A COVID-19 specific multiparametric and ECG-based score for the prediction of in-hospital mortality: ELCOVID score.

We aimed to develop and validate a COVID-19 specific scoring system, also including some ECG features, to predict all-cause in-hospital mortality at admission. Patients were retrieved from the ELCOVID study (ClinicalTrials.gov identifier: NCT04367129), a prospective, multicenter Italian study enrolling COVID-19 patients between May to September 2020. For the model validation, we randomly selected two-thirds of participants to create a derivation dataset and we used the remaining one-third of participants as the validation set. Over the study period, 1014 hospitalized COVID-19 patients (mean age 74 years, 61% males) met the inclusion criteria and were included in this analysis. During a median follow-up of 12 (IQR 7-22) days, 359 (35%) patients died. Age (HR 2.25 [95%CI 1.72-2.94], p < 0.001), delirium (HR 2.03 [2.14-3.61], p = 0.012), platelets (HR 0.91 [0.83-0.98], p = 0.018), D-dimer level (HR 1.18 [1.01-1.31], p = 0.002), signs of right ventricular strain (RVS) (HR 1.47 [1.02-2.13], p = 0.039) and ECG signs of previous myocardial necrosis (HR 2.28 [1.23-4.21], p = 0.009) were independently associated to in-hospital all-cause mortality. The derived risk-scoring system, namely EL COVID score, showed a moderate discriminatory capacity and good calibration. A cut-off score of ≥ 4 had a sensitivity of 78.4% and 65.2% specificity in predicting all-cause in-hospital mortality. ELCOVID score represents a valid, reliable, sensitive, and inexpensive scoring system that can be used for the prognostication of COVID-19 patients at admission and may allow the earlier identification of patients having a higher mortality risk who may be benefit from more aggressive treatments and closer monitoring.

A modified approach to percutaneous ultrasound-guided left stellate ganglion block for drug-refractory electrical storm: a case report.

Background: The use of percutaneous stellate ganglion block (SGB) in the management of drug-refractory electrical storm (ES) has been increasingly reported in the last years. Few data are available on the safety, duration, and dosage of local anaesthetic used. Case summary: A 66-year-old male patient with a history of ischaemic cardiomyopathy and an implantable cardioverter-defibrillator (ICD) presented to the emergency room complaining several ventricular arrhythmias and ICD shocks received in the last 24 h. He was treated with many lines of anti-arrhythmic drugs but his condition deteriorated with cardiovascular instability and respiratory distress, so he was intubated. The ES still worsened (82 episodes of ventricular arrhythmias), so we performed an ultrasound-guided left SGB, using a modified technique, with success in suppressing the ventricular arrhythmias. The patient was then treated with electrophysiological study and catheter ablation. Discussion: The ultrasound approach to SGB is feasible in emergency setting, and it is safe and effective also using a modified and easier technique in patient with difficult sonographic visualization of the neck structures. Moreover, it is possible and safe to use a combination of short-acting rapid-onset local anaesthetic with a long-lasting one with a good outcome.

Cardiac conduction disorders in young adults: Clinical characteristics and genetic background of an underestimated population.

BACKGROUND: Cardiac conduction disorder (CCD) in patients <50 years old is a rare and mostly unknown condition. OBJECTIVE: We aimed to assess clinical characteristics and genetic background of patients <50 years old with CCD of unknown origin. METHODS: We retrospectively reviewed a consecutive series of patients with a diagnosis of CCD before the age of 50 years referred to our center between January 2019 and December 2021. Patients underwent complete clinical examination and genetic evaluation. RESULTS: We enrolled 39 patients with a median age of 40 years (28-47 years) at the onset of symptoms. A cardiac implantable electronic device was implanted in 69% of the patients. In 15 of 39 CCD index patients (38%), we found a total of 13 different gene variations (3 pathogenic, 6 likely pathogenic, and 4 variants of uncertain significance), mostly in 3 genes (SCN5A, TRPM4, and LMNA). In our cohort, genetic testing led to the decision to implant an implantable cardioverter-defibrillator in 2 patients for the increased risk of sudden cardiac death. CONCLUSION: Patients with the occurrence of CCD before the age of 50 years present with a high rate of pathologic gene variations, mostly in 3 genes (SCN5A, TRPM4, and LMNA). The presence of pathogenic variations may add information about the prognosis and lead to an individualized therapeutic approach.

Interventricular Septal Hematoma Complicating Left Bundle Branch Area Pacing: A Case Report-The Devil Is Not So Black as He Is Painted.

BACKGROUND: This case report outlines the presentation of an emerging complication arising from left bundle branch area pacing (LBBAP). CASE SUMMARY: A 43-year-old male with no history of cardiac problems experienced recurrent episodes of syncope with no prodromal symptoms. During monitoring in the emergency department, the patient underwent an episode of asystole, leading to LBBAP implantation. The procedure encountered technical challenges, resulting in an interventricular septal hematoma and subsequent ventricular arrhythmias. Despite initial concerns, conservative management led to resolution, demonstrated through echocardiographic follow-ups. DISCUSSION: This report underscores the significance of ventricular arrhythmias as indicators of interventricular septal hematoma, providing insights into its diagnosis, management, and implications for LBBAP procedures.

Comparative Study of Lesions Obtained through Radiofrequency between the Irrigated Ablation Catheter with a Flexible Tip and the Non-Irrigated Catheter in Ex Vivo Porcine Hearts.

BACKGROUND: At the same conditions of delivered power and contact force, open-irrigated radiofrequency ablation catheters are believed to create deeper lesions, while non-irrigated ones produce shallower lesions. This ex vivo study aims to directly compare the lesion dimensions and characteristics of an irrigated ablation catheter with a flexible tip and a non-irrigated solid-tip catheter. METHODS: Radiofrequency lesions were induced on porcine myocardial slabs using both open-tip irrigated and non-irrigated standard 4 mm catheters at three power settings (20 W, 30 W, and 40 W), maintaining a fixed contact force of 10 gr. A lesion assessment was conducted including the lesion depth, depth at the maximum diameter, and lesion surface diameters, with the subsequent calculation of the lesion volume and area being undertaken. RESULTS: Irrigated catheters produced lesions with significantly higher superficial widths at all power levels (3.8 vs. 4.4 mm at 20 W; 3.9 mm vs. 4.4 mm at 30 W; 3.8 mm vs. 4.5 mm at 40 W; p = 0.001, p = 0.019, p = 0.003, respectively). Non-irrigated catheters resulted in significantly higher superficial areas at all power levels (23 mm2 vs. 18 mm2 at 20 W; 25 mm2 vs. 19 mm2 at 30 W; 26 mm2 vs. 19 mm2 at 40 W; p = 0.001, p = 0.005, p = 0.001, respectively). Irrigated catheters showed significantly higher values of lesion maximum depth at 40 W (4.6 mm vs. 5.5 mm; p = 0.007), while non-irrigated catheters had a significantly higher calculated volume at 20 W (202 µL vs. 134 µL; p = 0.002). CONCLUSIONS: Radiofrequency ablation using an irrigated catheter with a flexible tip has the potential to generate smaller superficial lesion areas compared with those obtained using a non-irrigated catheter.

Trends in atrial fibrillation-related mortality in Europe, 2008-2019.

AIMS: Update data regarding the atrial fibrillation (AF)-related mortality trend in Europe remains scant. We assess the age- and sex- specific trends in AF-related mortality in the European states between the years 2008 and 2019. METHODS AND RESULTS: Data on cause-specific deaths and population numbers by sex for European countries were retrieved through the publicly available World Health Organization (WHO) mortality dataset for the years 2008 to 2019. AF-related deaths were ascertained when the ICD-10 code I48 was listed as the underlying cause of death in the medical death certificate. To calculate annual trends, we assessed the average (AAPC) annual % change with relative 95% confidence intervals (CIs) using Joinpoint regression. During the study period, 773 750 AF-related deaths (202 552 males and 571 198 females) occurred in Europe. The age-adjusted mortality rate (AAMR) linearly increased from 12.3 (95% CI: 11.2 to 12.9) per 100 000 population in 2008 to 15.3 (95% CI: 14.7 to 15.7) per 100 000 population in 2019 [AAPC: +2.0% (95% CI: 1.6 to 3.5), p < 0.001] with a more pronounced increased among men [AAPC: +2.7% (95% CI: 1.9 to 3.5), p < 0.001] compared to women [AAPC: +1.7% (95% CI: 1.1 to 2.3), p < 0.001] (p for parallelism 0.01). The higher AAMR increased was observed in some eastern European countries such as Latvia, Lithuania and Poland while the lower were mainly clustered in the central Europe. CONCLUSIONS: Over the last decade, the age-adjusted AF-related mortality has increased in Europe especially among males. Disparities still exist between western and eastern European countries.

Ultrasound-Guided Venous Axillary Access Versus Standard Fluoroscopic Technique for Cardiac Lead Implantation: ZEROFLUOROAXI Randomized Trial.

BACKGROUND: Axillary vein puncture (AVP) and cephalic vein surgical cutdown are recommended in international guidelines because of their low risk of pneumothorax and chronic lead complications. Directly visualizing and puncturing the axillary vein under ultrasound guidance reduces radiation exposure, provides direct needle visualization, and lowers periprocedural complications. Our hypothesis is that ultrasound-guided axillary access is safer and more feasible than the standard fluoroscopic technique. OBJECTIVES: The purpose of this study was to assess the efficacy and safety of ultrasound-guided axillary venous access during cardiac lead implantation for pacemakers (PMs) and implantable cardioverter-defibrillator (ICD) implantations. METHODS: Patients were randomized in a 1:1 fashion to either axillary venous access under fluoroscopic guidance or ultrasound-guided axillary venous access. The composite outcome, including pneumothorax, hemothorax, inadvertent arterial puncture, pocket hematoma, pocket infection, lead dislodgement, and death, was evaluated 30 days after implantation. RESULTS: We randomized 270 patients into 2 groups: the standard group for fluoroguided AVP (n = 134) and the experimental group for ultrasound-guided AVP (n = 136). No disparities in baseline characteristics were observed between the groups. The median age of the patients was 81 years, with women comprising 41% of the population. The majority of patients received single- and dual-chamber PMs (87% vs 88%; P = 1.00), and slightly over 10% in both groups received ICDs (13% vs 12%; P = 0.85). In total, we placed 357 leads in PMs and 48 leads in ICDs. Among these, 295 leads were inserted via axillary vein access and 110 via cephalic vein access. Notably, the subclavian vein was never used as a vascular access. The composite outcome was lower in the ultrasound group according to intention-to-treat analysis (OR: 0.55; 95% CI: 0.31-0.99; P = 0.034). The main difference within the composite outcome was the lower incidence of inadvertent axillary arterial puncture in the experimental group (17% vs 6%; P = 0.004). The ultrasound group also exhibited lower total procedural x-ray exposure (10,344 µGy × cm2 vs 7,119 µGy × cm2; P = 0.002) while achieving the same rate of success at the first attempt (61% vs 69%; P = 0.375). CONCLUSIONS: Ultrasound-guided AVP is safer than the fluoroscopy-guided approach because it achieves the same rate of acute success while maintaining low total procedural radiation exposure. Ultrasound AVP should be considered the optimal venous access method for cardiac lead implantation. (Ultrasound Guided Axillary Access vs Standard Fluoroscopic Technique for Cardiac Lead Implantation [ZEROFLUOROAXI]; NCT05101720).

Zero fluoroscopy catheter ablation of premature ventricular contractions: a multicenter experience.

BACKGROUND: Catheter ablation has become an established treatment option for premature ventricular complexes (PVCs). The use of fluoroscopy exposes patients and medical staff to potentially harmful stochastic and deterministic effects of ionizing radiations. We sought to analyze procedural outcomes in terms of safety and efficacy using a "zero fluoroscopy" approach for catheter ablation of PVCs. METHODS: The present retrospective, multicenter, observational study included 131 patients having undergone catheter ablation of PVCs using "zero fluoroscopy" between 2019 and 2020 in four centers compared with another group who underwent the procedure with fluoroscopy. RESULTS: Median age was 51.0 ± 15.9 years old; males were 77 (58.8%). Among the study population, 26 (19.8%) had a cardiomyopathy. The most frequent PVC origin was right ventricular outflow tract (55%) followed by the left ventricle (16%), LVOT and cusps (13.7%), and aortomitral continuity (5.3%). Acute suppression of PVC was achieved in 127 patients (96.9%). At 12 months, a complete success was documented in 109 patients (83.2%), a reduction in PVC burden in 18 patients (13.7%), and a failure was recorded in four patients (3.1%). Only two minor complications occurred (femoral hematoma and arteriovenous fistula conservatively treated). CONCLUSIONS: The PVC ablation with a "zero" fluoroscopy approach appears to be a safe procedure with no major complications and good rates of success and recurrence in our multicenter experience.

A Comparative Assessment of Myocardial Work Performance during Spontaneous Rhythm, His Bundle Pacing, and Left Bundle Branch Area Pacing: Insights from the EMPATHY Study.

BACKGROUND: Physiological pacing has gained significant interest due to its potential to achieve optimal hemodynamic response. This study aimed to assess left ventricular performance in terms of electrical parameters, specifically QRS duration and mechanical performance, evaluated as myocardial work. We compared His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBBAP) to evaluate their effects. METHODS: Twenty-four patients with class I or IIa indications for pacing were enrolled in this study, with twelve patients undergoing HBP implantation and another twelve undergoing LBBAP implantation. A comprehensive analysis of myocardial work was conducted. RESULTS: Our findings indicate that there were no major differences in terms of spontaneous and HBP activation in myocardial work, except for global wasted work (217 mmHg% vs. 283 mmHg%; p 0.016) and global work efficiency (87 mmHg% vs. 82 mmHg%; p 0.049). No significant differences were observed in myocardial work between spontaneous activation and LBBAP. Similarly, no significant differences in myocardial work were found between HBP and LBBAP. CONCLUSIONS: Both pacing modalities provide physiological ventricular activation without significant differences when compared to each other. Moreover, there were no significant differences in QRS duration between HBP and LBBAP. However, LBBAP demonstrated advantages in terms of feasibility, as it achieved better lead electrical parameters compared to HBP (threshold@0.4 ms 0.6 V vs. 1 V; p = 0.045-sensing 9.4 mV vs. 2.4 mV; p < 0.001). Additionally, LBBAP required less fluoroscopy time (6 min vs. 13 min; p = 0.010) and procedural time (81 min vs. 125 min; p = 0.004) compared to HBP.

Trends in age- and sex-specific atrial fibrillation/flutter mortality in Italy between 2003 and 2017.

AIMS: We sought to assess the atrial fibrillation/flutter (AF/AFL) mortality rates and relative trends among the Italian population between 2003 and 2017. METHODS: Data regarding the cause-specific mortality and population size by sex in 5-year age groups were extracted from the World Health Organization (WHO) global mortality database. Decedents reporting the codes I48 were extracted accordingly to the International Classification of Disease-10 (ICD-10) coding system. The age-adjusted mortality rates (AAMRs), with relative 95% confidence intervals (CIs), also stratified by sex, were determined using the direct method. Joinpoint regression analyses were used to identify periods with statistically distinct log linear trends in AF/AFL-related death rates. To calculate nationwide annual trends in AF/AFL-related mortality, we assessed the average annual percentage change (AAPC) and relative 95% CIs. RESULTS: Over the study period, 90 623 (57 109 females) AF-related deaths were recorded. The AF/AFL AAMR increased from 8.1 (95% CI: 7.8-8.2) deaths per 100 000 to 18.7 (16.9-20.0) deaths per 100 000 population. Joinpoint regression analysis revealed a linear increase in age-standardized AF/AFL-related mortality [AAPC: +3.6 (95% CI: 3.0-4.3, P  < 0.0001)] in the entire Italian population. Moreover, the mortality rate increased with age, showing a seemingly exponential distribution with a similar trend between males and females. Although the increase was more pronounced among women [AAPC: +3.7 (95% CI: 3.1-4.3, P  < 0.0001)] compared with men [AAPC: +3.4 (95% CI: 2.8-4.0, P  < 0.0001)], the difference did not reach statistical significance ( P  = 0.16). CONCLUSIONS: In Italy, the AF/AFL-related mortality rates linearly increased from 2003 to 2017.

Non-Vitamin K Antagonist Oral Anticoagulants in Patients with ß-Thalassemia.

Background. Patients with ß-thalassemia have a high incidence of atrial fibrillation (AF) and other supraventricular arrhythmias. The use of non-vitamin K antagonist oral anticoagulants (NOACs) for thromboembolic prophylaxis in patients with ß-thalassemia has not been systematically evaluated. Methods. We enrolled patients with transfusion-dependent ß-thalassemia, who were on treatment with NOACs for thromboembolic prophylaxis of supraventricular arrhythmias. Data on thromboembolic and bleeding events were collected. Results. Eighteen patients were enrolled. The patients had a history of AF (sixteen), typical atrial flutter (five), and atypical atrial flutter (four). The patients were treated with dabigatran (seven), apixaban (five), rivaroxaban (four) or edoxaban (two). The mean follow-up duration was 22 ± 15 months. No thromboembolic events were reported. No major bleedings were observed. Three patients had non-major bleeding events. Two patients reported dyspepsia during treatment with dabigatran and were shifted to a different NOAC. Conclusions. Our study suggests the efficacy and safety of NOACs in patients affected by transfusion-dependent ß-thalassemia.

Impact of Systematic Use of Intracardiac Ultrasound during Transseptal Catheterization in the Electrophysiology Laboratory.

AIMS: To explore the impact of the use of intracardiac echocardiography (ICE) in the ablation of supraventricular arrhythmias requiring transseptal catheterization (TSC), whilst analyzing the reduction in periprocedural complications and complications specifically related to TSC. METHODS: A retrospective multicenter study collecting data from consecutive atrial fibrillation (AF) and supraventricular ablation procedures that required TSC was performed in five Italian centers. Based on physician discretion, TSC was performed with or without ICE. Periprocedural complications, separating all complications from complications directly related to TSC, were collected. Independent predictors of periprocedural complications and TSC-related complications were investigated. RESULTS: A total of 2181 TSCs were performed on 1862 patients at five Italian centers from 2006 to 2021, in 76% of cases by AF ablation and in 24% by ablation of other arrhythmias with a circuit in the left atrium. Overall, 1134 (52%) procedures were performed with ICE support and 1047 (48%) without ICE. A total of 67 (3.1%) complications were detected, 19 (1.7%) in the ICE group and 48 (4.6%) in the no ICE group, p < 0.001. A total of 42 (1.5%) complications directly related to TSC: 0.9% in the ICE group and 3.1% in the no ICE group (p < 0.001). The independent predictors of all complications were age (OR 1,02 95% C.I 1.00-1.05; p = 0.036), TSC with the use of ICE (OR 0.27 95% C.I 0.15-0.46; p < 0.001) and AF ablation (OR 2,25 95%C.I 1.05-4.83; p = 0.037). The independent predictors for TSC complications were age (OR 1.03 95% C.I 1.01-1.06; p = 0.013) and TSC with the use of ICE (OR 0.24 95% C.I 0.11-0.49; p < 0.001). CONCLUSIONS: ICE reduced periprocedural and TSC-related complications during electrophysiological procedures for ablation of left atrial arrhythmias.

Risk Scores for Cardiac Implantable Electronic Device Infection: Which One to Believe In?

Infections are important complications of cardiac implantable electronic devices (CIED), with a high prognostic impact. Several risk factors for CIED infections are known. Different studies have been published proposing different risk scores, in order to preoperatively assess the individual likelihood of developing a CIED infection. Among the different scores, large heterogeneity exists and there is no consensus or convergence on a single score finding large applicability in global practice. The aim of this review is to comprehensively present and analyze all the available risk scores for CIED infection, with particular regard to the evidence of comparison studies.

Three-Dimensional Electro-Anatomical Mapping and Myocardial Work Performance during Spontaneous Rhythm, His Bundle Pacing and Right Ventricular Pacing: The EMPATHY Study.

BACKGROUND: His bundle pacing (HBP) has emerged as an alternative site to right ventricular pacing (RVP) with encouraging outcomes. To date, no study has investigated the systematic approach of three-dimensional electroanatomic mapping (3D-EAM) to guide HBP implantation and to evaluate myocardial activation timing. Furthermore, studies reporting a comprehensive assessment of the ventricular function, using myocardial work (MW) evaluation are lacking. OBJECTIVES: (1) To evaluate the systematic use of the 3D-EAM as a guide to HBP; (2) to assess the electrical and mechanical activations with high-density mapping, comparing spontaneous ventricular activation (SVA), HBP and RVP; (3) to assess the myocardial function through speckle-tracking echocardiography (STE) and MW analysis in SVA, HBP and RVP. METHODS: 3D-EAM was performed in consecutive patients undergoing HBP implantation with a low use of fluoroscopy. All patients were systematically evaluated with high-density mapping, MW and STE. RESULTS: Fifteen patients were enrolled, of whom three had an implant failure (20%). RV activation time was not statistically different between SVA and HBP (103 vs. 104 ms, p = 0.969) but was significantly higher in RVP (133 ms, p = 0.011 vs. SVA and p = 0.001 vs HBP). Global constructive work was significantly lower during RVP (1191 mmHg%) than during SVA and HBP (1648 and 1505 mmHg%, p = 0.011 and p = 0.008, respectively) and did not differ between SVA and HBP (p = 0.075). CONCLUSIONS: 3D-EAM and MW evaluation showed that HBP was comparable to the physiological SVA in terms of activation time and cardiac performance. Compared to both SVA and HBP, RVP was associated with a worse activation timing and ventricular efficiency.

[Heavy metal! A case of severe iron overload and supraventricular arrhythmias in a thalassemia major patient]. / Heavy metal! Un caso di severo accumulo di ferro e aritmie sopraventricolari in paziente con talassemia major.

Cardiovascular complications are among the main causes of mortality and morbidity in patients with thalassemia major. Iron-chelation therapy is essential to prevent the chronic iron overload linked to the need for transfusions and the consequent cardiac hemosiderosis. Despite the wide use of iron-chelation drugs, today it is still possible to find cases of severe iron accumulation. Furthermore, even regardless of iron overload and cardiac dysfunction, the thalassemic patient has a high arrhythmic burden, especially for supraventricular arrhythmias. There are still many doubts and open questions about the management of such patients, especially regarding the correct use of anticoagulant therapy and the best utilization of therapeutic strategies available for rhythm control. The case presented shows how the interventional approach with catheter ablation can be useful also in the acute phase when antiarrhythmic drugs are ineffective and it is not possible to wait for the iron-chelation therapy to take effect.