The impact of neonatologist performed echocardiography in an Italian neonatal unit

BACKGROUND: The main goal of neonatologist performed echocardiography is to timely assess hemodynamic changes in order to properly manage unsteady neonates. Detailed structural heart assessment remains the domain of pediatric cardiologists. Nonetheless, many neonatologists take on an additional role in diagnosis of congenital heart defects, mostly compelled by the lack of in-house pediatric cardiology services. The experience of neonatologist performed echocardiography in an Italian neonatal unit was reported and the risk benefit profile of this practice was discussed. MATERIAL AND METHODS: We retrospectively reviewed the echocardiograms undertaken by the neonatologist on infants admitted to the neonatal unit and postnatal ward of the Hospital San Pio in Benevento, over a 2-year period. Details of scans and concordance between neonatologist and cardiologist were analyzed. RESULTS: A total of 160 echocardiographic studies were done by the neonatologist on 136 infants. The ECG was requested in a minority of infants. The most common reason for performing the echocardiogram was admission to the neonatal care unit. Around half of the echocardiograms were normal. The remaining scans resulted in functional and structural abnormalities, transitional changes, and doubtful findings. Cardiac anomalies were significantly more likely found in cases of echocardiograms performed for fetal indications. Only 28 patients were eventually referred to the cardiology services. The inter-rater agreement was satisfactory. CONCLUSIONS: The hemodynamic assessment of sick infants, as well as triaging and referral of neonates with structural heart diseases are valuable advantages of the echocardiography run by neonatologists. Collaboration with pediatric cardiologists and robust training and accreditation programs are essential to ensure safety and quality service.

Electrophysiological predictors of ventricular tachycardia recurrence in patients with structural heart disease after combined endo-epicardial substrate catheter ablation

Background Although there is a tremendous improvement in mapping and ablation techniques over the last decades, the recurrence rate of ventricular tachycardia (VT) in patients with structural heart diseases following endo-epicardial catheter ablation remains high. Purpose To determine predictors of VT recurrence in patients with structural heart disease after combined endo-epicardial radiofrequency (RF) VT ablation. Methods This prospective single-center study included 39 patients (34 men and 5 women, mean age 49.6±16.0 years), who underwent endo-epicardial mapping and ablation of the VT substrate. Etiology of structural heart diseases included: previous myocardial infarction (n=15); non-ischemic cardiomyopathy (n=24: 15 – arrhythmogenic right ventricular cardiomyopathy (ARVC), 6 – myocarditis, 3 – unspecified). First-line epicardial access was performed in 16 patients, as a second approach – in 23 subjects. We evaluated total ventricular myocardial areas, epi- and endocardial areas with bipolar low voltage (<1.5mV), scar area (bipolar <0.5mV), and unipolar low voltage (<5.0mV) and transient (<8.0mV) areas; areas of late potential registration were evaluated. Ratios of transient, low amplite and late-potential areas were calculated for endo- and epicardial surfaces, bipolar and unipolar maps. The following procedural electrophysiology characteristics were considered: inducibility of clinical VT, the number and morphology of induced VT, QRS width on sinus rhythm and VT, tachycardia cycle length, pseudo-delta wave extant and width, internal activation time, intrisicoud deflection time, and RS length. Clinical data such as echocardiography parameters, comorbidity and antiarrhythmic drug therapy were also taken into account. VT recurrences were documented using ICD/CRT-D interrogation, event ECG monitoring. Follow-up included mandatory visits at 6 and 12 months and unscheduled visits. Results Epicardial late potentials were registered in 69% of cases before ablation. Epicardial RF applications were delivered in 67% of patients; while only endocardial RF applications (including cases with intended epicardial substrate modification by endocardial ablation) were present in 28% cases. Non-inducibility of any VT plus abatement of local abnormal electrical activity was achieved in 32 (82%) of cases. The ratio epi/endo bipolar areas <0.5mV was much higher in patients with vs without VT recurrence at 6 months (4.3 (IQR: 2.5; 8.2) vs 0.75 (IQR:0.4; 1.6), P=0.001). A strong negative correlation was found between the induced VT cycle length and the ratio epi/endo bipolar areas <0.5mV: the shorter induced VT cycle length -the larger the area of the epicardial low voltage area (r=−0,52). Conclusion Regardless of epicardial substrate modification, patients with a larger epicardial low voltage area are more likely to have VT recurrence at 6 months after index ablation. A shorter induced VT cycle length is associated with a larger epicardial low-voltage area. FUNDunding Acknowledgement Type of funding sources: None.

Identifying patients with atrial fibrillation during sinus rhythm on ECG: confirming the utility of artificial intelligence algorithm in a small-scale cohort without structural heart diseases

Background Detection of atrial fibrillation (AF) out of electrocardiograph (ECG) on sinus rhythm (SR) using artificial intelligence (AI) algorithm has been widely studied within recent couple of years. Generally, it is believed that a huge number of ECGs are necessary for developing an AI-enabled ECG to be adequate to correspond to a lot of minor variations of ECGs. For example, structural heart diseases have typical ECG characteristics, but they could be a noise for the purpose of detecting the small signs of electrocardiographic signature of AF. We hypothesized that when patients with structural heart diseases are excluded, AI-enabled ECG for identifying patients with AF can be developed with a small number of ECGs. Methods We developed an AI-enabled ECG using a convolutional neural network to detect the electrocardiographic signature of AF present during normal sinus rhythm (NSR) using a digital, standard 10-second, 12-lead ECGs. We included all patients who newly visited the Cardiovascular Institute with at least one NSR ECG between Feb 1, 2010, and March 31, 2018. We classified patients with at least one ECG with a rhythm of AF as positive for AF (AF label) and others as negative for AF (SR label). We allocated ECGs to the training, internal validation, and testing datasets in a 7:1:2 ratio. We calculated the area under the curve (AUC) of the receiver operating characteristic curve for the internal validation dataset to select a probability threshold, which we applied to the testing dataset. We evaluated model performance on the testing dataset by calculating the AUC and the sensitivity, specificity, F1 score, and accuracy with two-sided 95% confidence intervals (CIs). Results We totally included 19170 patients with 12-lead ECG. After excluding patients with structural heart diseases, 12825 patients with NSR ECGs at the initial visit were identified (1262 were clinically diagnosed as AF anytime during the time course and 11563 were never diagnosed as AF). Of 11563 non-AF patients, 1818 patients who were followed over 1095 days were selected for the analysis with the SR label, to secure the robustness for maintaining SR. Of 1262 AF patients, 251 patients were selected for the analysis with the AF label, of whom a NSR ECG within 31 days before or after the index AF ECG (the first AF ECG during the time course) could be obtained. In the patients with AF label, the NSR ECG of which the date was the nearest to the index AF ECG was selected for the analysis. The AI-enabled ECG showed an AUC of 0.88 (0.84–0.92) with sensitivity 81% (72–88), specificity 80% (77–83), F1 score 50% (43–57), and overall accuracy 80% (78–83). Conclusion An AI-enabled ECG acquired during NSR allowed identification of patients with AF in a small population without structural heart diseases. FUNDunding Acknowledgement Type of funding sources: None.

THE RELATIONSHIP BETWEEN EPICARDIAL FAT TISSUE THICKNESS AND RISK OF FREQUENT PREMATURE VENTRICULAR CONTRACTIONS

Objectives: This study aimed to evaluate the relation between epicardial fat tissue (EFT) thickness and frequent premature ventricular contractions. Methodology: In this cross-sectional study, patients with no structural heart diseases diagnosed with PVCs on a 24 holter rhythm monitoring were included. EFT thickness was measured by 2-dimensional transthoracic echocardiography. PVCs of more than 10 per hour were considered as frequent PVCs. To investigate the effect of independent variables, univariate logistic regression was performed. Results: Of total 50 studied patients, 64% were females. The mean age of subjects was 46.8 ± 13.1 years. Twenty-five patients were experiencing frequent PVCs of >10 per hour. In univariate analysis, age (OR= 1.05, 95 % CI; 1.01-1.10, p=0.050), left ventricular end diastolic diameter (LVEDD) (OR= 1.14, 95 % CI; 1.01-1.28, p=0.036) and left atrial (LA) diameter (OR= 1.35, 95 % CI; 1.11-1.62, p=0.002) were significantly associated with developing frequent PVC. EFT thickness was positively correlated with age (r= 0.389, p= 0.005) and inter-ventricular septum thickness in diastole (IVSD) (r= 0.384, p= 0.006). No significant correlation between EFT and PVCs was found (p=0.669). Conclusion: Patients with frequent PVCs had significantly higher LVEDD and LA diameter. Although patients with higher EFT thickness were more likely to experience frequent PVCs, there was no statistically significant correlation between EFT thickness and frequent PVCs.

The Workload of the Interventional Cardiology Centers from Romania: a 2020 Overview and 2014-2020 Trends

This article provides data of the workload of the interventional cardiology centers from Romania during 2020. Members from all interventional cardiology centers from Romania wererequested to fill a standard form about the total number of various procedures performed during 2020. The report highlights the total number of coronary interventions, peripheral interventions, and interventions for structural heart diseases, that were performed in 2020 in Romania. A comparison of the workload of the interventional cardiology centers from Romania between 2014 to 2020 was done.

Novel cardiac manifestation of USH2A and GJB2 genes: A case report

Electrical storm can be caused by structural heart diseases and/or functional electrical abnormalities. We report a young boy without cardiac risk factors, having a positive family history of sudden cardiac death who presented with electrical storm. Stepwise diagnostic approach was not fruitful to determine previously known causes as the origin of the electrical storm. A new genotype related to the current electrical storm has been found, and intracardiac pacing ceased it.

Flecainide in Ventricular Arrhythmias: From Old Myths to New Perspectives

Flecainide is an IC antiarrhythmic drug (AAD) that received in 1984 Food and Drug Administration approval for the treatment of sustained ventricular tachycardia (VT) and subsequently for rhythm control of atrial fibrillation (AF). Currently, flecainide is mainly employed for sinus rhythm maintenance in AF and the treatment of idiopathic ventricular arrhythmias (IVA) in absence of ischaemic and structural heart disease on the basis of CAST data. Recent studies enrolling patients with different structural heart diseases demonstrated good effectiveness and safety profile of flecainide. The purpose of this review is to assess current evidence for appropriate and safe use of flecainide, 30 years after CAST data, in the light of new diagnostic and therapeutic tools in the field of ischaemic and non-ischaemic heart disease.

Imaging-guided transseptal puncture and transcatheter closure of patent foramen ovale/atrial septal defect, ventricular septal defect, and paravalvular leaks

Repairing structural heart diseases without surgery has been a major challenge. The title ‘The Father of Interventional Cardiology’ belongs to William J. Rushkind (1922–1986) who performed atrial balloon septostomy in newborn babies with D-transposition as early as 1968. He also designed devices for the transcatheter closure of atrial defects and of patent ductus arteriosus. The introduction of better devices and skilled operators led to successful procedures which are less traumatic, shorter, and in many cases significantly less expensive. The various modalities of cardiac imaging have become a crucial ingredient of the preprocedural diagnosis, procedural guidance, and the assessment of procedural results and follow-up. This chapter will demonstrate and discuss the role of imaging in several catheter-based procedures that are now commonly practised by the current generation of interventional cardiologists who are involved in structural heart disease.

Electrocardiographic recognition of benign and malignant right ventricular arrhythmias

Ventricular arrhythmias (VAs) can originate from different anatomical locations of the right ventricle. Ventricular arrhythmias originating from right ventricle have unique electrocardiographic (ECG) characteristics that can be utilized to localize the origin of the arrhythmia. This is crucial in pre-procedural planning particularly for ablation treatments. Moreover, non-ischaemic structural heart diseases, such as infiltrative and congenital heart diseases, are associated with the VAs that exhibit particular ECG findings. This article comprehensively reviews discriminatory ECG characteristics of VAs in the right ventricle with and without structural right ventricular diseases.