Head-to-head comparison of CAMPYAIR aerobic culture medium versus standard microaerophilic culture for Campylobacter isolation from clinical samples

Campylobacter spp. are considered the most frequent cause of acute gastroenteritis worldwide. However, outside high-income countries, its burden is poorly understood. Limited published data suggest that Campylobacter prevalence in low- and middle-income countries is high, but their reservoirs and age distribution are different. Culturing Campylobacter is expensive due to laboratory equipment and supplies needed to grow the bacterium (e.g., selective culture media, microaerophilic atmosphere, and a 42°C incubator). These requirements limit the diagnostic capacity of clinical laboratories in many resource-poor regions, leading to significant underdiagnosis and underreporting of isolation of the pathogen. CAMPYAIR, a newly developed selective differential medium, permits Campylobacter isolation without the need for microaerophilic incubation. The medium is supplemented with antibiotics to allow Campylobacter isolation in complex matrices such as human feces. The present study aims to evaluate the ability of the medium to recover Campylobacter from routine clinical samples. A total of 191 human stool samples were used to compare the ability of CAMPYAIR (aerobic incubation) and a commercial Campylobacter medium (CASA, microaerophilic incubation) to recover Campylobacter. All Campylobacter isolates were then identified by MALDI-TOF MS. CAMPYAIR showed sensitivity and specificity values of 87.5% (95% CI 47.4%-99.7%) and 100% (95% CI 98%-100%), respectively. The positive predictive value of CAMPYAIR was 100% and its negative predictive value was 99.5% (95% CI 96.7%-99.9%); Kappa Cohen coefficient was 0.93 (95% CI 0.79-1.0). The high diagnostic performance and low technical requirements of the CAMPYAIR medium could permit Campylobacter culture in countries with limited resources.

Cytoplasmic isoleucyl tRNA synthetase as an attractive multistage antimalarial drug target

Development of antimalarial compounds into clinical candidates remains costly and arduous without detailed knowledge of the target. As resistance increases and treatment options at various stages of disease are limited, it is critical to identify multistage drug targets that are readily interrogated in biochemical assays. Whole-genome sequencing of 18 parasite clones evolved using thienopyrimidine compounds with submicromolar, rapid-killing, pan-life cycle antiparasitic activity showed that all had acquired mutations in the P. falciparum cytoplasmic isoleucyl tRNA synthetase (cIRS). Engineering two of the mutations into drug-naïve parasites recapitulated the resistance phenotype, and parasites with conditional knockdowns of cIRS became hypersensitive to two thienopyrimidines. Purified recombinant P. vivax cIRS inhibition, cross-resistance, and biochemical assays indicated a noncompetitive, allosteric binding site that is distinct from that of known cIRS inhibitors mupirocin and reveromycin A. Our data show that Plasmodium cIRS is an important chemically and genetically validated target for next-generation medicines for malaria.

New targets for antimalarial drug discovery

Phenotypic screening methods have placed numerous preclinical candidates into the antimalarial drug-discovery pipeline. As more chemically validated targets become available, efforts are shifting to target-based drug discovery. Here, we briefly review some of the most attractive targets that have been identified in recent years.

Different clinical and pathological profiles of sudden cardiac death victims caused by coronary artery dissection or myocardial infarction with non-obstructed coronary arteries

Background

Spontaneous coronary artery dissection (SCAD) is a potential cause of acute coronary syndrome and sudden cardiac death (SCD). Coronary fibromuscolar dysplasia (FMD) has been correlated to SCAD occurrence.The prevalence of SCAD and FMD among SCD victims are unclear. Myocardial infarction with non-obstructed coronary arteries (MINOCA) could represent a cause of SCD. Since SCAD could clinically manifest as acute myocardial infarction, expert consensus documents have often considered SCAD as a subtype of MINOCA (1,2), but studies which address direct comparison between these two conditions are lacking.

Purpose

To assess characteristics of decedents with SCAD and/or FMD found at autopsy, and to compare their clinical and pathological profile with MINOCA SCD victims.

Methods

We reviewed a database of 5325 consecutive cases of SCDs referred to our cardiac pathology center between 1994 and July 2017.

Results

We identified 21 (0.4%) with SCAD and 37 (0.7%) victims with MINOCA (3), whereas FMD was found only in 2 (0.04%). SCAD decedents were females in 81%, versus 38% of MINOCA (p=0.02).

No signs of coronary FMD were found among SCAD and MINOCA victims. Necrotic myocardium was identified in the totality of MINOCA and only in 8 (38%) of SCAD decedents (p<0.001). Pre-mortem cardiac symptoms were present in 100% of SCAD and 49% of MINOCA victims (p<0.001); illicit drug use was reported in none of SCAD versus 46% of MINOCA decedents (p=0.001).

Conclusions

SCAD is a rare cause of SCD. Compared to MINOCA, SCAD victims are more frequently females, always experienced pre-mortem cardiac symptoms and have no habit of substances abuse. At autopsy coronary FMD is not present among SCAD victims. SCAD and MINOCA shows different clinical and pathological profile. SCAD should not be considered a subtype of MINOCA.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiac Risk in the Young (CRY) and the Charles Wolfson Charitable Trust.

Long-term prognosis in left ventricular non-compaction cardiomyopathy

Introduction

Left ventricular non compaction (LVNC) cardiomyopathy is an often underdiagnosed disease characterized by a thickened myocardium with a two-layered structure. Clinical presentations are very variable, ranging from an apparent lack of functional anomalies to heart failure, ventricular arrhythmias and, in some cases, even ischaemic stroke. Despite great improvements in diagnostic performance, there is still a wide lack of evidence regarding prognosis and management of affected patients.

Purpose

The aim of the present study was to investigate predictors of cardiovascular death or cardiovascular-related hospitalization in patients with LVNC over a long-term follow-up.

Methods

All consecutive patients with a definite diagnosis of LVNC admitted to the Cardiomyopathy Clinic of our institution from Jan 2015 to Dec 2020 were consecutively enrolled. Inclusion criteria were an age ≥18 years old and a diagnosis of LVNC made either by MRI or echocardiography. Exclusion criteria were a life expectancy ≤1 year and the inability to express informed consent for the study. All patients were follwed-up every six months. The primary endpoint was a composite of cardiovascular death and unplanned cardiovascular hospitalization.

Results

Twenty-one patients (14 male, age 40±17 years) meeting the inclusion criteria were prospectively enrolled and followed-up for a median of five years.

LVNC patients with a previous history of supraventricular tachycardia at the time of diagnosis are more likely to meet the primary composite endpoint during follow-up (60% vs. 18%; p=0.048; Figure 1). On the other hand, neither LVEF (measured either with echo or CMR) nor functional status were associated with a significantly increased risk of the composite endpoint (all p=NS). Other significant predictors of increased risk include history of OSAS (z2 = 4.158), active/previous smoking (z2 = 6.279), and ST-segment alterations (z2 = 4.158). NC/C, as measured by either echo or CMR, was not a predictor of cardiovascular events (HR 0.18; 95% CI 0.31–1.08; p=NS).

Conclusions

Our data show how, in patients with LVNC, supraventricular tachycardias are related to worse outcomes and their presence should prompt a closer follow-up in order to detect possible adverse events. ST-segment alterations, OSAS and smoking are also related to a poorer prognosis, but their relevance should be further assessed. Surprisingly, in our sample LVEF and NC/C ratio were not predictors of worse outcomes; the reason might be that in LVNC patients mortality and cardiovascular hospitalizations resemble complex genetic and molecular mechanisms that differentiate them from other cardiomyopathies, but the paucity of the population prevents us from making wider inferences.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of low QRS voltages in patients with cardiac amyloidosis

Introduction

Cardiac amyloidosis (CA) is an underdiagnosed and heterogeneous cardiac disease characterized by the extracellular deposition of misfolded proteins in the cardiac tissue. Clinical manifestations are heterogeneous leading to progressive heart failure, often complicated by arrhythmias and conduction system disease. Among several sign and symptoms that are suspicious for the disease, named “red flags”, disproportionally low QRS voltages on the ECG has been described.

Purpose

The aim of this prospective observational study is to evaluate potential prognostic features of QRS amplitude in AL e ATTR CA patients.

Methods

All consecutive patients admitted to the Cardiomyopathy Clinic of our institution have been enrolled after receiving CA diagnosis, according to the current guidelines. We included all patients ≥18 years with a diagnosis of CA and written informed consent. A complete assessment including a standard 12-lead electrocardiogram (ECG) and echocardiogram was performed at enrollment. Low QRS voltages (LQRSV) was defined as a QRS total amplitude of ≤5 mm in every limb leads and ≤10 mm in every precordial lead. LQRSV was tested as an independent predictor of death from all causes (primary endpoint), hospitalization from cardiovascular causes, ventricular and supraventricular arrhythmias.

Results

Sixty patients (46 males, 77±12 years old) were enrolled, of which 18 (30%) met the criteria for LQRSV. Patients with LQRSV presented more frequently with an history of ventricular arrhythmia (27.8% vs. 6.7%, p=0.04), a lower left ventricular diastolic volume (31±7 vs. 44±18 ml/m2; p=0.04), and higher retinol-binding-protein 4 (9.3±2.2 vs 3.2±1.5 mg/dl; p=0.02). No differences were seen in the primary outcome (46% vs. 50%; p=NS; Figure 1) or in the secondary ones (cardiovascular hospitalization 25% vs. 21%; ventricular arrhythmias 12% vs 4%; supraventricular arrhythmias 29% vs 19%; all p=NS) between the two groups during a median follow up of 1.1 year.

Conclusions

In the present cohort of CA patients LQRSV did not emerge as independent predictor of all-cause mortality at 1 year. Although LQRSV is a recognized diagnostic “red-flag” in the work-up of CA, its role as prognostic marker remains unclear. Further studies with a longer follow-up are needed to better define the prognostic role of LQRSV among CA patients.

Funding Acknowledgement

Type of funding sources: None.

Tachycardiomyopathy: long-term sequelae of arrhythmia-induced acute heart failure

Introduction

The definition of heart failure (HF) is known to include different etiological entities which may lead to the plethora of signs and symptoms characteristic of the syndrome. When it comes to HF with reversible forms of reduced ejection fraction (EF), tachycardiomyopathy (TCM) accounts for around 10% of all hospitalizations for acute HF.

Among the TCM group we can identify situations in which an arrhythmia is the sole cause for the reversible cause of LV (pure TCM), and cases in which LV deterioration is mediated by the arrhythmia, on a substrate of diseased heart.

Purpose

The aim of our study was to investigate the prognosis of patients with pure and impure TCM compared to patients with ischemic HF and idiopathic HF.

Methods

We conducted and observational prospective study enrolling all patients who were admitted with a diagnosis of de novo acute HF with reduced EF between January 2012 and June 2020. All patients were divided into four groups based on guideline-specific definitions: structural HF (encompassing ischemic, valvular, inflammatory, and infiltrative causes, as well as hypertrophic and arrhythmogenic cardiomyopathy), idiopathic HF, pure TCM and impure TCM. Patients presenting with a decline in EF due to any kind of tachyarrhythmia and a subsequent recovery of left ventricular EF after rhythm or rate control were diagnosed with TCM. Further grouping into pure or impure was made according to the presence of absence of underlying heart disease.

Results

456 patients were consecutively enrolled (304 males, 70±13 years). The four groups had significantly different estimates for all-cause death, with pure TCM having the highest survival and structural HF having the lowest over a median 6-year follow-up (pure TCM 22.1%; impure TCM 32.1%; idiopathic HF 26.3%; structural HF 51.9%; log-rank p<0.0001; Figure 1a). Using structural HF as a comparator, HRs for death were significantly lower for all the other three groups (pure TCM HR 0.35; 95% CI 0.21–0.57; impure TCM HR 0.48; 95% CI 0.24–0.96; idiopathic HF HR 0.53; 95% CI 0.31–0.90).

Unplanned hospitalizations showed a different trend, with TCM having the highest rate and non-ischemic HF having the lowest over the same follow-up (pure TCM 58.1%; impure TCM 40.2%; idiopathic HF 15.8%; structural HF 38.4%; log-rank p<0.0001; Figure 1b). The average total number of unplanned hospitalizations also differed significantly between the four groups (pure TCM 0.84; 95% CI 0.65–1.04; impure TCM 0.88; 95% CI 0.53–1.23; idiopathic HF 0.45; 95% CI 0.25–0.65; structural HF 1.02; 95% CI 0.78–1.25; p=0.021).

Conclusions

Among all patients with de novo acute HF, those who present structural heart disease present a lower survival rate over a 6-year follow up. However, patients with pure TCM present the highest rate of unplanned hospitalizations when compared to the other groups. It is therefore important to identify the etiology of HF to start appropriate treatment and prevent new hospitalizations.

Funding Acknowledgement

Type of funding sources: None.

Speckle-tracking global longitudinal strain predicts clinical outcomes in patients with systemic sclerosis

Introduction

Systemic-sclerosis related cardiomyopathy is frequent and, albeit often asymptomatic, is likely secondary to the underlying pathophysiology of SSc itself and represents a negative prognostic factor. Speckle-tracking derived global longitudinal strain (GLS) has been proven to be a cost-effective tool in the detection of LV and RV dysfunction in patients with SSc and no overt cardiac disease.

Purpose

The aim of our study was to assess whether baseline GLS could predict clinical outcomes in patients with SSc in terms of death, heart failure, hospitalizations, and development of pulmonary hypertension.

Methods

We conducted a prospective observational study on all consecutive patients referred to our clinic between June 2016 and January 2022 with a confirmed diagnosis of SSc and no overt cardiac disease, pulmonary hypertension, or atrial fibrillation at the time of enrollment.

We performed baseline echocardiogram and GLS calculations for all patients as well as collected clinical and ECG data at baseline and at each follow up.

Results

Out of 164 patients (148 female, 58±14 years), 19 (11.6%) patients died during a median follow-up of 3.2 years for mainly non-cardiovascular deaths (7.3%) while cardiovascular deaths were lower (3% non-sudden, 1.3% sudden).

Left GLS at first visit was associated with all-cause death, with a 1% left GLS worsening associated with a 19% increased risk of death after adjusting for age, gender, and LVEF (adjusted HR 1.19; 95% CI 1.05–1.35; p=0.007).

Similarly, right GLS at first visit was associated with all-cause death, with a 1% right GLS worsening associated with a 12% increased risk of death after adjusting for age, gender, and TAPSE (adjusted HR 1.12; 95% CI 1.03–1.21; p=0.005).

Patients with a left GLS worse (i.e. higher) than −20% had a 3.5-fold increased risk of death when compared to patients with better left GLS (HR 3.55; 95% CI 1.28–9.88; p=0.015; Figure 1a). Similarly, patients with a right GLS worse than −20% had a 4.5-fold increased risk of death when compared to patients with better left GLS (HR 4.47; 95% CI 1.4–13.74; p=0.009; Figure 1b).

Conclusions

Baseline GLS measured is an effective tool to recognize patients with SSc and negative prognosis. It may help us identify early those who need to be followed more closely and start appropriate treatment in order to prevent major cardiovascular and non-cardiovascular events. The close relationship between left and right GLS as risk predictors underlines the role of SSc in promoting overt cardiac disease, not limited to pulmonary hypertension.

Funding Acknowledgement

Type of funding sources: None.

Conduction velocity mapping in Bachmann Bundle using Omnipolar Technology

Funding Acknowledgements

Type of funding sources: None.

Background

Bachmann’s bundle is emerging as a critical component of atrial fibrillation (AF) catheter ablation (CA). The introduction of Omnipolar Technology (OT) in the new Ensite X Cardiac Mapping system, provides three-dimensional information on conduction velocity, activation direction and voltage of endocardial potentials, independently of catheter orientation. OT can create a wave speed map: a color map type coded by numeric value of conduction velocity.

Objective

To assess the feasibility and reliability of left atrium wave speed maps in Bachmann’s bundle identification and conduction velocity characterization.

Methods

We included 10 patients, (60% male, 40% female, mean age 56±8.7 years) undergoing CA for paroxysmal AF at our institution with new Ensite X Cardiac Mapping System; the left atrium (LA) was mapped with the Advisor HD Grid catheter. A sinus rhythm voltage map and wave speed map were obtained and analyzed to identify high conduction velocity areas throughout the Bachmann’s bundle location (septum, roof and left atrium appendage (LAA)).

Results

Wave speed mapping allowed the identification, at the septum, roof and LAA, of a myocardial bundle with greater speed values (2.5±0.3 m/s) with respect to mean atrial value (1±0.1). Pulmonary vein antra conduction velocity mean value was 1.2±0.4 m/s. Standard voltage map (low-voltage areas defined as any LA region with voltage values < 0.5 mV) was compared with wave speed map. Standard voltage map (Figure 1) did not discriminate Bachmann’s bundle, while wave speed map did (Figure 2).

Conclusion

Wave speed mapping introduced by OT is a promising new map type, allowing characterization and identification of Bachmann’s bundle. Further studies are needed to assess the impact of this new technology on procedural workflow and clinical outcome.

Pure and impure tachycardiomiopathy: key differences and long term prognosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Tachycardiomioathy (TCM) is a reversible cause of left ventricular (LV) dysfunction, secondary to both atrial and ventricular arrhythmias as well as high burden of ectopic beats. Almost 10% of all hospitalizations for acute heart failure (HF) meet the criteria for TCM. TCM is known to frequently recur and therefore cardiovascular related hospitalizations are often needed. While this is true in pure TCM, long term prognosis of impure TCM is still unknown.

Purpose

To compare long term prognosis of pure TCM to that of impure TCM in terms of survival rate, time free of recurrence and time free of hospitalizations.

Methods

Prospective, observational study enrolling all consecutive patients admitted for de novo acute heart failure, with a confirmed diagnosis of TCM, which was suspected in all patients admitted for heart failure (HF) with a LV ejection fraction <50% and concomitant persistent atrial or ventricular arrhythmia, and confirmed after clinical and echocardiographic recovery. Pure tachycardiomiopathy was defined as an arrhythmia-induced LV dysfunction in an otherwise healthy heart. Impure tachycardiomiopathy was defined as an arrhythmia-mediated TCM, where the arrhythmia may exacerbate an underlying condition and facilitate LV dysfunction.

Results

Population included 123 patients with pure TCM and 40 patients with impure TCM. Patients with pure TCM were significantly younger (68±13 vs. 74±10 years; p=0.008) but a with similar risk factor profile and the same prevalence of male gender (63% vs 72%; p=ns). Similarly, echo characteristics did not significantly differ between the two groups, while pure TCM presented a higher HR at admission (124±28 vs. 106±28 bpm; p=0.001) but not at discharge (70±15 vs. 71±14 bpm; p=ns). Pure and impure TCM had similar EF on admission (33±9 vs. 34±7%; p=ns) and time to recovery after the acute event (4.9±0.6 vs. 4.4±1.4 months; p=ns). Pure TCM were more often treated in the acute phase with a rhythm control strategy (81% vs. 67%; p=0.001), mainly electric cardioversion followed by anti-arrhythmic drugs (80% vs. 46%; p<0.001) and AF ablation (16% vs. 3%; p=0.025).

Kaplan Meier curves showed that pure TCM present a lower incidence of recurrence (26% vs. 50%; p=0.05; Figure 1) over a 40-month median follow-up. Cumulative incidences of death (24% vs. 30%; p=ns; Figure 2) and thromboembolism (3% vs. 3%; p=ns) were similar between the two groups over the same period. All-cause hospitalizations were similar between the two groups (62% vs. 67%; p=ns) with the impure TCMs experiencing more unplanned hospitalizations for HF recurrences.

Conclusions

While pure and impure TCM patients differs in terms of baseline characteristics, they present similar risk of death, thromboembolic events, and hospital admission during a long-term follow-up. Treatment strategy of pure TCM is more often rhythm-oriented and this could explain the lower incidence of HF recurrence.

High-density substrate mapping of the left ventricle as a guide for endomyocardial biopsy: an omnipolar, bipolar, and cardiac magnetic resonance imaging perspective

Funding Acknowledgements

Type of funding sources: None.

Background

The recent introduction of Omnipolar Technology (OT) has the potential to improve ventricular substrate characterization. In fact, the amplitude of omnipolar electrograms is less dependent of the propagation direction of the recorded wavefront than that of bipolar electrograms, potentially increasing the sensitivity for the detection of viable myocardium by electroanatomical voltage mapping (EVM).

Purpose

To assess the presence and extension of dense scar regions and low-voltage areas in omnipolar voltage (OV) maps of the left ventricle (LV) as compared to standard bipolar endocardial maps and cardiac magnetic resonance (CMR)-derived pixel signal intensity (PSI) maps, among patients undergoing EVM-guided endomyocardial biopsy (EMB).

Methods

The study included 10 patients undergoing LV substrate mapping and EVM-guided EMB at our institution using the Advisor HD Grid mapping catheter. Before the procedure, contrast enhanced-CMR was obtained for each patient and PSI maps were derived from late gadolinium enhancement sequences with the ADAS-VT software. Scar core and border zone areas were measured in PSI endocardial (10-40% of wall thickness) maps and compared to dense scar regions (<0.5 mV) and low-voltage areas (0.5-1.5 mV) measured by standard bipolar endocardial mapping and OV endocardial mapping, respectively. Continuous variables were checked for normality with the Shapiro-Wilk test, and are reported as mean±standard deviation or median [1st-3rd quartile], as appropriate. Statistical comparisons among the three types of mapping (PSI mapping, standard bipolar, and OV) were performed with Friedman test with post-hoc sign test, as appropriate. P values<0.05 were considered statistically significant, and all analyses were performed with the software RStudio.

Results

The indication for EVM-guided EMB was a clinical suspicion of arrhythmogenic or inflammatory cardiomyopathy in all cases. Dense scar regions and low voltage areas detected by OV (dense scar: 2.2 [1.2-6.9] cm2; low voltage areas: 8±3.8 cm2) and standard bipolar mapping (dense scar: 3.4 [2.3-9.6] cm2; low voltage areas: 8.4±4 cm2) were similar to scar core and border zone areas shown by PSI maps (scar core: 1.6[0.6-2.9] cm2; border zone: 3.9[3.7-7.6] cm2; all p=NS). However, dense scar regions were less widespread with OV mapping that with standard bipolar mapping (Friedman test p=0.07; adjusted p=0.006, Figure). The diagnostic yield of EMB measured 80%, whereas mean procedural and fluoroscopy times were 136±30 min and 11±4 min, respectively.

Conclusion

OV mapping allowed a refinement of endocardial substrate maps of the LV as compared to standard bipolar mapping, by reducing the dependency of electrogram amplitude on the direction of propagation, thus allowing the detection of viable myocardium even in bipolar scar regions. Therefore, OV mapping may soon become a preferred approach for EVM-guided EMB.

Incidence and predictors of cardiac arrhythmias in patients with systemic sclerosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Heart involvement in systemic sclerosis patients is frequent and represents a negative prognostic factor with around 25% of SSc patients dying from cardiovascular related causes. Cardiac arrhythmias represent 6% of the overall causes of death in SSc patients. Not only a plethora of conditions typical of the disease seem to favour the presence of an arrhythmic substrate such as microvascular disease or fibrosis but autoimmunity itself has been recognized as a pathogenic mechanism for cardiac arrhythmias.

Purpose

The aim of our study was to investigate the incidence of arrhythmias in patients with systemic sclerosis and identify potential predictors.

Methods

Prospective longitudinal study enrolling all consecutive patients with a diagnosis of SSc and no overt cardiac disease nor pulmonary hypertension. Echocardiographic parameters and GLS were obtained at baseline and at each follow up as well as 12 lead ECG. Presence of atrial fibrillation (AF), atrial tachycardia (AT), ventricular ectopic beats >1000/24 h (VEB), supraventricular ectopic beats (SVEB), bundle branch block (BBB) and atrioventricular block (AVB) was registered.

Results

160 patients (144 females, 90%, mean age 59±14 years) were enrolled from June 2016 to December 2021. At enrolment, 11.3% of patients with SSc presented a previous history of supraventricular arrhythmia (5.6% supraventricular ectopic beats, 3.1% atrial fibrillation, 2.5% atrial flutter) and 5.6% a history of ventricular arrhythmia (5.0% ventricular ectopic beats, 0.6% ventricular tachycardia). After a median follow-up of 3.1 years (95% CI 1.4-4.8 years), five patients (3.1%) died of cardiovascular causes, of which three (1.8%) experienced a sudden cardiac death. During the same period, 16 patients (10%) presented a new diagnosis of supraventricular arrythmia (8.7% atrial fibrillation, 1.3% atrial flutter) and two patients (1.2%) a new diagnosis of ventricular tachycardia.

PR interval significantly increased during the 3.1-year follow-up (154±27 vs. 178±32 ms; p=0.013), as well as corrected QT interval (420±23 vs. 436±19 ms; p=0.001). New diagnosis of complete right and left bundle branch block was made in 18 (11.2%) and two (1.2%) of all SSc patients.

Diagnosis of pulmonary arterial hypertension was associated with a 4-fold and a 10-fold increased risk of supraventricular and ventricular arrhythmias, respectively (Figure 1). A diffuse SSc variant (p=0.049), indexed right (p=0.020) and left atrial volumes (p=0.035), and E/E’ ratios (p=0.016) were all associated with an increased risk of supraventricular arrhythmias. TAPSE (p=0.040), as well as right (p=0.030) global longitudinal strain were associated with an increased risk of ventricular arrhythmias.

Conclusions

Ssc patients are often by an arrhythmic profile with an increased risk of supraventricular and ventricular events as well as sudden cardiac death. A comprehensive cardiological work up may help in lowering the risk of arrhythmic complications.

Remotely-driven management of diuretic therapy in heart failure patients with a multiparametric ICD algorithm

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

Background

HeartLogic algorithm combines data from multiple sensors to predict future heart failure (HF) decompensation in patients with an implantable defibrillator (ICD) . An optimal strategy to manage algorithm alerts is not yet known, although decongestive treatment with diuretics is the most frequent alert-triggered action reported so far.

Purpose

We describe the implementation of HeartLogic for remote monitoring of HF patients, and we evaluate the approach to diuretic dosing and timing of the intervention in patients with device alerts.

Methods

The study was conducted in eight Italian high-volume arrhythmia centers. The algorithm was activated in 229 ICD patients during a median follow-up was 17 months [25th–75th percentile: 11-24] between December 2017 and July 2020. Remote data reviews and patient phone contacts were undertaken at the time of HeartLogic alerts, to assess the patient’s status and to prevent HF worsening. The study protocol did not mandate any specific intervention algorithm, and physicians were free to remotely implement clinical actions, to schedule extra in-office visits when deemed necessary for additional investigations or for interventions, or to adopt an active monitoring approach. We analyzed alert-triggered augmented HF treatments, consisting of isolated increases in diuretics dosage.

Results

We reported 242 alerts (0.8 alerts/patient-year) in 123 patients, 137 (56%) alerts triggered clinical actions to treat HF. Overall, timely diuretic changes were associated with a shorter "in-alert" state duration in comparison with late changes, i.e. 28 days [25th-75th percentile: 20-43] versus 62 days [25th-75th percentile: 44-118], p<0.001. By contrast, major and minor diuretic augmentations resulted in comparable durations, i.e. 47 days [25th-75th percentile: 30-58] versus 38 days [25th-75th percentile: 23-79], p=0.954. Of the 56 decongestive treatment adjustments, 47 resolved the alert condition, while in the remaining 9 cases, further treatments were required (augmented HF therapy during hospitalization or unscheduled intravenous decongestive therapy in outpatients). The need of hospitalization for further treatments to resolve the alert condition was associated with higher HeartLogic index values on the day of the diuretics increase (odds ratio: 1.11, 95%CI: 1.02-1.20, p=0.013) and with late interventions (odds ratio: 5.11, 95%CI: 1.09-24.48, p=0.041). No complications were reported after drug adjustments.

Conclusions

Decongestive treatment adjustments triggered by HeartLogic alerts, even when such adjustments were completely dependent on the physicians’ clinical expertise and were not standardized. The early use of decongestive treatment and the use of high doses of diuretics seem to be associated with more favorable outcomes.

On the benefits of wearable devices for Parkinson's disease

Freezing of gait (FOG) is defined as episodic inability to generate an effective movement without any known cause other than parkinson-ism or gait disturbance. FOG is one of the most disabling symptoms of Parkinson's disease (PD), it affects mobility and increases the risk of falling in people with PD, making it a leading cause of hospitalization and of significantly worsening the quality of life (1). In recent years, new non-invasive intervention strategies have been implemented to decrease FOG symptoms. Thanks to technological progress, several devices have been developed as a support for the patients during diag-nosis, treatments and also everyday life. These types of interventions are based on cueing systems that rely on active stimulation. These devices are able to identify FOG states and to operate when this motor blocks occur, providing external stimuli to overcome these episodes. Hence, this work aims to provide a technological review of the literature related to wearable devices and focuses on auditory, visual, virtual and soma-tosensory cueing systems, which can provide a suitable intervention for patients with PD. The paper describes the technical functioning and effectiveness of the different reporting systems in overcoming FOG episodes. Moreover, a classification of existing devices, highlighting their advantages and disadvantages, will be provided in order to identify the ones with the best performance.

Trends in Sustainable Dentistry

The advance of Dentistry must take into account national, European and global policies for sustainable development and green transition. This article illustrates possible scenarios in this context for the next decade.

Impact of the COVID-19 pandemic on hospitalizations for acute coronary syndromes: a multinational study

BACKGROUND

COVID-19 has challenged the health system organization requiring a fast reorganization of diagnostic/therapeutic pathways for patients affected by time-dependent diseases such as acute coronary syndromes (ACS).

AIM

To describe ACS hospitalizations, management, and complication rate before and after the COVID-19 pandemic was declared.

DESIGN

Ecological retrospective study. Methods: We analyzed aggregated epidemiological data of all patients > 18 years old admitted for ACS in twenty-nine hub cardiac centers from 17 Countries across 4 continents, from December 1st, 2019 to April 15th, 2020. Data from December 2018 to April 2019 were used as historical period.

RESULTS

A significant overall trend for reduction in the weekly number of ACS hospitalizations was observed (20.2%; 95% confidence interval CI [1.6, 35.4] P = 0.04). The incidence rate reached a 54% reduction during the second week of April (incidence rate ratio: 0.46, 95% CI [0.36, 0.58]) and was also significant when compared to the same months in 2019 (March and April, respectively IRR: 0.56, 95%CI [0.48, 0.67]; IRR: 0.43, 95%CI [0.32, 0.58] p < 0.001). A significant increase in door-to-balloon, door-to-needle, and total ischemic time (p <0.04 for all) in STEMI patents were reported during pandemic period. Finally, the proportion of patients with mechanical complications was higher (1.98% vs. 0.98%; P = 0.006) whereas GRACE risk score was not different.

CONCLUSIONS

Our results confirm that COVID-19 pandemic was associated with a significant decrease in ACS hospitalizations rate, an increase in total ischemic time and a higher rate of mechanical complications on a international scale.

Antiplatelet therapy and outcome in patients with COVID-19. Results from a multi-center international prospective registry (HOPE-COVID19)

Background

No standard therapy is currently recommended for Corona-virus-19 disease (COVID-19). Autopsy studies showed high prevalence of platelet-fibrin rich micro-thrombi in several organs. Aim of the study was to evaluate safety and efficacy of antiplatelet therapy (APT) in COVID-19 hospitalized patients and its impact on survival.

Methods

7824 consecutive patients with COVID-19 were enrolled in a multicenter-international prospective registry (HOPE-COVID19). Clinical data and in-hospital complications were recorded. AP regimen, including aspirin and other antiplatelet drugs, was obtained for each patient.

Results

During hospitalization 730 (9.3%) patients received AP drugs with single (93%, n=680) or dual APT (7%, n=50). Patients treated with APT were older (73±12 vs 62±17 years, p<0.01), more frequently male (70% vs 64%, p<0.01) and had higher prevalence of diabetes (39.5% vs 17%, p<0.01).

Patients treated with APT showed no differences in terms of in-hospital mortality (18% vs 19%, p=0.64, Log Rank p=0.23), need of invasive ventilation (8.7% vs 8.5%, p=0.88) and bleeding (2.1% vs 2.4%, p=0.43); However, after excluding patients treated only with anticoagulation, APT was associated with lower mortality rates (Log Rank p<0.01, relative risk 0.79, 95% CI 0.70–0.94) (Figure 1).

At multivariable analysis including age, gender, diabetes, hypertension, respiratory failure, pre-hospital therapy with antiplatelet drugs, in-hospital APT, and anticoagulation therapy, in-hospital APT was associated with a lower mortality risk (relative risk 0.29, 95% CI 0.22–0.38, p<0.001).

Conclusions

APT during hospitalization for COVID-19 could be associated with lower mortality risk without increased risk of bleeding. Randomized trials are needed to confirm these preliminary data.

Funding Acknowledgement

Type of funding sources: None.

Long-term prognosis of tachycardiomyopathy without underlying heart disease

Background

Tachycardiomyopathy (TCM) is a reversible cause of left ventricular dysfunction, secondary to rapid and/or asynchronous, irregular myocardial contraction. Two categories of the disease have been described: arrhythmia-induced TCM (pure TCM), where the arrhythmia is the sole reason for the dysfunction, and arrhythmia-mediated TCM (impure TCM), where the arrhythmia can exacerbate or worsen heart failure (HF) or an underlying heart disease. Pure TCM has already been described as affecting almost 1 out of 10 patients admitted for acute HF-like symptoms. On the other side, acute HF leads to a chronic irreversible condition which tends to worsen over time and is burdened by a high rate of complications.

Purpose

The aim of our study was to compare pure TCM and de novo acute HF patients (including all forms of structural heart disease) in terms of mortality and cardiovascular (CV)-related hospitalizations.

Methods

Prospective, observational study enrolling all consecutive patients with a confirmed diagnosis of TCM and all patients admitted for de novo acute HF. The TCM diagnosis was suspected in all patients admitted for HF-related symptoms, an ejection fraction &lt;50% with concomitant persistent atrial or ventricular arrhythmia, and confirmed after clinical and echocardiographic recovery. Acute HF diagnosis was made in all patients with an ejection fraction &lt;50%, new HF-like symptoms, diagnosis of structural heart disease and no evidence of clinical or echocardiographic recovery. For each patient, all-cause death and CV-related hospitalizations were recorded. Propensity score matching was used in order to compare the two populations through sensitivity analysis.

Results

One-hundred-and-ten patients with TCM (61.8% males, 68±13 years old) were propensity matched with a control population of patients with HF and structural heart disease (76.6% males, 71±15 years old, 75% ischemic heart disease). After a median follow-up of 5.1 years (1st-3rd quartile 2.6–7.0 years) TCM patients showed an overall higher estimate of survival when compared to HF patients (78% vs. 58%; p=0.031; figure 1A) but a lower estimate of time free from CV-related hospitalization (31% vs. 57%, p=0.014; figure 1B). TCM patients got most often readmitted for AF-related elective procedures (60.8% of all hospitalizations), TCM recurrence (13.7%) and elective coronary angiography (5.9%). On the other hand, HF patients got readmitted for HF worsening (40.9%), cardiac or vascular surgery (22.7%) and elective coronary angiography (9.1%). Propensity-score matched analysis confirmed the results for all-cause death (81% vs. 49%; p=0.006) and CV-related hospitalizations (29% vs. 54%; p=0.007).

Conclusions

TCM is associated with a better survival when compared to de novo acute HF, even after propensity score adjustment. On the other hand, patients with TCM got readmitted more frequently, requiring more often elective procedures in order to control the triggering arrhythmia.

Funding Acknowledgement

Type of funding sources: None.

Long term prognosis and cardiovascular complications of patients with systemic sclerosis-related cardiomiopathy

Background

Both primary (SSc related cardiomyopathy) and secondary cardiac involvement in systemic sclerosis (SSc) is frequent albeit mostly asymptomatic. It represents a negative prognostic factor as almost 25% of SSc patients die from either heart failure or arrhythmia complications. Speckle tracking global longitudinal strain has been proven to be an effective tool both to identify and detect the progress of subclinical heart disease in SSc. The aim of our study was to assess the association between SSc diagnosis and the development of heart failure, pulmonary hypertension, death and need for hospitalization.

Materials and methods

We conducted an observational prospective study enrolling all patients with a diagnosis of SSc and no overt cardiac disease. We excluded all patients with a known diagnosis of pulmonary hypertension and atrial fibrillation. For each patient standard echocardiogram and GLS variables were collected.

Results

We enrolled 70 patients (61 females, age 56.2±15.4 years) who were followed for a median of 3 years. 68% of the patients had a limited variant of the disease.

All-cause mortality was 10% in a 5-year follow-up. During the same period, PH was reached in 13% of all patients, HF in 7% and 18% required at least one hospital admission for cardiovascular causes. A diagnosis of PH was associated with an increased risk of death (ARR 34%; p&lt;0.001) and hospitalization for CV causes (ARR 73%; p&lt;0.001). Moreover, a diagnosis of HF was associated with an increased risk of death (ARR 50%; p&lt;0.001) and hospitalization for CV causes (ARR 61%; p&lt;0.001). A 1% worsening of GLS was associated with an increased risk to develop PH in the following 5 years, both for the left ventricle (OR 1.2; 95% CI: 1.1–1.4; p=0.043) and for the right ventricle (OR 1.1; 95% CI: 1.1–1.3; p=0.045).

Conclusions

Pulmonary hypertension and heart failure often occur in patients with cardiac involvement. Both proved themselves to be associated with an increased risk of death and hospitalization for CV causes. Moreover, GLS worsening of both the left and right ventricles may allow us to predict the diagnosis of PH and therefore preemptively start appropriate management.

Funding Acknowledgement

Type of funding sources: None.

Speckle tracking assessment of the atrial function in patients with systemic sclerosis

Background

Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by small vessel vasculopathy, autoantibodies production and exaggerated extracellular matrix deposition, leading to extensive tissue fibrosis. Cardiac involvement in SSc, albeit often asymptomatic, is frequent and represents a negative prognostic factor. Speckle tracking global longitudinal strain (GLS) has proved itself to be an effective tool to identify the presence and the progression of subclinical SSc-related cardiomyopathy.

The aim of our study was to assess whether SSc-related cardiomyopathy affects not only the ventricles but also the right (RA) and left atria (LA) in patients with SSc and no overt cardiac disease nor pulmonary hypertension.

Materials and methods

Observational prospective study enrolling all consecutive patients with SSc age- and gender-matched 1:1 to healthy controls. Patients with structural heart disease, heart failure, atrial fibrillation and pulmonary hypertension were excluded.

For every patient, standard echocardiographic parameters and speckle-tracking derived variables were registered. The reservoir function (from the end of ventricular contraction to mitral valve opening), conduit function (from mitral valve opening through the onset of atrium contraction) and contraction function (from the onset of atrium contraction to the end of ventricular diastole) were assessed via GLS. Zero strain reference was set at left ventricular end diastole.

Results

Fifty-two SSc patients and 52 matched controls were consecutively enrolled. Left ventricular ejection fraction (66.5%±7.4% vs. 66.1%±5.9%; p=ns) right fractional area change (49.4%±9.6% vs. 49.2%±9.2%; p=ns) and mean sPAP (29.0%±5.3% vs. 24.4%±4.1%; p=ns) were well within the normal range and similar between SSc patients and controls. Right atrial reservoir function (35.0%±7.3% vs. 42.3%±8.5%; p=.024) and contraction function (14.8%±4.3% vs. 18.5%±4.1%; p=.034) were significantly lower in SSc patients when compared to matched controls. No difference was seen in right atrial conduit function or left atrial strain.

In patients with SSc, RA reservoir (r=.194; p=.033) and conduit function (r=.174; p=.036) were directly associated to right ventricular GLS. LA reservoir (r=.260; p=.008) and conduit function (r=.271; p=.006) were directly associated with left ventricular GLS. No association was observed between contraction function and GLS in both left and right chambers. Moreover, RA and LA reservoir (r=.358; p=.02), conduit (r=.525; p=.004) and contraction functions (r=.30; p=.0.18) were directly correlated.

Conclusions

While no significant difference was seen between cases and controls in terms of common echocardiographic parameters, RA reservoir and contraction function assessed through GLS were significantly impaired in patients with SSc. The correlation between impaired atrial and ventricular GLS in SSc may represent another indirect evidence of SSc-related heart global involvement.

Funding Acknowledgement

Type of funding sources: None.

Risk Management for a Legally Valid Informed Consent

ABSTRACT

Gelli-Bianco law (Law no. 24/2017) intervenes both in order to divide healthcare liability between the healthcare professional and the facility in which he/she exercises and to incentivize the latter to adopt an organizational model suitable for managing the risk associated with the provision of any healthcare service, including the information for consent. In fact, the healthcare facility must guarantee clear, complete and adequate information on the specific case, which, therefore, cannot consist of standard forms to be signed by the patient, under penalty of a flawed consent to treatment and consequent healthcare liability in the event of an adverse event. The regulation mandates that safety must be guaranteed through proper prevention tools and health care risk management, in con-junction with the most effective use of structural, technological and organizational resources available. It further spells out the obligation of health care professionals to contribute to risk prevention while administering health care procedures. For this reason, the consent information constitutes a source of risk for the responsibility of the healthcare provider and the Facility and it must necessarily be managed. Risk Management is the management tool that can allow the healthcare facility to improve the quality and safety of the services provided, optimizing the risk of adverse events through proper moni-toring of the same. This paper will be published, following a special agreement, on the two journals "Igiene e Sanità Pubblica" and "La Clinica Tera-peutica", in Italian and in English, in order to increase the diffusion to a wider audience.

Associations between bone retraction, lost teeth, and metabolic syndrome. A cross-sectional study in dentistry patients aged over 60 years

INTRODUCTION

In Italy, the number of elder is growing and people over 70 may be a problem in public health on present and next years. [ISTAT 2019].

METHODS

In this paper we analysed 150 patients aged 60÷99 by medical and instrumental examinations. Results. We analysed all data patients into three age groups: "A" patients aged 60÷69 years; "B" patients aged 70÷79 years, and "C" patients aged 80÷99 years.

CONCLUSION

This is the first study carried out on old and very old dentistry patients. Our people sample showed lost teeth, and bone retractions more than 6 millimetres associated with unilateral and/or bilateral carotidal plaques. They also suffered for many other pathologies connected with cardiovascular system. In our paper, we showed these specific aspects more in "B" subjects than in "A" and "C" elder patients.

The use of instant messaging in clinical data sharing: the EHRA SMS survey

Funding Acknowledgements

Type of funding sources: None.

Background

Nowadays, instant messaging (IM) provides fast and widespread communication. These platforms and apps enable the physicians to quickly share and send clinical data to their peers, to send information to their patients regarding their illnesses and to be reached for counselling and advise. Nevertheless, the use of IM has never been assessed in the cardiology community up until now.

Purpose

To assess the habits of cardiologists related to modern communication tools, their primary and secondary uses in clinical practice and the potential differences and preferences between different media in terms of ease of access, usefulness and trustworthiness.

Methods

An online survey was promoted by the EHRA e-Communication Committee and the EHRA Scientific Initiative Committee during the ESC Digital Health Week. All cardiologists were invited to participate via Twitter, LinkedIn, Facebook and other dedicated channels. The survey consisted of 22 questions and was made anonymous. The questions were made on an individual-basis and collected on SurveyMonkey.

Results

287 physicians from 33 countries responded to the survey. The mean age of the respondents was 43.4 ± 11.5 years, and 74.8% of them were male. 88.3% of all respondents routinely sends and 90.3% receives clinical data through IM. IM is used at least once a week (36.4%) or even once or more a day (40.4%) for sharing clinical data. WhatsApp is the most used IM app to share clinical data (79.4%). On a scale of 1 to 5, IM was second only to face-to-face contact (average 4.46) as the preferred method for sharing clinical data (average 3.69) and was considered better than phone calls (average 3.34) and e-mails (average 3.21). Twelve-lead ECGs (88.6%), medical history (61.4%) and echo loops (55.7%) are the data shared most often. Among potential pros of IM, the respondents listed being a fast way of communication (82.0%) and making it easy to contact colleagues (76.7%), while privacy issues regarding IM apps providers (62.7%) and other colleagues (45.6%) were commonly perceived as drawbacks. Only 57.4% of all respondents anonymize clinical data before sharing them through IM, and only 44.0% of the data received are reported to be anonymized. Of note, 29.3% of the respondents were not aware of the European General Data Protection Regulation (GDPR) on data protection at the time of the survey, and 29.8% do not know if their institution has a specific policy regarding the use of IM for professional use.

Conclusions

IM apps are used by cardiologists worldwide to share and discuss clinical data and are preferred to many other methods of data sharing, being second only to face-to-face contact. IM are often used and to share many different types of clinical data, being perceived as a fast and easy way of communication. Cardiologists should be sensitised to appropriate use of IM in accordance to GDPR and local policies in order to prevent legal and privacy issues.

Implantable cardioverter defibrillator multisensor monitoring during home confinement caused by the covid-19 pandemic

Funding Acknowledgements

Type of funding sources: None.

Background

Utilization of remote monitoring platforms was recommended amidst the COVID-19 pandemic. The HeartLogic algorithm combines data from multiple implantable cardioverter defibrillator (ICD) sensors (first and third heart sounds, intrathoracic impedance, respirations, night heart rate, and patient activity) to provide integrated data that may allow for detection of early signs of worsening HF.

Purpose

We examined whether the HeartLogic platform may elucidate behavioral changes that impact HF decompensation, and the possible consequences of home confinement caused by the COVID-19 pandemic.

Methods

The Italian lockdown was imposed from March 8th to May 18th. On March 8th 2020, the HeartLogic feature was active in 349 ICD and cardiac resynchronization therapy ICD patients at 20 Italian centers. The period from January 1st to July 19th was divided in 3 phases: Pre-Lockdown (weeks 1-11), Lockdown (weeks 12-20), Post-Lockdown (weeks 21-29).

Results

Immediately after the implementation of stay at home orders (week 12) we observed a significant drop in median activity level (65min [36-103] in week 12 vs. 101min [61-140] in Pre-Lockdown; p < 0.001), while there was no difference in the other contributing sensors. The median composite HeartLogic index increased at the end of Lockdown (4.7 [1.3-10.2] in week 20 vs. 2.5 [0.7-7.0] in Pre-Lockdown; p = 0.019). The weekly rate of HeartLogic alerts was significantly higher during Lockdown (1.56 alerts/week/100pts, 95%CI:1.15-2.06; IRR = 1.71, p = 0.014) and Post-Lockdown (1.37 alerts/week/100pts, 95%CI:0.99-1.84; IRR = 1.50, p = 0.072) than that reported in Pre-Lockdown (0.91 alerts/week/100pts, 95%CI:0.64-1.27). However, the median duration of alert state and the maximum index value did not change among phases, as well as the proportion of alerts followed by clinical actions at the centers (Pre-Lockdown: 31%, Lockdown: 22%, Post-Lockdown: 28%), and the proportion of alerts fully managed remotely (i.e. no in-clinic visits) (Pre-Lockdown: 89%, Lockdown: 90%, Post-Lockdown: 88%).

Conclusions

The system was sensitive to the behavioral changes occurred during the lockdown, i.e. decrease in activity. However, the home confinement had no impact on the other sensors. The higher rate of HeartLogic alerts during lockdown and the increase in the median index after 8 weeks of home confinement suggest the worsening of the HF status, possibly explained by the behavioral changes. Nonetheless, the management of the HF detected events (actions performed and management strategy) was not impacted by the restrictions.

Wearable Cardioverter Defibrillator (WCD) in Italy: results from the nationwide multicenter registry WEAR-ITA

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

The Wearable Cardioverter Defibrillators (WCD) has been used extensively in Italy since 2015, following long years of experience in other countries. This technology provides temporary protection from Sudden Cardiac Death (SCD) for patients with an evolving risk profile that may not yet be eligible for an Implantable Cardioverter Defibrillator (ICD). Collecting national data on use of the device can help build a picture that will enable an understanding on how to use the WCD appropriately in the future.

PURPOSE

Our purpose has been to investigate WCD usage on a nationwide level. This is in terms of target population, average wear time, patient compliance, diagnosed and treated arrhythmic events and patient outcome once they stopped wearing the device.

METHODS

WEAR-ITA is a nationwide, multi-centre retrospective observational project. Patient data was retrospectively collected from the Italian hospitals that agreed to take part in the data collection for all patients fitted with a WCD between April 2015 to May 2018. All data refers to the range from the first day of wear until the end of use.

RESULTS

We collected data for 411 patients from 15 (75%) Italian regions. WCD use among the different regions was heterogeneous with a median of 0.5 (0.2-1.2) WCD wore/105 inhabitants. The mean age of the population was 55(±14) and the majority of patients were male (79%). Main WCD indication was non-ischemic cardiomyopathy with reduced ejection fraction (51%), ischemic etiology with severe systolic dysfunction (31%), uncertain or unidentified diagnosis (10%) that then revealed to be predominantly channelopathies or myocarditis and after ICD extraction (8%). Patients wore the WCD for a median of 59 (33-90) days and the median daily weartime was 23 (22,7-23,8) hours. In 15 patients (4%), the WCD recorded non sustained ventricular tachycardia (VT), 10  patients (2%) had hemodynamically well-tolerated sustained VT not needing a shock. 8 patients (2%) received effective appropriate shocks. Time to episodes were respectively 61 (14-61) days for non-sustained VT and 28 (19-70) days for VT/VF. 2 patients (0.5%) received inappropriate shocks for sinus tachycardia and atrial fibrillation (AF) respectively. WCD recorded new onset of supra ventricular tachycardia episodes in 12 patients (3%) and of atrial fibrillation (AF) in 7 patients (2%). 7 patients (2%) died while wearing WCD; none of them from SCD. At the end of the WCD use, 195 patients (47%) did not receive an ICD while 209 patients (51%)were implanted.

CONCLUSIONS

WCD is an effective therapy for the treatment of SCD with a very low complication rates. The indication and penetration in Italy is quite heterogeneous. The patient’s compliance is high over time. The incidence of appropriate shock is not negligible; only half of patients, who wore WCD, received an ICD. There is however still a requirement to conduct further randomized trials to understand which patients could most benefit from the use of WCD. Abstract Figure. Wereable Cardioverter Defibrillator

Sacubitril/valsartan therapy and supraventricular arrhythmias detected through remote monitoring in heart failure patients

Funding Acknowledgements

Type of funding sources: None.

Background

Sacubitril/valsartan (S/V) has demonstrated a significant benefit in decreasing mortality and morbidity in patients with heart failure with reduced ejection fraction (HFrEF) when compared to angiotensin inhibition. Recent studies demonstrated that the benefits of S/V encompass a positive cardiac remodeling, leading to a reduction of ventricular arrhythmias. The effect of S/V on the supraventricular arrhythmic burden is still unknown. 

Purpose

To evaluate the effect of sacubitril/valsartan on the supraventricular arrhythmic burden in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy-defibrillator (CRT-D) and remote monitoring. 

Methods

The SAVE THE RHYTHM is a multicentre, observational, prospective registry is enrolling all patients with HFrEF, ICD or CRT-D actively followed through remote monitoring and starting treatment with sacubitril/valsartan. All patients are followed-up at least one year after sacubitril/valsartan start. The primary endpoint is the number of sustained atrial tachycardia or AF (AT/AF). Secondary endpoints include incidence of AT/AF in the total population, total burden of AT/AF (defined as the percentage of time in AT/AF per day), mean number of premature ventricular contractions (PVC) per hour and percentage of biventricular pacing per day (in patients with CRT-D).  All primary and secondary endpoints are collected through remote monitoring.

Results

At the time of the second ad interim analysis, 188 patients (85.2% male, age 68 ± 10 years) were consecutively enrolled. In patients without permanent AF, treatment with S/V was associated with a reduced incidence of AT/AF episodes,  which changed from 32.6% (before treatment start) to 24.3%, 20.5% and 6.9% according to the sacubitril/valsartan dose (24/26 mg, 49/51 mg and 97/103 mg respectively; p= 0.041). A significant decrease in the median annual number of AT/AF episodes was also seen in these patients (16/year before treatment; 12/year at 24/26 mg; 6/year at 49/51 mg and 1/year at 97/103 mg; p = 0.046). No significant differences were reported in terms of PVC or biventricular pacing (all p = NS). Patients with permanent AF experienced no benefits from sacubitril/valsartan therapy in terms of arrhythmic burden reduction. No new diagnosis of clinical AF was made after starting treatment with sacubitrl/valsartan in all patients.

Conclusions

Preliminary data suggest that therapy with S/V could reduce the episodes of AT/AF in patients with HFrEF and remote monitoring, and the benefit seems related to the maximum tolerated dose of S/V. No positive effect has been noted in patients with permanent AF.

Risk management and Healthcare responsibility. How to guarantee legal protection in Medicine

Having regard to the increasing attention to the issue of safety and health of patients and workers by low, the hypothesis that this topic will be the growing trend in the next years does not seem to be manifestly unfounded. For this reason, it is wise for healthcare professionals to already be aware that any violation of the interests underlying the legislation in question entails a ruling on civil and/or criminal liability. It is therefore necessary to identify the most suitable means to prevent undue harm occurring, partly to exempt healthcare professionals and hospitals from compensation costs, thereby providing them with recourse to insurance coverage. Healthcare facility organisations must adopt Risk Management techniques as a tool to simultaneously guarantee the effectiveness of health services (in this case), the efficiency of the management economy, and finally compliance with all legally required precautions. This will relegate the occurrence of an adverse event to remote and unpredictable hypotheses, thus guaranteeing useful recourse to insurance coverage to compensate any harm that does occur.

Current status and needs for changes in critical care training: the voice of the young cardiologists

AIMS

The implementation of the 2013 European Society of Cardiology (ESC) Core Curriculum guidelines for acute cardiovascular care (acc) training among European countries is unknown. We aimed to evaluate the current status of acc training among cardiology trainees and young cardiologists (<40 years) from ESC countries.

METHODS AND RESULTS

The survey (March-July 2019) asked about details of cardiology training, self-confidence in acc technical and non-technical skills, access to training opportunities, and needs for further training in the field. Overall 614 young doctors, 31 (26-43) years old, 55% males were surveyed. Place and duration of acc training differed between countries and between centres in the same country. Although the majority of the respondents (91%) had completed their acc training, the average self-confidence to perform invasive procedures and to manage acc clinical scenarios was low-44% (27.3-70.4). The opportunities for simulation-based learning were scarce-18% (5.8-51.3), as it was previous leadership training (32%) and knowledge about key teamwork principles was poor (48%). The need for further acc training was high-81% (61.9-94.3). Male gender, higher level of training centres, professional qualifications of respondents, longer duration of acc/intensive care training, debriefings, and previous leadership training as well as knowledge about teamwork were related to higher self-confidence in all investigated aspects.

CONCLUSIONS

The current cardiology training program is burdened by deficits in acc technical/non-technical skills, substantial variability in programs across ESC countries, and a clear gender-related disparity in outcomes. The forthcoming ESC Core Curriculum for General Cardiology is expected to address these deficiencies.

Sonographic cervical length predicts vaginal delivery after previous cesarean section in women with low Bishop score induced with a double-balloon catheter

OBJECTIVE

To assess the role of cervical length when predicting vaginal delivery after a previous cesarean section (CS) in women with low Bishop score following the use of a double-balloon catheter for induction of labor (IOL).

METHODS

A prospective, longitudinal study was conducted at a large teaching hospital in Santiago to recruit pregnant women at term with a previous CS and Bishop score ≤6 for IOL with a double-balloon catheter. The device was maintained for up to 24 h and the patient continued IOL with oxytocin only if the Bishop score was >6. Demographic and clinical variables were recorded and compared against vaginal delivery as the primary outcome. Multivariate logistic regression analysis was used to compare perinatal demographic and clinical variables in women achieving vaginal delivery versus those having a repeat CS.

RESULTS

The final cohort included 40 pregnant women. Women achieving vaginal delivery (n = 17, 42.5%) had statistically significant differences in mean cervical length (24.8 mm versus 33.4 mm, respectively; p = .006), median Bishop score after removing the double-balloon catheter (11 versus 7, respectively; p = .005), and mean interval between double-balloon catheter placement and vaginal delivery or the decision to perform a CS (17.4 h versus 23.6 h, respectively; p = .03). Backward stepwise selection revealed an odds ratio of 0.90 (95% confidence interval = 0.82-0.98) for cervical length and a receiver operating characteristic curve area of 0.73.

CONCLUSION

Cervical length, as determined by transvaginal sonography, proved to be effective in predicting vaginal delivery in women with a previous CS and low Bishop score following the use of a double-balloon catheter for IOL.

Which is the best communication strategy, based on anti-tobacco ads, to impress teenagers? A multicenter cross-sectional study

BACKGROUND

Well-planned mass-media campaigns can increase health literacy and raise awareness about the consequences of tobacco use. This study aims to evaluate the emotions and opinions of adolescents about several anti-tobacco spots delivered by the mass media over the world.

STUDY DESIGN

Cross-sectional study.

METHODS

The study was conducted in Italy in 2016-2017 among students aged 13-17 years. Students expressed their emotions and opinions about seven anti-tobacco spots from all over the world on different topics and styles.

RESULTS

499 students attended. The video "Sponge" was found to be the most impressive (30.2%) and what they would have chosen if they had been responsible for campaign launched by the Minister of Health (40.5%). The "Icons" spot ranged second, with 19.2% and 17.4%, respectively.

CONCLUSIONS

In summary, this study showed that the communication strategies most effective, according to the students interviewed, are those that give clear messages with a scientific profile or that discover the false stereotypes, as in the video "Icons". However, further research is needed to investigate the effectiveness of TV campaigns against smoking, in terms of habits and knowledge in young people.

Challenges in diagnosing and managing non-cavitated occlusal caries lesions. A Literature overview and a report of a case

AIM

Aim of this literature overview was to analyze the diagnostic procedures of hidden caries lesions and to present a restorative protocol.

METHODS

A literature overview was performed in order to evaluate hidden caries etiological hypothesis and the reported prevalence. The diagnostic procedure is performed with the aid of an intra-oral fluorescence based camera and the restorative procedure is completed with the use of a novel bisphenol-A free composite.

RESULTS

Non cavitated occlusal caries lesions prevalence is high in young adults population. Diagnosis of hidden caries requires both high sensitivity and specificity.

CONCLUSIONS

The novel diagnostic and restorative protocol showed to be highly effective in hidden caries assessment and restoration.

Role of an extensive diagnostic work-up in the detection of concealed cardiomyopathies in athletes with premature ventricular complexes and implications for sports' eligibility assessment

Background

Premature ventricular complexes (PVCs) are a common clinical problem and a critical issue with regard to sports eligibility in sportsmen. Although PVCs can be considered a benign feature of the athlete's heart adaptive phenotype, they may also be the only clinical manifestation of a concealed cardiomyopathy, potentially heralding sudden cardiac death (SCD) during sports activity. The optimal diagnostic evaluation of athletes with PVCs is currently uncertain.

Purpose

To evaluate the diagnostic contribution and the implications for sports eligibility assessment of a thorough non-invasive and invasive work-up including electroanatomical mapping (EAM) and endomyocardial biopsy (EMB) in athletes with PVCs.

Methods

We conducted a prospective, single-arm, open-label double center study. All consecutive athletes presenting for evaluation at our institution after being disqualified from participating in sports due to PVCs were included in our study. These athletes underwent a baseline non-invasive diagnostic protocol with transthoracic echocardiogram and gadolinium enhanced cardiac magnetic resonance imaging (cMRI). Subsequently, an invasive diagnostic work-up was performed, including EPS with programmed electrical stimulation, EAM and EAM-guided EMB if deemed necessary. When clinically indicated, catheter ablation was performed. Sports eligibility status was re-assessed at six months' follow-up according to Italian sports medicine guidelines.

Results

After diagnostic evaluation, 20 subjects out of 107 (19%) had a diagnosis of heart disease, most commonly myocarditis (n=8), arrhythmogenic right ventricular cardiomyopathy (ARVC, n=7) or dilated cardiomyopathy (DCM, n=2). On multivariate logistic-regression analysis, QRS complex/T wave abnormalities on ECG (OR 23), non left bundle branch block and inferior axis PVC morphology (OR 13), echocardiogram abnormalities (OR 24) and low-voltage areas on EAM (OR 33) were significantly associated with diagnosis of a concealed cardiac disease. Nondiagnostic abnormalities on cMRI were common in this population of athletes, prevalently involving the right ventricle. EAM-guided EMB was performed in 12 subjects (11%) and catheter ablation in 56 (52.3%). After six months, 63 athletes (59%) were judged eligible to participate in competitive sports and 23 subjects (21%) were deemed eligible to participate in non-competitive sports.

Conclusions

Almost one fifth of sportsmen presenting with PVCs have a concealed heart disease, most commonly myocarditis or ARVC. Non-outflow tract PVCs' morphology and abnormalities on ECG, echocardiogram and EAM are predictive of structural heart disease's detection, whereas nondiagnostic findings on cMRI can be misleading in athletes. Invasive diagnostic tests, including EAM and EAM-guided EMB, play a critical role in case of diagnostic uncertainty. More than ¾ of subjects were judged eligible to participate in sports at 6 months' follow-up.

Funding Acknowledgement

Type of funding source: None

The HALT score as a useful tool to predict postoperative atrial fibrillation in non cardiac surgery: preliminary data from the internal validation population

Background

Perioperative cardiac complications depend on the patient's risk factors and comorbidities, the type and duration of the surgery. More specifically, postoperative atrial fibrillation (POAF) can manifest after surgical procedures and it affects more than 3% of all &gt;45-year-old patients undergoing non cardiovascular surgery, around 30% of patients undergoing thoracic surgery and 40% of those experiencing cardiovascular surgery. POAF is associated to a higher risk of stroke and mortality.

Purpose

The aim of our study was to assess independent risk factors for POAF incidence in non-cardiac surgery. The secondary endpoint was to evaluate predictors of major cardiovascular events (MACE) which included non-fatal stroke, non-fatal myocardial infarction (MI), transient ischemic attack, decompensated acute heart failure and cardiac-related death.

Methods

Retrospective observational study including all patients attending our outpatient clinic for preoperative assessment from the 1st of January 2016 to the 31st of December 2018. For each enrolled patient we reviewed the clinical data referring to the period of their surgery and took note of all cases of POAF and MACE occurring before discharge.

Results

A total of 1383 patients were enrolled (910 men, age 71.6±12.9). 36 cases of POAF (2.6%), 4 cases of non-fatal MI (0.3%), 8 cases of acute heart failure (0.6%) and 1 cardiac death (0.1%) were registered. Systemic hypertension (HR 3.68, 95% CI 1.12–12.09, p=0.32) and thyroid dysfunction were independent predictor of POAF (HR 2.87, 95% CI 1.32–6.23, p=0.008) as well as age (HR 1.05 per each year, 95% CI 1.01–1.09, p=0.006). The Revised Cardiac Risk Index (RCRI) as defined by current guidelines was not able to predict POAF risk in our population, while low-risk surgery showed a highly protective effect towards POAF (HR 0.07, 95% CI 0.01–0.50, p=0.008). A four items point-based risk score called HALT (hypertension =1; age≥70 years = 1; low-risk surgery = −3; thyroid dysfunction = 1) &gt;0 had an 81% sensitivity and a 61% specificity in detecting POAF in our population (AUC 0.753, figure 1). A rhythm control strategy was attempted in 25 patients (69.4%), mainly through pharmacological cardioversion (24 patients), while only one patient underwent emergency electrical cardioversion due to hemodynamic instability. Out of the 36 POAF events, oral anticoagulation was started in only one (3.1%) case while 33 patients were treated with low-molecular-weight heparin, either at anticoagulation doses (6, 16.7%) or more frequently at sub-therapeutic doses (27, 80.6%). Two patients (5.6%) were treated with aspirin.

Conclusions

POAF complicates 2.6% of all non-cardiac surgery, and is seldom treated as recommended by current guidelines, especially regarding thromboembolic risk reduction. A four items point-based risk score could be effective in implementing POAF screening. Low-risk surgery should not be screened for POAF, as the associated risk is very low.

Figure 1

Funding Acknowledgement

Type of funding source: None

Patterns of anticoagulation for atrial fibrillation in cancer patients referred for cardio-oncological evaluation

Background

Direct oral anticoagulants (DOAC) are the standard of care for the prophylaxis of non-valvular atrial fibrillation (NVAF)-cardioembolism, but their use in oncological patients has been limited so far.

Methods

We retrospectively reviewed the records of the patients referred to two cardio-oncology outpatient units between January 2017 and July 2019, and selected those presenting with NVAF, CHA2DS2-VASc ≥1 for men and ≥2 for women, and cancer on active treatment. The following were considered as contraindications to DOAC: severe chronic kidney disease; anti-neoplastic therapy unknown or with potential moderate-to-severe adverse interactions; cirrhosis or liver metastases. Clinical characteristics of patients on DOAC (group 1), on VKA or LMWH with at least 1 contraindication to DOAC (group 2), and on VKA or LMWH despite not having contraindications to DOAC (group 3) were compared by chi-square or ANOVA.

Results

Of a total of 3,831 patients, 264 (6.9%) met the inclusion criteria (Figure 1). One-hundred fourteen (43.2%) were in group 1, 61 (23.1%) in group 2 (18 on VKA, 43 on LMWH), and 65 (24.6%) in group 3 (27 on VKA, 38 on LMWH). Anticoagulation was omitted in 24 (9.1%) cases for various reasons: spontaneous bleeding (5), anaemia and/or thrombocytopenia (5), frailty (4), CHA2DS2-VASc 1 (3), pharmacological interactions (1), single episode of NVAF (1); and not clearly motivated in 5 subjects.

The only significant difference between the 3 groups was serum creatinine concentration (Table 1). Of note, only 10% of subjects in group 1 received an inappropriate DOAC dose, while LMWH was under-dosed for 18% of patients in group 2 and 31% of patients in group 3 (P=0.002).

Conclusions

In the setting of a dedicated cardio-oncology consultation, DOAC and VKA are most often appropriately prescribed to cancer patients with NVAF. However, there is residual use of LMWH, not infrequently at non-anticoagulant dosage. This is a non-evidence based common practice in clinical oncology that clearly must be abandoned

Figure 1

Funding Acknowledgement

Type of funding source: None

Incidence and predictors of arrhythmias in patients with systemic sclerosis and no overt cardiac disease

Background

Cardiac involvement in SSc is frequent, mostly subclinical and represents a negative prognostic factor. Speckle tracking derived measurement global longitudinal strain (GLS) has been able to identify primary heart involvement in patients with SSc and no overt cardiac disease. SSc-related cardiomyopathy, defined as a condition affecting the heart primarily and globally, has been proven to progress over time and seems to be correlated to cardiac arrhythmias. Nonetheless, cardiac arrhythmias represent 6% of the overall causes of death in SSc patients.

Purpose

The aim of our study was to assess the incidence of cardiac arrhythmias in SSc patients with no overt cardiac disease and to identify potential predictors.

Methods

Prospective longitudinal study enrolling all consecutive patients with a diagnosis of SSc and no overt cardiac disease or pulmonary hypertension. Echocardiographic parameters and GLS were obtained at baseline and at each follow up. Presence of atrial fibrillation (AF), atrial tachycardia (AT), ventricular ectopic beats &gt;1000/24 h (VEB), supraventricular ectopic beats (SVEB), bundle branch block (BBB) and atrioventricular block (AVB) was assessed through clinical history, ECG and 24-Holter monitoring over time.

Results

Among 67 consecutive patients with SSc, 11 (16.7%) had at least one episode of AF or AT. Moreover, respectively 12 (17.9%) and 16 (23.9%) had a significant amount of SVEB and VEB at Holter monitoring. Conduction defects were common, with 4 (4.6%) of all patients with grade I AVB, 1 (1.5%) with grade II AVB and 1 (1.5%) with complete heart block. Complete right BBB was seen in 6 (6.9%) of patients. Four patients (4.6%) experienced a sudden cardiac death during follow-up (median 20 months, 1st-3rd quartile 12–24 months).

Years from SSc diagnosis (RR 1.10; 95% CI 1.02–1.23; p=0.047) and indexed right atrial volume (iRAV; RR 1.22; 95% CI 1.07–1.39; p=0.004), but not indexed left atrial volume were independently correlated with the diagnosis of AF/AT. The same two variables were independently correlated with any degree of AV block (years from SSc diagnosis: RR 1.11; 95% CI 1.01–1.23; p=0.004; iRAV: RR 1.14; 95% CI 1.02–1.27; p=0.019). Due to the low sample size, we were unable to detect any clinical predictors of sudden cardiac death in our population, however those who died experienced a larger worsening in left ventricle GLS values (4.0±1.6 vs. 0.9±0.4, p=0.056).

Conclusions

Supraventricular arrhythmias and conduction defects are common in patients with SSc. Time from diagnosis and right atrial volumes are able to predict the incidence of such conditions, supporting the hypothesis that a long-lasting disease and the anatomical remodelling of the right atrium could contribute to the developing of tachy- and bradyarrhythmias in this population.

Funding Acknowledgement

Type of funding source: None

Prognostic role of left ventricular late gadolinium enhancement (LV-LGE) in patients who received implantable cardioverter defibrillator (ICD) for secondary prevention

Introduction

LV myocardial fibrosis detected as LGE on cardiac magnetic resonance (CMR) is a predictor of arrhythmic risk in primary prevention both in ischaemic and non-ischaemic cardiomyopathy. However, we still do not know the prognostic role of LV-LGE in patients who suffered cardiac arrest (CA).

Purpose

To evaluate the prognostic role of CMR, and in particular of LV-LGE suggesting myocardial scar, in predicting appropriate ICD interventions in secondary prevention patients.

Methods

Ninety-seven consecutive patients 1) aged ≥14 years 2) hospitalized for CA because of ventricular arrhythmias from 2009/01/01 3) who underwent/undergoing a CMR within one month from the event 4) who received/receiving an ICD for secondary prevention and 5) with at least 1 year-follow-up, were enrolled for this multicentric study.

Results

97 patients (68 males, 70%), mean age 46±16 years, were enrolled. Seventy-six percent of patients received bystander cardiopulmonary resuscitation (CPR) and ventricular fibrillation (VF) was the first rhythm in 86% of cases. ST elevation was present in 18% of cases at the admission; however, angiography was found negative in 80% of patients. Myocardial oedema and LGE were identified in 26% and 64% of patients respectively. A diagnosis was made in 83.5% of cases, while in the remaining 16.5% CA was considered idiopathic. During a four-year-follow-up, 25% of patients had appropriate ICD therapy (10% of which ATP only). A significant correlation between LGE and appropriate ICD intervention was not found (p=0.89).

Conclusions

One fourth of patients who received ICD for secondary prevention had appropriate ICD therapy during a four-year-follow-up. In this setting, LV-LGE does not provide a prognostic value.

Funding Acknowledgement

Type of funding source: None

Sacubitril/valsartan reduces atrial fibrillation and supraventricular arrhythmias in patients with HFrEF and remote monitoring: preliminary data from the SAVE THE RHYTHM

Background

Sacubitril/valsartan, the first combined angiotensin receptor-neprilysin inhibitor, has demonstrated a significant benefit compared to angiotensin inhibitor in decreasing ventricular arrhythmias and appropriate implantable cardioverter defibrillator (ICD) shocks in patients with heart failure with reduced ejection fraction (HFrEF). At present, there is no study which evaluates the effect of sacubitril/valsartan on the supraventricular arrhythmic burden in HFrEF patients with an ICD or cardiac resynchronisation therapy-defibrillator (CRT-D) and remote monitoring.

Purpose

To evaluate the effect of sacubitril/valsartan on the supraventricular arrhythmic burden in HFrEF patients with an ICD or CRTD and remote monitoring.

Methods

The SAVETHERHYTHM ((SAacubitril Valsartan rEal-world registry evaluating THE arRHYTHMia burden in HFrEF patients with implantable cardioverter defibrillator) is a multicentre, observational, prospective registry enrolling all patients with HFrEF, ICD or CRT-D actively followed through remote monitoring and starting treatment with sacubitril/valsartan. All patients are followed-up for at least one year after sacubitril/valsartan start. The primary endpoint is the mean number of sustained atrial tachycardia or atrial fibrillation (AT/AF) episodes per month. Secondary endpoints include the total burden of AT/AF (defined as the percentage of time in AT/AF per day), the mean number of premature ventricular contractions (PVC) per hour and the percentage of biventricular pacing per day (in patients with CRT-D). All primary and secondary endpoints are collected through remote monitoring.

Results

At the time of the first ad interim analysis, 60 patients (85.2% male, age 69±10 years) were consecutively enrolled. After treatment with sacubitril/valsartan, patients with at least one episode of AT/AF per month decreased from 32.8% to 21.3% (p=0.015). A significant decrease in number of AT/AF episodes (from 4.3 to 1.2 per year), in AT/AF burden (from 12% to 9%) and in number of PVC (from 83 to 74 per hour) were seen in patients with a previous diagnosis of paroxysmal or persistent AF (n=15; all p&lt;0.05). Patients with permanent AF (n=7) experienced no benefits from sacubitril/valsartan therapy in terms of arrhythmic burden reduction. Patients with no previous history of AF (n=38) showed a decrease in number of AT/AF episodes (from 2.0 to 0.8 per year) and in number of PVC (from 77 to 49 per hour, all p&lt;0.05). No new diagnosis of clinical AF was made after starting treatment with sacubitrl/valsartan, and patients with subclinical AT/AF episodes decreased from 8% to 3%.

Conclusions

Preliminary data suggest that therapy with sacubitril/valsartan could decrease arrhythmic burden in patients with non-permanent AF and reduce subclinical AT/AF episodes in patients with no history of AF. No positive effect has been noted in patients with permanent AF.

Funding Acknowledgement

Type of funding source: None

Investigation of EGFR/pi3k/Akt signaling pathway in seminomas

Activation of the receptor for epidermal growth factor (EGFR) in some testicular tumors activates several signaling pathways. Some components of these pathways are phosphorylated or mutated in testicular germ tumors (TCGT), including EGFR, Kirstein ras oncogen (KRAS) and cell surface protein of the germ cell (KIT). The latter two activate RAF ⁄MEK⁄ERK and PI3 K⁄AKT, and interconnect with the EGFR/pI3 k/Akt pathway. We investigated the expression of EGFR/pI3 k/Akt pathway proteins in seminomas and in their precursor lesion, germinal cell neoplasia in situ (GCNIS) and related genetic mutations. We used immunohistochemistry for pEGFR, pI3 k and pAkt expression with a scoring system for 46 seminoma surgical specimens: 36 classical and 10 GCNIS. In 17 samples, the mutations of EGFR (exons 19 - 21), KIT (exons 11, 17) and KRAS (exons 2, 3) were investigated using qPCR and sequencing. Of the 36 seminomas studied, 22 (61%) expressed pEGFR. Ten samples exhibited high scores for pEGFR, pI3 k and pAkt. In 5 of 17 cases (33%) some mutation was exhibited in the exons studied: 21 of EGFR (2), 17 of EGFR (1), 3 of KRAS (1) and 11 of KIT (1). Six cases exhibited nuclear translocation of EGFR; of these, four exhibited mutations of EGFR, KRAS and KIT. Eight of ten of the GCNIS expressed a high pEGFR score (80%). In 2 of 6 cases (33%), mutation was detected in exon 21 of EGFR and one smear showed EGFR translocation to the nucleus. The translocation represents a subpopulation with worse prognosis for TCGT. The EGFR/pI3 k/Akt signaling pathway is linked to TDRG1, which regulates chemosensitivity to cisplatin; this is a mechanism of resistance to treatment. TDRG1 and the EGFR/pI3 k/pAkt pathway could be therapeutic targets for seminomas resistant to cisplatin.

P428Cost-effectiveness of sedation for electrical cardioversion in the emergency department: a subanalysis of the Instead trial

BACKGROUND 

Direct current cardioversion (DCCV) represents the most widely used and effective method to restore sinus rhythm in patients with persistent AF. No specific guidelines or recommendations with regards to the most appropriate drug that should be used for procedural sedation have been described. Propofol is one of the most used drugs, however it should be administered only by personnel trained in advanced airway management. Midazolam has been described as a potential alternative.

PURPOSOSE 

The aim of our study was to assess the cost-effectiveness of procedural sedation with midazolam compared to the one with propofol for urgent/emergency DCCV in the emergency department. 

METHODS 

Single centre, prospective, open blinded, randomized study including 66 consecutive patients admitted to the emergency department requiring urgent or emergency DCCV for haemodynamic instability, chest pain or symptomatic palpitations. The enrolled patients were randomized in a 1:1 fashion into the propofol or midazolam group. With regards to the propofol group, the procedure was carried out with the assistance of the anaesthesiologist. In the midazolam group, both the procedural sedation and the cardioversion were carried out by the cardiologist alone. 

RESULTS 

Thirty-tree patients underwent procedural sedation with propofol and 33 with midazolam. Medical costs included expenses for personnel and related to possible procedural delays. The median medical cost was of 14.9 € for the midazolam group and 46.7 € for the propofol group (p&lt;.001) and was mainly driven by an increased delay and lack of coordination between the cardiologist and the anaesthesiologist. The median material cost in the midazolam group was higher than in the propofol one as the former implied the use of flumazenil (83.7 € vs. 78.8 €, p&lt;.001). Hospitalization costs included the cost related to monitoring time in the emergency department and possible costs derived by the admission to a medical ward. They added up to a median of 28.1 € in the midazolam group and 48.7 for the propofol group (p=.004) as most patients were discharged safely after a few hours. The total median cost of urgent/emergency DCCV with midazolam was estimated to be 126.2 € (1st-3rd quartiles 114.4-142.6) and 203.3 € (1st-3rd quartiles 149.3-734.8) with propofol (p&lt;.001). There was no significant difference in terms of adverse events. Sedation with midazolam was as safe, efficient and tolerated as sedation with propofol. Length of procedure was shorter when midazolam was used compared to propofol usage. Patients who underwent sedation with midazolam were safely discharged earlier.

CONCLUSIONS

Procedural sedation for electrical cardioversion in the emergency department is more cost-effective than sedation with propofol. By using midazolam we estimated that 77 € are saved for each DCCV. This is driven by the absence of another operator and the possibility of a quicker discharge given the use of flumazenil.

P1110Role of an extensive diagnostic work-up in the detection of concealed cardiomyopathies in athletes with complex ventricular arrhythmias and implications for sports" eligibility assessment

Background

ventricular Arrhythmias (VAs) are a common clinical problem and a critical issue with regards to sports" eligibility in athletes. Although VAs can be considered a benign feature of the athlete’s heart adaptive phenotype, they may also be the only clinical manifestation of a concealed cardiomyopathy, potentially heralding sudden cardiac death (SCD) during sports activity.

Purpose

to evaluate the diagnostic contribution and the implications for sports eligibility assessment of a thorough non-invasive and invasive work-up including electrophysiology study (EPS), electroanatomical mapping (EAM) and endomyocardial biopsy (EMB) in athletes with complex VAs and to derive a multiparametric risk score in order to easily predict structural heart diseases’ diagnosis.

Methods

we conducted a prospective, single-arm, open-label single center, observational study. All consecutive athletes presenting for evaluation at our institution after being disqualified from participating in sports due to complex VAs were enrolled. The athletes underwent a baseline non-invasive diagnostic protocol with transthoracic echocardiogram and gadolinium enhanced cardiac magnetic resonance imaging (cMRI). Subsequently EPS, EAM and EAM-guided EMB were performed if deemed necessary. Sports eligibility status was re-assessed at 6 months’ follow-up. A multivariable logistic regression model was built, considering cMRI as the gold standard exam.

Results

after diagnostic evaluation, 55 subjects (26.4%) had a diagnosis of heart disease, most commonly myocarditis (n = 27) and arrhythmogenic right ventricular cardiomyopathy (ARVC, n = 16). After 6 months, 100 athletes (48.1%) were judged eligible to participate in competitive sports and 46 subjects (22.1%) were deemed eligible to participate in non-competitive sports. On multivariable logistic-regression analysis, abnormalities on ECG (OR 5.3) or on echocardiogram (OR 3.7), sustained VA inducibility on EPS (OR 17.7) and low-voltage areas on EAM (OR 7.7) proved all predictive of concealed structural heart diseases’ diagnosis. We derived two simple risk scores: a 40-points risk score and an 8-points risk score (obtained by weighing each variable according to the regression model’s ORs). Both these risk scores’ performance proved very good (AUC = 0.856 for the 40-points score and AUC = 0.852 for the 8-points score, figure 1).

Conclusions

approximately 1/4 of athletes presenting with complex VAs have a concealed heart disease, most commonly myocarditis or ARVC. ECG, echocardiogram and EAM abnormalities and sustained VAs inducibility on EPS are predictive of structural heart diseases’ detection. Therefore, these diagnostic tests should be routinely included in the evaluation of athletes with complex VAs. A risk score including the results of these tests can greatly help in the prediction of concealed structural heart diseases’ diagnosis. More than 2/3 of subjects were judged eligible to participate in sports at 6 months’ follow-up.

Abstract Figure 1. ROC curves for diagnosis

1324Reprocessing of electrophysiology catheters in EHRA countries. An EHRA Young EP survey

Introduction

Reprocessing of electrophysiology (EP) catheters in daily routine varies through countries and may depend on national laws, catheter (cath.) models or supplier. Data on reprocessing of EP materials is sparse and remains a matter of controversy. The aim of this study is to collect data on reprocessing usage through EHRA countries.

Methods and results

A structured online questionnaire comprising 27 questions was distributed among electrophysiologists in EHRA countries. Two-hundred-and-two participants from 34 countries completed the survey (161 males, 36.8 ± 5.8 years old). Overall, 111 (55%) of respondents currently use reprocessed materials and 30 (15%) have used them in the past. Cables, diagnostic cath. with deflectable curve and diagnostic cath. with fixed curve were the most frequently reprocessed materials (87%, 80% and 78% respondents, respectively). Maximum number of times (median) a cath. was usually reprocessed was 6 for diagnostic cath. and 5 for ablation cath. Among potential benefits of reprocessing, cost reduction for the providing hospital (65%), cost reduction for the health provider (42%) and making EP procedure available for more patients (42%) were most frequently reported. Respondents reported a need to change the reprocessed material due to its insufficient functionality in around 15% of cases. They were also concerned about the quality of the reprocessed material (58%), contamination issues (52%) and loss of precision (47%). Nineteen (17%) users of reprocessed EP material reported at least one complication potentially related to the reprocessing during their whole reprocessing experience. Sixty-six (73%) respondents who did not use reprocessed EP material would consider using it in the future.

Conclusions

Reprocessing of EP material is heterogeneously managed among the EHRA countries, as wide differences are present in terms of national and local regulations, clinical practice and technical aspects. Nonetheless, the current data show that European electrophysiologists consider the use of reprocessed EP material as generally safe and cost-effective.

P431Flecainide or propafenone oral bolus to facilitate electrical cardioversion of persistent atrial fibrillation

Background

 electrical cardioversion (ECV) of atrial fibrillation (AF) is a pivotal component of the rhythm control approach. Although ECV is safe and effective in the majority of patients, approximately one patient out of ten experiences an early or very early recurrence. In order to improve ECV’s success rate, oral or intravenous amiodarone pre-treatment is commonly prescribed and followed by a second ECV attempt. However, due to the long time needed to achieve therapeutic levels and the high risk of phlebitis, faster and safer strategies to facilitate ECV are highly needed.

Purpose

 to evaluate whether the administration of a flecainide or propafenone oral bolus followed by ECV would prove effective and safe in facilitating conversion to sinus rhythm in patients with persistent AF and a prior ECV failure.

Methods

we conducted a prospective, open-label, single center observational study. The case group was formed by patients with persistent AF and a prior ECV failure receiving flecainide or propafenone oral bolus (at the same doses used for the "pill-in-the-pocket" approach) followed by a second ECV attempt 3 hours after drug ingestion. For comparison, we selected patients with a prior ECV failure that underwent amiodarone-facilitated ECV. Before ECV, amiodarone was either administered orally for at least 1 month or intravenously for 24 hours. The primary outcome was conversion to sinus rhythm, defined as sinus rhythm persisting for at least 12 hours after ECV.

Results

patient’s characteristics were well balanced in the 3 groups, apart from slightly lower left ventricular ejection fraction values in the amiodarone groups. The day after ECV failure, 29 patients received oral flecainide at a 200 mg (n = 15) or at a 300 mg (n = 14) dose and one patient received oral propafenone at a 600 mg dose before undergoing a second ECV attempt. In nine patients, amiodarone was given intravenously for 24 hours. Amiodarone was prescribed orally to 22 patients for a median of seven weeks at an average daily dose of 241.4 mg. In the flecainide/propafenone group, one patient converted to sinus rhythm one hour after drug ingestion; among the other 29 subjects, the second ECV was effective in 23 (cumulative effectiveness: 80.0%). In the intravenous amiodarone group, 2 patients converted to sinus rhythm during drug infusion; among the other 7, the second ECV proved effective in 4 (cumulative effectiveness: 66.7%). In the oral amiodarone group, ECV was successful in 17 patients (77.3%). When comparing the three groups, the primary outcome occurred in a similar proportion of patients (Chi-squared test: p = 0.34; Fisher’s exact test: p = 0.24). Serious adverse events were not reported.

Conclusions

flecainide or propafenone oral bolus quickly facilitated conversion to sinus rhythm in the vast majority of patients with persistent AF and a prior ECV failure with a low inherent risk of adverse events. Flecainide effectiveness proved similar to intravenous or oral amiodarone.

SAT0307 PROGRESSION OF SUBCLINICAL MYOCARDIAL INVOLVEMENT IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Systemic sclerosis (SSc) is a progressive autoimmune disease affecting the skin as well as internal organs, including the heart. A few studies have identified a subclinical heart involvement in patients with no pulmonary hypertension. Changes in myocardial deformation are consistent with the idea of SSc-related cardiomyopathy as a primary condition affecting the heart globally through microvascular dysfunction and subsequent myocardial fibrosis.

Objectives:

The aim of the present study is to describe the progression of myocardial deformation in patients with SSc and no overt cardiac disease.

Methods:

Prospective longitudinal study enrolling consecutive SSc patients referred to the Clinica Medica, University Hospital ‘Ospedali Riuniti’, Ancona, Italy, from February 2016 to December 2018. All patients fulfilled the 2013 ACR/EULAR classification criteria for SSc. Patients with structural heart disease, heart failure, atrial fibrillation or pulmonary hypertension were excluded. Disease subset, antibodies pattern, cardiovascular risk factors and involvement of other organ systems were recorded for each patient. An echocardiographic exam was performed for all patients at baseline and during their follow-up evaluation. Standard and speckle-tracking derived variables for the systolic and diastolic function of the left ventricle (LV) and right ventricle (RV) were acquired. Speckle tracking analysis software (EchoPAC 13.0; GE Medical Systems, Milwaukee, USA) was used to assess the GLS of the left and right ventricle, excluding the ventricular septum from right ventricular GLS calculations.

Results:

Seventy-two patients (68 females, age 56.6±15.4 years) were enrolled. Common echocardiographic parameters of left and right systolic function were within normal range at baseline and did not change during follow-up. Mean GLS, however, worsened for both left (from -19.8±3.5% to -18.7±3.5%, p=.034) and right ventricle (from -20.9±6.1% to -18.7±5.4%, p=.013) during a median follow-up of 20 months (1st-3rd quartile 12-24 months). The increased impairment registered in SSc patients was homogenous across endocardial layers (LV from -22.5±-3.9 to -21.4±3.9, p=.041; RV from -24.2±6.2 to -20.6±5.9, p=.001), mesocardial layers (LV -19.7±3.6 to -18.7±3.5, p=.043; RV from -21.3±5.9 to -18.8±5.7, p=.012) and epicardial layers (LV from -17.1±3.0 to -16.4±3.1, p=.112, RV -18.8±6.3 to -16.0±8.4, p=.035), as well as myocardial segments. No difference in progression rate was observed stratifying patients according to disease subset or other clinical parameters.

Conclusion:

GLS impairment progressed over a 20-month follow-up period in a cohort of SSc patients without clinically overt cardiac involvement. Further studies are needed to assess the significance of subclinical heart involvement and its progression in patients with SSc.

Disclosure of Interests:

None declared

Oral health in a cohort of individuals on a plant-based diet: a pilot study

INTRODUCTION

Plant-based diets are associated with a lower: (i) body mass index, (ii) rates of death from ischemic heart disease, (iii) serum cholesterol, (iv) incidence of high blood pressure, (v) type II diabetes mellitus and cancer, with an overall longer life expectancy. However, little data concerning the oral health in individuals on a plant-based diet are available.

AIM

The aim of the present study was to investigate the general and clinical oral health status in a cohort of adults who had been following a plant-based diet for a minimum of 24 months.

MATERIAL AND METHODS

For this purpose, individuals were administered two questionnaires (a.Questionnaire investigating risk areas for oral diseases; b. Italian version of the Oral Health Impact Profile -14 (IOHIP-14)) by a dental hygienist and clinical examination of the oral cavity was carried out.

RESULTS

Seventy-seven adult individuals were enrolled. On average, they followed a plant-based diet for the last four years, had four meals a day and brushed their teeth twice a day. Fruit was the most frequently consumed food at breakfast by 48 of the participants. Thirty-four responders did not drink beer or wine, 65 did not drink spirits, 57 avoided carbonated beverages and 62 (80.5%) did not consume any highly-sugared beverages. Different dental therapies in the previous three years were reported in 36 of the responders. Overall, answers "never and almost never" to the IOHIP-14 questionnaire were observed in 87% to 100% of the individuals. Multiple logistic regression analysis revealed that fresh fruit consumption at lunch had a protective effect against caries (p<0.05).

CONCLUSIONS

In conclusion, this study showed that individuals on a plant-based diet have good overall oral health conditions. These features are in agreement with the behavior of these subjects towards an overall healthy life style.