Short-term outcome associated with remote evaluation (telecardiology) of patients with cardiovascular diseases during the COVID-19 pandemic.

INTRODUCTION: During the recent COVID-19 outbreak, Italian health authorities mandated to replace in-person outpatient evaluations with remote evaluations. METHODS: From March 16th 2020 to April 22th 2020, all outpatients scheduled for in-person cardiac evaluations were instead evaluated by phone. We aimed to report the short-term follow-up of 345 patients evaluated remotely and to compare it with a cohort of patients evaluated in-person during the same period in 2019. RESULTS: During a mean follow-up of 54 ± 11 days, a significantly higher proportion of patients evaluated in-person in 2019 visited the emergency department or died for any cause (39/391, 10% versus 13/345 3.7%, p = 0.001) and visited the emergency department for cardiovascular causes (19/391, 4.9% versus 7/345, 2.0%, p = 0.04) compared to 2020. No cardiovascular death was recorded in the two periods. To an evaluation with a satisfaction questionnaire 49% of patients would like to continue using remote controls in addition to traditional ones. CONCLUSION: These findings may have important implications for the management of patients during the current COVID-19 pandemic because they suggest that remote cardiovascular evaluations may replace in-hospital visits for a limited period.

Permanent His-bundle pacing maintains long-term ventricular synchrony and left ventricular performance, unlike conventional right ventricular apical pacing.

AIMS: Right ventricular apical pacing (RVAP) may be deleterious, determining abnormal left ventricular (LV) electrical activation and progressive LV dysfunction. Permanent His-bundle pacing (HBP) has been proposed to prevent this detrimental effect. The aim of our study was to compare the long-term effects of HBP on LV synchrony and systolic performance with those of RVAP in the same group of patients. METHODS: Our analysis included 26 patients who received both an HBP lead and an RVAP lead, as backup, in our electrophysiology laboratory between 2004 and 2007. After implantation, all devices were programmed to obtain HBP. An intra-patient comparison of the effects of HBP and RVAP on LV dyssynchrony and function was performed at the last available follow-up examination. RESULTS: After a mean of 34.6 ± 11 months, the pacing modality was temporarily switched to RVAP. During RVAP, LV ejection fraction significantly decreased (50.1 ± 8.8% vs. 57.3 ± 8.5%, P < 0.001), mitral regurgitation significantly increased (22.5 ± 10.9% vs.16.3 ± 12.4%; P = 0.018), and inter-ventricular delay significantly worsened (33.4 ± 19.5 ms vs. 7.1 ± 4.7 ms, P = 0.003) in comparison with HBP. However, the myocardial performance index was not statistically different between the two pacing modalities (P = 0.779). No asynchrony was revealed by tissue Doppler imaging during HBP, while during RVAP the asynchrony index was significantly higher in both the four-chamber (125.8 ± 63.9 ms; P = 0.035 vs. HBP) and two-chamber (126 ± 86.5 ms; P = 0.037 vs. HBP) apical views. CONCLUSION: His-bundle pacing has long-term positive effects on inter- and intra-ventricular synchrony and ventricular contractile performance in comparison with RVAP. It prevents asynchronous pacing-induced LV ejection fraction depression and mitral regurgitation.

Cardiac resynchronization therapy or sequential pacing in failing Mustard?

The atrial switch (Mustard, Senning procedures) was one of the treatments of choice for repair of transposition of the great arteries from the early 1960s to the mid-1980s. A significant proportion of patients with atrial switch develops systemic (right) ventricular failure. A series of surgical therapeutic options exists to manage cardiac failure in this setting, and, more recently proposed, cardiac resynchronization therapy. We describe case report of a 30-year-old woman with congenital heart disease (CHD) and previous Mustard procedure who underwent upgrading from single chamber to dual-chamber pacemaker. The narrower native QRS did not correlate with a better synchrony status nor with a better cardiac output. Functional evaluation confirmed a better performance in DDD mode with short atrioventricular delay and broad QRS. Some echocardiographic and electrocardiographic parameters, such as ejection fraction and QRS duration, well established in adults' heart for selection of candidates to cardiac resynchronization therapy, are much less studied in CHD. Postoperative CHD may provide unique patterns of asynchrony with poorly predictable hemodynamic outcome.

Patient risk profile and benefit from an invasive approach in the initial management of non-ST-segment elevation acute coronary syndrome.

BACKGROUND: Routine use of an invasive strategy (IS) has been shown to exceed a conservative strategy in reducing myocardial infarction (MI), angina and re-hospitalization rate in patients with non-ST elevation acute coronary syndrome (NSTEACS). The present study aimed to analyse, by use of randomized trials data, whether the risk profile of patients with NSTEACS influences the survival benefit of the IS over a conservative strategy from randomization to end of follow-up (range 6-24 months). METHODS: Eight studies were identified from 1970 to 2005. A fixed effect-meta-regression analysis for: (i) the log-odds ratio on death and (ii) the log-odds ratio on death/MI against the odds of death/MI in the control group was made. RESULTS: IS was associated with a significant reduction in death/MI [12% versus 13.7%, odds ratio (OR) = 0.86, P = 0.009], but not in mortality (5.1% versus 5.5%, OR = 0.92, P = 0.34). There was evidence of heterogeneity in the outcome mortality (P = 0.06 for heterogeneity) and the composite of death/MI (P = 0.01 for heterogeneity). Sensitivity analysis demonstrated that the source of heterogeneity was significantly related to the outlier VANQWISH trial. When the latter was removed from the analysis, IS was related to a significant reduction of both death (3.9% versus 4.9%, OR = 0.81, P = 0.04, P heterogeneity = 0.35) and death/MI (10% versus 12.1%, OR = 0.81, P = 0.001, P heterogeneity = 0.07). CONCLUSIONS: The main finding of this meta-analysis is that, compared to a conservative strategy, the benefits of IS for the management of NSTEACS in terms of death/MI reduction are related to the patient's risk profile.

Discrepancies between catheter and Doppler estimates of aortic stenosis: the role of pressure recovery evaluated 'in vivo'.

BACKGROUND AND AIM OF THE STUDY: Wide discrepancies are often observed between catheter- and Doppler-derived gradients and valve areas. The study aim was to verify if these measurements could be attenuated in a clinical setting by taking into account pressure recovery. METHODS: Between 1st January 2000 and 31st March 2005, a total of 259 patients with an aortic valve area (AVA) < or =2 cm(2) was prospectively collected. During a standard diagnostic catheterization, the aortic valve gradient was taken as: [peak left ventricular pressure-- peak aortic pressure]. The AVA was calculated using the Gorlin formula (AG). Echocardiography was performed within 30 days of this procedure. Transvalvular gradients were measured using the Doppler technique, and the AVA was computed using the continuity equation (ACE). The diameter of the ascending aorta was monitored in the parasternal long-axis view, and the values averaged. The ascending aorta sectional area (AA) was then computed according to geometric formulae. In order to correct for pressure recovery, an energy loss coefficient (ELCO) equation was used [ELCO = (AA x ACE)/(AA -ACE)]. Correlations between AG, ACE and ELCO were evaluated by linear regression analysis. As cardiac output affects the estimates of valve areas, the correlation was calculated separately for patients with a median cardiac index (CI) above and below 2.7 1/min/m(2). RESULTS: A good linear correlation was found between AG and ACE with regression coefficient 0.88, independent of cardiac output. A similar correlation was present between AG and ELCO, with correlation coefficient 0.99 in patients with CI >2.7 1/min/m(2), and