ABSTRACT
Background: COVID-19 pandemic, limiting the availability of anesthesiologists, has impacted heavily on the organization of invasive cardiac procedures such as transcatheter atrial fibrillation (AF) ablation. Purpose: We compared the safety and efficacy of deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision, against the standard protocol performed with propofol. Methods: We retrospectively included all AF ablation procedures performed in 2020: 23 patients sedated with 1% propofol (2 ml bolus followed by infusion starting at 1 mg/Kg/h), 26 patients with dexmedetomidine (infusion starting at 0.7 mcg/Kg/h). Both groups additionally received 1 mcg/Kg of midazolam as a single bolus and 0.05 mg single boluses of fentanyl prior to ablation on each pair of pulmonary veins (PV). Primary outcomes were oxygen desaturation (< 90%) or need for assisted ventilation/intubation, bradycardia (heart rate < 45 bpm) and persistent hypotension (systolic blood pressure < 90 mmHg). Results: Baseline characteristics and hemodynamic variables did not differ between the two groups (all p > 0.05). In 8/23 (35%) patients propofol infusion velocity reduction was necessary to maintain the hemodynamic values, compared to 7/26 (27%) with dexmedetomidine. Inter-group comparison of hemodynamic variables during the procedure showed no statistically significant difference, despite a trend in favor of dexmedetomidine (3 respiratory depressions and 3 persistent hypotension episodes with propofol vs. 0 with dexmedetomidine;p = 0.057). Conclusion: Deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision is safe and effective for AF transcatheter ablation. A trend towards a lower incidence of hypotension and respiratory depression was noted when compared to propofol.
ABSTRACT
Background: COronaVIrus Disease 19 (COVID-19) pandemic is a global health emergency. Since the first reported cases in Asia, the virus has now spread worldwide. Given its high contagiousness, one of the greatest challenges is early detection of infected patients. People affected by COVID-19 have had a wide range of presenting symptoms, from very mild to severe, including fever, cough, shortness of breath, gastrointestinal upset, anosmia and ageusia among others. Syncope as the presenting symptom of COVID-19 has been reported in case series or small sample size retrospective studies with variable results in terms of incidence, characteristics and outcomes. Purpose: The aim of the present analysis is to investigate all consecutive patients with COVID-19 who presented with syncope during the first wave of the pandemic to a high-volume Emergency Department (ED) in Italy. Methods: A total of 569 patients diagnosed with COVID-19 by positive nose and throat swab and admitted to the hospital between February 20th, 2020 (day of first reported COVID-19 case in Italy) and April 23rd, 2020 were retrospectively evaluated. Results: Syncope has been reported as the initial symptom which prompted medical attention in 46 out of 569 patients (8%). Mean age of patients presenting with syncope was 72±15 years, 28 were males. Baseline patients' clinical characteristics are reported in Table 1. In 18 out of 46 patients (39%) syncope was an isolated finding, being fever and cough the two most commonly associated symptoms. Arrhythmic etiology was excluded since no arrhythmia was observed at device interrogation or with ECG/prolonged heart monitoring during hospitalization. No significant abnormalities were present at baseline ECG. At the time of admission, all patients were normotensive, median O2 saturation was 94.5%, median Ddimer 362 ng/ml. One-third of the patients presenting with syncope had a complicated clinical course with quite rapid deterioration requiring noninvasive ventilation (30%) and intensive care unit admission with intubation (11%). In our group of consecutive patients with COVID-19 who presented with syncope, the mortality rate was surprisingly high, 15/46 (32%), compared to the mortality rate of the COVID population admitted to our hospital with other symptoms 93/523 (18%), p=0.023. Six out of 15 patients died in the ED, mainly during their first day of hospitalization. The other 9 had a quite rapid deterioration in the following days and died within a week (median syncope-to-death time was 7 days). Conclusion: Despite our new finding needs confirmation in studies with larger sample size, our report shows how syncope may be the presenting symptom of COVID-19. Whether the exact mechanism has to be demonstrated, the mortality rate in patients presenting with syncope is higher than the mortality rate of patients presenting with other symptoms;therefore COVID-19 patients presenting with syncope should be on a watch list for rapid deterioration.
ABSTRACT
Background: Due to the current CoViD-19 pandemic, the number of outpatient hospital visits has significantly decreased, creating a fundamental need for telemedicine. Remote monitoring of implantable cardiac devices has emerged as a powerful and well-validated tool to follow patients with heart failure (HF) and cardiac resynchronization therapy (CRTs) devices. Purpose: The aim of our study was to evaluate the CRT HeartLogic algorithm performance in the detection of HF episodes in a real-life population followed with remote monitoring. Methods: Fifty-four patient (mean age 73±7 years, 72% males) with HF and reduced left ventricular ejection fraction were implanted with a Heart- Logic-enabled CRT device and were enrolled in the Boston Scientific Latitude remote monitoring platform. Remote data were reviewed every month and at the time of an alert. The HeartLogic nominal value of 16 was used to trigger an alert episode. Patients were then contacted by phone and actions were taken to manage the potential HF condition detected by the alert. Results: During a median follow-up of 12 (6-18) months, the HeartLogic alert was triggered in 9 patients (9/54, 17%). The median time between threshold crossing and a HF clinical event was 11 (2-19) days. The maximum HeartLogic index value was 43 (mean 29±8). Three events occurred after inappropriate discontinuation of HF therapy. All the events required clinical action. Four out of 9 patients required diuretic dosage increase, 1/9 electrical cardioversion for new onset atrial fibrillation, 3/9 hospitalization for i.v. therapy. One patient showed only mild HF symptoms but was found to have concomitant CoViD-19 infection. Conclusion: The HeartLogic algorithm is useful to detect HF worsening and undertake appropriate clinical actions. Telemedicine and device remote monitoring are very helpful tools allowing early detection of HFrelated clinical conditions. This is of utmost importance in the era of CoViD- 19 pandemic, when scheduled access to the hospital for routine follow-up appointments might be limited.