Worldwide Survey of COVID-19-Associated Arrhythmias

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Coronavirus disease 2019 (COVID-19) has led to over 1 million deaths worldwide and has been associated with cardiac complications including cardiac arrhythmias. The incidence and pathophysiology of these manifestations remain elusive. In this worldwide survey of patients hospitalized with COVID-19 who developed cardiac arrhythmias, we describe clinical characteristics associated with various arrhythmias, as well as global differences in modulations of routine electrophysiology practice during the pandemic.

A case report of arterial and venous thromboembolism in a patient with severe COVID-19 pneumonia

Background

Coronavirus disease 2019 (COVID-19) has spread rapidly worldwide since the outbreak originated in Wuhan, China in December 2019. Cardiovascular complications in patients with severe COVID-19 have been reported and are associated with a worse outcome. Coagulopathy is one of the most common life-threatening complication increasing mortality; however, little evidence is available regarding prevention strategies or its treatment in COVID-19 patients.

Case summary

We report a case of a 70-year-old woman admitted to hospital with severe COVID-19 bilateral pneumonia who developed severe coagulopathy with multiple both, venous and arterial, embolisms in major vessels such as bilateral pulmonary embolism, acute thrombus in abdominal aorta, and acute thrombotic occlusion of the right iliac common artery. The patient underwent emergent surgical thrombectomy of the right lower limb; in spite of anticoagulant treatment at therapeutic doses, patient presented poor clinical evolution and an infracondylar amputation of right lower limb was made finally. Subsequently, the patient received low molecular weight heparin (LMWH), antibiotics and antiviral therapy improving her renal function and her pneumonia, so she could be discharged safely.

Discussion

Prothrombotic coagulopathy due to enhanced acute inflammatory response and diffuse intravascular coagulation has been described in severe critical COVID-19 patients. This state of hypercoagulability is associated with organ dysfunction and mortality and may predispose to both, venous and arterial, thromboembolism. Little data are available regarding the best therapeutic and prevention strategies in this scenario, although thrombosis prophylaxis with LMWH has been associated with a better outcome.

Effect of hydroxychloroquine, azithromycin and lopinavir/ritonavir on the QT corrected interval in patients with COVID-19

Background

Administration of Hydroxychloroquine and Azithromycin in patients with coronavirus disease 2019 (COVID-19) prolongs QTc corrected interval (QTc). The effect and safety of Lopinavir/Ritonavir in combination with these therapies have seldom been studied.

Objectives

Our aim was to evaluate changes in QTc in patients receiving double (Hydroxychloroquine + Azithromycin) and triple therapy (Hydroxychloroquine + Azithromycin + Lopinavir/Ritonavir) to treat COVID-19. Secondary outcome was the incidence of in-hospital all-cause mortality.

Methods

Patients under treatment with double (DT) and triple therapy (TT) for COVID-19 were consecutively included in this prospective observational study. Serial in-hospital electrocardiograms were performed to measure QTc at baseline and during therapy.

Results

168 patients (±66.2 years old) were included: 32.1% received DT and 67.9% received TT. The mean baseline QTc was 410.33 ms. Patients under DT and TT prolonged QTc interval respect baseline values (p < 0.001), without significant differences between both therapy groups (p = 0.748). Overall, 33 patients (19.6%) had a peak QTc and/or an increase QTc 60 ms from baseline, with a higher prevalence among those with hypokalemia (p = 0.003). All-cause mortality was similar between both strategy groups (p = 0.093) and high risk QTc prolongation was no related to clinical events in this series.

Conclusions

DT and TT prolong the QTc in patients with COVID-19. Addition of Lopinavir/Ritonavir on top of Hydroxychloroquine and Azithromycin did not increase QTc compared to DT.

Malignancy following heart transplantation: differences in incidence and prognosis between sexes - a multicenter cohort study

Male patients are at increased risk for developing malignancy postheart transplantation (HT); however, real incidence and prognosis in both genders remain unknown. The aim of this study was to assess differences in incidence and mortality related to malignancy between genders in a large cohort of HT patients. Incidence and mortality rates were calculated for all tumors, skin cancers (SCs), lymphoma, and nonskin solid cancers (NSSCs) as well as survival since first diagnosis of neoplasia. 5865 patients (81.6% male) were included. Total incidence rates for all tumors, SCs, and NSSCs were lower in females [all tumors: 25.7 vs. 44.8 per 1000 person-years; rate ratio (RR) 0.68, (0.60-0.78), P < 0.001]. Mortality rates were also lower in females for all tumors [94.0 (77.3-114.3) vs. 129.6 (120.9-138.9) per 1000 person-years; RR 0.76, (0.62-0.94), P = 0.01] and for NSSCs [125.0 (95.2-164.0) vs 234.7 (214.0-257.5) per 1000 person-years; RR 0.60 (0.44-0.80), P = 0.001], albeit not for SCs or lymphoma. Female sex was associated with a better survival after diagnosis of malignancy [log-rank p test = 0.0037; HR 0.74 (0.60-0.91), P = 0.004]. In conclusion, incidence of malignancies post-HT is higher in males than in females, especially for SCs and NSSCs. Prognosis after cancer diagnosis is also worse in males.

Incidence and prognostic implications of late bleeding events after percutaneous mitral valve repair

Objectives

MitraClip is an established therapy for patients with mitral regurgitation (MR) that are considered of high-risk or inoperable. However, late bleeding events (BE) after hospital discharge and their impact on prognosis in this cohort of patients have been poorly investigated. Our purpose is to address the incidence, related factors and clinical implications of BE after hospital discharge in patients treated with MitraClip.

Methods

Prospective registry of all consecutive patients (n = 80) who underwent MitraClip implantation in our Institution between June 2014 and December 2017. BE were defined according to MVARC definitions. A combined clinical end-point including admission for heart failure (HF) and all-cause mortality was established to analyze prognostic implications of BE.

Results

During a median follow up of 523.5 days, 41 BE were reported in 21 patients. Atrial fibrillation (AF, HR 4.54, CI95% 1.20–17.10) and combined antithrombotic therapy at discharge (HR 3.52, CI95% 1.03–11.34) were independently associated with BE. In the study period, 15 (18.8%) patients died, 20 (25%) were admitted for HF and 29 (36.3%) presented the combined end-point. After multivariable adjustment BE remained independently associated with an adverse outcome (HR 3.80, CI 95% 1.66–8.72). In the subgroup of patients with AF, HAS-BLED score was higher among subjects with BE (3.1 ± 1.3 vs 2.1 ± 0.9, p = 0.003). HAS-BLED score had a significant discrimination power for the occurrence BE (AUC: 0.677 [0.507–0.848]) in this subgroup.

Conclusions

BE are common after MitraClip and are associated with an impaired outcome. Strategies to reduce bleeding events are paramount in this cohort of patients.

Instantaneous wave-free ratio for guiding treatment of nonculprit lesions in patients with acute coronary syndrome: A retrospective study

BACKGROUND

The aim of this study was to analyze the feasibility of a physiological coronary evaluation with the instantaneous wave-free ratio (iFR) of nonculprit lesions in patients with acute coronary syndrome (ACS) successfully revascularized.

METHODS

A multicenter registry including patients of four high-volume PCI centers with ACS and underwent successful revascularization of the culprit vessel and had other nonculprit lesions that were physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, probable or definitive stent thrombosis and new revascularization (MACEs).

RESULTS

A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66 ± 11 years. The clinical presentation was ACS without persistent ST-segment elevation (NSTE-ACS) in 235 patients (66%) and ST-segment elevation myocardial infarction (STEMI) in 121 patients (34%). After a median follow-up period of 21 (14-30) months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding clinical presentation (NSTEMI vs. NSTE-ACS, 9.1 vs. 8.9%, p_adj  = 0.570) or iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion with an iFR > 0.89 deferred for revascularization, 10.5 vs. 8.4%, p_adj  = 0.476).

CONCLUSIONS

The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be feasible, with an acceptable percentage of MACEs at the mid-term follow-up. Patients with deferred revascularization of lesions without physiological significance and patients undergoing complete revascularization had a similar risk of MACEs.

Baseline profile and results of atrial fibrillation ablation in patients with arrhythmia-induced cardiomyopathy

Background

Atrial fibrillation (AF) is known to trigger a reversible dilated cardiomyopathy referred as arrhythmia-induced CM (AiCM). However, it remains unclear why some patients are more prone to develop AiCM than others and there is scarce information about their clinical outcomes after AF ablation.

Purpose

We ought to find clinical and analytical predictors for the development of AiCM and recovery of LVEF in patients referred for AF ablation.

Methods

A prospective multicenter study of consecutive patients undergoing point-by-point radiofrequency (RF) catheter ablation between September 2016 and November 2021 was conducted. The low voltage areas and left atrial (LA) volume were analyzed offline on high density electroanatomical maps collected prior to RF ablation. Peripheral blood sample for biomarker analysis (Gal-3, FABP4 and sRAGE) were obtained at the time of the procedure.

Results

803 consecutive patients were included, median age was 61 and 240 (30,81%) were women. AF pattern was paroxysmal in 254 (32,60%) and persistent in 534 (68,55%; of whom, long-standing persistent in 113 (14,51%) patients). The median follow-up period was 23.83 months [IQR 9 to 36]. The multivariate analysis revealed LA area, width of QRS segment, persistent AF and chronic kidney disease (CKD) as independent predictors for AiCM. Recurrence-free survival was not different amog both cohorts (Figure 1).

The median increase in LVEF from baseline to the 6-month follow-up visit in patients with AiCM was 16% (CI 14.31–18.47) without changes in the non-AiCM group. The median LVEF previously to CA from patients in the AiCM group was 38% (IQR 30–45%) and after the procedure 57% (IQR 50–60%) [see figure 2].

Conclusions

AiCM is characterized to have a particularly complex pathophysiology not fully understood thus far. Pulmonary vein isolation in patients is safe and suitable for patients that suffered from tachycardiomyopathy. We found that persistent AF and chronic kidney disease play a key role in its development. Neither peripheral blood biomarkers nor left atrial samples showed relevant association with its occurrence.

Funding Acknowledgement

Type of funding sources: None.

Thrombus in transit through a patent foramen ovale: An unusual cause of cardiac embolism

A 78-year-old woman with a history of transient ischemic attack was admitted for sudden aphasia. In order to assess the potential cardioembolic source an echocardiogram was performed, which revealed a large mass consistent with a thrombus in transit through a patent foramen ovale. Because of the high risk of systemic embolism, emergent surgical thrombectomy was performed with the intention to discharge the patient safely without any new embolic events. This case report highlights the importance of echocardiography in the evaluation of cardioembolic stroke and the requirement of an emergent approach in case of impending paradoxical embolism.

Effects of guideline-directed medical therapy in patients with left bundle branch block-induced cardiomyopathy

INTRODUCTION AND OBJECTIVES

Left bundle branch block (LBBB)-induced cardiomyopathy occurs in patients with long-standing LBBB. These patients characteristically exhibit hyperresponsiveness to cardiac resynchronization therapies (CRT). However, there is scarce information on their response to medical treatment. The aim of this study was to assess the change in left ventricular ejection fraction (LVEF) after a 3-month period following titration of guideline-directed medical therapy for heart failure.

METHODS

This retrospective analysis included all patients assessed in the heart failure unit of a Spanish University Hospital between 2020 and 2021, who presented with de novo ventricular dysfunction (LVEF <40%) and had a history of long-standing LBBB with no other possible causes of cardiomyopathy.

RESULTS

A total of 1497 patients were analyzed, of which 21 were finally eligible. Mean time from first diagnosis of LBBB to first consultation was 4.05± 4.1 years. Mean LVEF from first consultation to end of titration improved from 29.5±5.7% to 32.7±8.6% (P = .172), but none had recovered ventricular function at the end of follow-up. New York Heart Association functional class improved from 1.91±0.46 to 1.81±0.53 (P=.542). After CRT device implantation in 8 patients, LVEF improved by 18.1±6.4% (P=.003).

CONCLUSIONS

Guideline-directed medical therapy seems to be ineffective in improving LVEF and functional class in patients with de novo heart failure and LBBB-induced cardiomyopathy. Based on a positive response to CRT on LVEF improvement, early CRT implantation could be a reasonable strategy for these patients.

Effect of age on clinical impact and mid-term denervation in patients undergoing cardioneuroablation

Cardioneuroablation (CNA) represents a promising therapy for recurrent vasovagal syncope (VVS), extrinsically driven atrioventricular block (AVB) and sinus node dysfunction (SND). However, effectiveness in patients aged 50 and above is not well-established. In this prospective study of patients referred for CNA, we compared syncope and pacemaker implantation free survival, heart rate (HR) variability (HRV) and quality of life between two age groups: group A (< 50 years) and B (≥ 50 years). A total of 50 patients were included (17 Group A and 33 Group B). The etiologies comprised VVS (56%), AVB (22%), and SND (22%). After a median follow-up of 17.0 (12.5-26.0) months, there were no differences of the combined endpoint of syncope or pacemaker implantation free-survival between groups (29.4.% vs. 21.2%; p-log-rank = 0.736). 84% of the entire cohort remained free from syncope, with a better but not significant syncope free survival in the older group (23.5% vs. 12.1%; p-log rank = 0.486). There were no differences in pacemaker implantation rate (A 5.9% vs. B 17.6%; p log-rank = 0.658). Notably, older patients had lower HR values post-procedure compared to younger patients (68.9 ± 13.3 vs. 80.4 ± 16.3 bpm; p = 0.012). Both groups exhibited a decrease in HRV parameters and an improvement in quality of life. In conclusion, CNA has comparable clinical benefits for patients aged 50 and above in terms of syncope or pacemaker implantation free survival and HRV reduction when compared to younger patients.

Endocardial ablation of ganglionated plexus for the treatment of carotid sinus syndrome

INTRODUCTION

Carotid sinus syndrome (CSS), characterized by exaggerated vagal responses leading to asystolic pauses with carotid sinus massage (CSM), often necessitates pacemaker implantation. This study investigates cardioneuroablation (CNA) as an alternative strategy for CSS.

METHODS

Prospective study of consecutive patients referred for CNA due to CSS. All patients underwent CSM, atropine test and 24-h Holter monitoring before the procedure and at 6 months. The primary objective was the absence of any cardioinhibitory response to CSM following CNA. Secondary objectives included the combined endpoint of syncope and presyncope-free survival, pacemaker-free survival, differences in heart rate variation (HRV), as well as differences in the pre- and postprocedure atropine tests and in the SF-36 quality-of-life questionnaire.

RESULTS

A total of 13 consecutive patients (84.6% male, mean age 63.8 ± 12.3 years) were included. CSM revealed a symptomatic asystolic pause in all patients before CNA (7.3 [5.6-10.5] s). After the procedure, all the patients had a negative CSM, and only one patient (7.7%) had a positive CSM at 6 months. After a median follow-up of 11.2 (10.6-16.3) months, syncope or presyncope-free survival was 84.6%, and none required pacemaker implantation. There was an improvement in the energy and health change items in the SF-36 questionnaire. There was a reduction in HR increase in the atropine test at 6 months (pre-CNA: 66% [52-84] vs. post-CNA 26.0% (19.8-29.3]; p = .008) and in HRV parameters.

CONCLUSIONS

In this proof-of-efficacy study, performed in patients affected by asystolic CSS, CNA was effective in reducing the rate of cardioinhibitory responses, suggesting a potential efficacy in also reducing syncopal recurrences. Controlled trials are warranted to corroborate clinical findings.

Characterization of patients with extensive left atrial myopathy referred for atrial fibrillation ablation: incidence, predictors, and outcomes

BACKGROUND

Although atrial fibrosis has a relevant impact on ablation success rate, experimental studies have reported that extensive fibrosis may be accompanied by a reduced burden secondary to a prominent depression of atrial excitability.

OBJECTIVES

We aimed to identify clinical and echocardiographic factors associated with extensive left atrial myopathy (ELAM), to analyze the predictive ability of established scores (AF score, APPLE, and DR-FLASH) and assess outcomes in terms of AF recurrence, left atrial flutter, and post-procedural heart failure admissions.

METHODS

A total of 950 consecutive patients undergoing the first AF ablation were included. A 3D electroanatomical mapping system (CARTO3, Biosense Webster) was created using a multipolar mapping catheter (PentaRay, Biosense Webster). ELAM was defined as ≥ 50% low voltage area. A subanalysis with four groups was also created (< 10%; 10-20%; 10-20%; and > 30%). Logistic regressions, Cox proportional hazards models, and log-rank test were used to test the predictors independently associated with the presence of ELAM and AF recurrence. The model was prospectively validated in a cohort of 150 patients obtaining an excellent ability for prediction AUC 0.90 (CI 95% 0.84-0.96).

RESULTS

Overall, 78 (8.42%) presented ELAM. Age, female sex, persistent AF, first-degree AV block, and E/e' were significant predictors. The model incorporating these factors outperformed the existing scores (AUC = 0.87). During a mean follow-up of 20 months (IQR 9 to 36), patients with ELAM presented a higher rate of AF recurrence (42.02% vs 26.01%, p = 0.030), left atrial flutter (26.03% vs 8.02%, p < 0.001), and post-procedural heart failure admissions (12.01% vs 0.61%, p < 0.001) than non-ELAM patients.

CONCLUSIONS

This study reveals the incidence and clinical factors associated with ELAM in AF, highlighting age, female, persistent AF, first-degree AV block, and E/e'. Importantly, the presence of ELAM is associated with poorer outcomes in terms of recurrence and HF admission.

Utility of Soluble ST2 biomarker to predict recurrence after electrical cardioversion in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is the more frequent arrhythmia in clinical practice. The ST2S is a biomarker that has demonstrated to be predictor of cardiovascular outcomes in patients with heart failure but there is scarce information of his utility in patients with AF.

Purpose

Considering the characteristics of the ST2S we hypothesize this biomarker could correlate to recurrence in patients with AF and electrical cardioversion (ECV).

Methods

This was an observational and prospective clinical trial. We compared all patients with AF referred for ECV with a control group without AF, from September 1th 2016 to September 30 2019. Clinical, ECG, echocardiographic and ST2S levels were analyzed in both groups at basal, at 3 and 6 months of follow-up in such cases with AF. Patients with inflammatory or allergic diseases, moderate/severe ventricular dysfunction, structural cardiomyopathy, moderate/severe hepatic, renal or respiratory disease were excluded.

Results

We included a total of 94 patients with AF and 40 paired controls. Clinical variables are presented in Table 1. Fifty-eight (61.7%) patients with AF had recurrence at follow-up. There was a significant difference between the ST2S levels at baseline between AF patients (17163.8 pg/mL) and controls (11016.2 pg/mL) (p=0.001). ST2S biomarker levels at 3 and 6 months of follow-up decreased in those patients without AF recurrence as shown in Figure 1. Covariable models were performed and ST2S biomarker levels at 3 months were significant to predict recurrence at 6 months follow-up (Table 2). The calculated cut-point of the biomarker was of 15511.51 pg/ml with a c-value: 0.669.

Conclusions

In our experience ST2S was a useful biomarker to predict recurrence of AF after ECV. Considering the size of the study more studies should be performed to confirm this results.

Funding Acknowledgement

Type of funding sources: None.

Impact of initiation of SGLT2 inhibitor treatment on the development of arrhythmias in patients with implantable cardiac devices

INTRODUCTION AND OBJECTIVES

Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) have been associated with improved prognosis in patients with heart failure, but their impact on atrial arrhythmic (AA) and ventricular arrhythmic (VA) events is not fully understood.

METHODS

This multicenter retrospective study included patients with implantable cardioverter-defibrillators who initiated treatment with SGLT2i. AA and VA events were compared in 2 time periods for each patient: 1 year before and 1 year after starting SGLT2i.

RESULTS

The study included 195 patients (66.8 [61.3-73.1] years, 18.5% women). In the post-SGLT2i period, there was a reduction in the percentage of patients with any VA (pre: 52.3% vs post: 30.3%; P<.001) and clinically relevant VA (excluding nonsustained ventricular tachycardia) (pre: 21.5% vs post: 8.7%; P<.001). There was also a decrease in the number of episodes per patient/y of nonsustained ventricular tachycardia (pre: 2 (1-5) vs post: 1 (0-2); P<.001) and sustained ventricular tachycardia (pre: 1 (1-3) vs post: 0 (0-2); P=0.046). However, no differences were observed in the prevalence of AA (24.7% vs 18.8%; P=.117) or the burden of atrial fibrillation (pre: 0% (0-0.1) vs post: 0% (0-0); P=.097).

CONCLUSIONS

Initiation of SGLT2i treatment was associated with a decrease in the percentage of patients with relevant VA but this effect was not observed for AA.