Despite optimal oral anticoagulation with vitamin K antagonist, left atrial (LA) thrombus could be detected in the left appendage (LAA) in >2% of patients with atrial fibrillation (AF) and ...CHA2DS2-VASc score≥1 but few data are available for patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). We evaluated the occurrence and predictors of LA thrombi by means of transesophageal echocardiography (TOE) in consecutive patients with non-valvular AF who received for at least 3weeks Apixaban, Dabigatran, or Rivaroxaban.
This study included 414 consecutive patients (male 252, 60.6%, mean age 67.3years) referred to our Centers for catheter ablation of AF (n=220, 53.1%) or scheduled electrical cardioversion (n=194, 46.9%). Patients were on Dabigatran (n=160), Rivaroxaban (n=150) or Apixaban (n=104). TOE was performed in all cases within 12h prior to ablation or cardioversion.
Preprocedural TOE revealed LA thrombus in 15/414 patients (3.6%), all located in the LAA (Apixaban 3/104 2.9%, Dabigatran 5/160 3.1%, and Rivaroxaban 7/150 4.7%, p=0.69). Of these, 14 patients had persistent AF. Patients with LAA thrombus had a mean CHA2DS2-VASc score of 3 (3–4). Higher CHA2DS2-VASc score (p=0.02), but not the type of NOAC, significantly predicted the presence of LA thrombus.
The incidence of LAA thrombus in a cohort of patients anticoagulated with NOACs is low but not negligible, in any case similar among the 3 drugs. Preprocedural TOE should be considered in patients with a CHA2DS2-VASc score>3.
Whether ventricular arrhythmias (VAs) represent a feature of the adaptive changes of the athlete's heart remains elusive. We aimed to assess the prevalence, determinants, and underlying substrates of ...VAs in young competitive athletes.
We studied 288 competitive athletes (age range, 16-35 years; median age, 21 years) and 144 sedentary individuals matched for age and sex who underwent 12-lead 24-hour ambulatory electrocardiographic monitoring. VAs were evaluated in terms of number, complexity (ie, couplet, triplet, or nonsustained ventricular tachycardia), exercise inducibility, and morphologic features. Twenty-eight athletes (10%) and 13 sedentary individuals (11%) showed >10 isolated premature ventricular beats (PVBs) or ≥1 complex VA (
=0.81). Athletes with >10 isolated PVBs or ≥1 complex VA were older (median age, 26 versus 20 years;
=0.008) but did not differ with regard to type of sport, hours of training, and years of activity compared with the remaining athletes. All athletes with >10 isolated PVBs or ≥1 complex VA had a normal echocardiographic examination; 17 of them showing >500 isolated PVBs, exercise-induced PVBs, and/or complex VA underwent additional cardiac magnetic resonance, which demonstrated nonischemic left ventricular late gadolinium enhancement in 3 athletes with right bundle branch block PVBs morphologic features.
The prevalence of >10 isolated PVBs or ≥1 complex VA at 24-hour ambulatory electrocardiographic monitoring did not differ between young competitive athletes and sedentary individuals and was unrelated to type, intensity, and years of sports practice. An underlying myocardial substrate was uncommon and distinctively associated with right bundle branch block VA morphologic features.
•Evaluation of AP is usually performed by transesophageal and intracardiac studies.•In young athletes with AVP, our standard of care is to perform ESnoXR.•ESnoXR may considered a less invasive ...alternative for risk stratification of AP.
Athletes with asymptomatic ventricular pre-excitation (VP) should undergo electrophysiological study for risk stratification. We aimed to evaluate the feasibility, efficacy, safety and tolerability of an electrophysiological study using a percutaneous antecubital vein access and without the use of X-ray (ESnoXr). Methods: We collected data from all young athletes < 18 year-old with AVP, who underwent ESnoXr from January 2000 to September 2020 for evaluation of accessory pathway refractoriness and arrhythmia inducibility using an antecubital percutaneous venous access. Endocavitary signals were used to advance the catheter in the right atrium and ventricle. Results: We included 63 consecutive young athletes (mean age 14.6 ± 1.9 years, 46% male). Feasibility of the ESnoXr technique was 87% while in 13% fluoroscopy and/or a femoral approach were needed. Specifically, fluoroscopy was used in 7 cases to position the catheter inside the heart cavities with an average exposure of 43 ± 38 s while in 2 femoral venous access was needed. The mean procedural time was 35 ± 11 min. The exam was diagnostic in all patients, there were no procedural complications and tolerability was excellent. 53% of the patients had an accessory pathway with high refractoriness and no inducible atrio-ventricular reentry tachycardia: this subgroup was considered eligible to competitive sports and no event was observed during long-term follow-up (13.6 ± 5.2 years) without drug use. The others underwent catheter ablation. Conclusion. ESnoXr has been shown to be a feasible, effective, safe and well-tolerated procedure for the assessment of arrhythmic risk in a population of young athletes with asymptomatic VP.
Background: Hypnotic communication is a validated technique for reducing procedural anxiety and pain. The aim of our work was to evaluate the additional utility of hypnotic communication during ...catheter ablation procedures in the COVID-19 period. Materials and Methods: Sixteen consecutive patients undergoing electrophysiological study and catheter ablation underwent: 8 to standard sedation procedure (Group B) and 8 to this with the addition of hypnotic communication (Group A). In these two groups, we measured and compared preprocedure and intraprocedure anxiety, compliance to the procedure, perceived pain, use of drugs, the procedural time perceived by the patient compared to real time in minutes, and radiological exposure, using validated scales. Results: Hypnotic communication resulted in a significant reduction in anxiety during the procedure (Group A: 1.1 ± 0.6 vs. Group B: 3.4 ± 2; P = 0.003); better procedural compliance (Group A: 4.8 ± 0.5 vs. Group B: 3.7 ± 0.8; P = 0.002) and showed a trend toward a reduction in procedural pain (Group A: 2.4 ± 2 vs. Group B: 4.3 ± 1.8; P = 0.08) compared to standard sedation. Midazolam was not used in Group A, while an average of 3 ± 1.3 mg was used in Group B. The use of local anesthetic and Fentanest was comparable. The real procedural durations (Group A: 167.5 ± 30.1 vs. Group B: 150 ± 27.8 min; P = not significant) and perceived (Group A: 78.8 ± 15.5 vs. Group B: 86.3 ± 29.9 min; P = not significant) and the difference between these was also comparable. The radiological exposure was 74.4 ± 65.5 s in Group A and 118 ± 119 s in Group B (P = not significant). There were no complications in the two groups. Conclusions: Hypnotic communication as an additional strategy during electrophysiological interventional procedures has made possible to eliminate the use of midazolam and reduce anxiety during the procedure, but above all, it has improved the patient's compliance with the procedure compared to traditional sedation approach.
Abstract Brugada syndrome is an electrical cardiac disease predisposing to ventricular arrhythmias in which typical electrocardiographic (ECG) features consist of nonischemic repolarization ...abnormalities in the right precordial leads V1-V3. The appearance of a Brugada-ECG pattern is increasingly observed in critically ill patients and is traditionally attributed to the effect of body temperature and/or drug modulation on cardiac ion channels (“acquired Brugada syndrome”). A patient with complicated malaria in whom Brugada-ECG abnormalities appeared in concomitance with fever and propofol administration is presented. The repolarization changes did not disappear until the patient’s clinical course improved.
The aim of this prospective multicentre study is to evaluate safety and efficacy of the new bidirectional rotational mechanical lead extraction (LE) sheath (Evolution RL, Cook Medical, USA) in ...chronically implanted leads (>1-year-old leads).
Between September 2013 and June 2016, a total of 238 leads in 124 consecutive patients were removed by using the new Evolution RL rotational mechanical sheath. Indications for LE were cardiac device infection in 63 (50.8%) cases, lead malfunction in 41 (33.1%), upgrade in 1 (0.8%) case and for other reasons in the remaining 19 cases (15.3%). Ninety-one leads (38.2%) were implantable cardioverter defibrillator leads (81 dual coil vs. 10 single coil), 38 (16%) right ventricular leads, 86 (36.1%) right atrial leads, and 23 (9.7%) coronary sinus leads. The mean implant duration was 92.2 ± 52.9 months (range 12-336). 91.6% of the leads (218/238) were extracted completely with the Evolution RL alone, with the complete success rate rising to 98.7% (235/238 leads) with combined use of a snare. Overall clinical success rate was 100%. No Evolution sheath-related complications were noted. There were no deaths or major complications. Five minor complications (4%) were encountered. In cases of companion leads no wrapping or lead damage were observed.
On the basis of our prospective multicentre study, the new hand-powered bidirectional rotational mechanical LE sheath is an effective and safe tool for the extraction of chronically implanted leads without major complications and lead wrapping or lead damage.
Implantable cardiac monitors (ICMs) can generate false-positive (FP) alerts. Although these devices have an extended programmability, there are no recommendations on their optimization to reduce ...not-relevant activations.We tested a strategic programming optimization guide based on the type of FP and investigated the safety and feasibility of the nurse-led insertion of ICMs with a long-sensing vector.
Consecutive patients implanted by trained nurses with long-sensing vector ICM were enrolled in a 1-month observational stage (Phase A). Patients who had ≥10 FP episodes underwent ICM reprogramming based on the predefined guide and were followed for an additional month (Phase B). A total of 78 patients had successful ICM insertion by nurses with a mean R wave amplitude of 0.96 ± 0.43 mV and an 86% P wave visibility. Only one patient reported a significant device-related issue, and nurse-delivered ICM was generally well accepted by the patients. During Phase A, 11 patients (14%) generated most of FP (3,627/3,849; 94%) and underwent ICM reprogramming. In the following month (Phase B), five patients (45%) were free from FP and six (55%) transmitted 57 FP alerts (98% reduction compared with Phase A). The median number of FP per patient was significantly reduced after reprogramming 195 (interquartile range, 50-311) vs. one (0-10), P = 0.0002.
A strategic reprogramming of ICM in those patients with a high FP alert burden reduces the volume of erroneous activations with potential benefits for the remote monitoring service. No concerns were raised regarding nurse-led insertion of ICMs with a long-sensing vector.
The remote follow-up of pacemakers and implantable cardiac defibrillators (ICDs) usually includes scheduled checks and alert transmissions. However, this results in a high volume of remote data ...reviews to be managed. We measured the relative contribution of scheduled and alert transmissions to the detection of relevant conditions, and the workload generated by their management.
At our center, the frequency of remote scheduled transmissions is 4/year. Moreover, all system-integrity and clinical alerts are turned on for wireless notification. We calculated the number of transmissions received from January to December 2020, and identified transmissions that necessitated in-hospital access for further assessment and transmissions that required clinical discussion with the physician. For all alert transmissions, we identified whether the alert was clinically meaningful (i.e. center was not previously aware of the condition and no action had yet been taken to treat it).
Of 8545 transmissions received from 1697 pacemakers and ICDs, 5766 (67%) were scheduled and 2779 (33%) were alert transmissions received from 764 patients (45%); 499 (9%) scheduled transmissions required clinical discussion with the physician, but only 2 of these necessitated in-hospital visits for further assessment. Of the alert transmissions, 664 (24%) required clinical discussion, and 75 (3%) necessitated in-hospital visits. The proportion of alerts judged clinically meaningful was 7%.
Scheduled transmissions generate 67% of remote data reviews for pacemakers and ICDs, but their ability to detect clinically relevant events is very low. A strategy that relies exclusively on alert transmissions could ensure continuity of patient monitoring while reducing the workload at the center.
•In a remote follow-up service, two-thirds of remote data reviews are generated by scheduled data transmissions.•Scheduled transmissions display far less ability to detect clinically relevant events than automatic alerts.•A strategy based on alert transmissions could ensure continuity of patient monitoring while reducing the workload.
Background
Subclinical atrial fibrillation (SCAF) may represent a cause of embolic stroke of undetermined source (ESUS) and its detection has important implications for secondary prevention with ...anticoagulation. Indications to implantable cardiac monitors (ICM) include SCAF detection. The aims of this study were to (1) evaluate the frequency of ICM-detected SCAF; (2) determine predictors of SCAF; and (3) identify patients who would benefit most from ICM implantation.
Methods
Between February 2017 and November 2020, all consecutive patients referred for ICM implantation after a diagnosis of ESUS and without previous history of atrial fibrillation or atrial flutter were included in this study. SCAF was diagnosed if the ICM electrogram demonstrated an episode of irregularly irregular rhythm without distinct P waves lasting > 2 min.
Results
We enrolled 109 patients (age 66, SD = 13 years; 36% females). During a median follow-up of 19.2 (IQR 11.0–27.5) months, SCAF episodes were detected in 36 (33%) patients. Only abnormal P wave terminal force in lead V1, left atrial end-systolic indexed volume > 34 ml/m
2
, and BMI > 25 kg/m
2
were independently associated with an increased risk of SCAF (HR 2.44, 95% CI 1.14–5.21,
p
= 0.021; HR 2.39, 95% CI 1.11–5.13,
p
= 0.026; and HR 2.64, 95% CI 1.06–6.49,
p
= 0.036 respectively). The ROC curve showed that the presence of all three parameters had the best accuracy (74%) to predict SCAF detection (sensitivity 39%, specificity 91%).
Conclusion
A multiparametric evaluation has the best accuracy to predict SCAF in ESUS patients and may help identifying those who would benefit most from ICM.
In this study, we investigated a cohort of unselected patients with various indications for an implantable cardiac monitor (ICM). Our main objectives were to determine the incidence of arrhythmic ...diagnoses, both anticipated and incidental in relation to the ICM indication, and to assess their clinical relevance.
We examined remote monitoring transmissions from patients with an ICM at four Italian sites to identify occurrences of cardiac arrhythmias. Concurrently, we collected data on medical actions taken in response to arrhythmic findings.
The study included 119 patients, with a median follow-up period of 371 days. ICM indications were syncope/presyncope (46.2%), atrial fibrillation management (31.1%), and cryptogenic stroke (22.7%). In the atrial fibrillation management group, atrial fibrillation was the most common finding, with an incidence of 36% 95% confidence interval (CI) 22-55% at 18 months. Rates of atrial fibrillation were not significantly different between patients with cryptogenic stroke and syncope/presyncope 17% (95% CI 7-40%) vs. 8% (95% CI 3-19%), P = 0.229.For patients with cryptogenic stroke, the incidence of asystole and bradyarrhythmias at 18 months was 23% (95% CI 11-45%) and 42% (95% CI 24-65%), respectively, similar to estimates obtained for patients implanted for syncope/presyncope ( P = 0.277 vs. P = 0.836).Overall, 30 patients (25.2%) required medical intervention following ICM-detected arrhythmias, predominantly involving atrial fibrillation ablation (10.9%) and medication therapy changes (10.1%).
In a real-life population with heterogeneous insertion indications, approximately 25% of patients received ICM-guided medical interventions within a short timeframe, including treatments for incidental findings. Common incidental arrhythmic diagnoses were bradyarrhythmias in patients with cryptogenic stroke and atrial fibrillation in patients with unexplained syncope.
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