Peter Sleight: visionary cardiologist and inspiring leader

Mervyn George Bishop/Fairfax Media/Getty Images Peter Sleight, a professor at Oxford University, helped to transform heart attack treatment and prevent cardiovascular disease with angiotensin converting enzyme inhibitors and statins. Isis methodology influenced the design of studies into other conditions, including the Recovery trial, which showed that dexamethasone reduces covid-19 mortality. [...]unlike many eminent men, he was able, endearingly, to laugh at himself—for example, when medical students lampooned him as Professor BA Flight after he had flown to Tokyo for the day. In the last 10 years of his life, he generated global media interest after demonstrating with his Italian colleague Luciano Bernardi that certain musical rhythms lowered blood pressure.

Development of a carpark cardiac implantable electronic device clinic to improve time efficiency and patient satisfaction in the context of restrictions imposed by the COVID-19 pandemic.

INTRODUCTION: We evaluated time efficiency and patient satisfaction of a "car park clinic" (CPC) compared to traditional face-to-face (F2F) during the COVID-19 pandemic. METHODS: Consecutive patients attending CPC between September 2020 and November 2021 were surveyed. CPC time was recorded by staff. F2F time was reported by patients and administrative data. RESULTS: A total of 591 patients attended the CPC. A total of 176 responses were collected for F2F clinic. Regarding satisfaction, 90% of CPC patients responded "happy" or "very happy." 96% reported feeling "safe" or "very safe." Patients spent significantly less time in CPC compared to F2F (17 ± 8 vs. 50 ± 24 min, p < .001). CONCLUSION: CPC had excellent patient satisfaction and superior time efficiency compared to F2F.

Five waves of COVID-19 pandemic in Italy: results of a national survey evaluating the impact on activities related to arrhythmias, pacing, and electrophysiology promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

BACKGROUND: The subsequent waves of the COVID-19 pandemic in Italy had a major impact on cardiac care. METHODS: A survey to evaluate the dynamic changes in arrhythmia care during the first five waves of COVID-19 in Italy (first: March-May 2020; second: October 2020-January 2021; third: February-May 2021; fourth: June-October 2021; fifth: November 2021-February 2022) was launched. RESULTS: A total of 127 physicians from arrhythmia centers (34% of Italian centers) took part in the survey. As compared to 2019, a reduction in 40% of elective pacemaker (PM), defibrillators (ICD), and cardiac resynchronization devices (CRT) implantations, with a 70% reduction for ablations, was reported during the first wave, with a progressive and gradual return to pre-pandemic volumes, generally during the third-fourth waves, slower for ablations. For emergency procedures (PM, ICD, CRT, and ablations), recovery from the initial 10% decline occurred in most cases during the second wave, with some variability. However, acute care for atrial fibrillation, electrical cardioversions, and evaluations for syncope showed a prolonged reduction of activity. The number of patients with devices which started remote monitoring increased by 40% during the first wave, but then the adoption of remote monitoring declined. CONCLUSIONS: The dramatic and profound derangement in arrhythmia management that characterized the first wave of the COVID-19 pandemic was followed by a progressive return to the volume of activities of the pre-pandemic periods, even if with different temporal dynamics and some heterogeneity. Remote monitoring was largely implemented during the first wave, but full implementation is needed.

Single-center experience of temporary-permanent pacemaker use in COVID-19 patients supported with veno-venous ECMO: A case series.

INTRODUCTION: In the first year of the COVID-19 pandemic, nine out of 129 patients (7%) developed life-threatening bradycardia episodes ultimately requiring a TPPM, whilst being supported with VV-ECMO for severe COVID-19 ARDS in our tertiary cardio-pulmonary failure center. ANALYSIS: All subjects had asystole due to sinus node dysfunction and experienced at least one episode involving cardiopulmonary resuscitation. Most bradycardic events were seen in the context of vagal hypersensitivity. Mean time from general ICU admission to TPPM insertion was 20.6 ± 8.9 days. One patient developed a large chest wall hematoma weeks after TPPM implantation, no other TPPM-related issues were observed. No patient required a long-term pacing system. Six-months survival rate was high (89%). CONCLUSION: These findings suggested that transient life-threatening sinus node disease is not uncommon in ECMO-dependent COVID-19 ARDS patients. TPPM with an active fixation lead is sometimes needed to facilitate ongoing ICU care, however, long-term permanent pacing was not required.

Cardiac device implantation and complications in the west of Ireland, 6 years and a pandemic later

IntroductionThe rate of cardiac device insertion continues to rise worldwide, largely due to an aging population but also from technical advances. While these devices confer a clinical benefit, they are also associated with many complications that can cause significant morbidity and financial burden. Our aim was to re-look at rates of implanted cardiac devices in our centre and compare it to a previous 2014 study and the most recent ESC quality indicators for the care and outcomes of cardiac pacing.MethodsWe collected data retrospectively on cardiac device implantation from January to June 2020 in Galway. Patients were identified via device database and complications were recorded as per discharge summaries and documentation available on Evolve IT system.Results164 patients underwent cardiac device implantation from January to June 2020 with 37 (22.6%) of these performed in a private hospital owing to Covid restrictions on activity in UHG. 115 (70.1%) were male;with a mean age of 72.4 (± 13.4 years), similar to previous study (mean 74.8). The most common procedure was pacemaker insertion;85 (51.8%) with the majority being dual chamber at 56 (65.8%), reduced from 2014 at which time pacemakers accounted for 85% of procedures. The most common indication for a pacemaker was symptomatic bradyarrhythmia or pauses;50 (30.5%). Temporary pacing was required in 12 patients (7.3%). ICD accounted for 36 (22%), with 22 (61%) for primary prevention and 14 (38.9%) for secondary prevention. 4 patients had a CRT device inserted with all of them being an upgrade from an existing device. Routine change of generator for end of life accounted for 35 procedures (21.3%). Our patient population had an average of 4.6 comorbidities (SD 2.3), with hypertension, coronary artery disease and atrial fibrillation being the most common. In line with ESC recommendations, most patients (83.5%) received prophylactic antibiotics 1hr pre incision, commonly Flucloxacillin. 15 patients (9.1%) experienced a complication (average age 72 years), including: lead dislodgement 2 (1.2), pneumothorax 3 (1.8%), hematoma 4 (2.4%), pericardial effusion 1 (0.6%), ventricular perforation 1 (0.6%) and replant revision 3 (1.8%). Of the 4 hematoma patients, 1 was on NOAC, 1 therapeutic Enoxaparin and 2 were taking Aspirin monotherapy. Among the 3 patients who experienced an infection, 2 had hypertension, hyperlipidaemia, diabetes and heart failure. Finally, 94 (57%) received the recommended device check within 2–12 weeks of insertion with a mean waiting time of 70 days (IQR 53.5 – 113.5).ConclusionDespite the pandemic, UHG has managed to find alternative solutions to ensure an ongoing high volume of device insertions with a relatively low rate of complications in an at-risk aging population. Potential areas for quality improvement in the future could include: changes to the admission proforma to make important information easier to collect and more timely follow-up post-implantation.

Remote monitoring of chronic noncommunicable diseases: potential in the COVID-19 pandemic

Aim. To review the current progress in the use of remote health monitoring (RHM) technologies for chronic noncommunicable diseases (CNCD). To search for data, we used Web of Science, Scopus, Russian Science Citation Index, Academic Search Complete (EBSCO), Cochrain, and PubMed databases. The date range was 5-10 years. The importance of development of RHM technologies and their further study was shown to confirm the evidence of effect of certain RHM systems. New approaches to the integration of the medical community into the international telemedicine strategy are considered. It was established that RHM can potentially decrease treatment costs and reduce the burden on medical organizations. The review analyzes the experience in using RHM in patients with cardiovascular diseases, as well as respiratory and endocrine disorders. The review also summarizes and systematizes the findings of studies on assessing the effectiveness of RHM technologies in clinical practice, including their use in the COVID-19 pandemic. It is noted that despite high interest of the scientific community in the study of RHM technologies, unambiguous results demonstrating the effectiveness of such developments in clinical practice have not been presented.

Electro-fluid-mechanics of the heart

This article presents an overview of the dynamics of the human heart and the main goal is the discussion of its fluid mechanic features. We will see, however, that the flow in the heart can not be fully described without considering its electrophysiology and elastomechanics as well as the interaction with the systemic and pulmonary circulations with which it is strongly connected. Biologically, the human heart is similar to that of all warm-blooded mammals and it satisfies the same allometric laws. Since the Paleolithic Age, however, humans have improved their living conditions, have modified the environment to satisfy their needs and, more recently, have developed advanced medical knowledge which has allowed triple the number of heartbeats with respect to other mammals. In the last century, effective diagnostic tools, reliable surgical procedures and prosthetic devices have been developed and refined leading to substantial progress in cardiology and heart surgery with routine clinical practice which nowadays cures many disorders, once lethal. Pulse duplicators have been built to reproduce the pulsatile flow and ‘blood analogues’, have been realized. Heart phantoms, can attain deformations similar to the real heart although the active contraction and the tissue anisotropy still can not be replicated. Numerical models have also become a viable alternative for cardiovascular research: they do not suffer from limitations of material properties and device technologies, thus making possible the realization of truly digital twins. Unfortunately, a high-fidelity model for the whole heart consists of a system of coupled, nonlinear partial differential equations with a number of degrees of freedom of the order of a billion and computational costs become the bottleneck. An additional challenge comes from the inherent human variability and the uncertainty of the heart parameters whose statistical assessment requires a campaign of simulations rather than a single deterministic calculation;reduced and surrogate models can be employed to alleviate the huge computational burden and all possibilities are currently being pursued. In the era of big data and artificial intelligence, cardiovascular research is also advancing by exploiting the latest technologies: equation-based augmented reality, virtual surgery and computational prediction of disease progression are just a few examples among many that will become standard practice in the forthcoming years.

Teledermatology versus Face-to-Face Dermatology: An Analysis of Cost-Effectiveness from Eight Studies from Europe and the United States.

(1) Background: The aim of this systematic review was to compare the cost-effectiveness of two follow-up methods (face-to-face and telemedicine) used in dermatology in the last ten years. (2) Methods: A search for articles that included economic analyses was conducted in August 2021 in the databases PubMed, Medline, Scielo and Scopus using the following keywords: "Cost-Benefit Analysis", "Dermatology", "Telemedicine", "Primary Health Care", as well as other search terms and following the PICOS eligibility criteria. (3) Results: Three clinical trials and five observational studies were analyzed, providing information for approximately 16,539 patients (including four cost-minimization or saving analyses, three cost-effectiveness analyses, and one cost-utility analysis) in Europe and the United States. They describe the follow-up procedures in each of the cases and measure and analyze the direct and indirect costs and effectiveness. All the articles indicate that teledermatology lowers costs and proves satisfactory to both patients and professionals. (4) Conclusions: Although it has been found that follow-up via teledermatology can be more efficient than traditional hospital follow-up, more work is needed to establish evaluation protocols and procedures that measure key variables more equally and demonstrate the quality of the evidence of said studies.

GENDER AND REGIONAL DISPARITIES IN EMERGENCY ARRHYTHMIA PROCEDURES DURING COVID-19 LOCKDOWN

Objectives: Worldwide reduction in emergency procedures has been observed during the current COVID-19 pandemic. The effects of the pandemic and its associated lockdown on arrhythmia related emergency procedures is not known. This study was done to see the effects of the COVID-19 pandemic lockdown on provision of emergency arrhythmia procedures and to identify vulnerable patient groups that may be disproportionately affected during lockdown. Methodology: Data for patients requiring emergency intracardiac devices including temporary and permanent pacemakers was collected from three public sector hospitals of Sindh, Pakistan, for the COVID-19 lockdown period of March to May 2020. This was compared to the data for the same period for 2019. Results: Patients presenting during lockdown decreased by 32.8% (from 250 to 168) compared to the same period without lockdown. The decline was across all emergency procedures considered. There was a more than fivefold reduction in the number of patients in patients from outside the metropolitan area of the hospital (64.3%) compared to those residing within the city (12.5%) (p=0.001). There was a trend showing women to be more effected, with the percentage decline in women being statistically significant in the rural setting (-93.8% vs. -52.9%, p=0.043). All age groups were equally affected (p=0.152). Conclusion: A marked reduction in the number of patients who presented for emergency intra cardiac devices and TPM procedures was seen during COVID-19 lockdown. The patients who presented from outside the city of the hospital and women in rural setting were significantly more effected.

Cardiac implantable electronic devices procedures and their recipients characteristic during COVID-19 pandemic: 3.8 million population analysis.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic disorganised healthcare systems and has caused a reduction in the number of hospitalizations and procedures. Cardiac implantable electronic device (CIED) procedure rates and clinical characteristics of their recipients were compared in corresponding weeks of 2019 and 2020 were analyzed. METHODS: The database of the National Health Fund (NHF) in Poland was retrospectively analyzed. 3206 patients who underwent CIED implantation in the Silesia - a region in Southern Poland comprising an adult population of 3.8 million between 12th and 31st week of 2020. Patients were classified into groups: the recipient of an implantable cardioverter-defibrillator or cardiac resynchronization therapy group (ICD/CRT) or pacemaker group (PM). RESULTS: During the pandemic a reduction of 39.38% of implantations was observed compared to the same period in 2019 (1210 vs. 1996 patients) and had impacted both groups. Two phases lasting 10 weeks each could be distinguished: total lockdown (maximal reduction) and the recovery phase with growing numbers of procedures. Patient baseline characteristics (sex, age, comorbidities) who were implanted during the COVID-19 pandemic did not differ from the 2019 period. The rate of peri-procedural mortality was also similar. CONCLUSIONS: During COVID-19 pandemic period a reduction in CIED implantations of all types was observed. Despite the decreased number of performed CIED implants, no differences in baseline patient characteristics were observed.

Knowledge Update on the Economic Evaluation of Pacemaker Telemonitoring Systems.

(1) Introduction: In the last two decades, telemedicine has been increasingly applied to telemonitoring (TM) of patients with pacemakers; however, presently, its growth has significantly accelerated because of the COVID-19 pandemic, which has pushed patients and healthcare workers alike to seek new ways to stay healthy with minimal physical contact. Therefore, the main objective of this study was to update the current knowledge on the differences in the medium-and long-term effectiveness of TM and conventional monitoring (CM) in relation to costs and health outcomes. (2) Methods: Three databases and one scientific registry were searched (PubMed, EMBASE, Scopus, and Google Scholar), with no restrictions on language or year of publication. Studies published until July 2021 were included. The inclusion criteria were: (a) experimental or observational design, (b) complete economic evaluation, (c) patients with implanted pacemakers, and (d) comparison of TM with CM. Measurements of study characteristics (author, study duration, sample size, age, sex, major indication for implantation, and pacemaker used), analysis, significant results of the variables (analysis performed, primary endpoints, secondary endpoints, health outcomes, and cost outcomes), and further miscellaneous measurements (methodological quality, variables coded, instrument development, coder training, and intercoder reliability, etc.) were included. (3) Results: 11 studies met the inclusion criteria, consisting of 3372 enrolled patients; 1773 (52.58%) of them were part of randomized clinical trials. The mean age was 72 years, and the atrioventricular block was established as the main indication for device implantation. TM was significantly effective in detecting the presence or absence of pacemaker problems, leading to a reduction in the number of unscheduled hospital visits (8.34-55.55%). The cost of TM was up to 87% lower than that of CM. There were no significant differences in health-related quality of life (HRQoL) and the number of cardiovascular events. (4) Conclusions: Most of the studies included in this systematic review confirm that in the TM group of patients with pacemakers, cardiovascular events are detected and treated earlier, and the number of unscheduled visits to the hospital is significantly reduced, without affecting the HRQoL of patients. In addition, with TM modality, both formal and informal costs are significantly reduced in the medium and long term.

Environmental Fe, Ti, Al, Cu, Hg, Bi, and Si Nanoparticles in the Atrioventricular Conduction Axis and the Associated Ultrastructural Damage in Young Urbanites: Cardiac Arrhythmias Caused by Anthropogenic, Industrial, E-Waste, and Indoor Nanoparticles.

Air pollution exposure is a risk factor for arrhythmia. The atrioventricular (AV) conduction axis is key for the passage of electrical signals to ventricles. We investigated whether environmental nanoparticles (NPs) reach the AV axis and whether they are associated with ultrastructural cell damage. Here, we demonstrate the detection of the shape, size, and composition of NPs by transmission electron microscopy (TEM) and energy-dispersive X-ray spectrometry (EDX) in 10 subjects from Metropolitan Mexico City (MMC) with a mean age of 25.3 ± 5.9 and a 71-year-old subject without cardiac pathology. We found that in every case, Fe, Ti, Al, Hg, Cu, Bi, and/or Si spherical or acicular NPs with a mean size of 36 ± 17 nm were present in the AV axis in situ, freely and as conglomerates, within the mitochondria, sarcomeres, lysosomes, lipofuscin, and/or intercalated disks and gap junctions of Purkinje and transitional cells, telocytes, macrophages, endothelium, and adjacent atrial and ventricular fibers. Erythrocytes were found to transfer NPs to the endothelium. Purkinje fibers with increased lysosomal activity and totally disordered myofilaments and fragmented Z-disks exhibited NP conglomerates in association with gap junctions and intercalated disks. AV conduction axis pathology caused by environmental NPs is a plausible and modifiable risk factor for understanding common arrhythmias and reentrant tachycardia. Anthropogenic, industrial, e-waste, and indoor NPs reach pacemaker regions, thereby increasing potential mechanisms that disrupt the electrical impulse pathways of the heart. The cardiotoxic, oxidative, and abnormal electric performance effects of NPs in pacemaker locations warrant extensive research. Cardiac arrhythmias associated with nanoparticle effects could be preventable.

Digital health in electrophysiology and the COVID-19 global pandemic.

The tools of digital health are facilitating a much-needed paradigm shift to a more patient-centric health care delivery system, yet our health care infrastructure is firmly rooted in a 20th-century model that was not designed to receive medical data from outside the traditional medical environment. COVID-19 has accelerated this adoption and illustrated the challenges that lie ahead as we make this shift. The diverse ecosystem of digital health tools share 1 feature in common: they generate data that must be processed, triaged, acted upon, and incorporated into the longitudinal electronic health record. Critical abnormal findings must be identified and acted upon rapidly, while semi-urgent and noncritical data and trends may be reviewed within a less urgent timeline. Clinically irrelevant findings, which presently comprise a significant percentage of the alerts, ideally would be removed to optimize the high-cost, high-value resource (ie, the clinicians' attention and time). We need to transform our established health care infrastructure, technologies, and workflows to be able to safely, effectively, and efficiently manage the vast quantities of data that these tools will generate. This must include new technologies from industry as well as expert consensus documents from medical specialty societies, including the Heart Rhythm Society. Ultimately, research will be fundamental to inform effective development and implementation of these tools.

Bradyarrhythmias in patients with COVID-19: Marker of poor prognosis?

BACKGROUND: Despite descriptions of various cardiovascular manifestations in patients with coronavirus disease 2019 (COVID-19), there is a paucity of reports of new onset bradyarrhythmias, and the clinical implications of these events are unknown. METHODS: Seven patients presented with or developed severe bradyarrhythmias requiring pacing support during the course of their COVID-19 illness over a 6-week period of peak COVID-19 incidence. A retrospective review of their presentations and clinical course was performed. RESULTS: Symptomatic high-degree heart block was present on initial presentation in three of seven patients (43%), and four patients developed sinus arrest or paroxysmal high-degree atrioventricular block. No patients in this series demonstrated left ventricular systolic dysfunction or acute cardiac injury, whereas all patients had elevated inflammatory markers. In some patients, bradyarrhythmias occurred prior to the onset of respiratory symptoms. Death from complications of COVID-19 infection occurred in 57% (4/7) patients during the initial hospitalization and in 71% (5/7) patients within 3 months of presentation. CONCLUSIONS: Despite management of bradycardia with temporary (3/7) or permanent leadless pacemakers (4/7), there was a high rate of short-term morbidity and death due to complications of COVID-19. The association between new-onset bradyarrhythmias and poor outcomes may influence management strategies for acutely ill patients with COVID-19.

Impact of COVID-19 pandemic on the clinical activities related to arrhythmias and electrophysiology in Italy: results of a survey promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

COVID-19 outbreak had a major impact on the organization of care in Italy, and a survey to evaluate provision of for arrhythmia during COVID-19 outbreak (March-April 2020) was launched. A total of 104 physicians from 84 Italian arrhythmia centres took part in the survey. The vast majority of participating centres (95.2%) reported a significant reduction in the number of elective pacemaker implantations during the outbreak period compared to the corresponding two months of year 2019 (50.0% of centres reported a reduction of > 50%). Similarly, 92.9% of participating centres reported a significant reduction in the number of implantable cardioverter-defibrillator (ICD) implantations for primary prevention, and 72.6% a significant reduction of ICD implantations for secondary prevention (> 50% in 65.5 and 44.0% of the centres, respectively). The majority of participating centres (77.4%) reported a significant reduction in the number of elective ablations (> 50% in 65.5% of the centres). Also the interventional procedures performed in an emergency setting, as well as acute management of atrial fibrillation had a marked reduction, thus leading to the conclusion that the impact of COVID-19 was disrupting the entire organization of health care, with a massive impact on the activities and procedures related to arrhythmia management in Italy.

Rhythm blues in the time of coronavirus disease 2019 (COVID-19): how the cardiac electrophysiologist adapts to a viral pandemic in Singapore.

Coronavirus disease 2019 (COVID-19) is a major healthcare disaster in the modern times. Healthcare services must adapt to effectively juggle between pandemic management and maintenance of business-as-usual services so that both COVID-19 and non-COVID-19 patients receive appropriate clinical care. We share our experience of significant cardiac rhythm abnormalities seen in COVID-19 patients in Singapore, how the viral pandemic has affected the cardiac electrophysiology and pacing service in a large acute care general hospital and the steps taken to alleviate the negative impact.