key: cord-0979011-37z1so4h
authors: Curnis, Antonio; Arabia, Gianmarco; Salghetti, Francesca; Cerini, Manuel; Milidoni, Antonino; Calvi, Emiliano; Beretta, Daniele; Bisegna, Stefano; Ahmed, Ashraf; Mitacchione, Gianfranco; Bontempi, Luca
title: 460 Assessment of long-term arrhytmic sequelae in patients recovering from COVID-19 infection
date: 2021-12-08
journal: Eur Heart J Suppl
DOI: 10.1093/eurheartj/suab127.020
sha: 32410f10b96de13045c96ef2e0437e287dc65061
doc_id: 979011
cord_uid: 37z1so4h

AIMS: COVID-19 has been associated with acute cardiac complications including cardiac arrhythmias. We aimed to assess the prevalence of long-term cardiac arrhythmias in patients recovering from severe COVID-19 infection with proved or suspected of cardiac involvement. METHODS AND RESULTS: All patients with COVID-19 infection discharged from the cardiology department of our institution from the 1 March to the 30 April 2020 were considered eligible for this study. Patients were fitted out with an adhesive patch and a wireless single-lead 24-h electrocardiogram (ECG) Holter monitor (Rooti Rx(®) System, Rooti Labs Ltd, Taipei, Taiwan). RootiRx(®) is a small device consisting of an integrated sensor system, a microelectronic board with memory storage, and an internal rechargeable battery. This system can provide continuous ECG and was set to monitor heart rhythm for 24 h. The Holter system provides also blood pressure measurements and sleep apnea data which are evaluated through chest wall motion/cyclic variation of heart rate and reported along with the sleep efficiency (percentage of time spent asleep while in bed). Arrhythmic findings, sleep apnea detections, and residual COVID-19 symptoms were reported. The study follow-up was performed 174 (range = 166–190) days after hospital discharge in a cohort of 63 (76% males, median age 66 years) patients. New diagnosis of atrial fibrillation (AF) was performed in three sinus rhythm patients (4.8%). Eleven (18%) patients had asymptomatic bradycardia (<45 b.p.m.) with no pauses lasting more than 3 s. Non-sustained ventricular tachycardia (<30 s) episodes were recorded in two (3.2%) patients, while no sustained ventricular arrhythmia was documented. The Holter system indicated the presence of moderate-to-severe obstructive sleep apnea episodes in 33 (53%) patients without known history of sleep disorders. Some previously unrecognized long-lasting COVID-19 symptoms were also described: fatigue (10, 16%), myalgia (3, 4.8%), and impaired attention (1, 1.6%). CONCLUSIONS: Six months after the infection, we performed new diagnoses of AF in patients who recovered from severe COVID-19 infection with proved or suspected cardiac involvement using 24-h Holter monitoring. No other arrhythmias were observed, but the Holter system identified obstructive sleep apnea episodes in half of the patients. A relevant percentage of patients also described persisting symptoms of COVID-19 infection. These findings suggest further prospective studies to better describe long-term arrhythmic manifestations and residual symptoms in patients hospitalized with COVID-19 infection.

Aims: Post-operative atrial fibrillation (POP AF) is frequent in patients who undergo cardiac surgery. However, its prognostic impact in the long-term remains unclear. Methods and results: We followed for an average of 10 6 3 years 1386 patients who underwent a variety of cardiac surgical procedures (cardiac transplantation and surgery for heart failure included) while they were in sinus rhythm. Among 1178 patents without a history of AF, 726 (62%) did not develop AF during the entire duration of the study and 452 (38%) developed new-onset POP AF during the first 30 perioperative days after heart surgery. Other 125 patients with a positive history of paroxysmal or persistent AF were in sinus rhythm at the time of surgery and 87 of them (70%) developed POP AF. Finally, 83 patients had permanent AF when they underwent surgery. All-cause mortality was the primary outcome of the study. We tested the associations of potential determinants with all-cause mortality using univariable and multivariable statistical analyses by means of Cox proportional hazard models. Overall, 473 patients (34%) died during a long-term follow-up. Compared with patients who never developed AF, neither the patients with new-onset POP AF [adjusted HR ¼ 1.31 (95% CI: 0.90-1.89); P ¼ 0.1609], nor those with history of AF at the time of surgery (adjusted HR ¼ 1.33, 95% CI: 0.71-2.49; P ¼ 0.3736) showed a significantly increased risk of mortality ( Figure 1 ). In new-onset POP AF patients, oral anticoagulation was not associated with mortality [adjusted HR ¼ 1.13 (95% CI: 0.83-1.54), P ¼ 0.4299]. Conclusions: In this huge prospective cohort of patients who underwent different types of heart surgery, POP AF was not associated with an increased risk of mortality. In this setting, the role of long-term anticoagulation remains unclear.

204 Permanent his bundle pacing using stylet-driven lead in patients with right atriomegaly: a single-centre experience Leonardo Marinaccio 1 , Francesco Vetta 2 , Eros Rocchetto 3 , Paola Napoli 3 , and Domenico Marchese 1 1 Aulss 6 Euganea, Italy, 2 Saint Camillus International University, Italy, and 3 Biotronik Italia, Italy Aims: His bundle pacing (HBP) is becoming an increasing widespread approach for physiological pacing. However, successful HBP procedure could be hampered by limited implantation tools especially in challenging anatomies. We aimed to report our experience with HBP technique using a novel stylet-driven lead system in patients with right atriomegaly. Methods and results: Consecutive patients with right atrium (RA) volume >25 ml/m 2 in men and >21 ml/m 2 in women who underwent permanent HBP for standard indications were enrolled from March 2020 to March 2021. The tool of first choice for HBP attempt was a stylet-driven lead (Solia S 60, Biotronik) delivered via a dedicated introducer sheath (Selectra 3D, Biotronik). The acute, 1-month and 6-month procedural success rates were assessed. We enrolled 24 patients [median age: 75 (70-79) years, 85% men] with an average RA volume of 50.7 6 7.8 ml/m 2 . At implant, conduction system pacing using stylet-driven lead was achieved in 21 patients (87%): 12 (50%) selective HBP, 6 (25%) non-selective HBP, and 3 (12.5%) left bundle branch area pacing. In the three failures, HBP was further attempted with a lumen-less lead with fixed helix (SelectSecure 3830, Medtronic) with final procedural success in two cases. In the successful cases, there was a significant reduction of QRS duration between paced and spontaneous beats [152.5 (130-167.5) ms vs. 130 (122.5-137.5) ms, P ¼ 0.003]. No lead dislodgment nor significant pacing threshold increase was observed at 1-month (1.30 6 0.76 V@0.4 vs. 1.32 6 0.80 V@0.4 ms, P > 0.9) and 6month follow-up (1.30 6 0.76 V@0.4 vs. 1.38 6 0.97 V@0.4 ms, P ¼ 0.66). Conclusions: In patients with right atriomegaly, the novel stylet-driven lead system showed high implant success rates with stable pacing thresholds. Aims: Recent studies have shown that evolution RL bidirectional rotational mechanical sheath (Cook Medical, USA) is an effective and safe technique for transvenous lead extraction (TLE). We reported our experience with the bidirectional rotational mechanical tools using a multidisciplinary approach highlighting the value of a joint cardiac surgeon and electrophysiologist collaboration. Methods and results: The study population comprised 84 patients (77% male; mean age 65 6 18 years) undergoing TLE. After multidisciplinary evaluation, a combined procedure was considered. The main indication for TLE was infection in 54 cases (64%).Overall, 152 leads were extracted with a mean implant duration of 94 6 63 months (range: 6-421). Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 91.6% (77/84), 97.6% (82/84), and 98.6% (150/152), respectively. Eighteen combined procedures were performed in 12 patients (14%), such as 'hybrid approach' (n ¼ 2) or TLE concomitant to: (i) transcatheter aspiration procedure for large vegetation (n ¼ 8); (ii) left ventricular assistance device implantation as bridge to cardiac transplantation (n ¼ 1); (iii) permanent pacing with epicardial leads (n ¼ 6); and (iv) tricuspid valve replacement (n ¼ 1).One major complication (1.2%) and 11 (13%) minor complications were encountered. No injury to the superior vena cava occurred and no procedure-related deaths were reported. During a mean time follow-up of 21 6 18 months, 17 patients (20%) died. They were more often diabetics (P ¼ 0.02), and they underwent TLE more often for infection (P ¼ 0.004). Conclusions: Our results support the finding that excellent outcomes can be achieved in performing TLE of chronically implanted leads by using the evolution RL bidirectional rotational mechanical sheath and a multidisciplinary team approach involving both electrophysiologist and cardiac surgeon as first line operators. Aims: COVID-19 has been associated with acute cardiac complications including cardiac arrhythmias. We aimed to assess the prevalence of long-term cardiac arrhythmias in patients recovering from severe COVID-19 infection with proved or suspected of cardiac involvement. Methods and results: All patients with COVID-19 infection discharged from the cardiology department of our institution from the 1 March to the 30 April 2020 were considered eligible for this study. Patients were fitted out with an adhesive patch and a wireless single-lead 24-h electrocardiogram (ECG) Holter monitor (Rooti Rx V R System, Rooti Labs Ltd, Taipei, Taiwan). RootiRx V R is a small device consisting of an integrated sensor system, a microelectronic board with memory storage, and an internal rechargeable battery. This system can provide continuous ECG and was set to monitor heart rhythm for 24 h. The Holter system provides also blood pressure measurements and sleep apnea data which are evaluated through chest wall motion/ cyclic variation of heart rate and reported along with the sleep efficiency (percentage of time spent asleep while in bed). Arrhythmic findings, sleep apnea detections, and residual COVID-19 symptoms were reported. The study follow-up was performed 174 (range ¼ 166-190) days after hospital discharge in a cohort of 63 (76% males, 655 Figure Combined procedure consisting of transvenous lead extraction of a CRT-D device using the bidirectional rotational mechanical sheath, transcatheter aspiration using an extracorporeal circuit for large vegetations attached to the ICD lead and implantation of a permanent left ventricular epicardial pacing lead for absence of spontaneous rhythm and severe systolic dysfunction. Collaboration between electrophysiologists and cardiac surgeon during the procedure (A).Transesophageal echocardiography view during the procedure, showing a large vegetation adhering to the ICD lead course in the right atrium (B). Fluoroscopy view during the procedure (C). CRT-D, cardiac resynchronization therapy-defibrillator and ICD, implantable cardioverter defibrillator. median age 66 years) patients. New diagnosis of atrial fibrillation (AF) was performed in three sinus rhythm patients (4.8%). Eleven (18%) patients had asymptomatic bradycardia (<45 b.p.m.) with no pauses lasting more than 3 s. Non-sustained ventricular tachycardia (<30 s) episodes were recorded in two (3.2%) patients, while no sustained ventricular arrhythmia was documented. The Holter system indicated the presence of moderate-to-severe obstructive sleep apnea episodes in 33 (53%) patients without known history of sleep disorders. Some previously unrecognized long-lasting COVID-19 symptoms were also described: fatigue (10, 16%), myalgia (3, 4.8%), and impaired attention (1, 1.6%). Conclusions: Six months after the infection, we performed new diagnoses of AF in patients who recovered from severe COVID-19 infection with proved or suspected cardiac involvement using 24-h Holter monitoring. No other arrhythmias were observed, but the Holter system identified obstructive sleep apnea episodes in half of the patients. A relevant percentage of patients also described persisting symptoms of COVID-19 infection. These findings suggest further prospective studies to better describe long-term arrhythmic manifestations and residual symptoms in patients hospitalized with COVID-19 infection. Aims: 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 and results: 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 haemodynamic 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. 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 three cases, in addition to rotational mechanical sheaths and laser sheaths in one case, 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. Conclusions: 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.

Gianfranco Mitacchione 1 , Marco Schiavone 1 , Gianmarco Arabia 2 , Francesca Salghetti 2 , Manuel Cerini 2 , Alessio Gasperetti 1 , Murizio Viecca 1 , Antonio Curnis 2 , and Giovanni Forleo 1

were prospectively considered at the Cardiology Department of Spedali Civili Hospital (Brescia) and Luigi Sacco Hospital (Milan). R-wave sensing amplitude (mV), pacing impedance (Ohm), and PT (V@0.24 ms) were recorded twice: upon Micra final positioning, and after removal of the delivery system. All pts received a follow-up visit at 1-and 12-month after discharge. Electrical parameters were recorded at each visit. A total of 93 pts underwent Micra-VR implantation were enrolled

Conversely, PT significantly decreased of 22.1% at 12-month follow-up respect to baseline

Among patients with high PT, acute increase of R-wave sensing of 1.5 mV after 14 6 4 min significantly predicted PT normalization ( 1 V@0.24 ms) 12 months post-implant (R ¼ 0

Aims: Cardiac implantable electronic devices (CIEDs) may sustain damages during a course of radiation therapy, especially when the beam is directed onto the pulse generator, with device electrical reset and/or sudden battery drain. 2010 HRS/ASA expert consensus, and all CIEDs manufacturers, recommend to avoid devices direct irradiation with an accumulated dose that exceed five grays (Gy). In our prospective study, we tested the effects of direct irradiation on CIEDs with different radiation doses, also higher than 5 Gy. Methods and results: Thirty-seven CIEDs of Medtronic, Abbott, Biotronik, and Boston Scientific were collected during system upgrading or lead extraction procedures. All devices were considered if they had at least 80% of residual battery capacity. All CIEDs were programmed with same default electrical parameters. Depending by CIED type, pacing mode was configured in VVI, VVIR, VDDR, or DDDR, and biventricular stimulation was activated, if present. ICDs electrical therapies were set-up with a pre-determined configuration. All devices were singularly placed in a 30 cm  30cm plastic bowl containing 2 l of deionized water that was placed over 5 cm Rockwool to simulate the backscatter and irradiated by a linear accelerator (Elekta Synergy V R ). CIEDs were divided into two groups depending on irradiation dose delivered: 5 Gy and 10 Gy. No significant differences in battery drainage were observed after irradiation respect to baseline in 5 Gy as well 10 Gy group [7.9 6 3.1 vs. 7.5 6 2.1 (years) battery longevity, P ¼ 0.693; 7.7 6 3.1 vs. 7.4 6 2.1 (years) battery longevity, P ¼ 0.677, respectively) (Figure) . Moreover, all CIEDS saved the baseline program setting, without device reset events (Table) . Conclusions: Our data confirm that CIEDs direct irradiation of 5 Gy is safe, of note, direct irradiation up to 10 Gy seems to be similarly safe concerning the risk of CIEDs electrical reset and/or unexpected battery drain.536 Intraoperative predictors of long-term pacing threshold improvement in leadless pacemakers