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.

Cardiac Contractility Modulation (CCM) Italian Registry: preliminary analysis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac contractility modulation (CCM) therapy is a treatment option for patients suffering symptomatic Chronic Heart Failure (HF) with reduced left ventricular ejection fraction (LVEF) despite optimal medical therapy (OMT) [1]. CCM, by delivering high-output electrical impulses during ventricular absolute refractory period, increases the activity of proteins involved in intracellular calcium handling. This therapy has been associated with improvement in quality of life (QoL) and reduction of HF-hospitalizations [2,3]. Our aim is to present preliminary data from the CCM Italian Registry.

Methods

The CCM Italian Registry is a prospective, observational, multicentre study investigating the long-term impact of CCM therapy in HF patients on LVEF, Minnesota Living With HF Questionnaire (MLWHFQ) and 6-minutes walking test (6MWT) [4]. Preliminary results after one year of follow-up have been analysed in this abstract. Data are expressed as median and interquartile range. Changes from baseline have been tested with Wilcoxon signed-rank test.

Results

A total of 42 patients suffering HF, with LVEF<45%, NYHA class>II despite OMT, have been enrolled and implanted with CCM device in 10 Centres. Most of patients were male (41 patients, 98%), with a median age of 76 years (70-79). The most frequent aetiology was ischemic (29 patients, 69%) and 32 (79%) had another implanted device (24 ICD, 8 CRT-D). Twelve (29%) patients presented chronic atrial fibrillation (AF). Thirty-eight (90%) patients were treated with beta-blockers and 32 (76%) received sacubitril/valsartan (15) or ACE-inhibitors (17). A significant reduction in HF-related hospitalization has been observed after 6 and 12 months of CCM therapy, compared to the incidence in the 12 months before CCM implantation (Figure 1), with a relative risk reduction of 75% at 12 months (p<0.001). As shown in Figure 2, LVEF significantly improved both at 6 and 12-month follow up (p=0.042 and p=0.004, respectively), as well as MLWHFQ score (p=0.001 and p=0.032, respectively). The 6MWT distance did not show significant changes (6-month, p=0.252 and 12-month, p=0.281), mainly due to physical limitations in some patients. NYHA class improved significantly both at 6 (p=0.001) and 12-months (p=0.012), with 80% of patients showing an improvement of at least 1 class compared to baseline. After stratifying by HF aetiology, LVEF at 12-months improved significantly in non-ischaemic HF (p=0.028), while in patients with ischaemic aetiology improved significantly at 6-months (p=0.0416) but not at 12-months (p=0.135).

Conclusion

CCM proved to be effective in improving symptoms, QoL and in reducing CHF-hospitalizations in patients with symptomatic CHF with reduced LVEF despite OMT. This prospective Italian Registry will be fundamental to gather more evidence, to assess the long-term effect of CCM, and also to measure the impact of CCM therapy in the Italian clinical practice.

A clinical-in silico study on the effectiveness of multipoint bicathodic and cathodic-anodal pacing in cardiac resynchronization therapy

Up to one-third of patients undergoing cardiac resynchronization therapy (CRT) are nonresponders. Multipoint bicathodic and cathodic-anodal left ventricle (LV) stimulations could overcome this clinical challenge, but their effectiveness remains controversial. Here we evaluate the performance of such stimulations through both in vivo and in silico experiments, the latter based on computer electromechanical modeling. Seven patients, all candidates for CRT, received a quadripolar LV lead. Four stimulations were tested: right ventricular (RVS); conventional single point biventricular (S-BS); multipoint biventricular bicathodic (CC-BS) and multipoint biventricular cathodic-anodal (CA-BS). The following parameters were processed: QRS duration; maximal time derivative of arterial pressure (dPdt_max); systolic arterial pressure (P_sys); and stroke volume (SV). Echocardiographic data of each patient were then obtained to create an LV geometric model. Numerical simulations were based on a strongly coupled Bidomain electromechanical coupling model. Considering the in vivo parameters, when comparing S-BS to RVS, there was no significant decrease in SV (from 45 ± 11 to 44 ± 20 ml) and 6% and 4% increases of dPdt_max and P_sys, respectively. Focusing on in silico parameters, with respect to RVS, S-BS exhibited a significant increase of SV, dPdt_max and P_sys. Neither the in vivo nor in silico results showed any significant hemodynamic and electrical difference among S-BS, CC-BS and CA-BS configurations. These results show that CC-BS and CA-BS yield a comparable CRT performance, but they do not always yield improvement in terms of hemodynamic parameters with respect to S-BS. The computational results confirmed the in vivo observations, thus providing theoretical support to the clinical experiments.

Could specific EKG markers identify a pharmacologically induced type 1 Brugada pattern? Insights from a large, single-centre cohort

Funding Acknowledgements

Type of funding sources: None.

Background. Pharmacological (Ajmaline) induction of a type 1 Brugada pattern is currently considered mandatory for the diagnosis of Brugada syndrome. However, performing the test requires time and healthcare resources. Some EKG markers have been proposed as predictors of positive result at Ajmaline test.

Aim. To evaluate in a large population the predictive value of multiple EKG markers for Ajmaline test results.

Methods. We retrospectively analysed consecutive patients (pts) referred to our Centre to perform Ajmaline test. All pts had type 2 Brugada pattern detected at a conventional EKG or were relatives of pts with positive Ajmaline test, with or without type 2 Brugada pattern at EKG. All pts performed the Ajmaline pharmacological test (1 mg/Kg iv) with EKG "superior" right precordial unipolar derivations monitoring. To determine whether clinical parameters (age, gender, cardiomyopathy, history of arrhythmias, symptoms, familiarity) and EKG markers (heart rate (HR), PR duration, R1V1 and SV6 duration and amplitude, QRSV1/QRSV6 duration, V1 and V2 ST amplitude (coved or saddle back pattern) were independently associated to positivity at Ajmaline test, a logistic regression model was applied.

Results. From January 2010 to December 2019 we evaluated 442 consecutive pts: mean age 40.1 ± 14.5 years; 273 (65%) male; 352 (80%) pts were included because of type 2 Brugada pattern at EKG and 90 (20%) for familial screening. The Ajmaline test was positive in 150 (34%) pts. At multivariate logistic regression analysis adjusted for baseline confounders, age > 45 years (OR= 1.64, 95%CI: 1.03 to 2.54; p = 0.0385), female gender (OR = 1.79, 95%CI: 1.12 to 2.85; p = 0.0141), HR > 60 bpm (OR = 2.44, 95%CI: 1.48 to 4.03; p = 0.0005), QRSV1/QRSV6 duration (msec) >1 (OR = 5.34, 95%CI: 3.28 to 8.69; p < 0.0001) and non isoelectric pattern (coved/saddle back) in V2 (OR = 1.93, 95%CI: 1.03 to 3.63, p = 0.0416) remained associated with a positive Ajmaline test. The percentage of pts with positive Ajmaline test increased according to the presence of significant EKG markers in their risk profile: 11.3% (8 out 71, absence of both QRSV1/QRSV6 duration (msec) >1 and V2 non isoelectric pattern), 24.3% (50 out 206, presence of only V2 non isoelectric pattern), 48.5% (16 out 33, presence of only QRSV1/QRSV6 duration (msec) >1), 57.6% (76 out 132, presence of both factors).

Conclusions. In our large population: 1) we confirmed the positive predictive power of QRSV1/QRSV6 duration (msec) >1 and of a non isoelectric pattern (coved/saddle back) in V2 for a pharmacologically induced type 1 Brugada pattern; 2) we observed a non-negligible percentage of pts who would not be correctly diagnosed for type 1 Brugada pattern, if selected according to an EKG parameters-based prescreening.

Cathodic-anodal left ventricular stimulation during cardiac resynchronization therapy: haemodynamic evaluation and electrocardiographic analysis

Background

Cardiac resynchronization therapy (CRT) is an established treatment for heart failure with reduced ejection fraction (HFrEF). However, one third of patients are “non responders”. Cathodic-anodal (CA) left ventricle (LV) capture is a multisite pacing occurring during CRT using both bipolar and quadripolar LV lead. It allows depolarization to arise simultaneously from the cathode and the anode of the bipole located on the LV epicardium, activating a larger volume of myocardium than cathodal pacing alone, thus potentially improving electromechanical synchrony (figure 1). We have previously proven that CA-LV stimulation is feasible and similar to bicathodic multipoint pacing (MPP) in terms of QRS wavefront activation.

Purpose

We aimed to evaluate both the acute intraprocedural haemodynamic and electrical effects of CA biventricular stimulation (CA-BS), comparing it with right-ventricle only pacing (Right Ventricle-Stimulation: RV-S), single-point CRT (Single Point-Biventricular Stimulation: SP-BS) and multipoint bicathodic biventricular stimulation (Multi Point-Biventricular Stimulation:MP-BS) in de novo CRT implants.

Methods

Ten patients candidates to CRT (LV ejection fraction ≤35% and left bundle branch block) received a quadripolar LV lead. Four pacing configurations were tested: RV-S, SP-BS, MP-BS and CA-BS, where cathode and the anode were the same electrodes used as cathodes in MP-BS. QRS duration by 12-lead ECG was defined as the time from the earliest ventricular deflection until the return to the isoelectric line. Haemodynamic assessment by radial artery catheterization using Pressure Recording Analytical Method processed the following parameters: dP/dT max (mmHg/msec), systolic arterial pressure (aPsys, mmHg), diastolic arterial pressure (aPdia, mmHg), mean arterial pressure (aPmean, mmHg), Cardiac Index (CI, l/min/m2), Stroke Volume Index (SVI, ml/min/m2).

Results

dP/dT max and aPmean increased significantly from RV-S to SP-BS (mean dP/dT max 0,82±0,28 versus 0,87±0,29 mmHg/msec, p=0,02; mean aPmean 89±19 versus 93±20 mmHg, p=0,01), but not from RV-S to MP-BS. Comparing RV-S to CA-BS, only aPmean exhibited a significant increase (mean aPmean 89±19 versus 92±20 mmHg, p=0,01). There were no haemodynamic differences between SP-BS, MP-BS and CA-BS. QRS duration reduced significantly from RV-S (167±10 msec) to each biventricular stimulation (135±14 msec, p=0,0002 for SP-BS; 130±17 msec, p=0,0001 for MP-BS; 129±18 msec, p=0,0002 for CA-BS) and from SP-BS to MP-BS and CA-BS (p=0,03 for both), whereas there were no difference comparing MP-BS and CA-BS.

Conclusions

CA-LV stimulation is not superior to single-point CRT in terms of acute haemodynamic performance, whereas it reduces the duration of ventricular electrical activation, showing an electrohaemodynamic mismatch. Long-term studies are needed to evaluate if acute electrical benefits of CA stimulation can predict chronic benefits, in terms of reverse cardiac remodelling.

Cathodic-anodal left ventricular capture

Funding Acknowledgement

Type of funding source: None

P1493Cardiac contractility modulation in left ventricular systolic dysfunction: 1-year single Centre experience and clinical outcome

Funding Acknowledgements

None

Introduction. Cardiac contractility modulation (CCM) is a treatment option for patients suffering symptomatic chronic heart failure (CHF) with reduced ejection fraction (LVEF) despite optimal medical therapy, who are not eligible for or non-responders to cardiac resynchronization therapy (CRT). Despite randomized trials showing benefit in the short term, data on mid-term follow-up (over 12 months) are limited to small observational studies.

Purpose. The aim of this observation, prospective study is to assess the impact of CCM therapy on quality of life, symptoms, exercise tolerance and left ventricular function in a population of patients with CHF and moderate-to-severe left ventricular systolic dysfunction.

Methods. Consecutive patients suffering from CHF with LVEF <45%, symptomatic, in NYHA class > II despite optimal medical therapy, underwent CCM implantation at our Centre from October 2017 to October 2018. Enrolled patients underwent baseline evaluation and at 3, 6 and 12 months with transthoracic echocardiogram, ECG, clinical assessment, 6-min hall walking test and Minnesota Living With Heart Failure Questionnaire (MLWHFQ).

Results. Overall, 10 patients underwent CCM implantation (100% males, mean age 70 ± 8 years, 80% ischaemic cardiomyopathy, mean LVEF 29.4 ± 8%). All patients had at least one hospitalization for worsening heart failure during the previous 12 months. After a mean follow-up of 15 months, 9 patients were alive, while one patient died for worsening heart failure precipitated by pneumonia 2 months following CCM implantation. Among the remaining 9 patients, LVEF improved non-significantly to 32.2 ± 10% (p = 0.092), 6-min walking test distance improved from 170 ± 132 m to 305 ± 99 m (p < 0.001), mean NYHA class improved from 3.0 ± 0.4 to 1.6 ± 0.5 (p = 0.003) and MLWHFQ score improved from 59.0 ± 33 to 34.0 ± 38 (p = 0.037) (Figure 1). Only 2 patients have been hospitalized during the 12 months, for worsening heart failure and sustained ventricular tachycardia, respectively. Overall, a net clinical benefit was detected in 6 out of 9 patients. Among the responders, 2 patients were device-naïve, presenting LVEF > 35%; one patient was a CRT non-responder, while the remaining 3 had narrow QRS. All the non-responders patients had ischaemic cardiomyopathy, one of them with a moderately reduced LVEF and one with a CRT.

Conclusion. CCM is effective in improving quality of life, symptoms and exercise tolerance, and reduces hospitalizations in patients with symptomatic CHF on top of optimal medical and electrical therapy. The benefit in responders is maintained over one year after implantation, so this treatment should be considered for highly symptomatic patients suffering from CHF and reduced LVEF.

Abstract Figure 1

P1009Procedural success and long-term outcome of CTI ablation targeted with maximum voltage-guided approach: preliminary results from an Italian multicenter registry

Background

Ablation technique targeting high-amplitude signals (maximum voltage guided - MVG -) on the cavotricuspid isthmus (CTI) has emerged as viable alternative option compared to standard anatomical approach (ST) for the creation of bidirectional conduction block (BDB) across the isthmus but limited data are available to date.

Purpose

To evaluate the effectiveness of acute and long-term outcome of CTI ablation through MVG technique for AFL compared to standard linear (SL) lesion ablation.

Methods

Atrial Flutter Ablation in a Real World Population (LEONARDO) is a prospective, multicenter cohort study aimed at providing an estimate of acute to long-term outcome in a large population of patients (pts) indicated for AFL ablation. Recurrence of AFL were retrieved at 12-month follow-up. Complete BDB was defined by agreement with the presence of widely split double potentials (DP) along the ablation line and assessment of the atrial activation sequence (AAS). For MVG technique the ablation catheter was positioned at the site of maximum local electrogram voltage.

Results

Two-hundred fifteen consecutive pts were included (mean age 68 years, 73% male). A median of 4 [2–6] ablation lesions were required. Median follow up was 359 [192–443] days. Complete BDB was achieved in 175 (81.4%) pts (9 pts had DP only criterion, 30 pts had AAS only criterion whereas in 1 pt we failed to reach a BDB). In the 106 pts with complete data at 1-year follow-up, 10 (9.4%) had a recurrence of AFL. 171 pts (79%) underwent a SL ablation whereas 44 pts (21%) were treated by MVG approach. The median number of lesions/pt was significantly lower in the group of pts targeted with MVG compared to the SL approach (3 [2–4] vs 4 [2–8], p<0.01), whereas no differences were found in terms of fluoroscopy time (16 [12–18] min vs 12 [7–22] min, p=NS) or proportion of pts with BDB achievement (86.4% of the cases for MVG vs 80.1% of the cases for ST, p=NS). No complications were reported. AFL recurrence was comparable during follow-up between groups (8.3% for MVG vs 9.8% for SL ablation; p=NS).

Conclusion

Ablation of a targeted site through MGV approach seems to be safe and effective as standard anatomical ablation technique. This strategy may avoid unnecessary ablation of the entire anatomic isthmus.

Acknowledgement/Funding

None