Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective.

BACKGROUND: Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing. METHODS: Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA2DS2VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up. RESULTS: Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure. CONCLUSION: Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed.

COVID-19 pandemic and elderly: is the curtain dropped for urgent pacemaker implantations?

BACKGROUND: Permanent cardiac pacing is the therapy of choice for treating severe and/or symptomatic bradyarrhythmia. During the COVID-19 outbreak, it has been reported a decrease in the incidence of acute coronary syndrome, but few data are available about pacemaker implantation rates. This study aimed to analyze patients referred to our center with permanent cardiac pacing indication during the COVID-19 outbreak. METHODS: We compared the number, the characteristics and the outcomes of patients who underwent urgent pacemaker implantation between March and April 2019 (Group I) with those performed in the corresponding 2020 period (Group II). RESULTS: A total of 27 patients (Group I) were implanted in March-April 2019 and 34 patients (Group II) in the corresponding 2020 period. In both groups, about half of the patients received a dual-chamber pacemaker. No significant differences in baseline patients' characteristics were observed. The most frequent indication was advanced atrio-ventricular block with a prevalence of 78% and 62% in Group I and II, respectively. The rate of procedural complications, the in-hospital and 1-month mortality were also similar between the two groups. CONCLUSIONS: In our regional referral center, we observed a routine activity in terms of urgent pacemaker implantations for the treatment of symptomatic bradyarrhythmia during the COVID-19 outbreak.

Home delivery of the communicator for remote monitoring of cardiac implantable devices: a multicentre experience during the COVID-19 lockdown

Aims During the COVID-19 pandemic in-person visits for patients with cardiac implantable electronic devices should be replaced by remote monitoring (RM), in order to prevent viral transmission. A direct home-delivery service of the RM communicator has been implemented at 49 Italian arrhythmia centres. Methods and results According to individual patient preference or the organizational decision of the centre, patients were assigned to the home-delivery group or the standard in-clinic delivery group. In the former case, patients received telephone training on the activation process and use of the communicator. In June 2020, the centres were asked to reply to an ad hoc questionnaire to describe and evaluate their experience in the previous 3 months. RM was activated in 1324 patients: 821 (62%) received the communicator at home and the communicator was activated remotely. Activation required one additional call in 49% of cases, and the median time needed to complete the activation process was 15 min (25th–75th percentile: 10–20). 753 (92%) patients were able to complete the correct activation of the system. At the time when the questionnaire was completed, 743 (90%) communicators were regularly transmitting data. The service was generally deemed useful (96% of respondents) in facilitating the activation of RM during the COVID-19 pandemic and possibly beyond. Conclusions Home delivery of the communicator proved to be a successful approach to system activation, and received positive feedback from clinicians. The increased use of a RM protocol will reduce risks for both providers and patients, while maintaining high-quality care.