the first study carried out on the subject in southern Europe.

Methods and Study Design

The study comprised the 740 children resident in Turin and in whom a cancer had been diagnosed in the period 1967-1991. Nominal data were obtained for 723 fathers and 733 mothers. At the end of the follow-up in 1995, 645 fathers were alive, 68 dead and 10 untraceable. Corresponding figures for mothers were 700, 28 and 5. Cause of death was known for 91 of 96 parents.

Results

The period of observation of parents started on the birth of the index child, however mortality analyses were restricted to the period after 1965 because of limited availability of local reference rates. Total mortality was lower than expected among fathers (66 observed deaths vs 88.2 expected, P <0.05) and mothers (28 vs 31.4). Fathers showed deficits (not statistically significant) of lung neoplasms (4 vs 9.9), cardiovascular diseases (18 vs 27.1) and hepatic cirrhosis (2 vs 6.6). No statistically significant variations in mortality were observed with time from diagnosis or according to life status of the children. No cancer deaths occurred among the mothers of sarcoma cases whereas 1.9 were expected.

Conclusions

The data do not indicate any increase in mortality from cancer or other causes and, on the contrary, show a reduction in mortality which was more evident for the causes related to life style.

High Incidence of Laryngeal Cancer in the Province of Torino (Italy)

The present report shows that the province of Torino, Italy, (6830 sq Km, population in 1966, 2.074.893) is a high risk area for laryngeal cancer. A total of 875 cases occurring in residents in the province were forwarded to the Cancer Registry of Piedmont (RTP) in 1965–69. A histological report was available in 67.9 % cases, while in 21.8 % the death certificate was the only document with diagnosis of laryngeal cancer (table 1). Cases were uniformly distributed throughout the 5 years covered by the study: the number of cases with death certificate only progressively decreased from 59 in 1965 to 21 in 1969 (table 3). For the purposes of the present study, the province of Torino has been divided into 3 areas, i.e. the city of Torino (population 1.107.919), the 23 suburbs (total population 340.951) and the non-metropolitan part of the province (population 626.023). Among the three areas, the relative frequency of laryngeal cancer/all malignant tumours recorded at the RTP in men was 5.78 % in the city of Torino, 6.43 % in the suburbs and 4.77 % in the non-metropolitan part of the province (table 4). The difference between the city of Torino and the suburbs was not significant (p > 0.05) while the difference both between the city of Torino and the non metropolitan part of the province and between the suburbs and the non metropolitan areas was significant (p < 0.05 and p ∼ 0.01 respectively). In other cancer registries (3) the relative frequencies of laryngeal cancer were under 2.86 % with the exception of Israel (3.24 %) and Bombay (9.26 %). In women, the relative frequency of laryngeal cancer fluctuated between 0.25 and 0.32 % in the different areas of the province of Torino, i.e. in the same order of those observed in other cancer registries with the exception of Bombay (2.07%) (3). In the province of Torino considered as a whole, age standardized annual incidence/100.000 of laryngeal cancer was 12.6 in men and 0.6 in women. Incidences truncated to ages 35–64 were 25.5 and 0.9 respectively (table 5). In men these rates are approximately 5–7 times higher than those recorded in Norway, Sweden and Denmark and about 3.5–6 times higher than those recorded in the six cancer registries operating in Great Britain. A comparison between the province of Torino and other cancer registries on age specific incidences (table 6, text-fig. 3) shows that the ratio province of Torino/other registries is relatively higher at age 35–44 than later in life. This is considered as evidence of an increase of the environmental carcinogenic load in the province of Torino during recent years. In men, age standardized incidences and incidences truncated to ages 35–64 were slightly but not significantly higher in the city of Torino than in the suburbs. On the other hand, in both the city of Torino and the suburbs they were 1.5–1.7 times higher than in the non-metropolitan part of the province (table 5). The difference concerned mainly age groups over 55 (text-fig. 2). However, the incidence of laryngeal cancer truncated to ages 35–64 in the non-metropolitan part of the province of Torino was still 7.2 times higher than in the rural population of Norway and 2.1–4.1 times higher than in the six cancer registries operating in Great Britain (3). This suggests that factors connected with life in the metropolitan area of Torino (such as air pollution) are a minor cause of the excess of laryngeal cancer in the province of Torino.

Epidemiology of Childhood Cancer in Piemonte and Valle d'Aosta during 1965-69

Piemonte and Valle d'Aosta are in the NW part of Italy. In 1967 total population and population aged 0-14 were respectively 4.338.000 and 841.000. During the period 1965-69 a total of 688 cases of cancer (including leukemia) were diagnosed in children under 15 years of age resident in this area. The Cancer Registry of Piedmont and Valle d'Aosta (RTP) provided information on 465 children; the other 223 were collected through additional investigation in the files of 31 university or hospital departments of the region and 5 extraregional hospitals. Distribution through the 5 years covered by the investigation is shown in Table 1. Histological or hematological confirmation of the diagnosis was available in 499 cases (73%). The 688 cases included 216 leukemias, 131 tumors of the central nervous system, 40 neuroblastomas, 82 lymphomas (including 34 cases of Hodgkin's disease), 46 nephroblastomas, 32 soft-tissue sarcomas, 29 bone sarcomas (including 5 cases of Ewing's disease), 25 retinoblastomas, 12 thyroid tumors, 10 extragenital teratomas, 5 ovarian dysgerminomas, 4 tumours of the testes, 4 hepatoblastomas and 52 other tumours (Table 2). The number of children under 15 years of age dying of cancer during 1965-69 was 341 (Table 2). Incidence and mortality rates by age groups are given in Tables 3 and 4. The rates were of the same order as those observed in the U.S. and in other European cancer registries during the same period (Tables 4, 5 and 6). The mortality rate for nephroblastomas at age 0-4 was 1,09/100.000/year, i.e. slightly higher than that observed in the U.S. in 1960 but about twice as high as that observed in the U.S. in 1967 (14). Incidence and mortality rates for both Hodgkin's and non-Hodgkin's lymphomas were about 3 times higher in males than in females (Table 3). The difference was less obvious during the first five years of life, in which the total number of diagnosed lymphomas was 16.

Increase of Mortality Kate of Cancer of the Larynx in the Town of Torino and in Italy since 1951

Mortality rates of cancer of the larynx in the town of Torino, in the whole of Italy and in France during 1950–71 are reported. Age standardized mortality rates as well as mortality rates truncated to the period 35–64 years of age are reported in Table 1 for males and in Table 2 for females. Graph 1 represents age specific mortality rates for cancer of the larynx in the three areas in 1966–67. Graphs 2, 3 and 4 report mortality rates in males in the three ares for cohort of birth. All rates are annual/100.000. An increase of mortality for cancer of the larynx in men is well documented in the town of Torino. From 1951 to 1966 the mortality rate truncated to age 35–64 increased from 6.3 to 12.0. The proportion of mortality for cancer of the larynx/mortality for all cancers during the same period increased from 3.1 % to 5.4%. In Italy, the mortality rate in men aged 35–64 was 6.5 in 1952 and 9.3 in 1967: during the same period the proportion of mortality for cancer of the larynx/mortality for all cancers increased from 3.8 % to 4.4 %. In France, the tendency to an increase of mortality for laryngeal cancer after 1951 was absent or debatable, although both the mortality rates of cancer of the larynx and the proportion of mortality for cancer of the larynx/mortality for all cancers were consistently higher than in Italy or in Torino. However, in 1966–67 at ages 35–44 the mortality rate for cancer of the larynx in men was higher in Torino than in France (Graph 1).

Survival of Childhood Cancer Patients in Italy, 1978–1989

In the framework of the ITACARE project, a cooperative investigation conducted on the data from the Italian population-based cancer registries, survival of patients with childhood malignant neoplasms was studied. The study included 1,768 cases diagnosed at age 0–14 plus 29 osteosarcoma cases diagnosed at age 15–19. Cases were collected over the period 1978–1989, or more limited periods for some participating registries. A total of 1,138 cases were from the Childhood Cancer Registry of Piedmont and 659 from the registries operating in the provinces of Varese, Parma, Modena, Forlì and Ravenna, Florence, Latina, Ragusa and in the cities of Genova and Torino (the last contributed only for bone neoplasm diagnosed at age 15–19). Overall 5-year survival was 54% for malignancies diagnosed in 1978–1981, 60% for the period 1982–1985, and 69% for the period 1986–1989. The range among registries of 5-year survival for cases diagnosed in 1986–1989 was 55–78%. Most diagnostic categories presented an improved prognosis for the cases diagnosed more recently. For cases diagnosed in 1986–1989, 5-year survival was: 74% for acute lymphatic leukaemia, 40% for acute non-lymphatic leukaemia, 65% for central nervous system neoplasms (76% for astrocytoma, 75% for ependymoma and 85% for medulloblastoma), 66% for osteosarcoma, 55% for Ewing's sarcoma, 87% for Hodgkin's disease, 64% for non-Hodgkin's lymphoma, 74% for rhabdomyosarcoma, 64% for neuroblastoma, 78% for nephroblastoma and 100% for retinoblastoma. Italian survival was similar to that observed in other population-based surveys in the UK and USA.

Physical Impairment and Social Life, Goals among Adult Long-term Survivors of Childhood Cancer: A Population-based Study from the Childhood Cancer Registry of Piedmont, Italy

Aims and Background

The study describes the health status and the attainment of life goals in the adult survivors of childhood cancer recorded at the Childhood Cancer Registry of Piedmont.

Methods and Study Design

A postal questionnaire was sent to the general practitioner of the 690 cases born before 1976 and alive in 1991 after at least 5 years from diagnosis. The answer was received for 485 (72.9%) included in the analyses. Items in the questionnaire were: sequelae related to cancer and its treatment, health-related quality of life (according to Bloom's criteria), educational level attained, and employment status.

Results

Vital and marital status were obtained for all 690 cases at the offices of the town of residence. No medical condition was reported for 309 cases (63.7%). The overall proportion with a high school or university education was compared to corresponding figures for Piedmont in 1991, adjusted by age, and was as high as in the general population. Similar results are observed for occupation. Patients of both genders were married less than expected. Patients with leukemia (112 cases), non-Hodgkin's lymphoma (34) or Hodgkin's lymphoma (52) were reported to have the highest quality of life. In contrast, patients with tumors of the central nervous system (151) had the highest frequency of sequelae and the lowest score for health-related quality of life. They also presented the lowest educational achievement, the lowest proportion of employment and, among males, the lowest frequency of marriage.

Conclusions

Our study shows a good social adjustment of adult survivors from childhood cancer, with the exception of central nervous system tumors. From the methodologic point of view, the present study shows the feasibility of surveillance surveys on health-related quality of life with the contribution of general practitioners.