Abstract
Background
Automatic diagnosis of implantable cardioverter defibrillator (ICD) requires confirmation through analysis of electrograms (EGM) recordings by an electrophysiologist (EP) ...specialist.
Purpose
To investigate whether the atrial sensing capability in single-chamber ICD improves reliability in episodes assessment.
Methods
The THINGS registry enrolled 526 consecutive patients without atrial pacing indication who underwent single-lead ICD implantation. Of them, 343 patients received a conventional single-chamber ICD (ICD VR) and 183 a single-lead ICD with atrial sensing capability (ICD DX, BIOTRONIK). Device-detected ventricular episodes were independently classified by two experienced electrophysiologists as ventricular (VT) or supraventricular tachycardia (SVT) by analyzing the EGMs. In case of disagreement, a third experienced EP specialist, blinded to previous assessment, was consulted. The inter-rate reliability was evaluated using the Cohen's kappa (k) coefficient in the ICD VR and ICD DX group.
Results
A total 441 (383 in the ICD VR and 58 in the ICD DX group) device-detected events were analyzed. Using ventricular EGM alone for ICD VR patients, the proportion of observed agreement between the 1st and 2nd adjudicator was 86.4% consisting of 268 (70.0%) episodes confirmed as VT and 63 (16.4%) classified as SVT. The k coefficient was 0.61 and no agreement was reached for 52 (13.6%) tracings. For them, the third assessment had low agreement with both previous EP evaluations (the k coefficients 1st/3th and 2nd/3th EP specialist were 0.03 and −0.05, respectively).
In ICD DX group, with available atrial EGM, the proportion of observed agreement in the first stage improved to 93.0%: 44 (75.8%) episodes were adjudicated as VT and 10 (17.2%) as SVT with a k=0.79. Only 4 (7.0%) recordings had a discordant classification. For them, the 2nd and 3rd EP specialist had perfect agreement (k=1).
Conclusions
Atrial sensing capability improves EP specialist assessment of ICD episodes allowing dual EGMs analysis. Misinterpretation of ICD recordings may thus be less common in ICD DX than in conventional single-chamber ICD VR and may improve clinical decisions.
Funding Acknowledgement
Type of funding sources: None.
COVID-19 outbreak had a major impact on the organization of care in Italy, and a survey to evaluate provision of for arrhythmia during COVID-19 outbreak (March–April 2020) was launched. A total of ...104 physicians from 84 Italian arrhythmia centres took part in the survey. The vast majority of participating centres (95.2%) reported a significant reduction in the number of elective pacemaker implantations during the outbreak period compared to the corresponding two months of year 2019 (50.0% of centres reported a reduction of > 50%). Similarly, 92.9% of participating centres reported a significant reduction in the number of implantable cardioverter-defibrillator (ICD) implantations for primary prevention, and 72.6% a significant reduction of ICD implantations for secondary prevention (> 50% in 65.5 and 44.0% of the centres, respectively). The majority of participating centres (77.4%) reported a significant reduction in the number of elective ablations (> 50% in 65.5% of the centres). Also the interventional procedures performed in an emergency setting, as well as acute management of atrial fibrillation had a marked reduction, thus leading to the conclusion that the impact of COVID-19 was disrupting the entire organization of health care, with a massive impact on the activities and procedures related to arrhythmia management in Italy.
This study reports on the results and safety of a simplified method of trans-septal catheterization for radiofrequency catheter ablation of cardiac arrhythmias.
Over 5 years, 411 patients underwent ...trans-septal catheterization for radiofrequency catheter ablation: 388 patients had a left-sided accessory pathway, 19 a left-sided focal atrial tachycardia, two atrial fibrillation and two post-infarction ventricular tachycardia. All but one patient with ventricular tachycardia underwent elective trans-septal catheterization. In the absence of a patent foramen ovale, puncture of the atrial septum was performed by using an 8F Mullins sheath and a Brockenbrough needle, according to the simplified method described in this paper. Trans-septal catheterization was accomplished in 383/388 patients (98.7%); in 41 patients a second trans-septal catheterization and radiofrequency catheter ablation was performed for initial failure or recurrence. Radiofrequency catheter ablation was successful in 96% of accessory pathway patients, 90% of atrial tachycardia patients, in both patients with atrial fibrillation and in both patients with ventricular tachycardia. No complication related to trans-septal catheterization was observed.
In experienced hands and according to the method described in this paper, the elective use of transseptal catheterization for radiofrequency catheter ablation in a large cohort of patients with cardiac arrhythmias is feasible, safe and allows successful ablation in the vast majority of the patients.
Abstract
Funding Acknowledgements
Type of funding sources: None.
BACKGROUND
The occurrence of conduction disturbances remains frequent after TAVR. However, the effect of PM on mortality is ...controversial and many patients may recover spontaneous AV conduction during follow-up.
PURPOSE
To evaluate the incidence of PM implantation after TAVR, PM dependency and burden of ventricular pacing during follow-up and their influence on mortality.
METHODS AND RESULTS
We performed a retrospective analysis of all consecutive 293 patients who underwent TAVR from 2015 to 2019 at our hospital, regional hub for this procedure. Patients were classified into 3 groups: patients without PM (no-PM), patients with a PM implanted prior to TAVR (pre-PM) and patients requiring a PM following TAVR (post-PM) and their clinical and procedural characteristics are listed in Table 1.
The rate of PM implantation after TAVR was 20,8%, at a median of 3.6 days after the procedure. The most common indication was complete AV block. A VVIR pacemaker was implanted in 28 patients, a DDD/DDDR PM in 27 patients and 2 patients received a CRT device. Among post-PPM patients, only 16% were PM-dependent at 2-month and 1-year follow-up. All of them received a PM for complete AV block (AVB). At 1-year follow-up, RV pacing burden was 60% among AVB patients and 23% in patients with a PM implanted for other reasons. PM implantation after TAVR was not associated with a mortality difference at 30-day, 1-year and long-term follow-up. Pre-PPM patients showed a higher mortality rate at long-term follow-up although not statistically significant.
CONCLUSIONS
Our data suggest that a single chamber device should be preferred in patients implanted for reasons other than complete AVB; in patients with AVB, the use of dual chamber device with an algorithm to minimize RV pacing should be the most suitable choice. Overall (293)No PPM (216)Pre-PPM (19)Post-PPM (57)p-valueAge, median(IQR)82(80-86)82(80-86)82(79-87)82(80-86)0,53Female, n(%)160(55)129(59)6(32)25(44)0,40NYHA III-IV, n(%)191(65)147(68)15(79)29(51)0,06Logistic Euroscore, mean (IQR)7,53(3,5-8,3)7(3,5-8)9,83(3,6-12)6(3,5-7,4)0,51Right bundle-branch block, n(%)21(7)13(6)na8(14)0,04AVA, mean ± SD0,69 ± 0,190,7 ± 0,190,7 ± 0,160,66 ± 0,180,23Self-expandable valve, n(%)181(62)123(57)12(63)46(81)0,001Balloon-expandable valve, n(%)102(35)86(40)7(37)8(14)0,0003Implant depth, mean ± SD6,87 ± 2,96,32 ± 2,65,71 ± 39,12 ± 30,0001Abstract Figure. Kaplan-Meier survival curve
"Inappropriate" sinus tachycardia (IST) is an uncommon and poorly defined atrial tachycardia characterized by inappropriate tachycardia and exaggerated acceleration of heart rate with "normal" P ...wave. The mechanism of this tachycardia is unknown. The purpose of the present study was to determine the role of autonomic balance in the genesis of IST.
Six female patients aged 23 to 38 years with IST and 10 age- and sex-matched control subjects were assessed with the following autonomic function tests: (1) sympathovagal balance to the sinus node assessed by calculating the LF/HF (low frequency/high frequency) ratio using power spectral analysis both in the supine position and after 10 minutes of head-up tilt to 60 degrees, (2) cardiovagal reflex assessed by cold face test (CFT), (3) beta-adrenergic sensitivity as determined by calculating isoproterenol dose-response curves and isoproterenol chronotropic dose 25 (CD25), and (4) intrinsic heart rate (IHR) assessed after autonomic blockade with atropine 0.04 mg/kg and propranolol 0.2 mg/kg administered as an intravenous bolus. No significant differences in the LF/HF ratio both in the supine position (2.8 +/- 0.3 versus 2.6 +/- 0.4) and during upright tilt (8.7 +/- 1.3 versus 8.5 +/- 0.5) were observed between control subjects and IST patients. Cardiovagal response to CFT was markedly depressed in all patients (6.3% IST patients versus 24.2% control subjects, P < .001). beta-Adrenergic hypersensitivity to isoproterenol was noted in all patients (mean CD25, 0.29 +/- 0.10 microgram IST patients versus 1.27 +/- 0.4 microgram control subjects; P < .001), and high IHR was noted in all cases. The patients were treated with high doses of beta-blockers with adequate short-term control. Radiofrequency catheter ablation of the sinus node area was performed in one drug-refractory patient.
These findings suggest that the mechanism leading to IST is related to a primary sinus node abnormality characterized by a high IHR, depressed efferent cardiovagal reflex, and beta-adrenergic hypersensitivity.
Adherence to guidelines was not homogeneous in Europe, according to the survey on cardiac resynchronization therapy conducted in 2008-2009. The aim of our study was to compare the results in the ...Italian and European cohorts of the Second European Cardiac Resynchronization Therapy Survey.
Patients' characteristics, procedural data and follow-up were collected. Italian records were compared with European countries.
Italian hospitals enrolled 526 patients. The italian cohort was older (71.6 ± 9.5 vs. 68.4 ± 10.8; P < 0.00001), had less severe NYHA class (>II 47.2 vs. 59.6%; P < 0.00001), higher ejection fraction (30.3 ± 7.4 vs. 28.4 ± 8.2%; P < 0.00001), and less atrial fibrillation prevalence (34.4 vs. 41.2%; P = 0.00197) than the European cohort. Italian patients were more frequently hospitalized for heart failure in the previous year (51.9 vs. 46.2%; P = 0.01118) and had lower mean QRS duration (151 ± 26 vs. 157 ± 27 ms; P < 0.0001). CRT-D were more often implanted in Italian patients (79.3 vs. 69.3%; P < 0.00001). The complication rate was similar (4.6% vs. 5.6%; ns). The rate of use of ACEi/ARBs in Italy was lower than in Europe (77.2 vs. 86.9%; P < 0.00001). Patients were followed up in the implantation centre (92.1 vs. 86%; P = 0.00014), but rarely with remote monitoring (25.9 vs. 30%; P = 0.04792).
The survey demonstrates important similarities as well as substantial differences regarding most of the aspects evaluated. Efforts to implement adherence to guidelines will be endorsed in Italy.
The purpose of the present investigation was to study the distribution and subunit composition of type IIX fibers in mouse muscles. The existence of a population of type IIX fibers in fast-twitch ...muscles of the mouse was shown by mean of immunohistochemistry and gel electrophoresis. In the hindlimb muscles, tibialis anterior (TA) and extensor digitorum longus (EDL), type IIX fibers account for approximately one third of the total fiber number, with the superficial portion of the TA (TAS) being composed exclusively of type IIB and IIX fibers. A similar proportion of IIX fibers was found in diaphragm (DIA) while in tongue muscles approximately 40% of the fibers were IIX. Single fiber gel electrophoresis revealed a significant number of fibers in TAS that contain both IIB and IIX myosin heavy chain (MyHC). This was confirmed with immunohistochemistry, which revealed the presence of fibers with various degrees of staining intensity. This suggests that there may exist a degree of plasticity which results in the conversion of IIX fibers to IIB fibers and vice versa. Analysis of myosin light chain (MyLC) composition of type IIX fibers revealed that the ratio of MyLC3f to MyLC1f was significantly lower than in type IIB fibers.
Background Segmental/diffuse dilatation of the main pancreatic duct (MPD) is the typical feature of combined/main-duct intraductal papillary mucinous neoplasms (CMD-IPMNs). MPD dilation in IPMNs may ...be also expression of mucus hypersecretion/obstructive chronic pancreatitis (OCP). The aim of this study was to evaluate the presence and extension of MPD involvement by tumor/OCP and assess the risk of overtreatment. Methods Retrospective analysis of suspected CMD-IPMNs resected between January 2009 and October 2014 were included. Pathologic correlations among MPD dilatation, IPMN, and OCP was searched. Results Overall, 93 patients were resected for suspected CMD-IPMNs. At pathology, CMD-IPMNs were found in 69 patients (74%). Branch-duct IPMNs (BD-IPMNs) were found in 8 cases (9%), pancreatic ductal adenocarcinoma (PDAC) in absence of IPMN in 9 (10%), cystic neuroendocrine tumor (NET G2) in 1 (1%), serous cystadenoma in 2 (2%), and OCP alone/mucinous metaplasia in 4 patients (4%). Overall, 18 patients (19%) underwent an overtreatment because unnecessary (2 BD-IPMNs, 2 serous cystadenomas, and 4 OCPs only) or too extensive resections (9 CMD-IPMNs and 1 PDAC with associated OCP). In these, total pancreatectomy was the most common procedure (67%). Median size of MPD in IPMN-involved area was 12 mm compared with 7 mm when only OCP was found ( P < .05). Conclusion There is a considerable risk of overtreatment in patients with a preoperative morphologic diagnosis of CMD-IPMNs. Partial pancreatectomy with margin examination should be performed instead of upfront total pancreatectomy. Radiologic observation can be considered in asymptomatic patients with “worrisome” MPD dilatation (5–9 mm) and lacking other high-risk stigmata.
To investigate whether in vitro derived eosinophils release nitric oxide (NO), whose role in the pathogenesis of asthma is under intense debate.
Human umbilical cord mononuclear cells were isolated ...from umbilical cord blood cells and cultured in vitro in presence of interleukin-3 and interleukin-5. Superoxide generation was monitored with dihydrorhodamine-123, NO release was estimated by measuring the accumulation of nitrite. Expression of NO synthases proteins was detected by immunoblotting.
Both N-formyl-L-Methionyl-L-Leucyl-L-Phenylalanine, and 1-O-Alkyl-2-acetyl-sn-glyceryl-3-phosphorylcholine induced superoxide release in umbilical cord eosinophils, while no response was observed with lipopolysaccharide, interleukin-4 and/or interferon-gamma. Furthermore, upon activation with different inflammatory stimuli, neither induction of nitric oxide synthesis nor expression of the constitutive and/or inducible nitric oxide synthase were observed in these eosinophils derived in vitro.
Human umbilical cord derived eosinophils are able to produce superoxide as peripheral blood eosinophils. Whether human peripheral eosinophils are capable of NO synthesis is still the subject of considerable debate, nevertheless, our results suggest that these in vitro derived eosinophils are not capable of nitric oxide synthesis.
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