Hospital attendance and admission trends for cardiac diseases during the COVID-19 outbreak and lockdown in Greece

Objectives

The coronavirus disease 2019 (COVID-19) outbreak, along with implementation of lockdown and strict public movement restrictions, in Greece has affected hospital visits and admissions. We aimed to investigate trends of cardiac disease admissions during the outbreak of the pandemic and possible associations with the applied restrictive measures.

Study design

This is a retrospective observational study.

Methods

Data for 4970 patients admitted via the cardiology emergency department (ED) across 3 large-volume urban hospitals in Athens and 2 regional/rural hospitals from February 3, 2020, up to April 12 were recorded. Data from the equivalent (for the COVID-19 outbreak) time period of 2019 and from the postlockdown time period were also collected.

Results

A falling trend of cardiology ED visits and hospital admissions was observed starting from the week when the restrictive measures due to COVID-19 were implemented. Compared with the pre–COVID-19 outbreak time period, acute coronary syndrome (ACS) [145 (29/week) vs. 60 (12/week), −59%, P < 0.001], ST elevation myocardial infarction [46 (9.2/week) vs. 21 (4.2/week), −54%, P = 0.002], and non-ST elevation ACS [99 cases (19.8/week) vs. 39 (7.8/week), −60% P < 0.001] were reduced at the COVID-19 outbreak time period. Reductions were also noted for heart failure worsening and arrhythmias. The ED visits in the postlockdown period were significantly higher than in the COVID-19 outbreak time period (1511 vs 660; P < 0.05).

Conclusion

Our data show significant drops in cardiology visits and admissions during the COVID-19 outbreak time period. Whether this results from restrictive measures or depicts a true reduction of cardiac disease cases warrants further investigation.

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The coronavirus disease 2019 (COVID-19) outbreak has led to an unprecedented health system overload.

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The restrictive measures in Greece resulted in a low number of COVID-19 cases.

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Hospital visits and cardiovascular events have diminished after implementation of restrictive measures.

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Acute coronary syndromes reduced by approximately 55%, despite limited incidence of COVID-19.

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The multifactorial etiology of this finding should be thoroughly investigated.

P1321 A case of multiple levels of ventricular obstruction

Subaortic stenosis (SAS) is a rare entity in adults with unclear etiology and variable presentation. SAS may be presented with symptoms mimicking Hypertrophic Cardiomyopathy (HCM). Often a combination of imaging modalities is needed to distinguish SAS from HCM with obstruction.

A 53 years old man, smoker, was referred to our medical center suffering from shortness of breath on exertion. He first presented at another facility with a 2 month history of shortness of breath and chest discomfort during brisk physical activity and the possible diagnosis of HCM was made. On physical examination, a 3/6 systolic murmur was audible along the left sternal border, that became louder with standing and the Valsalva maneuver. The patient had non distended jugular veins, clear lung fields and no ankle edema. The results of laboratory exams did not reveal any pathological sign.

The transthoracic echocardiogram revealed significant left ventricular hypertrophy (Interventricular septum 21 mm, Posterior wall 16 mm) with normal left ventricular systolic performance (ejection fraction &gt;70%). The aortic valve was tricuspid and calcified whereas mitral valve was morphologically normal, with systolic anterior motion and mild posterolaterally directed regurgitation. Two systolic gradients, one dynamic, late peaking of 85mmHg and another fixed of 70mmHg were detected in left ventricular outflow track (LVOT).

Transesophageal echocardiography was performed for the better evaluation of aortic valve and showed a three level obstruction caused by the systolic motion of the mitral valve towards the hypertrophic septum at LVOT, the presence of a membranous subaortic membrane and the calcified aortic valve respectively. The aortic valve was calcified with a moderate stenosis (0.8cm2 / m2) from 3D planimetry. A Cardiac Magnetic Resonance exam was ordered and confirmed the significance of hypertrophy and the presence of circumferential subaortic membrane. No late enhancement after the administration of Gadolinium was observed. Coronary angiography was performed and demonstrated normal coronary arteries.

We hypothesized that the presence of subaortic membrane led to marked myocardial wall thickness and to the destruction of the aortic valve due to turbulent flow in the LVOT. The patient was referred for surgical management

Extended septal myectomy combined with complete resection of orbital subaortic membrane were performed. he calcified aortic valve was replaced by bioprosthetic valve No 23mm.

The patient tolerated the procedure well with significant symptomatic improvement. TTE performed 1 month postoperatively showed no remarkable LVOT gradient. The results of histopathology and genes investigations are pending.

Subaortic membrane is a rare cause of symptoms that can mimic hypertrophic cardiomyopathy. A combination of imaging modalities is needed to distinguish subaortic stenosis from aortic valve stenosis and hypertrophic obstructive cardiomyopathy.

Abstract P1321 Figure. Three levels obstruction

Atrial septal pacing to synchronize atrial depolarization in patients with delayed interatrial conduction

The current method of pacing the right atrium from the appendage or free wall is often the source of delayed intraatrial conduction and discoordinate left and right atrial mechanical function. Simultaneous activation of both atria with pacing techniques involving multisite and multilead systems is associated with suppression of supraventricular tachyarrhythmias and improved hemodynamics. In the present study we tested the hypothesis that pacing from a single site of the atrial septum can synchronize atrial depolarization. Five males and two females (mean age 58 +/- 6 years) with drug refractory paroxysmal atrial fibrillation (AF) were studied who were candidates for AV junctional ablation. All patients had broad P waves (118 +/- 10 ms) on the surface ECG. Multipolar catheters were inserted and the electrograms from the high right atrium (HRA) and proximal, middle, and distal coronary sinus (CS) were recorded. The atrial septum was paced from multiple sites. The site of atrial septum where the timing between HRA and distal CS (d-CS) was < or = 10 ms was considered the most suitable for simultaneous atrial activation. An active fixation atrial lead was positioned at this site and a standard lead was placed in the ventricle. The interatrial conduction time during sinus rhythm and AAT pacing and the conduction time from the pacing site to the HRA and d-Cs during septal pacing were measured. Atrial septal pacing was successful in all patients at sites superior to the CS o.s. near the fossa ovalis. During septal pacing the P waves were inverted in the inferior leads with shortened duration from 118 +/- 10 ms to 93 +/- 7 ms (P < 0.001), and the conduction time from the pacing site to the HRA and d-CS was 54.3 +/- 6.8 ms and 52.8 +/- 2.5 ms, respectively. The interatrial conduction time during AAT pacing was shortened in comparison to sinus rhythm (115 +/- 18.9 ms vs 97.8 +/- 10.3 ms, P < 0.05). In conclusion, simultaneous activation of both atria in patients with prolonged interatrial conduction time can be accomplished by pacing a single site in the atrial septum using a standard active fixation lead placed under electrophysiological study guidance. Such a pacing system allows proper left AV timing and may prove efficacious in preventing various supraventricular tachyarrhythmias.

Circadian modulation of ventricular tachycardia cycle length variability in ICD patients with dilated cardiomyopathy

VT is usually characterized by stability of the RR intervals after a few cycles from the onset. The aim of this study was to evaluate the VT cycle length (VTCL) variability in patients with dilated cardiomyopathy (DCM), in whom a third-generation ICD was previously implanted. Eighty-three episodes of VT were analyzed in 10 patients (8 male, 2 female, 65 +/- 6 years) with DCM, and NYHA Class II (7 patients) or III (3 patients). As an index of VTCL variability, the coefficient of variance of the last 15 consecutive RR intervals (CVRR) of the detected and stored VT by the device was considered. The mean value of the RR intervals and the mean value of CVRR of the VT episodes recorded during day versus night time were compared. Fifty-five VT episodes were recorded during the day and 28 episodes during the night time. The mean RR intervals of VT episodes during day time was 335 +/- 29 ms and during the night time was 350 +/- 22 ms (P = NS). The mean CVRR of VT episodes during day time and night time were 2.83 +/- 0.52 and 3.36 +/- 0.48, respectively (P = 0.017). In conclusion, a circadian modulation of VTCL variability exists in patients with DCM. The VTCL variability is less during day time compared to night time. A possible explanation is a circadian alteration of sympathovagal balance modifying the electrophysiological properties of the arrhythmogenic substrate.