Five waves of COVID-19 pandemic in Italy: results of a national survey evaluating the impact on activities related to arrhythmias, pacing, and electrophysiology promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

BACKGROUND

The subsequent waves of the COVID-19 pandemic in Italy had a major impact on cardiac care.

METHODS

A survey to evaluate the dynamic changes in arrhythmia care during the first five waves of COVID-19 in Italy (first: March-May 2020; second: October 2020-January 2021; third: February-May 2021; fourth: June-October 2021; fifth: November 2021-February 2022) was launched.

RESULTS

A total of 127 physicians from arrhythmia centers (34% of Italian centers) took part in the survey. As compared to 2019, a reduction in 40% of elective pacemaker (PM), defibrillators (ICD), and cardiac resynchronization devices (CRT) implantations, with a 70% reduction for ablations, was reported during the first wave, with a progressive and gradual return to pre-pandemic volumes, generally during the third-fourth waves, slower for ablations. For emergency procedures (PM, ICD, CRT, and ablations), recovery from the initial 10% decline occurred in most cases during the second wave, with some variability. However, acute care for atrial fibrillation, electrical cardioversions, and evaluations for syncope showed a prolonged reduction of activity. The number of patients with devices which started remote monitoring increased by 40% during the first wave, but then the adoption of remote monitoring declined.

CONCLUSIONS

The dramatic and profound derangement in arrhythmia management that characterized the first wave of the COVID-19 pandemic was followed by a progressive return to the volume of activities of the pre-pandemic periods, even if with different temporal dynamics and some heterogeneity. Remote monitoring was largely implemented during the first wave, but full implementation is needed.

Implantable defibrillator-detected heart failure status predicts ventricular tachyarrhythmias

Background

The occurrence of ventricular tachyarrhythmias is associated with increased mortality and hospitalizations for heart failure in implantable cardioverter defibrillator (ICD) patients. Nonetheless, the temporal relationship between heart failure worsening and ventricular tachyarrhythmias has been scarcely explored so far.

Purpose

We hypothesized that in patients with heart failure and reduced ejection fraction with ICDs, physiological sensor-based heart failure status, as reflected in the HeartLogic index, would predict appropriate device therapies for ventricular tachyarrhythmias (shocks and antitachycardia pacing).

Methods and results

568 patients implanted with ICDs (n=410, 72%) or cardiac resynchronization therapy-defibrillators (CRT-D, n=158, 28%) endowed with the HeartLogic algorithm were included in this prospective observational multicenter analysis. Over a follow-up of 25 [25th-75th percentile: 15–35] months, 122 (21%) patients received an appropriate device therapy (shock, n=74, 13%), while the HeartLogic index crossed the threshold value 1200 times (0.71 alerts/patient-year) in 370 subjects (65%). The occurrence of at least one HeartLogic alert was significantly associated with both appropriate shocks (HR: 2.44, 95% CI: 1.49–3.97, p=0.003) and any ICD therapies (HR: 1.95, 95% CI: 1.37–2.85, p=0.003). Using a time-dependent Cox model, the weekly IN-alert state was the strongest predictor of ICD shocks (HR: 2.94, 95% CI: 1.73–5.01, p<0.001), after correction for age, secondary prevention, and use of CRT. As compared to clinically stable subjects with no therapies, patients experiencing shocks had significantly higher baseline values of the HeartLogic index, third heart sound amplitude, and respiratory rate. Beginning about one month prior to the arrhythmic event, we noticed further increase of the combined index and the third heart sound amplitude, a decrease of thoracic impedance, and higher resting heart rate (Figure 1).

Conclusions

The HeartLogic index is an independent predictor of appropriate defibrillator therapies. The combined index and its individual physiological components change well before the arrhythmic event, suggesting the existence of a window of opportunity to prevent shocks.

Funding Acknowledgement

Type of funding sources: None.

Performance of a multisensor implantable defibrillator algorithm for HF monitoring in presence of comorbidities

Background

Cardiovascular and non-cardiovascular comorbidities are common in heart failure (HF) patients and impact disease severity and prognosis. Select modern implantable defibrillators (ICDs) are equipped with multisensor algorithms for HF monitoring. The HeartLogic index combines multiple ICD-based sensor data (heart rate, heart sounds, thoracic impedance, respiration, activity), and the associated alert has proved to be a sensitive and timely predictor of impending HF decompensation in cardiac resynchronization therapy (CRT-D) patients The algorithm was developed using data from CRT-D patients; the performance in non-CRT ICD patients and the impact of selected comorbidities on performance requires further study.

Methods

The HeartLogic feature was activated in 568 ICD patients (410 with CRT) from 26 centers. The median follow-up was 25 months [25th–75th percentile: 15–35].

Results

During follow-up, 97 hospitalizations were reported (53 cardiovascular) and 55 patients died. We recorded 1200 HeartLogic alerts (0.71 alerts/patient-year) in 370 patients. Overall, the time IN the alert state was 13% of the total observation period. The rate of cardiovascular hospitalizations or death was 0.48/patient-year (95% CI: 0.37–0.60) with the HeartLogic IN alert state and 0.04/patient-year (95% CI: 0.03–0.05) OUT of alert state, with an incidence rate ratio of 13.35 (95% CI: 8.83–20.51, p<0.001). Among patient characteristics, atrial fibrillation (AF) at implantation (HR: 1.62, 95% CI: 1.27–2.07, p<0.001) and chronic kidney disease (CKD) (HR: 1.53, 95% CI: 1.21–1.93, p<0.001) independently predicted alerts. HeartLogic alerts were not associated with CRT vs. non-CRT device implantation (HR: 1.03, 95% CI: 0.82–1.30, p=0.775). The comparisons of the clinical event rates in the IN alert state with those in the OUT of alert state yielded incidence rate ratios ranging from 9.72 to 14.54 (all p<0.001) in all groups of patients stratified by: CRT/non-CRT, AF/non-AF, CKD/non-CKD. Indeed, after multivariate correction for CKD and AF at implantation, the time IN the HeartLogic alert state >13% was associated with the occurrence of the combined endpoint of cardiovascular hospitalization or death (HR: 2.54, 95% CI: 1.61–4.01, p<0.001).

Conclusions

The burden of HeartLogic alerts appears similar between CRT and non-CRT patients, while patients with AF and CKD seem more exposed to alerts. Nonetheless, the ability of the HeartLogic algorithm to identify patients during periods of significantly increased risk of clinical events is confirmed regardless of the type of device, the presence of AF, or CKD.

Funding Acknowledgement

Type of funding sources: None.

Association between atrial fibrillation and cardiac implantable defibrillator detected heart failure status

Funding Acknowledgements

Type of funding sources: None.

Background

In heart failure (HF) patients, atrial fibrillation (AF) is a common comorbidity and is associated with a worse prognosis. Implantable defibrillator (ICD) diagnostics allow continuous monitoring of atrial high-rate events (AHRE), as a surrogate of AF, and are equipped with algorithms for HF monitoring. We evaluated the association between the values of the multisensor HF HeartLogic Index and the incidence of AF, and assessed the performance of the Index in detecting follow-up periods of significantly increased AF risk.

Methods

The HeartLogic feature was activated in 568 ICD patients. The median follow-up was 25 months [25th–75th percentile: 15-35]. The HeartLogic algorithm calculates a daily HF index and identifies periods IN the alert state on the basis of a configurable threshold. The endpoints were: daily AF burden of ≥5 minutes, ≥6 hours and ≥23 hours.

Results

The HeartLogic index crossed the threshold value 1200 times (0.71 alerts/patient-year). The time IN the alert state was 13% of the total observation period. During the observation period, an AF burden of ≥5 minutes/day was documented in 183 (32%) patients, ≥6 hours/day in 118 (21%) patients, and ≥23 hours/day in 89 (16%). On using a time-dependent Cox model, the weekly time IN the alert state was independently associated with an AF burden of ≥5 minutes/day (HR:1.95, 95%CI:1.22-3.13, p=0.005), ≥6 hours/day (HR:2.66, 95%CI:1.60-4.44, p<0.001), and ≥23 hours/day (HR:3.32, 95%CI:1.83-6.02, p<0.001), after correction for baseline confounders. Comparison of the episode rates in the IN-alert state with those in the OUT-of-alert state yielded HRs ranging from 1.57 to 3.11 for AF burden from ≥5 minutes to ≥23 hours.

Conclusions

The HeartLogic alert state was independently associated with AF occurrence. The intervals of time defined by the algorithm as periods of increased risk of HF allow risk stratification of AF according to various thresholds of daily burden.

Predictors of heart failure events detected by a multisensor implantable defibrillator algorithm

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiovascular and non-cardiovascular comorbidities are common in heart failure (HF) patients and determine disease severity and prognosis. Select modern implantable defibrillators (ICDs) are equipped with multisensor algorithms for HF monitoring. The HeartLogic index combines multiple ICD-based sensor data (heart rate, heart sounds, thoracic impedance, respiration, activity), and the associated alert has proved to be a sensitive and timely predictor of impending HF decompensation in cardiac resynchronization therapy (CRT) patients.

Purpose

This analysis aims to investigate the performance of the algorithm in non-CRT patients, as well as in relation to the presence of comorbidities.

Methods

The HeartLogic feature was activated in 568 ICD patients (410 with CRT) from 26 centers. The median follow-up was 25 months [25th–75th percentile: 15-35].

Results

We recorded 1200 HeartLogic alerts (0.71 alerts per patient-year) in 370 patients. Among patient characteristics, atrial fibrillation (AF) at implantation (HR: 1.62, 95%CI: 1.27-2.07, p<0.001) and chronic kidney disease (CKD) (HR: 1.53, 95%CI: 1.21-1.93, p<0.001) independently predicted alerts. HeartLogic alerts were not associated with CRT vs. non-CRT device implantation (HR: 1.03, 95%CI: 0.82-1.30, p=0.775). Comparing the combined index and all physiologic parameters during clinically stable periods we did not notice differences between CRT and non-CRT patients. Thoracic impedance was significantly lower in CKD than non-CKD patients. (46±11ohm versus 49±10ohm; p=0.047). We found a higher S3 amplitude (0.9±0.3mG versus 0.8±0.2mG; p=0.005) and nocturnal heart rate (72±9bpm versus 66±7bpm; p<0.001), and lower S1 amplitude (2.0±0.8mG versus 2.4±0.9mG; p<0.001) in AF patients vs non-AF. These differences persisted at the time of alerts (all p<0.05). In the overall population, and in patients stratified by device type, CKD and AF, we measured significant changes of all contributing sensors (paired t-test; p<0.05) from clinically stable periods to the time of alert.

Conclusions

The burden of HeartLogic alerts appears similar between CRT and non-CRT patients, while patients with AF and CKD seem more exposed to alerts. ICD-measured thoracic impedance is sensitive to the fluid overload that characterizes kidney disease, as well as the first and third heart sound amplitudes seem sensitive to the reduced ventricular efficiency during AF. Nonetheless, ICD sensors seem to equally contribute to the HeartLogic alerts in all patient subgroups.

P175 ELECTROCARDIOGRAPHIC ELEMENTS ASSOCIATED WITH ARRHYTHMIC RISK IN BRUGADA SYNDROME

Introduction

Brugada syndrome is an inherited disease characterized by an increased arrhythmic risk and sudden death. The type 1 ECG pattern is the only standard required to make a diagnosis but the stratification of arrhythmic risk remains a controversial element. Some electrocardiographic signs have been described as associated with an increased arrhythmic risk. We present a case of Brugada Syndrome in which different electrocardiographic elements of incremental risk could have predicted the later evolution of the clinical case.

Clinical Case

A 68–year–old male patient with family history of sudden cardiac death (brother 51aa) and occasional finding of Brugada type 1 ECG pattern (2009), implanted with Medtronic bicameral ICD device in primary prevention. The electrocardiogram shows type 1 Brugada pattern in the right precordials with characteristic ST–elevation, followed by a concave ST segment, one of the signs of association with an increased arrhythmic risk; first–degree AV block with a long PR (323 msec) associated with the presence of the SCN5A mutation and an increased risk of arrhythmic events and sudden cardiac death; in the end a fragmented QRS in V2 with extended duration (153 ms). At the next follow–up the patient had some episodes of arrhythmic storm, effectively treated by the device; in consideration of the arrhythmic burden, he was subjected to epicardial ablation and was also subjected to genetic analysis that was positive for pathological mutation on the SCN5A gene (SCN5A ex 22: c.3929C>T;p.Pro1310Leu).

Conclusions

Brugada Syndrome can be diagnosed from the type 1 ECG pattern, but the current risk stratification score remains a controversial element. Electrocardiographic signs of malignancy can contribute to create a multiparametric evaluation of the patient in order to predict future arrhythmic events. Fig 1. ECG: RS 74 bpm, first–degree AV block (PR 323 msec), BFA, Brugada type 1 pattern (QRS 153 ms), fragmented QRS in V2. Fig. 2 Family tree.

P379 CARDIAC CONDUCTION DISEASE IN YOUNG PEOPLE: DON‘T FORGET THE GENES

Introduction

Heart rhythm disorders in young individuals are often associated with mutations in genes encoding ion channels. A frequently encountered mutation is in the SCN5A gene, which encodes the alpha subunit of the sodium channel. Mutations in this gene can be expressed through a wide spectrum of phenotypic manifestations including rhythm disturbances, structural cardiac changes and/or overlap syndromes (long/short QT syndrome, Brugada syndrome, sinus node syndrome, progressive cardiac conduction disorder, dilated cardiomyopathy and arrhythmogenic cardiomyopathy).

Case Report

23–year–old boy with no relevant history. During the induction of anaesthesia for a surgical intervention of nasal polyposis, episodes of asystole with a maximum duration of about 6 seconds were documented. During the hospital stay, a syncopal episode followed, with electrocardiographic monitoring showing a sinus arrest of approximately 16 seconds (Fig. 1). Echocardiography and cardiac resonance ruled out the presence of structural alterations. In view of the documented bradyarrhythmia, the clinical findings and the absence of secondary causes, a dual–chamber pacemaker implant was performed. The patient was subsequently admitted for ectopic atrial tachycardia (Fig. 2) symptomatic for heart palpitations, treated with medical therapy. After careful reconstruction of the family tree (Fig. 3), a positive family history of bradyarrhythmias emerged (grandfather and sister of the paternal grandfather were pacemaker carriers). A blood sample was taken for genetic analysis and a mutation in the SCN5A gene (ex28 c5207 A>G) was detected. The genetic study was extended to first–degree relatives (still in progress). During follow–up visits the patient reported subjective well–being and at pacemaker interrogation evidence of 29% atrial pacing, in the absence of ventricular pacing.

Conclusions

When faced with a young patient with a conduction disorder, once possible secondary causes have been excluded, genetic analysis should be included in routine examinations because it helps to define an adequate clinical–instrumental follow–up and to identify, at an early stage, the possible progression of the disease and/or the onset of concomitant structural heart disease. Family genetic screening is also essential in order to identify patients at risk of developing the disease.

P18 ATRIAL FIBRILLATION IN BETA–THALASSAEMIA: PHYSIOPATHOLOGY AND CLINICAL MANAGEMENT

Beta–thalassaemia is an inherited blood disorder with worldwide distribution characterized by a defective synthesis of haemoglobin. Transfusions and iron–chelation therapy have radically improved the prognosis of beta–thalassaemic patients, while also allowing the development of new chronic complications, cardiac and non–cardiac (diabetes, dystyroidism, autonomic disorders and many others), among which atrial fibrillation (AF) stands out. Prevalence of AF in patients with beta–thalassemia is dramatically higher than in general population, ranging from 2 to 33%. Studies on this topic are lacking and the scarse available evidence comes from a few observational studies. The underlying pathophysiology of AF in thalassaemic is not yet well understood; responsible mechanisms are many (Figure 1) and different from those recognized in general population. Atrial iron overload appears to be the main “risk factor”, although this arrhythmia may develop even before cardiac siderosis. Clinical presentation is early and mainly paroxysmal, and patients are highly symptomatic. Furthermore, the numerous treatments available for AF (pharmacological and interventional), extensively studied in the general population, are largely unexplored in beta–thalassemia. A specific management is required for these patients (Figure 2); in particular, rhythm control should be preferred over rate control, and the most important antiarrhythmic therapy resides in iron–chelating drugs. Thromboembolic risk is also higher than in the general population and the choice of anticoagulant therapy should be considered early (well pondering the serious consequences of a haemorrhage in this setting), but the risk scores available for patients with AF are not validated in the beta–thalassemia.

P384 SUDDEN CARDIAC ARREST: LET’S LOOK BEYOND CORONAROPATHY

Introduction

Sudden cardiac arrest (SCA) is a high mortality event. Up to 70% of SCAs are caused by an acute coronary syndrome; nevertheless, it is essential to consider also non–ischemic causes while evaluating a post–SCA patient.

Clinical Case

A 68–year–old male patient with history of hypertension and dyslipidemia, presenting to the emergency room (ER) for syncope. While waiting in the ER, another sincopal episode happened and ventricular fibrillation was detected, therefore he was treated with a DC shock. At the ECG record after SCA, any acute alteration was seen. At the blood tests, an early rise of myocardial injury markers was found. At bedside echocardiography, a slight apical hypokinesia with hypertrabeculation was reported. Hence, coronarography was performed and a multivasal ateromasic coronaropathy was treated with angioplasty and drug–eluting stenting of left main artery, left anterior descending artery and left circumflex artery. In the following days, other ventricular tachyarrhythmias episodes happened and were treated with DC shocks. Due to ventricular arrhythmias relapses and echocardiographic findings, a cardiac MRI was performed, showing subepicardial fatty infiltration in the mid–apical lateral wall with parietal bulging suggesting left ventricle arrhythmogenic cardiomyopathy. So, a cardiac defibrillator was implanted in secondary prevention. Genetic analysis was run and reported a VUS mutation on RYR2 gene, still under evaluation as a possible cause for the clinical events.

Conclusions

The present clinical case shows that many causes may lead to SCA. Our patient experienced syncopal episodes related to ventricular arrhythmias and an arrhythmic storm which were most likely caused by an ischemic event on the base of an undiagnosed left ventricle arrhythmogenic cardiomyopathy.

P1 ATRIAL TACHYCARDIA IN PATIENT WITH TRANSFUSION–DEPENDENT BETA THALASSEMIA AND SEVERE HEMOCHROMATOSIS: A CASE REPORT

Background

Beta thalassemia is the most common inherited disease and it’s characterized by the reduced synthesis of the beta–globin chains of the hemoglobin. Patients usually need long life transfusions since the disease leads to chronic hemolytic anemia. Iron chelation therapy is essential to prevent the chronic iron overload, which is responsible for heart failure, supraventricular and ventricular arrhythmias up to sudden cardiac death.

Case Report

A 31 year old female patient suffering from transfusion–dependent beta thalassemia has rarely taken iron chelation therapy during the years. Because of that, she developed a severe iron overload and heart failure. Furthermore, she started suffering from several episodes of supraventricular tachycardia and she was referred to our cardiological institution for medical help. She was initially treated with a pharmacological rhythm control strategy, which was ineffective. Then, even if the cardiac iron overload wasn’t completely resolved, we decided to perform an electrophysiological study and catheter ablation of atrial tachycardia. After the ablation, the patient had no more relapses during the follow up and she started to be more adherent with the iron chelation therapy.

Discussion

Cardiovascular complications are among the main causes of morbidity and mortality in patients suffering from beta thalassemia. Despite the wide use of iron–chelation therapy, today it’s still possible to find patients with severe iron overload. Furthermore, thalassemic patients have a high arrhythmic burden, especially for supraventricular arrhythmias. The best rhythm control treatment is represented by iron chelation therapy but there are still many doubts and open questions about the optimal pharmacological and interventional strategy. This clinical case shows how the interventional approach with catheter ablation can be an useful tool for rhythm control during the acute phase, even when the cardiac iron overload is still present.

Look at me while having sex! Eye-to-eye contact affects homosexual behaviour in bonobo females

In humans, eye-to-eye contact (EEC) or mutual gazing is a reflexive predisposition occurring in intimate contexts. We investigated the role of EEC during bonobo socio-sexual contacts. Females engage in homosexual ventro-ventral, genito-genital rubbing (VVGGR) during which they embrace each other while rubbing part of their vulvae and, sometimes, clitoris. VVGGR facilitates conflict resolution, anxiety reduction and social bonding. We found that EEC was negatively affected by female bonding: the more the eye contact, the weaker the social relationship. This suggests that EEC promotes an intimate contact between the more unfamiliar subjects. Moreover, VVGGRs were successfully prolonged in presence of at least one event of EEC compared to VVGGRs during which none of the partners looked towards the other or only one looked at the other’s face. EEC has been probably favoured by natural selection to enhance the cohesion between bonobo females, who can gain social power through socio-sexual contacts.

Predictors of infection after "de novo" cardiac electronic device implantation

BACKGROUND

Cardiac implantable electronic device (CIED) infection is a major complication that increases morbidity and mortality after the procedure. Several infection risk scores have been suggested to identify patients at higher pre-procedural risk of infection OBJECTIVE: this study sought to evaluate rates of infection, potential risk factors and the role of a modified "Shariff" score as predictor of infection in high-risk patients undergoing de novo CIED implantation.

METHODS AND RESULTS

We retrospectively analysed 1391 patients underwent a de novo CIED procedure during the study period. At the median follow-up of 48 months, 20 patients of 1391 (1.4%) developed a CIED-related infective event. In our population, we studied a modified version of the "Shariff" score for only first-time implant patients. At multivariate regression analysis, three factors were independent predictors of infection: previous pocket hematoma [RR 27.2 (8.30-54.02), p = 10^-10], a Shariff Score ≥ 4 [RR 3.20 (1.29-12.59), p= 0.029]. and reintervention for catheter malfunction or dislocation [RR 3.57 (1.2-37.4), p= 0.048].

CONCLUSIONS

a "Shariff" score > 4 is suggested as a predictor of higher risk of infection in patients after de novo device implantation. The use of an infection risk score may help to improve tailored pre-operatory strategies to prevent infection.

P538Single- and Multi-Site Pacing Strategies for Optimal Cardiac Resynchronization Therapy: Impact on Device Longevity and Therapy Cost

Funding Acknowledgements

No funding

Introduction

Multiple left ventricular pacing strategies have been suggested for improving response to cardiac resynchronization therapy (CRT). However, these programming strategies can be obtained by accepting configurations with high pacing threshold and accelerated battery drain. We assessed the feasibility of predefined pacing programming protocols and we evaluated their impact on device longevity and their cost-impact.

Methods

We estimated battery longevity in 167 CRT-D (RESONATE, Boston Scientific) patients based on measured pacing parameters and according to multiple programming strategies: single-site pacing associated with lowest threshold, non-apical location, longest interventricular delay, pacing from two electrodes. To determine the economic impact of each programming strategy, we applied the results of a published model-based cost analysis to a 15-year time-horizon.

Results

Selecting the electrode with the lowest threshold resulted in a median device longevity of 11.5 years. Non-apical pacing and interventricular delay maximization were feasible in most patients (99% non-apical pacing, 65% RV-to-LV interval >80ms), and were obtained at the price of a few months of battery life. Device longevity of >10 years was preserved in 87% of cases of non-apical pacing and in 77% on pacing at the longest interventricular delay. The mean reduction in battery life when the second electrode was activated was 1.5 years. Single-site pacing strategies increased the therapy cost by 4-6%, and multi-site pacing by 12-13%, in comparison with the best-case scenario.

Conclusions

Modern CRT-D systems ensure effective pacing and allow multiple optimization strategies for maximizing service life or for enhancing effectiveness. Single- or multi-site pacing strategies can be implemented without compromising device service life and at an acceptable increase in therapy cost.

Abstract Figure. Image1

P2871Attenuated clinical benefit after ICD replacement over long term follow-up in a contemporary large world population: insight to the DECODE registry

Background

Cardiac Implantable Electronic Device (CIED) surgery is threatened by serious complications both during the procedure and during follow-up. The factors associated to attenuated clinical benefit over long term follow-up are poorly understood.

Purpose

To evaluate type and extent of Adverse Events (AEs) and potential predictors of major AEs over 12 months after ICD/CRT-D replacement/upgrade in a contemporary Italian population.

Methods

Detect long-term complications after ICD replacement (DECODE) was a prospective, single-arm, multicenter cohort study aimed at estimating medium- to long-term complications in a large population of patients (pts) who underwent ICD/CRT-D replacement/upgrade from 2013 to 2015. The endpoint for this analysis is death from any cause, procedure-related infection, and surgical actions/hospitalizations necessary to treat the AEs.

Results

We included 983 consecutive pts (median age 71 years, 76% male, 55% ischemic, 47% CRT-D). During a mean follow-up duration of 353±49 days, 7% of the pts died. A total of 104 AEs occurred in 70 (7.1%) pts. 43 (4.4%) pts needed at least one surgical action to treat the AEs. A total of 23 (2.3%) pts had infective AEs (CIED related in 12 pts, due to other causes in 11). Mortality was unrelated to the occurrence of overall AEs, or of CIED-related AEs, or of surgical actions/hospitalizations needed to correct AEs. The endpoint was reached by 109 (11%) pts over 12-month follow-up (97 pts had a single event, and 12 pts had two events). The median time to the endpoint was 137 [50 - 254] days. On multivariate Cox regression analysis adjusted for baseline confounders, ischemic cardiomyopathy (HR = 1.86, 95% CI: 1.18 to 2.91; p=0.0076), hospitalization prior to the procedure (2.34, 1.35 to 4.05; 0.0025) and anticoagulation (1.91, 1.25 to 2.92; 0.0032) were associated with the endpoint during follow-up.

Conclusion

Evaluation of the patient's profile may assist in predicting vulnerability and should prompt reconsideration of the procedure by deferring at a more stable clinical status, and carefully individualized in the setting of upgrades and anticoagulation management

Acknowledgement/Funding

None

Lights and shadows about health claims: analysis of food labels in a field survey in Florence

BACKGROUND

Health claims (HC) are those statements on food labels that state, suggest, or imply that a relationship exists between a food category, a food product, or one of its constituents, and health of consumer. The European legislation on the use of HC aims to encourage responsible consumption by people. The aim of this study is to assess the adherence of HC to EU norms in foodstuffs sold in the large-scale retail distribution in Florence.

METHODS

Two independent researchers have separately selected and assessed the foodstuffs with HC sold in at least two of four supermarkets identified randomly in Florence. Each selected product was assessed by a checklist with seven macro-criteria, extrapolated from the 'Specific Conditions' and 'Restrictions of Use' provided by EU regulations, rating the adherence of the chosen foods to the legislation.

RESULTS

Seventy-seven products were assessed. Only a limited number of products show full compliance to all the criteria. Specifically, noncompliance related to Criterion 3 ("the amount of the food and pattern of consumption required to obtain the claimed beneficial effect are reported") is the most significant: the absence of indications about the maximum amount to be consumed or the modality of consumption could represent a risk of overconsumption and, consequently, a risk for health.

CONCLUSION

According to the results, we hypothesize a lack of knowledge of the EU norms on the part of the manufacturer. A great deal of work is still to be done to assess and manage these products in the right way, as well as to communicate the right messages to the consumers.

Insomnia is Associated with Systolic Hypertension in Uremic Patients on Hemodialysis

A newly developed questionnaire was administered to 140 hemodialyzed patients (82 M and 58 F) who have achieved adequate anemia correction according to the best guidelines with the aim: to evaluate the prevalence of clinical/subclinical dyssomnias in these patients; to study the influence of the dialytic shift (morning versus afternoon schedules) on sleep duration and disturbancies; and to evaluate the relationship between clinical sleep disorders and blood pressure values in uremic patients. Results indicated that 85% of uremic patients undergoing hemodialysis complain of clinical insomnia (frequent, persistent and associated with daytime consequences) or subclinical sleep disorders; patients dialyzing in the morning sleep significantly less during the night preceding the treatment, than those dialyzing in the afternoon; older patients complaining of clinical insomnia have a higher risk of failure to achieve target-optimal values in systolic blood pressure.

Use of robotic colonoscopy in patients with previous incomplete colonoscopy

OBJECTIVE

Conventional colonoscopy (CC) is the gold standard to diagnostic and therapeutic approach to colon. However, in few cases, cecal intubation could fail due to colon anatomy, patient compliance and physician expertise. Endotics robotic colonoscopy is a novel, safe, mini-invasive modality to explore the entire colon. Our aim was to assess, in a retrospective study, Endotics ability of cecal intubation in all cases in which CC failed.

PATIENTS AND METHODS

Between January 2008 and December 2012, 276 Endotics robotic colonscopy examinations were performed at the Gastroenterology and Metabolic Diseases Unit of Pisa University Hospital, Pisa, Italy, in a series of consecutive patients who had undergone CC and failed cecal intubation.

RESULTS

We assessed the cecal intubation rate in 102 patients addressed to Endotics after previous incomplete CC. Overall, endotics system was successful in 93.1% of the incomplete conventional colonoscopy cases (95% performance).

CONCLUSIONS

Whenever the intended exploration of the entire colon with CC failed, the endotics robotic endoscopy represented a useful tool as it helped examine the entire colon in almost all cases.

An update on atrial fibrillation in 2014: From pathophysiology to treatment

Atrial fibrillation (AF) is the most frequently encountered cardiac arrhythmia. The trigger for initiation of AF is generally an enhanced vulnerability of pulmonary vein cardiomyocyte sleeves to either focal or re-entrant activity. The maintenance of AF is based on a "driver" mechanism in a vulnerable substrate. Cardiac mapping technology is providing further insight into these extremely dynamic processes. AF can lead to electrophysiological and structural remodelling, thereby promoting the condition. The management includes prevention of stroke by oral anticoagulation or left atrial appendage (LAA) occlusion, upstream therapy of concomitant conditions, and symptomatic improvement using rate control and/or rhythm control. Nonpharmacological strategies include electrical cardioversion and catheter ablation. There are substantial geographical variations in the management of AF, though European data indicate that 80% of patients receive adequate anticoagulation and 79% adequate rate control. High rates of morbidity and mortality weigh against perceived difficulties in management. Clinical research and growing experience are helping refine clinical indications and provide better technical approaches. Active research in cardiac electrophysiology is producing new antiarrhythmic agents that are reaching the experimental clinical arena, inhibiting novel ion channels. Future research should give better understanding of the underlying aetiology of AF and identification of drug targets, to help the move toward patient-specific therapy.

Psychoneuroimmunology and health psychology: inflammation and protective factors

A common clinical observation is the adverse relationship between stress and human diseases. The attention of scientific research on health has been disproportionately focused on risk factors that predict the onset of certain health outcomes, in particular there has been an increasing interest in the role of inflammation as a common mechanism of disease in a number of medical and neuropsychiatric diseases. Despite the importance of such research being undisputed, it is necessary to emphasize what the protective factors are that promote psychosocial recovery processes and increased survival rates in a biopsychosocial perspective. This article aims to understand the relationship between psychosocial factors and immune system in the interests of health psychology, highlighting the protective factors that promote recovery, resiliency and resistance to disease.

Aminaphtone in the treatment of pseudophakic cystoid macular edema: a case report

PURPOSE

Cystoid macular edema (CME) following cataract surgery has been recognized for over 50 years as an important cause of suboptimal post-operative vision. The incidence of CME varies widely, but is likely in the range of 1-2% using modern cataract extraction techniques. We report the case of resolution of post-operative CME after treatment with aminaphtone 75 mg three time a day for one month.

METHODS

A 74-year-old causasian woman presented with reduced vision in the left eye after one month from uneventful cataract phacoemulsification. She underwent a complete ophthalmological examination comprehensive of spectral domain optical coherence tomography (SD-OCT) which showed CME and a central foveal thickness (CFT) of 703 micron. The patient was treated with aminaphtone for one month.

RESULTS

CME disappeared, the CFT was within normal limits when aminaphtone was ceased, and best corrected visual acuity was 20/20 at the end of the treatment.

CONCLUSION

Aminaphtone is a novel proposal in the treatment of pseudophakic cystoid macular edema.

Echocardiography and non-invasive imaging in cardiac resynchronization therapy

The beneficial effects of cardiac resynchronization therapy (CRT) on morbidity and mortality in advanced heart failure patients have been extensively demonstrated. However, previous single- and multicenter studies demonstrated that approximately 30-40% of CRT patients do not show significant clinical improvement or LV reverse remodeling despite fulfilling current inclusion criteria. In search of novel indices that may help to improve the selection of responders to CRT, non-invasive multimodality imaging has provided further insight into the mechanisms underlying CRT response. LV dyssynchrony, extent and location of myocardial scar and LV lead position have shown to be independent determinants of CRT response. An integrated evaluation of these three pathophysiological mechanisms may provide a more accurate selection of heart failure patients who will benefit from CRT and may maximize the cost-effectiveness of this therapy. The present review article provides a critical appraisal of the role of multimodality imaging in the selection of heart failure patients who are candidates for CRT with special focus on the assessment of LV mechanical dyssynchrony, LV myocardial scar tissue extent and LV lead position.

Advanced applications of 3-dimensional echocardiography

Over the last few decades, advancements in ultrasound, electronic and computing technologies have permitted current second generation 3-dimensional (3D) echocardiography to display on-line 3D rendered images of the heart. Since various studies demonstrated its superiority over 2-dimensional echocardiography, there is growing enthusiasm to embrace this new 3D echocardiographic technology. With its increasing widespread clinical availability, 3D echocardiography is getting closer to routine clinical use. However, as with any new emerging technologies, clinical applications of 3D echocardiography should be based on current evidence. This review will focus on the evidence from clinical studies that form the scientific basis for the advanced applications of 3D echocardiography, from cardiac chamber volume assessments, left ventricular dyssynchrony assessments, quantifications of valvular abnormalities, to the role of 3D echocardiography during cardiac interventions.

Long term results of a randomized study performed by Intergruppo Italiano Linfomi comparing Mini-CEOP vs P-VEBEC in elderly patients with diffuse large B-cell lymphoma

The Intergruppo Italiano Linfomi started, in 1996, a randomized trial for the initial treatment of elderly patients (older than 65 years) with Diffuse Large B-Cell Lymphoma (B-DLCL) comparing 6 courses of Mini-CEOP vs 8 weeks of P-VEBEC chemotherapy. Study objectives were survival, response and Quality of Life (QoL). Two hundred and thirty-two patients were evaluable for final analysis. Complete Response (CR) and Overall Response Rates (ORR) were 54% vs 66% (p = 0.107) and 90% vs 78% (p = 0.021) for P-VEBEC and Mini-CEOP, respectively. With a median follow-up of 72 months, the 5-year Overall Survival (OS), Relapse Free Survival (RFS), and Failure Free Survival (FFS) were 32%, 52%, and 21%, respectively. Subjects achieving a CR showed improvement of QoL regardless of treatment arm. Both Mini-CEOP and P-VEBEC determined a similar outcome for elderly patients with B-DLCL, with a third of patients alive after more than 6 years of follow-up. Both regimens can be considered equally for combination treatment with anti-CD20 monoclonal antibody.

Expenditure and value for money: the challenge of implantable cardioverter defibrillators

Many technology-driven interventions entail considerable financial cost, raising affordability issues. The implantable cardioverter defibrillator (ICD) is a case of an effective primary prevention intervention with high initial costs that is capable of delivering long-term population benefits. At first glance, such interventions may provoke diffidence, if not active resistance, due to the financial burdens which inevitably accompany their widespread adoption. In this article, we review the available economic tools that can help address the ICD cost issue. We think awareness of such knowledge may facilitate dialogues between physicians, administrators and policymakers, and help foster rational decision-making.

Efficacy of a combination of human recombinant erythropoietin + 13-cis-retinoic acid and dihydroxylated vitamin D3 to improve moderate to severe anaemia in low/intermediate risk myelodysplastic syndromes

The efficacy of human recombinant erythropoietin (rEPO) in myelodysplastic syndromes (MDS) has generally been best in untransfused patients with 'refractory anaemia' according to the World Health Organization (WHO). We treated 63 MDS patients [excluding refractory anaemia with excess blasts, type 2 (RAEB2)] with a previously tested combination of 13-cis-retinoic acid and dihydroxylated vitamin D3 +/- 6-thioguanine in addition to rEPO. Most patients were categorized as refractory cytopenia with multilineage dysplasia and RAEB1, with intermediate 1 International Prognostic Scoring System (IPSS) score; all had Hb <95 g/l, and 70% required regular erythrocyte transfusions. Treatment was well tolerated, and erythroid response rate according to new International Working Group criteria was 60%: 50% in RAEB1 and 64% in non-RAEB patients (P = 0.383). Response rate was not affected by transfusion requirement (63%; 58% in untransfused), IPSS and WHO Prognostic Scoring System scores, and weekly rEPO dosage (30-50 000 U vs. 80 000 U). Median response duration was 16 months. Median survival reached 14 months for RAEB1 and 55 months for non-RAEB patients, with a significant difference in the latter between responders and non-responders (median 82 months vs. 44 months; P = 0.036). Our combined therapy, independent of rEPO dosage, achieved in patients with unfavourable response predictors, a rate of anaemia improvement comparable to the best obtained in lower risk patients by high-dose rEPO.