Low incidence of arrhythmic syncope and pacemaker implantation in older patients with bifascicular block and implantable cardiac monitor

BACKGROUND

In patients with unexplained syncope, bifascicular block (BFB) is considered associated with syncope due to either heart block or sinus arrest. Immediate or delayed pacemaker (PM) implantation after ECG documentation of syncopal recurrence by means of implantable cardiac monitors (ICM) is still debated. We aimed to assess the incidence of recurrent syncope and guideline-based PM implantation in patients with syncope and BFB implanted with ICM.

METHODS

Consecutive patients with syncope and BFB followed at two tertiary care syncope units and implanted with ICM from 2012 to 2020 were retrospectively reviewed. Only patients with ≥2 clinical visits and ≥ 18 years of age were included. Incidence of a Class I indication for PM implantation was the primary outcome.

RESULTS

Of 635 syncope patients implanted with an ICM, 55 (8.7%) had a BFB and were included. Median age at implantation was 75 [interquartile range, IQR:64-81] years, and 28(49.1%) were women. At 26 [IQR:12-41] months follow-up, 20 (36.3%,16.3%/year) patients experienced syncope: in 6(10.9%) patients syncope was classified 'arrhythmic' with a higher prevalence in older individuals (p = 0.048). PM implantation (N = 14,25.5%) was more frequent in patients ≥75 years (p = 0.024). At survival analysis, patients ≥75 years were at highest risk of arrhythmic syncope and guideline directed PM implantation (Hazard Ratio: 4.5, 95% Confidence Intervals 1.5-13.3).

CONCLUSIONS

Most older patients with syncope who received an ICM did not have events during follow-up. One-in-three experienced syncope, and an even smaller number had an arrhythmic syncope with indication for PM implantation. Older age was strongly associated with PM implantation.

595 LOW INCIDENCE OF ARRHYTHMIC SYNCOPE AND PACEMAKER IMPLANTATION IN OLDER PATIENTS WITH BIFASCICULAR BLOCK AND IMPLANTABLE CARDIAC MONITOR

Background

In patients with unexplained syncope, bifascicular block (BFB) is considered associated with syncope due to either heart block or sinus arrest. Immediate or delayed pacemaker (PM) implantation after ECG documentation of syncopal recurrence by means of implantable cardiac monitors (ICM) is still debated. We aimed to assess the incidence of recurrent syncope and guideline-based PM implantation in patients with syncope and BFB implanted with ICM.

Methods

Consecutive patients with syncope and BFB followed at two tertiary care syncope units and implanted with ICM from 2012 to 2020 were retrospectively reviewed. Only patients with >2 clinical visits and >18 years of age were included. Incidence of a Class I indication for PM implantation was the primary outcome.

Results

Of 635 syncope patients implanted with an ICM, 55 (8.7%) had a BFB and were included. Median age at implantation was 75 [interquartile range, IQR:64-81] years, and 28(49.1%) were women. At 26 [IQR:12-41] months follow-up, 20 (36.3%,16.3%/year) patients experienced syncope: in 6(10.9%) patients syncope was classified ‘arrhythmic’ with a higher prevalence in older individuals (p=0.048). PM implantation (N=14,25.5%) was more frequent in patients >75 years (p=0.024). At survival analysis, patients >75 years were at highest risk of arrhythmic syncope and guideline directed PM implantation (Hazard Ratio: 4.5, 95% Confidence Intervals 1.5-13.3).

Conclusions

Most older patients with syncope who received an ICM didn't have events during follow-up. Only one-in-three experienced syncope, and an even smaller number had an arrhythmic syncope with indication for PM implantation. Older age was strongly associated with PM implantation.

Divergent molecular and growth responses of young "Cabernet Sauvignon" (Vitis vinifera) plants to simple and mixed infections with Grapevine rupestris stem pitting-associated virus

Grapevine rupestris stem pitting associated virus (GRSPaV) is one of the most widely distributed viruses; even so, little is known about its effect on Vitis vinifera. To provide new insights, the effects of single and mixed GRSPaV infections on the V. vinifera cultivar "Cabernet Sauvignon" were studied by evaluating growth parameters, such as measurements of the total plant length, the number and distance of internodes and the number of leaves per shoot. In addition, parameters relating to gas exchange, i.e., the stomatal conductance, net photosynthetic rate, internal CO2 concentration and leaf transpiration, were also assessed. All the measurements were performed in one- and two-year-old plants with a single GRSPaV infection or mixed infections of GRSPaV and Grapevine fanleaf virus (GFLV). The results show that the plant phytosanitary status did not significantly alter the growth and gas exchange parameters in one-year-old plants. However, in two-year-old plants, single GRSPaV infections increased shoot elongation, which was accompanied by the overexpression of genes associated with the gibberellic acid response pathway. The gas exchange parameters of these plants were negatively affected, despite exhibiting higher LHCII gene expression. Plants with mixed infections did not have modified growth parameters, although they presented a greater reduction in the primary photosynthetic parameters evaluated with no change in LHCII expression. The results presented here confirm the co-evolution hypothesis for V. vinifera and GRSPaV during the early stages of plant development, and they provide new evidence about the effects of GRSPaV and GFLV co-infections on the "Cabernet Sauvignon" cultivar.

First Report of Crown Rot of Strawberry Caused by Macrophomina phaseolina in Chile

In recent years, an increase of collapsed and dead strawberry plants has been observed in several fields in central Chile, specifically in San Pedro, Melipilla, an important area for strawberry cultivation in the country. To determine the causal agent of the disease and the extent of the problem, 25 sample sites of 1 ha each, distributed in different San Pedro zones, were surveyed at the end of the 2011 season (from December 2010 to February 2011). Cross sections of the crowns of symptomatic strawberry plants showed necrotic tissue and brown-red to dark brown areas on the vascular ring. Samples of the affected crowns were superficially disinfested and plated on potato dextrose agar with 200 μg/ml of streptomycin sulfate. Dark gray colonies were observed after 7 days of incubation at 24°C. Pure cultures of the pathogen showed aerial mycelium and abundant dark oblong sclerotia. Fifty sclerotia were measured, averaging 120 × 74 μm. Twenty-one isolates were identified molecularly utilizing the species specific primers MpKFI and MpKRI (2) that yielded a 350-bp fragment. The amplified DNA fragments were sequenced and BLAST analysis showed a 99% nucleotide sequence identity with Macrophomina phaseolina (GeneBank Accession No JX535007.1). Both morphological and molecular analyses confirmed that the isolated species corresponded to M. phaseolina, causal agent of crown and root rot in strawberry. Four representative isolates were selected to conduct pathogenicity tests. Inoculum was prepared by incubating the pathogen for 28 days at 20°C in sterilized oat seeds. Pots of 1.5 liters were filled with a mixed substrate of peat and perlite (2:1), amended with inoculated oats at 9 g per liter of substrate. 'Camarosa' strawberry plants were planted and grown in a glasshouse for 1 month. Six replicated plants per isolate and six plants growing on non-inoculated substrate were left as controls. Ninety-five percent of the inoculated plants showed wilt and collapse symptoms 22 days after transplant, whereas no symptoms were observed in the control plants. M. phaseolina was reisolated from the crowns of symptomatic plants, fulfilling Koch's postulates. The pathogen was isolated from symptomatic strawberry plants in 14 of the 25 sampled sites. Although M. phaseolina was described previously on other crops in Chile, to our knowledge, this is the first report of M. phaseolina causing crown rot of strawberry. The disease has been recently reported in Spain, the United States, and Argentina (1,3,4). References: (1) M. Avilés et al. Plant Pathol. 57:382, 2008. (2) B. Babu et al. Mycologia 99:797, 2007. (3) O. Baino et al. Plant Dis. 95:1477, 2011. (4) S. Koike. Plant Dis. 92:1253, 2008.

Treatment of pulmonary nocardiosis in heart-transplant patients: importance of susceptibility studies

Pulmonary nocardiosis is an infrequent but insidious disease in transplant patients. It has occurred in our centre in 3 out of 233 heart-transplant recipients since 1988. Common clinical features were mild symptoms and a severe nodular lung involvement. Early diagnosis was based upon cultures of bronchoalveolar lavage or fine-needle aspirate specimens of the lung lesions. Susceptibility studies and tests of antibiotic synergism guided the therapy. Two patients were treated with a combination of piperacillin-tazobactam and ciprofloxacin, and one with imipenem and amikacin, for 3-4 wk followed by a 3-month course of trimethoprim-sulphamethoxazole. The nocardial disease was successfully treated in the 3 patients; however, one died of subsequent invasive pulmonary aspergillosis. In the absence of consensus on the length of therapy, this experience suggests that a synergistic combination of a beta-lactam/beta-lactamase inhibitor with ciprofloxacin or amikacin followed by a short course of trimethoprim-sulphamethoxazole may be effective in eradicating nocardial disease and may reduce the need for long-term treatment.

Serum HCV RNA levels correlate with histological liver damage and concur with steatosis in progression of chronic hepatitis C

The role of HCV RNA levels and host factors in the severity of liver injury was studied. Enrolled were 298 consecutive liver biopsy-proven chronic hepatitis (CH) C patients (179 men; median age: 52 years, range 19-68; CH, 198; cirrhosis, 100) and 18 chronic hepatitis C with normal ALT. HCV genotypes were: 1a, 4.3%; 1b, 53%; 2a/c, 28%; 3a, 7%; 4, 1.3%, and mixed 6.4%. Serum HCV RNA levels were similar for all genotypes (median: 2.8 x 10(6) eq/ml; range <0.2-69). In patients with chronic hepatitis without cirrhosis, the serum HCV RNA levels reflected the grade of liver necroinflammatory activity (R = 0.45; P < 0.001) and the stage of fibrosis (R = 0.51; P < 0.001), regardless of age, gender, HCV genotype, hepatic steatosis, and hepatic iron overload. Patients with high serum HCV RNA levels (> or =3 x 10(6) eq/ml) had higher ALT values (P < 0.002) than those with lower HCV RNA levels. Patients with normal ALT showed low HCV RNA levels (median: 0.82 x 10(6) eq/ml) and histological features of minimal or mild chronic hepatitis. Cirrhotic patients showed significantly lower levels of viremia than those with chronic hepatitis with a similar HAI. The data of a subgroup of 62 patients with an established time of infection showed that for a similar duration of disease, patients with serum HCV RNA levels > or =3 x 10(6) eq/ml had a significantly higher fibrosis score than those with lower levels. HAI and fibrosis score were significantly higher in patients with HCV RNA levels > or =3 x 10(6) eq/ml and grade 3-4 steatosis than those with lower HCV RNA levels and steatosis grades. The data indicate that the liver damage is correlated with the HCV RNA levels and that a high viral load acts together with steatosis in accelerating the progression of liver injury.

Steatosis accelerates the progression of liver damage of chronic hepatitis C patients and correlates with specific HCV genotype and visceral obesity

The role of steatosis in the progression of liver damage in chronic hepatitis C (CHC) was studied. Enrolled were 180 consecutive liver biopsy-proven CHC patients and 41 additional subjects with a known duration of infection. We evaluated the histological activity index (HAI), grade of fibrosis and steatosis, body mass index (BMI; kg/m(2)), distribution of body fat, HCV genotype, and levels of HCV RNA. Eighty six (48%) patients showed steatosis, and a higher prevalence was observed in genotype 3a infection (P <.01). A correlation between the grade of steatosis and fibrosis was observed (P <.001). Fibrosis was also associated with age (P <.001). After adjusting for age, the association between steatosis and fibrosis remained significant. The grade of steatosis also correlated with the HAI (P <.007) with a significant increase in periportal necrosis. No relation was found between steatosis and age, gender, iron storage, or levels of HCV RNA. Patients with a high grade of steatosis (>30%) showed higher serum levels of gamma-GT and ALT (P <.001). Overall, steatosis was not significantly associated to BMI. Analysis by single genotype showed a significant association between the grade of steatosis and BMI in type 1 infection r =.689; P <.001) and with levels of HCV RNA in type 3a infection r =.786; P <.001). Visceral fat distribution rather than BMI proved to be associated with steatosis (P <.001). Data obtained from patients with a known date of infection confirmed that steatosis grades 3-4 were associated with a higher annual rate of fibrosis progression, and showed that alcohol and steatosis act together in increasing fibrosis (P <.05). Our data indicate that steatosis is an important cofactor in increasing liver necroinflammatory activity and in accelerating fibrosis in CHC. Visceral obesity and genotype 3a play a role in the development of steatosis.