Introduction
Cognitive complaints and psychological distress are common in oncologic patients, in particular many studies have focused on women with breast cancer.Patients presenting the phenomenon ...of “chemofog” show changes after chemotherapy with regard to memory and emotional regulaiton.
Objectives
To explore brain connectivity prior to chemotherapy that nevertheless,is understudied.
Methods
We used fMRI to investigate the resting state connectivity in 24 patients before chemotherapy and 15 controls.Patients were assessed with self-administered questionnaires,such as the Patient’s Assessment of Own Functioning Inventory (PAOFI) that quantifies the decrease in perceived functioning in memory, language and problem solving (Image 1).We used a preliminary structural analysis in order to choose which neuropsychological test was affected in correlation with a significant anatomical volume alteration,as showed in the p-value table.Therefore, patients were ranked and divided into two group of “Impaired vs Preserved”, measured using the median of the questionnaire results.Higher scores indicate a poor cognitive self-perceived performance.
Results
Connectivity was altered in amygdala and hippocampus, in the subgroup of patients with higher subjective cognitive complaints i.e with a high PAOFI Memory score.More specifically, we found an association between memory impairment and the increase of the resting state connectivity of both right structures, as opposed to a reduction in left amygdala (Image 3).
Conclusions
These findings may suggest a potential effect on brain functional connectivity of the psychological awareness and stress of cancer itself. We found connectivity alterations for both amygdala and hippocampus, two structures belonging to the limbic system, that is involved in the interplay between cognition and emotions, such as anxiety and fear.
Malnutrition is a major negative prognostic factor in dialysis patients. Simple and reliable estimations of nutritional status may therefore prove of particular value in the follow-up of these ...patients. To validate subjective global assessment (SGA) in dialysis patients we compared subjective global assessment with objective measurements (anthropometry, bioelectrical impedance, biochemical measurements) in 59 chronic uraemic patients treated by haemodialysis (n = 36) or CAPD (n = 23). Subjective global assessment was performed by an observer unaware of the results of objective measurements and was related to serum albumin (r = -0.51, P < 0.001) and bioelectric impedance phase angle (r = -0.58, P < 0.001) as well as with MAMC (r = -0.28 P = 0.028), %fat (r = -0.27, P = 0.042) and nPCR (r = -0.29 P = 0.027). Multiple regression analysis showed that the relationship of subjective global assessment (as a dependent variable) with objective measurements (covariates) was stronger (multiple r = 0.77) than the relationship found with univariate analysis. This finding indicates that subjective global assessment gives a well-based and balanced estimation of nutritional status. Our data show that subjective global assessment is a clinically adequate method for assessing nutritional status in dialysis patients. Being an inexpensive method of well-proven reliability, subjective global assessment can be recommended for a more frequent assessment of nutritional status in dialysis patients.
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Previous studies have demonstrated that cardiac biomarkers elevate after both cryoballoon (CB) and radiofrequency atrial ...fibrillation (AF) ablation, depending on the amount of energy delivered and the site of ablation. To date no comparison has been made between these thermal energy source and a novel non-thermal pulsed-field ablation (PFA) technology based on cells electroporation.
Purpose
Our analysis aims to compare acute myocardial injury through cardiac troponin I variation after pulmonary vein isolation (PVI) performed with different technologies (PFA vs CB).
Methods
All consecutive patients undergoing paroxysmal AF ablation with CB and PFA at our center from July to November 2022 were included. Protocol-directed cryoablation (CBA) was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation was not available. A standard PFA protocol-directed PVI was applied using 2kV with eight applications per vein (four applications each in the basket and flower poses). The ablation endpoint was PVI as assessed by entrance and exit block. Pre- and post-procedure samples of cardiac troponin I (CTpI) were collected before CBA/PFA and at 24h after ablation. Only patients with normal baseline values for myocardial injury were included.
Results
A total of 71 patients met inclusion criteria and were included in this analysis. The CBA group consists of 50 (70%) patients and the PFA group comprises 21 (30%) patients. The number of CBA applications to reach PVI was 5.0±1.4 and the number of PFA applications to achieve PVI was 32±4. All (100%) patients were in sinus rhythm at the time of the procedure. Evaluating the kinetic of CTpI, baseline values were homogeneous between CBA and PFA groups (p=0.979) whereas CTpI values significantly rose from baseline (7±2 ng/L) to 24h (8979±3691 ng/L, p<0.0001) and were significantly different between groups after CBA/PFA (8148±3311 ng/L for CBA vs 11900±7143 ng/L for PFA, p=0.0056). PVI was achieved in all patients (100%) using only CB or PFA. No major procedure-related adverse events were reported.
Conclusion
Our preliminary results showed that cardiac troponin I enzyme level increased after PVI by means of both cryoballoon and pulsed-field ablation and were higher after cellular electroporation by PFA than cryoablation.
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Pulsed-field ablation (PFA) is a new non-thermal, tissue-specific ablation technique. Through the application of a local ...electric field, it is possible to induce a selective electroporation of cardiomyocytes membranes, resulting in myocytic apoptosis and sparing of non-myocardial structures (nerves, connective tissue, esophagus, vessels).
Purpose
A new PFA system for atrial fibrillation (AF) ablation has recently been introduced in our hospital. The aim of this retrospective review is to share the initial results of our experience in terms of acute efficacy and safety.
Methods
A total of 41 adult patients suitable for AF percutaneous ablation underwent PFA between April and November 2022 in our Institute. PFA system consisted of a current generator, a deflectable sheath and a multielectrode PFA catheter. Once inside the left atrium (LA), the PFA catheter was directed to the pulmonary veins (PVs) ostia through an over-the-wire system. Then, 8 electric impulses were applied for each PV to achieve electrical isolation; in some cases, applications to the posterior left atrium wall (LAPW) were delivered to obtain LAPW isolation (LAPWI). A moderate-to-deep sedation was provided by an anesthesiologist during all the procedures. Acute ablation efficacy was defined as absence of intracavitary signals at the electroanatomic mapping and local capture failure at the pacing maneuvers. Intra and peri-procedural safety was defined as the absence of major complications (pericardial effusion/ tamponade, stroke, vascular complications, death) during the procedure and the hospitalization period.
Results
Of the 41 patients included, 24 (58.5%) were treated for paroxysmal AF and 17 (41.5%) for persistent AF. In almost all cases (n=40, 97.6%) pulmonary veins isolation (PVI) was performed; in 14 cases (34.1%, almost all persistent AF patients) a LAPWI was performed with the application of a variable number of pulses (mean value = 13). In most of the cases (n=28, 68.3%) an electroanatomic mapping was acquired before and after the ablation. Acute efficacy was observed in all PVI cases (n=40, 100%) and in all LAPWI cases (n=14, 100%).
No periprocedural major complications were observed (n=0, 0%).
Conclusions
PFA is a promising ablation technique capable of inducing selective myocytic apoptosis through electroporation, causing a thick damage across the muscle with no injury of other tissues, and could become a game changer in electrophysiology in the next future.
Our initial data report a combination of ease of use and high efficacy and safety profiles.
PVs and LAPW isolation after PFA
PVs isolation after PFA
Abstract
Background
Left-dominant arrhythmogenic cardiomyopathy (LDACM) represents an underdiagnosed subtype of the classical right-dominant ACM, with a fibro-fatty infiltration of the left ventricle ...ab disease initio. To date, ACM diagnosing criteria do not include any paradigm for LDACM and no shared consensus or position statement has been issued yet.
Purpose
To analyse the diagnostic work-up needed to reach a definite diagnosis in LDACM patients (pts).
Methods
All pts with a high clinical suspicion of ACM admitted at our institution were evaluated. Disease and familiar history, and both baseline ECG and cardiac ultrasound (US) were retrieved in all pts. Before invasive evaluation, all pts underwent cardiac magnetic resonance imaging (MRI) for morphology assessment and tissue characterization by late gadolinium enhancement (LGE). An invasive evaluation with an electrophysiological study (EPS) and an endo-cavitary electro-anatomical mapping (EAM) was then subsequently performed; EAM-guided endo-myocardial biopsy (EMB) was performed at physician discretion, for direct histological evaluation of myocardial substrate.
Results
30 ACM pts (53±6 y.o.; 66% male) were defined as LDACM; 22 (73%) pts presented unspecific ECG abnormalities, with 8 (27%) pts instead presenting negative t-waves in V4-V6. Cardiac US resulted unremarkable in 27 (90%) pts. Sustained ventricular arrhythmia with right bundle brunch block were experienced in 4 (14%) pts, while frequent premature ventricular beats with the same morphology in 10 (33%).
LDACM diagnosis was mainly suspected upon MRI evaluation: all 30 pts presented a late gadolinium enhancement (LGE) pattern revealing an isolate left ventricle fibro-fatty infiltration, with normal biventricular contractility (LV and RV ejection fraction 57±9% and 53±2%, respectively).
Right ventricular, left ventricular and biventricular endo-cavitary EAM was performed in 10 (33%), 11 (37%) and 9 (30%) pts respectively, revealing pathologically low unipolar voltages in 7 (23%) and both unipolar and bipolar low voltages in 15 (50%) pts. In 18 (60%) pts an EMB was performed, revealing in 15 (83%) a fibro-fatty infiltrate and a fibro-fatty infiltrated with a superimposed viral myocarditis in a single pt. Genetic testing was performed in 16 (53%) pts, of which 10 (33%) showed causative mutation of desmosomal genes.
If strictly adhering to the existing criteria, only 7 (23%) LDACM definite diagnosis would have been reached, even when using EMB and genetic testing.
LDACM EAM with late potentials
Conclusion
LDACM is an underestimated ACM subtype that require MRI evaluation and an invasive work-up for definite diagnosis. Although EMB and genetic testing being the most effective diagnostic tools currently at disposal adhering to existing criteria, a definite diagnosis could be reached only in a fraction of patient population. Existing diagnostic criteria should be revised, mainly to take in consideration EAM specific role and to properly define the LDACM entity.
Abstract
Background
Arrhythmogenic Cardio-Myopathy (ACM) is characterized by epi-endocardial fibro-fatty replacement. Depending on the most affected ventricle, right dominant (RDACM) or left dominant ...(LDACM) phenotypes can be defined. RDACM voltage mapping characteristics have already been described, with late potentials strongly correlating with arrhythmia recurrence risk; LDACM voltage features have not been described yet.
Purpose
To analyze voltage map characteristics in LDACM patients (pts) and compare them with RDACM; to assess if there is any correlation between late potentials and recurrence rate in LDACM as well.
Methods
We retrospectively enrolled all consecutive ACM patients treated c/o our center and diagnosed according to the 2010 Task Force Criteria. Procedural and follow up data were collected. Patient were sorted by ventricular involvement lateralization. Recurrence rates were evaluated and linearly regressed for the presence of late potentials.
Results
89 ACM patients were enrolled (67 RDACM, 22 LDACM; 76% males, 69±4 y.o.) in our study. All patients underwent endocardial voltage mapping; procedurally, 43 (48%) pts underwent catheter ablation, while 46 (52%) were managed conservatively with anti-arrhythmic drugs.
Bipolar pathological potentials were found in 43 (64%) and 13 (59%), unipolar pathological potentials in 45 (67%) and 14 (63%), while late potentials in 19 (31%) and 8 (36%) in the RDACM and LDACM group respectively p = 0.66, p=0.63, and p=0.33.
The average follow-up was 18 months 14–48; 15 (22%) in the RDACM and 9 (40%) in LDACM arrhythmic recurrences were respectively encountered; recurrences in both groups were regressed for the presence of late potentials. Results were as follows: the presence of late potentials correlated with recurrences with an 4,3 1.15–16.1; p=0.03 OR and with an 11 0.4–85; p=0.022 OR in the RDACM and LDACM group respectively.
Conclusion
Pathologically low unipolar, bipolar and late potentials can be found in comparable % both in RDACM and LDACM; like in RDACM, late potentials represent an important risk factor for arrhythmic recurrence in LDACM as well.
Abstract
Background
A myocardial substrate assessment through percutaneous endomyocardial biopsy (EMB) represents an important additional diagnostic test for cardiomyopathies when uncertainties ...remain after non-invasive evaluation. Yet, extensive application of EMB has been limited by the low sensitivity of biopsies. Electroanatomic voltage mapping (EVM) is a promising modality for guiding Endomyocardial biopsies (EMB).
Aim
The aim of our study is to evaluate the diagnostic yield of EVM-guided EMB and the role of histological analysis in the diagnosis of patients with suspected cardiomyopathies and arrhythmic presentation.
Methods
One-hundred and sixty-two consecutive patients undergoing EMB at our Institution from 2010 to 2019 were included. Demographics, clinical data, CMR data and peri-procedural complications were retrospectively retrieved. All procedures were guided by endo-cavitary EVM. According to non-invasive data collected before proceeding with EMB a suspected clinical diagnosis was expressed and compared to histological diagnosis
Results
One-hundred and sixty-two patients were included in the study. Mean age of the cohort resulted 40.9±14.7 years, with 26.5% of the included patients being females. ECG alterations were present in 51.3% of the population, with the most common abnormality being T wave inversion. Sustained or non-sustained ventricular tachycardia was registered in 51 (31.5%) of the patients, while 44 (27.2%) patients were referred for frequent isolated premature ventricular complex (PVC), and 19 (11.7%) after an episode of an arrhythmogenic syncope or resuscitated cardiac arrest. Suspected ARVC (41.6%) together with acute/chronic myocarditis (28.0%) were the main clinical diagnosis leading to an invasive approach. The sampling site was the right ventricle in 116 (72.5%), the left ventricle in 31 (19.4%), and both ventricles in 13 (8.1%) patients. Biopsy samplings were judged appropriate for histological analysis in 141 (87.0%) patients. Among the analyzed samples, a diagnosis was reached in 120 patients (74.1%). In the remaining 21 cases (25.9%), the analysis yielded nonspecific histologic findings, inconclusive results, or sampling error. The biopsy allowed to confirm the clinical diagnosis in 72 (60.0%) patients, while a different diagnosis was reached in 48 (39.0%) cases (Reclassification are showed Figure 1).In particular of 67 (41.6%) patients suspected for ARVC, only 32 (22.7) reached a confirmation. Conversely, the number of patients with acute/chronic myocarditis augmented from 45 (28.0%) to 47 (33.3%).
Conclusion
EMB guided by EVM reached a diagnostic yield as high as 74.1%. EMB proved to be a useful tool in the clinical management of patients, as it allowed to correctly reclassify a significant number of patients who would have been misdiagnosed based only on non-invasive assessment.
Sankey Diagram
Funding Acknowledgement
Type of funding source: None
Abstract
Background
Current arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnostic criteria are mostly based on ventricle function and dimension. Previous studies have reported a ...significant overlap between ARVC and chronic myocarditis, at non-invasive assessment.
Purpose
Tto compare biopsy-proven ARVC and myocarditis patients, in order to identify clinical, imaging and invasive electroanatomic voltage mapping (EVM) differences between the two groups.
Methods
Patients with borderline diagnosis of ARVC or suspected myocarditis underwent compete assessment with cardiac magnetic resonance (CMR). All patients underwent endomyocardial biopsy (EMB) with targeted tissue sampling guided by EVM. All patients with an histological diagnosis of myocarditis or ARVC were included.
Results
83 patients were included, divided into 35 (42.2%) ARVC and 48 (57.8%) myocarditis. Among ARVC patients, 25 (71.4%) had right dominant ARVC, 5 (14.3%) left dominant patter and 5 (14.3%) bi-ventricular involvement. Nine patients (23.1%) with suspected clinic diagnosis of ARVC before EMB, received and histological diagnosis of myocarditis. Two (5.7%) patients with suspected myocarditis were proven to have ARVC. When comparing patients with ARVC and patients with myocarditis, univariate analysis showed that age, sex, family history, arrhythmic disorders at presentation and ECG abnormalities were similar between the two groups (P>0.05 for all the variables). There was also no significant difference with regards to bi-ventricular function and dimension at CMR evaluation. More patients with myocarditis resulted positive at late gadolinium enhancement (LGE) evaluation, although non-significantly (P=0.082). Oedema was more frequently present in patients with myocarditis (P=0.01), while adipose tissue infiltration and segmental wall motion abnormalities were more often observed in patients with ARVC (P=0.002 and P<0.001 respectively). At EVM analysis, a significant greater number of patients had a pathological uni- and bi-polar EVM (P<0.05 in all cases) and the scar-area was greater in patients with ARVC: 18.8 vs 11.0 cmq (P=0.041).
Conclusion(s)
A significant number of patients who received a clinical diagnosis of Myocarditis or ARVC according to current guidelines, were subsequently reclassified after histological analysis. Patients with ARVC and myocarditis were not distinguishable on the basis of clinical features and ventricular function and dimensions. Conversely, tissue analysis with CMR demonstrated how patient with ARVC had less oedema, more adipose tissue infiltration and had more extensive scar at EVM evaluation.
Funding Acknowledgement
Type of funding source: None
Abstract
Background
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a leading cause of sudden cardiac death, but its diagnosis is challenging and the role of endomyocardial biopsy (EMB) is ...controversial and has been recently questioned.
Purpose
We aimed to 1) analyse the role of EMB in improving the diagnostic performance of 2010 Task Force Criteria (TFC) in the diagnosis of ARVC; 2) assess EMB safety in our population.
Methods
We retrospectively analysed data from 54 consecutive patients admitted to our Hospital with a clinical suspicion of ARVC undergoing endomyocardial biopsy. During hospitalization a complete assessment was performed for every patient (including electrocardiogram, echocardiogram, cardiac MRI, genetic analysis, and electroanatomic-mapping-guided endomyocardial biopsy). ARVC diagnosis was assessed for every patient using both traditional 2010 TFC and a non-invasive modified TFC (2010 TFC criteria excluding biopsy).
Results
Overall, 9/54 (17%) patients showed a left-dominant variant of ARVC and were therefore excluded from the analysis. Non-invasive modified TFC allowed 16/45 (36%) patients to receive a definite diagnosis; when biopsy results were added the number of definite diagnosis increased to 22/45 (49%), increasing the number of patients with a definite diagnosis by 13%. More specifically: 8/11 patients not reaching a possible diagnosis were reclassified as either possible (4/8) or borderline (4/8); 3/9 patients with a possible diagnosis were reclassified as borderline; 6/9 borderline patients received a definite diagnosis of ARVC. Globally, in 6 out of 29 patients with a non-definite diagnosis, EMB confirmed ARVC diagnosis and 17/45 (38%) patients received an upgrade in their diagnostic status with EMB. Notably, EMB also revealed the coexistence of myocarditis and fibro-fatty replacement in 5/45 (9%) patients. No patient experienced complications related to EMB.
Conclusions
Endomyocardial biopsy is a safe, reliable, and useful tool for ARVC diagnosis, allowing to upgrade the diagnostic status of 38% of our patients with a suspect of ARVC diagnosis. It should be performed in experienced centers and it should be guided by electro-anatomic mapping, to maximize its diagnostic power.
Funding Acknowledgement
Type of funding source: None
Abstract
Background
The rate of post–vaccine myocarditis is being studied from the beginning of the massive vaccination campaign against Sars–Cov–2, reporting a very low incidence. Although a direct ...cause–effect relationship has been described, in most cases the vaccine pathophysiological role is doubtful. Moreover, it is not quite as clear as having had a previous myocarditis could be a risk factor for a post–vaccine disease relapse.
Case Presentation
A 27–year–old man presented to the ED for palpitations and pericardial chest pain radiated to the upper left limb, on the 4th day after the third dose of BNT162b2 vaccine. He experienced a previous myocarditis 3 years before, with full recovery and no other comorbidities. ECG showed a diffuse ST segment elevation and a cardiac echo showed lateral hypokinesia with preserved ejection fraction. Troponine–T was elevated (160ng/l), chest x–ray was normal, and the Sars–Cov–2 molecular buffer was negative. High–dose anti–inflammatory therapy with ibuprofen and colchicine was started; in the 3rd day high sensitivity Troponin I reached a peak (hsTnI) of 23000 ng/L. No heart failure or arrhythmias were observed. A cardiac MRI was performed showing normal biventricular systolic function, areas of LGE with non–ischemic subepicardial pattern at the level of the anterior wall with increased T2 signal, suggestive for a recurrence of myocarditis. A left ventricle electroanatomic voltage mapping was negative (both unipolar and bipolar), while the endomiocardial biopsy showed a picture consistent with active myocarditis. The patient was discharged in good shape, with normal hsTnI values on bisoprolol 1.25mg, ramipril 2.5mg, ibuprofen 600 mg three times a day, colchicine 0.5 mg twice a day. Discussion: We presented the case of a young man with history of previous myocarditis, admitted with a non–complicated acute myopericarditis relapse occurred 4 days after Sars–Cov–2 vaccination (3rd dose). Despite the observed very low incidence of cardiac complications following BNT162b2 administration, and the lack of a clear proof of a direct cause–effect relationship, we think that in our patient this link can be more than likely. In the probable need for additional Sars–Cov–2 vaccine doses in the next future, studies addressing the risk–benefit balance of this subset of patient are warranted.
Conclusion
We described a multidisciplinary management of a case of myocarditis recurrence after the third dose of Sars–Cov–2 BNT162b2 vaccine.
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