bluuebunny/crossref_metadata_2025 huggingface dataset:
Social Work Education in Post-Soviet Countries: Progress of Azerbaijan
Authors: Huseynli Aytakin
Published: December 2022

The article presents the findings of a qualitative study that was conducted in Azerbaijan to identify achievements and issues of social work education in the country. As in many former Soviet Union (fSU) countries, social work education in Azerbaijan is in its infancy. Formal education was established in 2005. Currently, sixteen universities offer social work education at the bachelor’s, master’s and doctoral levels. Despite a relatively high number of graduates from these programmes, the country lacks professional social workers in the field. Thus, with financial support from the Ministry of Education, the Azerbaijan Social Work Public Union explored this paradox. Data were collected via focus groups and in-depth interviews. The sample size was thirty-nine key informants, which included representatives of the government and non-government agencies, universities, social work students and alumni. Data were analysed by NVivo software. Themes such as the high number of social work education programs, strong commitment to launch social work programmes, wrong image of social work, need for resources in the local language, need for social work teachers, need for the minimum national quality standards for social work education and an uninformed selection of social work education by students have emerged. The study aims to contribute to the literature on social work education in former fSU countries.
Fetal development of functional thalamocortical and cortico–cortical connectivity
Authors: Taymourtash Athena , Schwartz Ernst , Nenning Karl-Heinz , Sobotka Daniel , Licandro Roxane , Glatter Sarah , Diogo Mariana Cardoso , Golland Polina , Grant Ellen , Prayer Daniela , Kasprian Gregor , Langs Georg
Published: December 2022

Measuring and understanding functional fetal brain development in utero is critical for the study of the developmental foundations of our cognitive abilities, possible early detection of disorders, and their prevention. Thalamocortical connections are an intricate component of shaping the cortical layout, but so far, only ex-vivo studies provide evidence of how axons enter the sub-plate and cortex during this highly dynamic phase. Evidence for normal in-utero development of the functional thalamocortical connectome in humans is missing. Here, we modeled fetal functional thalamocortical connectome development using in-utero functional magnetic resonance imaging in fetuses observed from 19th to 40th weeks of gestation (GW). We observed a peak increase of thalamocortical functional connectivity strength between 29th and 31st GW, right before axons establish synapses in the cortex. The cortico–cortical connectivity increases in a similar time window, and exhibits significant functional laterality in temporal-superior, -medial, and -inferior areas. Homologous regions exhibit overall similar mirrored connectivity profiles, but this similarity decreases during gestation giving way to a more diverse cortical interconnectedness. Our results complement the understanding of structural development of the human connectome and may serve as the basis for the investigation of disease and deviations from a normal developmental trajectory of connectivity development.
Do women evaluate their lower earnings still to be fair? Findings on the contented female worker paradox examining the role of occupational contexts in 27 European countries
Authors: Brüggemann Ole , Hinz Thomas
Published: December 2022

It is still a puzzling question which gender inequalities in the labour market are perceived as fair and which are not – in the eye of the beholder. This study focuses on gender differences in the perceptions of the fairness of one’s own wage and the role of the occupational context individuals are embedded in. Based on data collected from 27 European countries as part of the 2018 European Social Survey (Round 9), our study contributes to the growing field of wage fairness perceptions by analysing the role of the occupational context (measured as the share of women and the gender pay gap in the respondent’s occupation), and how it moderates gender differences in fairness perceptions. Results indicate that – overall – female workers across Europe perceive their wages more often as unfairly “too low” than their male counterparts within the same country context and occupation, and that this gender gap is more pronounced in occupations with a high proportion of women and higher levels of gender inequality. We interpret these results as an indicator of growing awareness among women regarding the persisting “unfair” gendered wage distributions.
579 ACUTE ISCHEMIC HEART FAILURE: PHARMACOLOGICAL AND INTERVENTIONAL MANAGEMENT OF A FRAIL PATIENT
Authors: Calvelli Pierangelo , Sorrentino Sabato , Polimeni Alberto , Aquila Iolanda , Ventura Ettore , Lucchino Alessandro , Purri Ilaria , Indolfi Ciro
Published: December 2022

An 87-year-old male patient with worsening dyspnea was admitted to our institution. The patient had a history of acute myocardial infarction treated with coronary stenting of the left descending artery (LAD), diagonal (Diag), right coronary artery (RCA), and chronic kidney disease. For acute pulmonary edema, the patient was admitted to our cardiac intensive care unit and rapidly treated with non-invasive positive-pressure ventilation with continuous positive airway pressure (C-PAP), IV high dosage diuretic therapy, inotropes, and vasoactive agents. Chest X-ray revealed cardiomegaly (cardiothoracic ratio, 56%) and pulmonary congestion. Electrocardiogram revealed sinus tachycardia and diffuse ST-segment abnormalities. An echocardiogram demonstrated left ventricular apical akinesia, with a left ventricular ejection fraction (LVEF) of 25% and severe mitral regurgitation. Blood tests revealed very high levels of NT-pro-brain natriuretic peptide (NT-proBNP) (>30000 pg/ml) and myocardial necrosis markers (hs-Trop 5055 ng/l; CK-MB 72 ng/ml).

After 24 hours, the patient was placed on intra-aortic balloon pump (IABP) support to further hemodynamic support through the right femoral artery, nonetheless, he showed no improvement in symptoms or urine output. Because of a state of hypoxemic and hypercapnic respiratory failure, non-invasive ventilation (NIV) was given to the patient with a gradual improvement in blood gas analysis. The optimization of diuretic therapy allowed to treat the state of acute oliguric kidney disease, avoiding dialytic treatment.

After 48 hours, because of a new worsening in hemodynamic state, we decided for a percutaneous left ventricular assist device (Impella CP, Denver, Massachusetts, USA). After placing the Impella device, coronary angiography was performed, showing critical stenosis of the left main (LM), involving the origin of the left anterior descending artery and a collateralized chronic occlusion of the circumflex artery and the LAD, after the origin of a large first diagonal branch. Because of the high procedural risk, we decided to perform only percutaneous coronary intervention and stent implantation of LM. After 3 days his symptoms improved, the required dose of inotropic agents and furosemide decreased and Impella was removed. After 12 days the patient was admitted to the cardiological ward and discharged after 21 days because of a urinary infection requiring antibiotic therapy.

The management of acute heart failure in very old patients is challenging, limiting in many cases the use of invasive procedures such as coronary angiography or left ventricular assist devices. In this case, although the patient presented a very high-risk profile considering age and comorbidities, the use of Impella resulted to be safe and guaranteed hemodynamic support during the procedure of revascularization and in the immediate post-operative phase.
602 CRITICAL AORTIC STENOSIS IN PROFOUND CARDIOGENIC SHOCH: BRIDGE TO TAVI WITH LEVOSIMENDAN.
Authors: Farina Andrea , Daus Francesca , Savonitto Stefano , Giannattasio Cristina , Pezzini Sara
Published: December 2022

Cardiogenic shock (CS) in severe aortic stenosis (AS) is associated with high mortality. Percutaneous aortic valve implantation (TAVI) is a possible definite solution, but generally it cannot be performed on an emergency base. In patients with severe systolic dysfunction an augmentation of cardiac index (CI) during dobutamine and nitroprusside infusion can demonstrate contractile and afterload reserve. Invasive hemodynamic monitoring is necessary to keep optimal filling pressure and verify arterial pressure stability. If the hemodynamic response is positive we administer levosimendan to bridge the patient to decision and/or to TAVI. In our small experience this strategy is efficacy and well tolerated.
917 HYBRID TRANSVENOUS AND SURGICAL APPROACH FOR THE EXTRACTION OF CORONARY SINUS LEADS: A CASE SERIES
Authors: Arabia Gianmarco , Bontempi Luca , Cerini Manuel , Salghetti Francesca , Milidoni Antonino , Cersosimo Angelica , Mitacchione Gianfranco , Muneretto Claudio , Curnis Antonio
Published: December 2022

Background

The rates of cardiac device-related infection have increased substantially over the past years. Transvenous lead extraction is the standard therapy for such cases. In some patients, however, the procedure cannot be completed through the transvenous route alone. A hybrid surgical and transvenous approach may provide the solution in such cases.

Methods

We present three cases who underwent hybird transvenous and surgical extraction for coronary sinus leads due to infection of CRT-D systems. One patient had an Attain Starfix lead implanted in the coronary sinus. The procedures were performed under local anaesthesia with continuous hemodynamic and transthoracic echocardiographic monitoring. We highlight the characteristics of the patients, the features of the devices, the technical difficulties and the outcomes of the procedures.

Results

In all cases, the right atrial and right ventricular leads were extracted through the transvenous route. In one patient, they were extracted using regular stylets and manual traction, while in the other two patients, telescoping dilator sheaths (Cook), Tightrail hand-powered mechanical sheaths (Spectranetics) and/or Glidelight Excimer Laser sheaths (Spectranetics) were used. The coronary sinus lead could not be retrieved due to extensive fibrosis after utilizing locking stylets and mechanical dilator sheaths in all 3 cases, in addition to rotational mechanical sheaths and Laser. sheaths in one case, so the so the patients were referred to surgery. Two patients underwent left mini-thoracotomy and one patient underwent midline sternotomy to extract the remaining CS lead. The target vein was identified and ligated, then the fibrosis around the lead was dissected, this was followed by lead retrieval through the surgical incision. The patient who underwent sternotomy suffered from mediastinitis, which required reoperation and mediastinal lavage. There were no complications in the other two patients. All three patients were reimplanted with a new CRT-D device on the contralateral side after the resolution of infection.

Conclusion

A hybrid surgical and transvenous approach can be complementary in case the transvenous route alone fails to completely extract the coronary sinus lead. The transvenous approach can be used to free the proximal part of the lead, while the distal adhesions can be removed surgically, preferably though a limited thoracic incision.
328 IMPACT OF INTEGRATED CARE WITH ABC PATHWAY IN PATIENTS WITH ATRIAL FIBRILLATION AND HEART FAILURE: DATA FROM MORE THAN 11000 PATIENTS ENROLLED IN A EUROPEAN REGISTRY
Authors: Bonini Niccolo´ , Proeitti Marco , Vitolo Marco , Romiti Giulio Francesco , Imberti Jacopo Francesco , Mei Davide , Marta Mantovani , Righelli Ilaria , Marconi Irma , Gerra Luigi , Malavasi Vincenzo Livio , Lip Gregory Y h , Boriani Giuseppe
Published: December 2022

Background and aim

Heart failure (HF) is closely associated with atrial fibrillation (AF). The Atrial fibrillation Better Care (ABC) pathway is recommended in guidelines as a holistic or integrated care approach to AF management. However, few data are specifically available on ABC pathway adherence in AF patients with HF, especially according to HF phenotypes. Therefore, we aimed to retrospectively investigate the effect of ABC management in a large contemporary cohort of AF patients with HF and the impact on the clinical outcomes.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. According to the availability of HF status and ejection fraction (EF) values, patients were categorized as follows: i) non-HF; ii) HF EF>40% iii) HF EF≤40%. The primary outcome was a composite outcome of all-cause death and major adverse cardiac events.

Results

Among the original 11 096 AF patients enrolled, 9175 (82.7%) were included in this analysis (median age 71 years, interquartile range [IQR 63-77], 40.1% were female, with median EF 55% [IQR 45-61%] and median CHA2DS2-VASc 3 [2-4]). In this cohort, 5935 (64.7%) were non-HF patients, and 3240 (35.3%) had HF patients. According to the EF values, 2005 (65%) were categorized as HF EF>40%, and 1235 (35%) were HF EF≤40%. Overall, ABC pathway adherence in HF patients was 23.3% [95% CI: 21.6-25.2], being higher in HF EF≤40% patients (28.0%) and lower in HF EF>40% ones (21.9%). After a median follow-up of 731[IQR 690-748] days, ABC adherence was associated with a lower risk for the composite outcome compared to non-ABC adherent patients in each HF group (HF EF>40%: ABC 15.4% vs no ABC 20.9%; HF EF≤40%: ABC 20.3% vs no ABC 33.9%; both p<0.001). Cox regression analysis showed that ABC adherence was associated with a lower risk of composite outcome in each HF category (HF EF>40%: HR 0.66 [95% CI: 0.46-0.96], p=0.030; HF EF≤40%: HR 0.60 [95% CI: 0.40-0.90], p=0.013). ABC adherence was associated with a consistent risk reduction for the composite outcome across the entire EF spectrum [Figure].

Conclusions

In this large contemporary cohort of AF-HF patients, adherence to the ABC pathway was associated with a lower occurrence of the primary outcome, irrespective of baseline EF. ABC pathway is consistently associated with a lower risk for adverse outcomes across the entire spectrum of EF.
431 LONG-TERM ATRIO-VENTRICULAR BLOCK FOLLOWING VALVE SURGERY: ELECTROCARDIOGRAPHIC AND SURGICAL PREDICTORS
Authors: Farina Jacopo , Biffi Mauro , Savini Carlo , Martin Sofia , Marco Luca Di , Folesani Gianluca , Ziacchi Matteo , Diemberger Igor , Martignani Cristian , Pacini Davide
Published: December 2022

Background

Bradyarrhythmias requiring pacemaker implantation (PM) in patients undergoing valve surgery may occur even after several years. The incidence of PM implantation after valve surgery and its predictors are unclear.

Methods

A retrospective, monocentric, cohort study was conducted. Consecutive patients undergoing valve surgery at the Division of Cardiac Surgery at the Bologna University Hospital from 2005 to 2010 were enrolled. The primary endpoint of the study was to evaluate the incidence of PM implantation in patients undergoing valve surgery, at different follow-up times, and to evaluate the predictors of PM implantation.

Results

We included 1046 patients (61.8% male, median age 63 years). Of these 735 (70%) reached a 10 year of follow-up and 11.4% required PM implantation. In single valve surgery, mitral interventions had a higher incidence of PM implantation compared to aortic ones, albeit not significantly different (11% vs 8.1%, HR 1.2, IC 95% 0.6-2.1, p=0.590). Among combined surgery, interventions on both atrioventricular valves doubled the risk compared to those performed on aortic and mitral valves (23.1% vs 12%). Moreover, interventions involving both atrioventricular valves independently predicted PM implantation in the long term (HR 2.0, IC 95% 1.1-3.7, p=0.022). Preoperative atrioventricular conduction disease strongly predicted long-term atrio-ventricular block: right bundle branch block with or without left anterior fascicular block (LAFB) was the major predictor (HR 7.2, IC 95% 2.8-19, p<0.001, HR 6.8, IC 95% 3.9-11.7, p<0.001 respectively), followed by left bundle branch block (HR 5.1, IC 95% 2.6-10.3, p<0.001), LAFB (HR 4.2, IC 95% 1.9-8.9, p<0.001) and a non-specific ventricular conduction delay (HR=3.3, IC 95% 1.3-8.4, p=0.012). Age was also predictive, PM implantation probability increasing at each year-age increase (HR 1.02, IC 95% 1.01-1.04, p=0.022)

Conclusions

Patients undergoing valvular surgery have a continuing risk of atrioventricular block requiring PM therapy late after surgery; combined surgery on atrio-ventricular valves carries the highest risk, while preoperative atrioventricular conduction disease have different risks of AVB at long-term.
595 LOW INCIDENCE OF ARRHYTHMIC SYNCOPE AND PACEMAKER IMPLANTATION IN OLDER PATIENTS WITH BIFASCICULAR BLOCK AND IMPLANTABLE CARDIAC MONITOR
Authors: Gambardella Marco , Fumagalli Carlo , Rafanelli Martina , Brignole Michele , Guarducci Caterina , Bettoni Niccolò , Pieragnoli Paolo , Casolaro Flavia , Paolisso Giuseppe , Marfella Raffaele , Sardu Celestino , Ungar Andrea
Published: December 2022

Background

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

Methods

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

Results

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

Conclusions

Most older patients with syncope who received an ICM didn't have events during follow-up. Only one-in-three experienced syncope, and an even smaller number had an arrhythmic syncope with indication for PM implantation. Older age was strongly associated with PM implantation.
984 ARRHYTHMOGENIC DYSPLASIA: JUST A PROBLEM OF THE YOUNG?
Authors: Giacalone Giuseppe , Cadeddu Dessalvi Christian
Published: December 2022

Arrhythmogenic dysplasia is a disease of genetic aetiology characterised by the progressive replacement of functioning myocardium by fibro-adipose tissue with high arrhythmogenic potential, as well as by morpho-functional impairment. Molecular genetic studies have revealed a deficiency of demosomal proteins such as placoglobin, desmoglein, desmoplazine, placophylline and desmocollin. It usually begins at a young age and in sports subjects. It mainly affects the right ventricle, although over time it can also affect the left sections due to a biventricular alteration of the heart pump. Forms with major left-sided involvement have been described in the literature, but these are rare.

A 73-year-old man, a sportsman with over 40 marathons, presented with an episode of sustained VT during exercise in 2011. Admitted to our hospital, he was diagnosed with arrhythmogenic cardiomyopathy and was subsequently implanted with an ICD-DR mod.Teligen 100F. After 3 months, however, there was a new episode of VT, so it was decided to subject the patient to transcatheter ablation with radiofrequency, using an endocardial approach, which proved ineffective. Two months later, a new attempt at radioablation with an endocardial approach. Due to the persistence of arrhythmic symptoms, sustained VT episodes, in February 2012 it was decided to proceed with a third ablation, but adopting an endo-epicardial approach, with apparent resolution of the symptomatology. After severals episodes of atrial fibrillation, he underwent a new ablation with pulmonary vein isolation and ablation line at the level of the cavo-tricuspid isthmus in August 2020. On echocardiogram, the left ventricle had normal dimensions with upper limit thicknesses, diffuse parietal hypokinesis with markedly reduced EF (30%), dilated right ventricle (DTD 48 mm) with parietal hypertrabeculature and free wall hypokinesis (TAPSE 1.4) and dilated right atrium. In May 2020 new relapse of atrial fibrillation successfully cardioverted, maintenance therapy set up with sotalol.

In the literature, mainly forms of arrhythmogenic dysplasia in youth (30 years) have been described, whereas older forms appear to be rare. A search of the Medline database (National Library of Medicine, Bethesda, MD) found 5 cases of ARVD among the elderly; all these patients had died and were diagnosed by histology. The diagnosis is multi-parametric and the main aim of therapy is the prevention of sudden cardiac death. Currently, ICD defibrillator implantation is the only effective therapy for the prevention of sudden death. New drug therapies, radiofrequency ablation and defibrillators are likely to have a favourable impact on the survival of these patients and make it not unlikely that elderly patients with ARVD will be present. The possibility of a late onset of the disease should also be suspected.
352 PROGNOSTIC VALUE OF THE TPEAK-TEND INTERVAL FOR IN-HOSPITAL SUBACUTE VENTRICULAR ARRHYTHMIAS IN TAKOTSUBO SYNDROME
Authors: Rosa Giulio La , Pelargonio Gemma , Lucia Narducci Maria , Pinnacchio Gaetano , Bencardino Gianluigi , Perna Francesco , Follesa Federico , Galiuto Leonarda , Crea Filippo
Published: December 2022

Introduction and objectives

The clinical value of ECG repolarization parameters associated with ventricular arrhythmias (VAs) in Takotsubo syndrome is still under debate. We aimed to evaluate ECG predictors of subacute VAs, defined as those occurring after the first 48 hours from admission.

Methods

This is a single-center observational study enrolling patients admitted to the Cardiology Department between 2012 and 2018 with confirmed diagnosis of Takotsubo syndrome. Data collection included a 12-lead ECG on admission and at 48 hours, continuous telemetry monitoring, blood testing, transthoracic echocardiography and coronary angiography during hospitalization. VAs events were defined as: premature ventricular contractions ≥2000 within a 24-hour window of telemetry monitoring, ventricular fibrillation, sustained ventricular tachycardia (VT), polymorphic VT and non-sustained VT.

Results

A total of 87 patients (age 72±12 years old) were enrolled. During an average of 16±14 days of hospitalization, subacute VAs were documented in 22 patients (25%) after 127±75 hours from admission. Subacute VAs were associated with an increased in-hospital mortality (p=0.030). The corrected global (mean of the 12-lead ECG values) Tpeak-Tend interval at 48 hours from admission was an independent predictor of subacute VAs. The corrected global Tpeak-Tend was statistically superior to the standard corrected QT interval to predict subacute VAs (Z test, p=0.040). A cut-off of 108 msec for the corrected global Tpeak-Tend yielded a 71% sensitivity and 72% specificity for subacute VAs.

Conclusions

In patients with Takotsubo syndrome subacute VAs are associated with repolarization alterations that can be identified on the conventional ECG using the Tpeak-Tend interval.
281 CARDIAC RESYNCHRONIZATION TERHAPY IN PERSISTENT LEFT SUPERIOR VENA CAVA WITH A BRIDGING INNOMINATE VEIN
Authors: Liccardo Mattia , Pilato Giovanni , Vittoria Domenico , Rea Maria , Ciardiello Carmine , Cipolletta Ersilia
Published: December 2022

Background

The Persistent Left (PL) Superior Vena Cava (SVC) is a congenital malformation of the thoracic venous return that has an incidence of 0.2-3% in the general population and an incidence of about 0.5% in patients undergoing cardiac implantable electronic device. In this case, the placement of the leads, especially for the Right Ventricle (RV) and Left Ventricle (LV) through one of the branches could be challenging.

Methods

A 66-year-old man with hypertension, diabetes and dyslipidemia, in optimal pharmacologic therapy for congestive heart failure (NYHA II), hospitalized for recurrent syncopal episodes, with extreme sinus bradycardia, first-degree AV block and Left Bundle Branch Block, The patient had a LV hypertrophy and mild global systolic function (LV ejection fraction of 40%) for these we opted for a pacemaker CRT device implantation.

Results

Isolation of left cephalic vein was used as venous access for right atrium (RA) and RV leads while Seldinger technique via subclavian vein was used as venous access for LV lead. The guidewire through the subclavian vein pointed out the presence of PLSVC. Left subclavian venogram confirmed PLSVC and revealed a bridging innominate vein. To pass through the innominate vein and reach the SVC, a 0.035-inch hydrophilic guidewire was used. A 6Fr-sheath was advanced through the hydrophilic guidewire, subsequently a second metallic guidewire was advanced through the same introducer by removing the dilator. The RV and RA leads were placed respectively on low right interventricular septum and RA appendage passing through bridging innominate vein. Electrical parameters were normal. For the placement of the LV lead a 9.5Fr sheath introducer was advanced over the guidewire through the PLSVC. A venogram showed a lateral and a postero-lateral branch of the coronary sinus with acute angulation. With a 6Fr quadripolar Josephson catheter the postero-lateral branch was entered, eventually a 9Fr peelable outer guide catheter was advanced through the electrophysiology catheter becoming selective with the interested branch. A quadripolar S shaped lead was used, it was advanced into the targeted vein through a 0,014fr hydrophilic guidewire. Adequate electrical parameters and stability were achieved.

Conclusion

Lead implantation in patient with PLSVC is challenging. Placing the RA and RV leads through SVC ensure a better stability along time. The cannulation of CS is easily achieved by approach via PLSVC while selective vein cannulation can be difficult due to the modified acute angulation.
805 FAILURE OF RYTHMIQ, AN ALGORITHM FAVOURING INTRINSIC CONDUCTION: WHEN IS TOO MUCH OF A GOOD THING?
Authors: LoSavio Armando , Vetta Giampaolo , Caminiti Rodolfo , Parlavecchio Antonio , Luongo Alfredo , La Cognata Olga Mariarita , Crea Pasquale , Dattilo Giuseppe , Luzza Francesco , Carerj Scipione , Micari Antonio , Di Bella Gianluca
Published: December 2022

An 80-year-old woman received a dual chamber pacemaker (Boston Scientific Accolade MRI DR) for pre-syncopal episodes associated with transient type 1 and 2:1 II degree atrioventricular block, recorded in 24-hour Holter monitoring. Due to residual AV conduction, pacemaker was set with RYTHMIQ algorithm, in order to reduce inappropriate ventricular pacing. A month later, the patient began to complain of severe asthenia and bradycardia (46-48 bpm). Telemetry-supported pacemaker control revealed III degree AV block with junctional escape rhythm, unmasking failing to switch of RYTHMIQ algorithm.

Why did it happen?

The RythmIQ algorithm has been designed to promote intrinsic conduction in Boston Scientific devices. With RythmIQ the device provides AAI(R)[i] at the lower rate limit and/or sensor indicated rate. It provides backup VVI pacing at a rate 15 bpm slower than the programmed lower rate limit, with backup VVI pacing rate limited to no slower than 30 bpm and no faster than 60 bpm. If 3 slow ventricular beats are detected in a window of 11 beats, the device automatically switches to DDD(R) mode. A slow beat is defined as a ventricular paced or ventricular sensed event that is at least 150 ms slower than the AAI(R) pacing rate. Slow ventricular beats are any of the following: - V paced event- V sensed event > AAI lower rate limit + 150 ms- V sensed event > AAI(R) sensor indicated rate + 150 ms

In our case LRL was set at 50 bpm (1200 ms). During III degree AV block, patient's ventricular rate was always about 46-48 bpm, due to stable junctional escape rhythm. Thus no ventricular sensed event occurred with a V-V cycle greater than AAI lower rate limit + 150 ms, namely 1350 ms (around 44 bpm). Moreover the device didn't provide backup VVI pacing at a rate 15 bpm slower, namely 35 bpm. This two conditions impaired Rhythm IQ switching from AAI with VVI backup to DDD.

The device was set manually in DDD with restoring of AV synchrony and adequate ventricular rate followed by complete resolution of symptoms.

Rhythm-IQ algorithm doesn't check for AV synchrony, providing switch from AAI with VVI backup to DDD just in case of sudden and marked bradycardia. Loss of AV synchrony doesn't represent a switching criteria and moreover it is not recognized by the device. This condition could be dangerous failing to correct AV conduction disturbances in pacemaker recipient, especially if LRL was set ≤ 50 bpm. For this reason, adequate knowledge of the algorithm would indicate greater caution in using RythmIQ in certain categories of patients, such as the one in the case just described.
197 INTERMUSCULAR TWO-INCISION TECHNIQUE FOR IMPLANTATION OF THE SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR: 3-YEAR FOLLOW-UP
Authors: Pittorru Raimondo , Giacomin Enrico , Dall´aglio Pietro Bernardo , Falzone Pasquale Valerio , Bertaglia Emanuele , Lazzari Manuel De , Iliceto Sabino , Corrado Domenico , Migliore Federico
Published: December 2022

Background

The aim of the present study was to evaluate the outcome of patients underwent subcutaneous implantable cardioverter defibrillator (S-ICD) implantation with the intermuscular (IM) two-incision technique during 3-year follow-up.

Methods

the study population consisted of 105 consecutive patients (79 male; median 50 [13-77] years) underwent S-ICD implantation with the IM two-incision technique.

Results

according to the PRAETORIAN score, the risk of conversion failure was classified as low in 99 patients (94.3%), intermediate in 6 (5.7%). Ventricular fibrillation was successfully converted at ≤65 J in 97.4% of patients. During a median follow-up of 39 (16-53) months, 10 patients (9.5%) experienced device-related complications and 9 (8.5%) patients reported shocks (IAS). Lead-associated complications were the most common (3.8%), including 2 cases of lead failure (1.9%). Pocket complications were reported in 2 patients (1.9%). Extra-cardiac oversensing (3.8%) represented the leading cause of IAS. No T-wave oversensing episodes were recorded. Twelve patients (11.4%) experienced appropriate shocks. Eight patients (7.6%) died during follow-up. IAS or device-related complications did not impact on mortality (HR 0.5;95%CI 0-4.3;P=0.5; HR 0.7;95%CI 0.1-6.0;P=0.8, respectively).

Conclusions

according to our findings, the IM two-incision technique allows for optimal positioning of the device achieving a low PRAETORIAN score with a high conversion rate. IM two-incision technique allows low incidence of pocket complications, shifting the type of complications towards lead-related complications, which represent the most common complications. The IM two- incision technique would not seem to impact the occurrence of IAS. Management of complications are safe without impact on the outcome.
929 LEADLESS PACEMAKER IMPLANTATION FOLLOWING TRANSVENOUS LEAD EXTRACTION: DATA FROM HIGH-VOLUME REFERRAL CENTERS
Authors: Mitacchione Gianfranco , Schiavone Marco , Arabia Gianmarco , Gasperetti Alessio , Denora Marialessia , Arosio Roberto , Palmisano Pietro , Montemerlo Elisabetta , Manuel Cerini , Russo Giulia , Mazzone Patrizio , Ziacchi Matteo , Pisanò Ennio , Rovaris Giovanni , Gulletta Simone , Steffel Jan , De Asmundis Carlo , Breitenstein Alexander , Biffi Mauro , Battista Chierchia Giovanni , Dello Russo Antonio , Bella Paolo Della , Claudio Tondo , Battista Forleo Giovanni , Curnis Antonio
Published: December 2022

Background

limited data on real-world safety and efficacy of leadless pacemakers (LPMs) in patients who underwent transvenous lead extraction (TLE) are currently available. The present study aims to assess long-term safety and efficacy of LPMs implantation following TLE, compared with LPM de novo implant patients.

Methods

consecutive patients who underwent LPM implantation in 12 centers joining the International LEAdless PacemakEr (i-LEAPER) registry were enrolled end retrospectively considered. Patients receiving LPM following TLE (n=184) were compared with patients with de novo implant (n=995). The primary endpoint was LPM-related complications rate at implant and during follow-up (FU). Additionally, differences in electrical performance were assessed between the two groups.

Results

1179 patients were enrolled in this study and followed for a median of 33 months. LPM related major complications and all-cause mortality did not differ among the two groups (1.6% TLE group vs. 2.2% de novo group, p=0.785, and 5.4% TLE group vs. 7.8% de novo group, p=0.288, respectively). Pacing threshold (PT) resulted higher in the TLE group throughout the whole follow-up (FU) (Figure 1). Higher PTs were recorded in LPMs implanted at same location from where the previous transvenous lead was removed, as far as 24-months postimplant (Figure 2), with a higher proportion of patients with high PT (>1 to 2V @0.24ms) in the first group at implant, 1-month, and 12-month FU (Figure 3).

Conclusion

In this real-world registry, LPMs showed a satisfactory safety and efficacy profile after TLE. In the post-TLE cohort, better electrical parameters were obtained when LPMs were implanted at a different location from where the previous transvenous lead was extracted.
365 ANALYSIS OF PIVOT POINTS AND SLOW CONDUCTION AREAS IN PATIENTS UNDERGOING ATRIAL FIBRILLATION ABLATION
Authors: Pinna Gabriele Diego , Ceriotti Carlo , Poggio Luca , Latini Alessia Chiara , Battaglia Vincenzo , Mincione Gianluca , Del Monaco Guido , Taormina Antonio , Galimberti Paola , Frontera Antonio
Published: December 2022

Introduction

Little is known about progression of atrial fibrillation (AF) from paroxysmal to persistent form. Electrical remodeling may play a pivotal role in the arrhythmia transition. The aim of the study was the characterization of the atrial electrical substrate in patients suffering from AF.

Methods

Twenty-seven patients were included in the study (14 with paroxysmal AF and 13 with persistent AF). Two simultaneous electroanatomical maps of the left atrium were collected using PentaRay catheter using the parallel mapping feature [first map during sinus rhythm and a second one with an extrastimulus from coronary sinus (CS)]. We analyzed the propagation of the wavefront and we identified zones of abnormal conduction: slow conduction (SC) corridors and pivot points (PP). SC corridors were defined by the slowing of conduction velocity; pivot points were zones in which propagation pattern changed the direction of 90° or more. Maximum delay between the recording dipoles located at the extremities of the PentaRay splines was calculated. At each of these sites, EGMs were collected and analyzed in terms of amplitude and duration. We checked if areas of abnormal conduction during sinus rhythm were present or they disappeared by delivering an extrastimulus from the coronary sinus.

Results

The average number of collected EGMs per map was 4790 ± 1333 (PAF 4829 ± 1407; PsAF 4745 ± 1402).

Total abnormal conduction areas in the 27 patients were 62, 65% of which were slow conduction. Pivot points and slow conduction manifested a trend to cluster in some areas: both of them were mostly present at the ostia of pulmonary veins, in a specific segment between LAA ostium and mitral annulus and in the posterior wall. During sinus rhythm, pivot points were 29, while pacing from distal CS catheter the same zones showed normal conduction in 14 cases: they were still present in 60% in PAF group and 50% in PsAF. Slow conduction corridors, instead, show a trend to remain while pacing from CS: 76% in the first group and 78% in the second one.

Conclusions

SC corridors are fixed alterations of atrial substrate, while pivot sites may be more dynamic entities: both of them may have a key role in remodeling atrial structures and atrial fibrillation progression and maintenance. These may represent future targets for AF therapy and prevention.
452 ONE-YEAR OUTCOMES OF DIFFERENT ANTITHROMBOTIC STRATEGIES IN OLDEST OLD STEMI PATIENTS WITH NEW ONSET ATRIAL FIBRILLATION
Authors: Ruzzarin Alessandro , Unterhuber Matthias , Baessato Francesca , Donazzan Luca
Published: December 2022

Introduction

Management of antithrombotic therapy (ATT) in oldest old STEMI patients undergoing percutaneous coronary intervention (PCI) with new onset atrial fibrillation (NOAF) is a clinical conundrum given the gamut of possible ATT strategies and the lack of studies in this population.

We sought to evaluate ATT patterns at discharge and 1-year outcomes in our center.

Methods

A retrospective cohort study of all consecutive oldest old (i.e. over 85 years) STEMI patients undergoing primary PCI (pPCI) was performed at our institution. NOAF was defined according to its documentation within 48 hours of STEMI diagnosis.

Primary outcomes were 1-year major adverse cardiac or cerebrovascular events (MACCE: composite of death, myocardial infarction, stroke, heart failure hospitalization) and major bleeding events (Bleeding Academic Research Consortium 3 or 5).

Results

Among the 248 patients studied, NOAF was detected in 25.4% of patients (mean patient age 88.9±2.4 years, 56.5% females). At logistic regression analysis, baseline chronic kidney disease (eGFR<60 ml/min) was associated to nAF (OR: 2.38, 95% CI: 1.3 to 4.2; p<0.05).The development of heart failure during hospitalization was statistically higher in patients with nAF compared to patients without nAF (p=0.05). At discharge, triple therapy (TT: 1 anticoagulant and 2 antiplatelet agents) was prescribed in 11.5%, dual antiplatelet therapy (DAPT) in 77% and dual therapy (1 anticoagulant plus 1 antiplatelet agent) in 11.5% of patients.

No group differences by ATT strategy were observed in 1-year MACCE (TT 32% vs dual therapy 27.2% vs DAPT 25.7%; p=0.81), or BARC 3,5 (TT 8% vs dual therapy 12.8% vs DAPT 9%; p=0.74).

Conclusions

The high incidence of NOAF in oldest old STEMI patients highlights the need of an adequate calibration between ischaemic and bleeding risk.

Despite differences in the choice of ATT strategy, there were no significant differences in clinical outcomes up to 1 year.
577 PACING LEADS THROMBOSIS IN CHILDREN AND YOUNG ADULTS WITH IMPLANTABLE ELECTRONIC DEVICES: OCCURRENCE OF A RARE COMPLICATION.
Authors: Yammine Marie Laure , Gimigliano Fabrizio , Rinelli Gabriele , Campisi Marta , Battista Virginia , Tamburri Ilaria , Anselmo Saputo Fabio , Stefano Silvetti Massimo , Drago Fabrizio
Published: December 2022

Background

Pacemakers (PMKs) and implantable cardioverter-defibrillators (ICDs) are frequently utilized in patients with specific cardiac rhythm disorders. The downfalls of these devices are several but no data exist regarding leads thrombosis.

Aim of the study

the analysis of pacing lead thrombosis occurrence in paediatric PMK-ICD patients.

Methods

single Centre retrospective study of a series of paediatric/young adult patients showing pacing lead thrombosis. Data are reported as median (interquartile range).

Results

from 2015 to 2021 five patients (2 males), aged 16 (12-22) years, showed transthoracic echocardiographic evidence of lead vegetations during routine follow-up after 5 (1-16) years from lead's initial implantation. Age at device implantation was 9 (5-12) years. Two patients had dual-chamber ICD, 3 had PMKs (2 DDD, 1 VVI). No patient had any early wound complications after implantation. At the time of thrombosis detection, no patient reported any recent fever or symptoms of clinical illness. Devices and leads were normally functioning in all patients. Blood examination revealed absence of infectious or inflammatory signs, and all patients had negative hemocultures for aerobic, anaerobic bacteria and fungi. Therefore, lead thrombosis was diagnosed. Transesophageal echocardiogram (TEE) confirmed the echo finding. Thrombophilia testing revealed that 4 out of 5 patients had methylenetetrahydrofolate reductase (MTHFR) mutation, homozygous and heterozygous (2 each). Patients received oral anticoagulation therapy (OAT) and TEE showed complete recovery in 4 patients after 6-12 months; one adult patient is followed-up elsewhere.

Conclusions

pacing lead thrombosis is a rare complication in paediatric/young adult patients with PMK/ICD, well treated with OAT. MTHFR mutation is a risk factor for this complication.
155 CARDIO PSYCHE: OBSERVATION IN PRACTICAL MEDICINE
Authors: Acquistapace Flavio
Published: December 2022

Background

Our historical period is characterized by speeding evolution of technological processes that have allowed us to achieve excellent results in all fields. The association with the improvement of the quality of life, in its global aspect, is not a so obvious condition. Environmental factors affect more and more our perception of psychophysical health, up to, in the most serious cases, to undermine the same organic functionality, particularly at the cardiovascular level.

Purpose

Our observational study in clinical practice wants, as primary outcome, to evaluate the impact, on subjects showing characteristics of neurovegetative dystonia, of an integration with a homeopathic product (in association with the therapy) on the functional capacity and on the perception of psychophysical health and, as secondary outcome, the control and stabilization of functional parameters related to the cardiovascular system.

Method

50 patients were selected and evaluated for characteristics of homogeneity and adherence. Features of eligibility: anxiety, panic attacks, heart palms, fatigue syndrome, autonomic (nurovegetative) dystonia, insomnia. The evaluation of the therapy by integrating a homeopathic product, where provided, in support of therapies and raise awareness to the correct lifestyle was carried out in two stages based on the following parameters: psychophysical perception of the state of health, through Questionnaire SF-36, specialist cardiological visit. The therapeutic indication provided for the intake of 15 drops of medicine 3 times a day, plus 10 drops (every 10 minutes up to an hour) in case of episodes.

Results and Conclusions

The observational study in real practice indicated an efficacy of the treatment both individually and in support of the therapy, without presenting contraindications. Patients reported an improvement in psychophysical health, also confirmed by medical observation and the improvement of parameters (in particular HR, but also PA, as an adjuvant to stabilization).
1141 CARDIAC METASTASIS
Authors: Ricci Giulia , Vannelli Andrea , Onorato Federica , Morgagni Riccardo
Published: December 2022

Introduction: in medical literature, studies on cardiac metastases are few and discordant and their actual incidence is underestimated. Autoptic examination shows evidence of cardiac metastases in about 9% of all the patients affected by malignant tumor. Each malignant tumor can metastasize to the heart (incidence varying from 2.3% to 18.3%); nevertheless, formation of cardiac metastases is more frequently associated with primitive neoplasms such as pleural mesothelioma (48.4%), melanoma (27.8%), adenocarcinoma as well as lung and kidney carcinomas.

Clinical case: patient aged 66, former smoker, no further cardiovascular disease risk factors, no occurrences of heart disease in his past medical history. In 2008 surgical excision of melanoma skin cancer, negative sentinel lymph node. In 2014 cancer relapse, final cycle of chemotherapy treatment completed in July. In October 2014 evidence of liver and adrenal gland metastases. In November 2014 evidence of bone metastases. As the CT scan showed evidence of pleural and pericardial effusion, the patient was requested to undergo cardiac examination and an echocardiogram test in preparation for further chemotherapy treatment. During the medical examination the patient presented with symptoms of marked asthenia, dyspnea under moderate effort (NYHA II), palpitations. BP: 100/60 mmHg. ECG: low voltages, sinus tachycardia, incomplete RBBB, inverted T waves in V1 – V4, III. Home Therapy: Furosemide 25 mg, Cortisone 25 mg, Tramadolo Cloridrato 50 mg, Albumina. The findings of the echocardiogram test showed: enlarged and hyperkinetic left ventricle, abundant circumferential pericardial effusion measuring up to 2,3 cm. Evidence of hyperechogenic areas in the epicardium, myocardium and at the level of mitral valve flaps (figure 1 and 2). In December 2014 hospital admission due to worsening of clinical symptoms, onset of ascites, hyperpotassemia, anemization (Hb 8.6g/dL). During the 72 hours following hospitalisation: STEMI, acute kidney failure, respiratory failure, metabolic acidosis, death. The autoptic examination showed evidence of undifferentiated large cell neoplasm with formation of metastases in the myocardium, mitral valve apparatus and coronary tree.

Conclusions

echocardiography should always be included in the clinical examinations which patients affected by neoplasm are required to undergo. Serial evaluations allow to identify the occurrence of pericardial effusion and/or heart involvement even in the absence of clinical suspicion. Identifying such anomalies may have important therapeutic implications.