The Impact of COVID-19 Outbreak on Syncope Units Activities in Italy: A Report from the Italian Multidisciplinary Working Group on Syncope (GIMSI).

The aim of our study was to evaluate the impact of the COVID-19 outbreak on Syncope Units (SUs) Activities in Italy. Methods: Data about types of SU activities and admissions were obtained from 10 SUs throughout Italy, certified by the Italian Multidisciplinary Working Group on Syncope (GIMSI), from 10 March 2020 to 31 December 2020 and compared with the same time frame in 2019. Results: A remarkable reduction in overall non-invasive diagnostic tests (-67%; p < 0.001) and cardiac invasive procedure. Elective cardiac pacing procedures disclosed a significant decrease (-62.7%; p < 0.001); conversely, the decrease of urgent procedures was not significant (-50%; p = 0.08). There was a significantly increased rate of patients who underwent both telemedicine follow-up visits (+225%, p < 0.001) and cardiac implantable electronic devices (CIEDs) remote monitoring follow-up visits (+100%; p < 0.001). Conclusion: The COVID-19 outbreak was associated with a remarkable decrease in all clinical activities of Syncope Units in Italy, including both non-invasive tests and cardiac invasive procedures; conversely, a significant increase in telehealth activities was shown.

Cardiac resynchronization therapy as an 'alternative' approach to a non-operable severe aortic stenosis with left ventricular dysfunction.

Severe symptomatic aortic stenosis (AS) is an indication for surgical replacement of the aortic valve in adults. Patients are often affected by comorbidities, and the surgical indication is sometimes problematic. Non-surgical techniques have been developed during the past few years, though their roles have not yet been established. Cardiac resynchronization therapy has been shown to be effective in selected patients, but no data yet exist on the role of this therapy in AS patients. The case is presented of a patient with non-operable severe symptomatic AS and cardiac dissynchrony who showed significant improvement following the implantation of a biventricular pacemaker.

Transesophageal electrical cardioversion of persistent atrial fibrillation: a new approach for an old technology.

BACKGROUND: Low energy intracardiac cardioversion may be considered the elective, alternative method for the acute restoration of sinus rhythm when direct current cardioversion fails or is contraindicated. Transesophageal cardioversion is a further alternative method for the recovery of sinus rhythm and obviates the potential complications of the low energy intracardiac cardioversion venous approach. METHODS: The present prospective study including 30 patients (21 males, 9 females, mean age 65.1 years, range 52-76 years), with persistent atrial fibrillation (mean duration 4.3 months), was undertaken in order to further evaluate, with regard to transesophageal cardioversion: 1) the acute efficacy, 2) the patient acceptance of the procedure, 3) the preferable choice among direct current cardioversion, low energy intracardiac cardioversion and transesophageal cardioversion, 4) the time required to perform the procedure, 5) the incidence of complications, and 6) the persistence of sinus rhythm after 1 month. RESULTS: Sinus rhythm was acutely restored in 29 patients (96.7%). Discomfort induced by the electrical shock was minimal or mild in most patients (75.8%). Transesophageal cardioversion was usually preferred by patients who had been previously submitted to direct current cardioversion or low energy intracardiac cardioversion. The mean total time required to perform the procedure was 107.9 min. No complications related to the procedure occurred. In spite of adequate pharmacological prophylaxis of atrial fibrillation only 41.4% of patients were in sinus rhythm 1 month after successful transesophageal cardioversion. CONCLUSIONS: Transesophageal cardioversion may be considered a very effective, well accepted and non-time consuming procedure for the short-term restoration of sinus rhythm. The incidence of complications is low.

Management of patients with low-risk chest pain at the time of admission: a prospective study on a non-selected population from the Emergency Department.

BACKGROUND: The management of patients with acute chest pain is a common and difficult challenge from the epidemiological, clinical, organizational and malpractice points of view. Our purpose was to test and implement a simple clinical protocol for the management of patients with acute chest pain and at low-risk for an acute coronary syndrome (ACS) at the time of admission to the Emergency Department (ED). METHODS: During a 5-month study period, 570 consecutive patients were admitted to the ED with acute chest pain: 224 patients were excluded owing to the presence of a clear diagnosis of an ACS or of high-risk factors. The remaining 346 were considered, at the time of admission, as being at low risk for an ACS and constituted the study group (208 males, 138 females, mean age 65 years). These 346 patients were evaluated in the ED area by means of multiple ECGs and multiple blood sampling for the creatine kinase-MB mass and troponin I serum levels at the time of admission and 6 and 12 hours later. In selected cases a treadmill stress test was requested in order to further clarify the diagnosis. RESULTS: The ECG at the time of admission was normal or nearly normal in 79% of the patients. Stress testing was performed in 79 patients (25%). Sixty-six/346 low-risk patients (19%) were admitted to the coronary care unit during ED observation: 38 patients because of positive markers, 10 because of a positive ECG, 13 because of positive markers and ECG, and 5 because of a positive stress test. Two hundred and eighty low-risk patients without evidence of acute ischemia were definitively discharged and classified as having non-ischemic chest pain. At 1 month of follow-up, 1 patient underwent coronary artery bypass grafting, 1 patient was again admitted to the ED for acute pulmonary edema, and 2 patients had acute extracardiac events. Within 1 year of follow-up 4 deaths occurred: 2 were cancer-related and 2 were sudden deaths. CONCLUSIONS: The tested strategy, based on integrated clinical, ECG and multimarker data, and on a short "test of time" period of low-risk patient observation, can allow the identification of patients having an ACS on the one hand and of those for whom a safe, rapid and early discharge is possible on the other, in a low-cost environment.

[Safety and effectiveness of dual chamber pacing in patients over 80 years of age with previous episodes of paroxysmal atrial fibrillation]. / Utilità ed appropriatezza della stimolazione bicamerale nell'ultraottantenne con storia di fibrillazione atriale parossistica.

BACKGROUND: Dual chamber pacing (DDD) in the elderly is still a controversial issue because of its short life expectancy and the risk of atrial fibrillation. The aim of the study was 1) to evaluate the cumulative survival and the events capable of modifying it, 2) to evaluate the stability of sinus rhythm, and 3) to try to identify patients who are at a higher risk of developing permanent atrial fibrillation after DDD implantation. We evaluated clinical, electrophysiological and pacing parameters at the time of implantation. METHODS: We examined retrospectively a group of 135 consecutive patients who were > 80 years old and who were treated with DDD in the last decade. RESULTS: At the time of evaluation (mean 33.51 +/- 27.10 months, range 4-148 months) after DDD implantation, 72% of patients were still alive. Sinus rhythm was documented in 96 (71%) patients (group A). Thirty-nine (29%) patients (group B) developed atrial fibrillation after a mean period of 28.56 +/- 30.9 months (range 1-125 months). The right atrial endocavitary signal amplitude was lower in group B compared to that observed in group A (2.6 +/- 1.16 vs 3.27 +/- 1.91 mV). The pacing and sensing atrioventricular delay were not statistically different in both groups. The minimum heart rate was higher in patients who developed atrial fibrillation (64.53 +/- 7.7 vs 67.7 +/- 5.72 b/min respectively in group A and in group B, p = 0.02). Group B patients had a higher rate of atrial fibrillation pre-implantation episodes. The incidences of sick sinus disease and of atrioventricular nodal disease were similar in both groups. CONCLUSIONS: In elderly patients the benefits of DDD are maintained for a long period of time before the development of atrial fibrillation. Episodes of atrial fibrillation prior to DDD, apart from sinus dysfunction alone, are predictive of the development of a permanent atrial fibrillation. Permanent atrial fibrillation does not seem to reduce life expectancy. A higher minimum heart rate does not seem to prevent atrial fibrillation. The capability of recording a right atrial signal amplitude > 3 mV seems to identify those patients with a lower risk of developing atrial fibrillation.

[Proarrhythmic effects of propafenone in a woman with hepatopathy: is it always a simple drug in clinical practice?]. / Effetto proaritmico del propafenone in donna con epatopatia: è sempre un farmaco di semplice utilizzo nella pratica clinica?

A 65-year-old woman with a history of alcoholic liver disease and presenting with fever and vomiting was admitted to an internal medicine unit. In view of recent atrial fibrillation with inadequate heart rate control, digoxin and propafenone were included in the therapeutic regimen. After a few days sinus rhythm was restored but suddenly ventricular arrhythmias with the characteristics of a non-responsive electrical storm arose shortly following the appearance of clinical symptoms of drug intoxication.

[The effects of implementation of heart failure guidelines in the Pordenone province: analysis of the results following databases of the regional health guide system]. / Gli effetti dell'implementazione delle linee guida sullo scompenso cardiaco nella provincia di pordenone: valutazione dei risultati mediante utilizzo delle banche dati del sistema informativo sanitario regionale.

BACKGROUND: The aim of this study was to evaluate the effects of heart failure guideline implementation in the Pordenone province area, by using the regional health system databases. METHODS: We created the provincial registry of hospitalization for heart failure and we defined a set of indicators to assess the adequate use of the hospital facility, the correct use of diagnostic instruments, the appropriate use of medications, the in-hospital, 6-month and 1-year mortality rates. RESULTS: Up to December 31, 2002, 2977 subjects, living in the Pordenone province area, were hospitalized for heart failure (10.4 for 1000 inhabitants). Repeated hospitalizations in the years have percentage values oscillating at around 20%. The average length of hospitalization appeared declining, ranging from 11.1 days in 2000 to 10.3 days in 2002. The in-hospital death rate varied between 16-17%. The cumulative death rate within 6 months (33.2%) and 1 year (41.0%) of hospitalization resulted rather high, also considering the patients' advanced mean age (79 years). The percentage of patients who underwent an echocardiogram as outpatients in the previous year increased from 5.7% in 2000 to 13.1% in 2002. As for therapy, an increase in the percentage of patients treated with ACE-inhibitors (from 44.6 to 50.2%), sartans (from 8.2 to 11.7%), beta-blockers (from 11.7 to 16.7%) and diuretics (from 66.4 to 68.5%) was evident from 2000 to 2001. A mild reduction in the percentage of patients treated with digitalis (from 35.0 to 33.8%) and with calcium antagonists (from 22.4 to 20.9%) was also noted. CONCLUSIONS: The results of this study show that it is possible to use some indicators in evaluating the effects of guideline implementation in heart failure, by using the regional health system data. The final goal is to gradually involve all the professionals in the different phases of the natural course of heart failure patients, particularly the general practitioners.

[Long QT and torsade de pointes in a patient with acquired human immunodeficiency virus infection in multitherapy with drugs affecting cytochrome P450]. / Allungamento del QT e torsione di punta in un paziente con immunodeficienza virale acquisita in multiterapia con farmaci utilizzatori del citocromo P450.

In acquired human immunodeficiency virus (HIV) infection, a long depolarization period at ECG may be the consequence of cardiac complications due to viral myocarditis or cardiomyopathy or indirectly due to autonomic neuropathy, or sometimes resulting from pharmacological treatments. Several drugs administered for direct treatment of HIV disease or its complications, such as antiretrovirus, fluconazole, and antibiotics, may induce ventricular arrhythmias due to long QT prolonged depolarization period. Also methadone, frequently associated with HIV therapy to treat patients with opiate addiction, is described in the literature to have cardiac inotropic effects. It has also the potential to increase the QT period and to develop ventricular torsade de pointes, primarily through interference with the rapid component of the delayed rectifier potassium ion current. Moreover, the use of methadone associated with other inhibitors of cytochrome P450 might increase plasma concentrations and contribute to methadone cardiac toxicity. We report the case of an HIV patient receiving antiretroviral treatment, fluconazole and high-dose methadone, who suddenly complained of vertigo, dizziness, pre-syncope and syncope due to severe ventricular arrhythmias that disappeared after discontinuation of all treatments.

Clinical spectrum of fascicular tachycardia.

AIMS: Ventricular tachycardia spreading from the anterior or posterior division of the left bundle branch is generally called fascicular tachycardia (FT). We will present our experience with FT, a type of ventricular tachycardia not necessarily implying the absence of heart disease and/or sensitivity to selective antiarrhythmic drugs, but only particular routes of left ventricular depolarization. METHODS: Since 1981 we have had the opportunity to study 10 cases of FT (nine men and one woman; aged 28-77 years, mean ±â€ŠSD 55 ±â€Š18.6 years) by means of echocardiography, coronary angiography (seven cases), endomyocardial biopsy (five cases), signal-averaged electrocardiogram (SAECG, nine patients), electrophysiological and electropharmacological evaluation. RESULTS: Seven patients had paroxystic, extrastimulus inducible FT that was sensitive to verapamil given intravenously (group A); three patients, on the other hand, showed repetitive or incessant FT, not modifiable by stimulation techniques and sensitive to class 1 antiarrhythmic drugs (group B). Patients presented histologic substrates ranging from the absence of heart disease to previous myocardial infarction or myocarditis. FT spontaneously disappeared within 2 years in group B, while frequently persisted in the long term in group A. CONCLUSIONS: FT is not a homogeneous group of ventricular tachycardia, as patients may differ according to clinical presentation, mechanisms that are involved in the genesis of the arrhythmia and natural history; the histologic substrate is highly variable, ranging from the total absence of heart disease to severe forms of myocardial involvement.

Severe ventricular dysrhythmias and silent ischemia during infusion of the antimetabolite 5-fluorouracil and cis-platin.

The antimetabolite 5-fluorouracil is frequently used in the therapy of various malignancies. Cardiotoxicity has frequently been described during treatment, but there is no common agreement on the need to perform cardiovascular monitoring of patients during 5-fluorouracil administration. We report the case of a young patient with an head-neck cancer on whom a continuous electrocardiogram recording was performed, documenting serious ventricular dysrhythmias in the presence of myocardial ischemia during 5-fluorouracil and cis-platin infusion.

Dynamic left ventricular outflow tract obstruction in the setting of acute anterior myocardial infarction: a serious and potentially fatal complication?

Dynamic left ventricular outflow tract (LVOT) obstruction was thought to be a hallmark of hypertrophic obstructive cardiomyopathy, especially in those cases with isolated asymmetric septal hypertrophy and systolic anterior motion (SAM) of the mitral valve. Recently, several authors described the occurrence of a dynamic LVOT obstruction during acute coronary insufficiency in ventricles without significant myocardial hypertrophy. The LVOT gradient was reported to disappear following resolution of the ischemic syndrome. Furthermore, it was reported that LVOT obstruction in the setting of acute myocardial infarction could predispose to cardiac rupture. We describe four cases with acute anterior myocardial infarction complicated with a dynamic LVOT obstruction documented by transthoracic Doppler echocardiogram. The detection of the dynamic LVOT obstruction allowed us to optimize the pharmacological treatment in each case. In spite of therapy, two of our patients worsened progressively to fatal cardiogenic shock and cardiac rupture. In conclusion, the development of a LVOT obstruction during acute anterior myocardial infarction has to be considered a serious and potentially fatal complication.