Automatic Defibrillator Research Articles

AED drones on the rise? : Use of drones to improve public access defibrillation

The poor availability of automatic external defibrillators (AED) and the modest knowledge of lay persons in handling these devices has led to an insufficient spread of public access defibrillation in Germany. This article examines whether the automated deployment of AED drones to out-of-hospital cardiac arrest can help to remedy this situation. Narrative literature review, evaluation of statistics, analysis of relevant media reports, and discussion of key research. The present investigations are mainly located in the experimental field and demonstrate the feasibility and safety of drone use, as well as shorter times to first defibrillation, which is confirmed by initial clinical studies. Mathematical models also indicate cost-effectiveness of airborne AED delivery compared to ground dispatch. Integration into the chain of survival appears to be possible but adaptations to existing emergency medical service structures and close cooperation with regional first responder and AED schemes as well as local authorities is required to optimise patient benefit and efficiency. The use of AED drones could probably contribute to improving public access defibrillation in Germany. This applies to both rural and urban regions. The technological requirements are met but flight regulations still have to be amended. In order to explore the full potential of this novel technology, further field trials are required to achieve smooth integration into existing emergency medical services.

Cardiocutaneous Syndrome: Naxos Disease

Naxos disease is a recessively inherited condition, caused by mutation in genes encoding desmosomal proteins Plakoglobin. It is characterized by peculiar woolly hair, palmoplantar keratoderma with arrhythmogenic Right Ventricular dysplasia /cardiomyopathy. A syndrome (a variant of Naxos) with same cutaneous phenotype and predominant Left Ventricular involvement is CARVAJAL syndrome. Patients are at risk of sudden cardiac death due to cardiomyopathy. We herein report a rare case of Naxos disease in a 16 years old male born of a 3º consanguineous marriage, presented with features suggestive of congestive cardiac failure with clubbing (grade 1), woolly hair, and focal keratoderma over palms and soles. ECG demonstrated – inverted T waves (V1-V3), QRS prolongation and complete RBBB. Echocardiography revealed-severe biventricular dysfunction with EF-15-20%, severe MR, severe TR and PAH. Patient was treated with diuretics, ß blockers and ACE inhibitors. These children may need implantation of automatic cardioverter defibrillator to prevent arrhythmogenic attacks and sudden cardiac death. CONCLUSION: For child with woolly hair and palmoplantar keratoderma, the pediatrician should provide a cardiac assessment, considering Naxos/Carvajal disease associated cardiomyopathy. When an early diagnosis is made, life expectancy can be increased by treatment of Heart failure and arrhythmias. Keywords: Naxos disease, Palmoplantar keratoderma, Cardiomyopathy, Wolly hair

Experience in implementing a program for basic life support and available automated defibrillation in a cancer center

Unified approaches to ensuring the chain of survival can improve the patient’s prognosis both in out-of-hospital and in-hospital cardiac arrest.Aim. To discuss practical issues of introducing a program for the availability of automated external defibrillation in a cancer center.Material and methods. For four years, our healthcare facility has been implementing a training program for basic and advanced life support according to the European Resuscitation Council standards, combined with the creation and development of an infrastructure for the availability of automatic defibrillation. A roadmap and infrastructure were developed for the project implementation.Results. In 2018-2022, 229 employees (114 doctors, 85 nurses and 30 nonmedical workers) were trained under the basic life support program. Fifteen defibrillators were placed in various units. During the specified period, first aid in case of sudden cardiac arrest using an automated external defibrillator before the resuscitation team arrival was independently provided by doctors and nurses of departments three times. To implement training in the continuous education system, the curriculum has passed the examination and accreditation in the edu. rosminzdrav system.Conclusion. The development and implementation of such initiatives requires significant organizational and methodological work, including continuous education system. However, in our opinion, this is an extremely useful tool for improving the safety and quality of medical care.

Effect of Novel Programming on Inappropriate Implantable Cardioverter-Defibrillator Therapy in Patients With Very Low Ejection Fraction (from A MADIT-RIT)

The Multicenter Automatic Defibrillator Implantation Trial - Reduce Inappropriate Therapy showed a significant reduction in the risk of inappropriate therapy in patients with a programmed high-rate cutoff ≥200 beats per minute or delayed therapy for events ≥170 beats per minute compared with conventional programming. We aimed to characterize outcomes by left ventricular ejection fraction (LVEF) ranges for patients with high-rate, delayed, or conventional implantable cardioverter-defibrillator programming. We assessed the effect of LVEF (LVEF <15%, LVEF 15% to 25%, LVEF >25%) on the risk of inappropriate conventional implantable cardioverter-defibrillator therapy and death in Multicenter Automatic Defibrillator Implantation Trial - Reduce Inappropriate Therapy. Inappropriate therapies and death were independently evaluated by the adjudication committee. Statistical methods involved Kaplan-Meier time-to-event graphs and Cox proportional hazards regression analyses. The study involved 140 patients (9%) with LVEF 15%, 585 with LVEF 15% to 25% (39%), and 774 with LVEF >25% (52%). High-rate or delayed programming significantly reduced the risk of inappropriate therapy compared with conventional programming in patients with all LVEFs (p <0.001 for all LVEF). Patients with LVEF <15% had an exceptional 97% lower risk of inappropriate therapy, with high-rate programming than conventional programming (hazard ratio 0.028, p=0.001), without an increase in mortality. High-rate and delayed programming is superior to conventional programming in all LVEF ranges, without adverse effects.

One and Done Epinephrine in Out-of-Hospital Cardiac Arrest? Outcomes in a Multiagency United States Study

Background Cardiac arrest guidelines recommend epinephrine every 3–5 minutes during cardiac arrest resuscitation. However, it is unclear if multiple epinephrine doses are associated with improved outcomes. The objective of this study was to determine if a single-dose epinephrine protocol was associated with improved survival compared to traditional multidose protocols. Methods We conducted a pre-post study across five North Carolina EMS agencies from 11/1/2016 to 10/29/2019. Patients ≥18 years old with attempted resuscitation for non-traumatic prehospital cardiac arrest were included. Data were collected 1 year before and after implementation of the single-dose epinephrine protocol. Prior to implementation, all agencies used a multidose epinephrine protocol. The Cardiac Arrest Registry to Enhance Survival (CARES) was used to obtain patient outcomes. Study outcomes were survival to hospital discharge (primary) and return of spontaneous circulation (ROSC). Analysis was by intention to treat. Outcomes were compared pre- vs. post-implementation using generalized estimating equations to account for clustering within EMS agencies. Adjusted analyses included age, sex, race, shockable vs. non-shockable rhythm, witnessed arrest, automatic external defibrillator availability, EMS response interval, and bystander cardiopulmonary resuscitation. Results During the study period there were 1,690 encounters (899 pre- and 791 post-implementation). The population was 74.7% white, 61.1% male, and had a median age of 65 (IQR 53–76) years. Survival to hospital discharge was similar pre- vs. post-implementation [13.6% (122/899) vs. 15.4% (122/791); OR 1.19, 95%CI 0.89–1.59]. However, ROSC was more common post-implementation [42.3% (380/899) vs. 32.5% (257/791); OR 0.66, 95%CI 0.54–0.81]. After adjusting for covariates, the single-dose protocol was associated with similar survival to discharge rates (aOR 0.88, 95%CI 0.77–1.29), but with decreased ROSC rates (aOR 0.58, 95%CI 0.47–0.72). Conclusion A prehospital single-dose epinephrine protocol was associated with similar survival to hospital discharge, but decreased ROSC rates compared to the traditional multidose epinephrine protocol.

The Case for Home AED in Children, Adolescents, and Young Adults NotMeeting Criteria for ICD.

Children, adolescents, and young adults with conditions such as cardiomyopathies and channelopathies are at higher risk of sudden cardiac death caused by lethal arrhythmias, especially ventricular fibrillation. Timely defibrillation saves lives. Patients thought to be at significantly high risk of sudden death typically undergo placement of an implantable cardioverter-defibrillator. Patients thought to be at lower risk are typically followed medically but do not undergo implantable cardioverter-defibrillator placement. However, low risk does not equal no risk. Compared with the general population, many of these patients are at significantly higher risk for lethal arrhythmias. We make the case that such individuals and families will benefit from having an at-home automatic external defibrillator. Used in conjunction with conventional measures such as training on cardiopulmonary resuscitation, an at-home automatic external defibrillator could lead to significantly shortened time to defibrillation with better overall and neurological survival. We recommend that the cost of such home automatic external defibrillators should be covered by medical insurance.

Differences in mode of death between men and women receiving implantable cardioverter-defibrillators or cardiac resynchronization therapy in the MADIT trials

Studies have reported sex differences in outcomes following implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy-defibrillator (CRT-D) implantation. However, little is known about sex differences with regard to mode of death or device efficacy following ICD or CRT-D implantation. The purpose of this study was to investigate whether sex influenced mode of death or device efficacy in ICD and CRT-D subjects enrolled in the MADIT (Multicenter Automatic Defibrillator Implantation Trial) studies (MADIT-II, MADIT-CRT, and MADIT-RIT). The combined MADIT cohort consisted of 3038 men and 1000 women with ischemic cardiomyopathy (ICM) or nonischemic cardiomyopathy (NICM), left ventricular ejection fraction ≤30%; New York Heart Association functional class I-III heart failure who received ICD or CRT-D. Mode of death was divided into cardiac and noncardiac causes, reviewed by independent adjudication committees. A total of 295 men and 66 women died (9.7% vs 6.6%; P =.003) during 26 months. The most common cause of death was nonarrhythmic cardiac death in men (n = 121 [41%]) and noncardiac death in women (n = 22 [33%]). All-cause mortality and cardiac deaths were 1.5- to 2.0-fold higher in men vs women with ICM but similar for those with NICM after adjustment for covariates. ICD efficacy was similar in men and women, resulting in a 50% reduction in all-cause mortality. CRT-D was more effective at reducing all-cause and cardiac death in women than men. Mode of death differs between sex and is dependent on the underlying cardiac substrate. Compared to women, cardiac death is higher in men with ICM but similar in those with NICM. ICDs are equally effective at reducing mortality in both men and women. However, CRT-D may be more effective at reducing mortality in women.

Sport Related Sudden Death: The Importance of Primary and Secondary Prevention.

Sports are a double-edged sword. On the one hand, cardiovascular benefits from sports activity are well-known, and on the other hand, sports may increase the risk of sudden cardiac death (SCD) in subjects with known or unknown cardiovascular diseases. SCD is rare but has a very strong emotional issue. There are many examples involving famous professional athletes, but this is only scratching the surface of a widespread phenomenon that also involves amateur athletes. The importance of safely performing physical activity appears clear in both professional and amateur athletes. In particular, the former undergo a pre-participation screening for SCD primary prevention with different recommendations in each country. On the other hand, a medical examination is not mandatory for non-professional athletes and, therefore, for people who practice sports as an amateur. Widespread distribution of automatic external defibrillators and people trained for cardiopulmonary resuscitation are necessary to promote secondary prevention of SCD. We briefly report a case series of athletes with aborted SCD during sports activity in order to underline and discuss in this review the previously highlighted issues.

Network of Automated External Defibrillators in Poland before the SARS-CoV-2 Pandemic: An In-Depth Analysis.

Introduction: Sudden cardiac arrest (SCA), which causes more than half of all cardiovascular related deaths, can be regarded as a common massive global public health problem. Analyzing out-of-hospital cardiac arrest (OHCA) cases, one of the key components is automatic external defibrillators (AEDs). Aim: The aim of this study was to analyze the use and distribution of AEDs in Polish public places. Materials and methods: The data were analyzed by using the Excel and R calculation programs. Results: The data represents 120 uses of automatic external defibrillators used in Polish public space in the period 2008–2018. The analysis describes 1165 locations of AEDs in Poland. It was noted that the number of uses in the period 2010–2016 fluctuated at a constant value, with a significant rise in 2017. When analyzing the time of interventions in detail the following was noted: the highest percentage of interventions was observed in April, and the lowest in November; the highest number of interventions was observed on a Friday, while the least number of interventions was observed on a Sunday; most occurred between 12:00 to 16:00, and least between 20:00 to 8:00. Conclusions: The observed growth in the number of cases of AED use in public places is associated with the approach to training, the emphasis on public access to defibrillation, and, therefore, the growth of social awareness. This study will be continued. The next analysis would include 2020–2022 and would be a comparative analysis with the current research.

Efficacy of Basic Life Support and Automatic External Defibrillator Educational Program for High School

Background: Bystander-initiated cardiopulmonary resuscitation (CPR), the automatic external defibrillator (AED), and rapid activation of emergency medical service have major roles in the chain of survival of out-of-hospital cardiac arrest patients. To integrate the basic life support (BLS) knowledge into the high school curriculum, teachers are the key person. Objective: To examine the effectiveness of the BLS training program for high school teachers. Methods: In this prospective study of 146 participants, before and immediately after 2 hours lecture and 3 hours hands-on activity of BLS training program consisting of instruction on CPR, AED, and first aid for foreign body aspiration, written tests were done to assess knowledge while participants’ attitudes were evaluated by a questionnaire survey. Results: A total of 146 participants, BLS knowledge increased in all parts (early activation, chest compression, and defibrillation increased by 27.3%, 51.3%, and 82.1% with adjusted OR 13.81, 19.08, and 849.47, respectively; P < .001), as well as participant’s confidence increased from 47.6% to 95.8% (adjusted OR, 31.69; P < .001). Conclusions: BLS training in high school teachers increased both knowledge of chains of survival and confidence.

Sex Differences in the Risk of First and Recurrent Ventricular Tachyarrhythmias Among Patients Receiving an Implantable Cardioverter-Defibrillator for Primary Prevention

Current guidelines for primary implantable cardioverter-defibrillator (ICD) therapy do not account for sex differences in arrhythmic risk in ICD candidates. To evaluate the association between sex and risk of ventricular tachyarrhythmia (VTA) and mortality. This cohort study compared differences in the risk of VTA and mortality between 4506 men and women enrolled in the 4 Multicenter Automatic Defibrillator Implantation Trials (MADIT) between July 1, 1997, and December 31, 2011. Data from prospective randomized controlled multicenter studies were analyzed retrospectively. Men and women with an ICD or cardiac resynchronization therapy defibrillator who were enrolled in all MADIT studies were included. Data were analyzed between January 10 and June 10, 2021. ICD implant. The primary end point was sustained VTA, defined as ICD-recorded, treated or monitored VTA at least 170/min or ventricular fibrillation. Secondary VTA end points included VTA at least 200/min, appropriate ICD shocks, and appropriate antitachycardia pacing. All end points were included in a first and recurrent event analysis. Of the 4506 study participants, 3431 were men (76%). Mean (SD) age of the cohort was 64 (12) years. For women vs men, the mean (SD) age (64 [12] years vs 64 [11] years) and left ventricular ejection fraction (24% vs 25%) were similar, but women exhibited a higher frequency of nonischemic cardiomyopathy (454 of 1075 women [42%] vs 2535 of 3431 men [74%]). Women had significantly lower 3-year cumulative probability of sustained VTA (16% vs 26%), fast VTA (9% vs 17%), and appropriate ICD shocks (7% vs 15%) compared with men (P < .001 for all). Multivariable analysis showed that female sex was independently associated with at least 40% lower risk of all first and recurrent VTA end points (P < .001 for all), including the primary end point (first event, HR = 60 [95% CI, 50-73], P < .001; recurrent event, HR = 49 [95% CI, 43-55], P < .001), after accounting for the competing risk of all-cause mortality and nonarrhythmic mortality. The lower VTA risk associated with female sex was consistent in risk subsets but was significantly more pronounced in patients with nonischemic cardiomyopathy (female vs male in the ischemic group: hazard ratio, 0.73 [95% CI, 0.56-0.95], P = .02; nonischemic group: hazard ratio, 0.50 [95% CI, 0.38-0.66], P < .001; P = .03 for interaction between female sex and cardiomyopathy). Findings suggest that women display a significantly lower risk of first and recurrent life-threatening VTA events than men, and that it is more pronounced in patients with nonischemic cardiomyopathy, suggesting a need for sex-specific risk assessment for primary prevention ICD therapy.

P105 How effective is the “Kids Save Lives” program on students’ knowledge on the subject of automatic external defibrillators

P105 How effective is the “Kids Save Lives” program on students’ knowledge on the subject of automatic external defibrillators

P109 The effectiveness of “Kids Save Lives” program on students’ knowledge on the subject of automatic external defibrillators after two years of implementation

P109 The effectiveness of “Kids Save Lives” program on students’ knowledge on the subject of automatic external defibrillators after two years of implementation

P60: A decade on LVAD support

Objective: The use of left ventricular assist devices (LVADs) to support patients with end-stage heart failure (HF) has been progressively adopted over the past 2 decades, with long-term outcomes reporting 50% survival at 5 years, particularly related to development of complications on support. However, there is a paucity of information related to survival beyond 10 years. Herein, we report the case of an 85-year-old man with end stage ischemic cardiomyopathy with an 11-year continuous LVAD support as destination therapy (DT). Case Report: An 85-year-old man transferred from an outside hospital, presented to the emergency department due to concerns for a driveline infection. The patient has an 11-year-old history of HeartMate2-LVAD support as destination therapy (DT) due to an end-stage ischemic cardiomyopathy. Patient has undergone automatic implantable cardioverter defibrillator secondary to atrial fibrillation, as well as a primary coronary artery disease requiring multiple percutaneous coronary interventions, in addition to an aortic and mitral valve repair. He was last seen 2 years prior to this consultation for an external LVAD drive line replacement and a chronic infection which is under oral Cefalexin management (500mg/day). Additionally, the patient continues anticoagulation therapy (aspirin 81 mg/day; warfarin 10 mg/day) with a target INR of 2.5, and has not experienced any thromboembolic or hemorrhagic complications. On clinical evaluation, driveline insertion showed a non-tender, mild erythematous aspect, with no exudation. A CT scan of the thorax and abdomen was performed, demonstrating no involvement of deep tissues. Results: Initial echocardiographic evaluation showed a left ventricular ejection fraction of 20%, moderate-to-severely reduced right ventricular systolic function, a right atrial pressure of 15 mmHg, moderate tricuspid regurgitation, and a left ventricular end diastolic diameter of 6.5 cm. Upon physical examination the patient was warm and well-perfused with an euvolemic appearance. The LVAD settings remain steady at 9400 rpm and a 5.0 L/min flow. The driveline exit site elicited no pain at palpation, with mild erythema. Due to a sustained hemodynamic function in perspective to the patient’s end-stage heart failure, 500 mg of cefalexin/daily was continued and patient was discharged with no complications and continued monitorization. Conclusion: To the authors’ knowledge, this case represents one of longest reports of LVAD support as DT. The continuing improvement of LVAD management has led to the safe and feasible application of long-term cardiac function support as DT for patients deemed not transplant candidates. As our elderly population expands, and over 80% of patients with heart failure are older than 65 years, the role LVAD for long-term support will become more relevant, and this case reveals that safe LVAD support is possible beyond 10 years.

Catheter ablation of well tolerated ventricular tachycardia in patients with structural heart disease: long term follow-up of 62 cases without automatic defibrillator implantation

Abstract Funding Acknowledgements Type of funding sources: None. Background The occurrence of a sustained monomorphic ventricular tachycardias (SMVT) in patients with underlying structural heart disease (SHD) is considered correlated to a poor prognosis, based on historical data in patients with heterogeneous heart disease and clinical presentation; therefore the recommendation for implantation of automatic implantable cardioverter defibrillator (AICD) is strong. Information about prognosis of patients with SMVT is still limited, but recent studies have established that these patients represent a low-risk subgroup for sudden death that could benefit from radiofrequency (RF) ablation of the arrhythmic substrate and the AICD implantation could be deferred during the follow up. Purpose Patients with well-tolerated SMVT, SHD and left ventricular ejection fraction (LVEF) over 30% can benefit from a primary VT ablation strategy without the immediate need for AICD implantation. Methods We reviewed consecutive SHD patients with LVEF over 30% admitted for the occurrence of SMVT and who were treated by RF ablation as a first-choice therapy in a single Italian center, between 2009 and 2020 and who were discharged without AICD implantation. The primary outcome of the study was a composite of all-cause death and recurrence of VT. The secondary outcome was death from all causes. Patients with similar characteristics but who underwent AICD implantation during the same period served as control group. Results Clinical and electrophysiological features of 62 patients were analyzed (Table 1). In the study group, 88% were male; the median age was 72 years (IQR 55-81) and the median LVEF was 50.0% (IQR 40.0-55.0). The estimated success rate of ablative procedures (defined as VT no longer inducible) was around 82%. After a median follow-up of 38.8 months (IQR 15.6-76.1), the primary outcome occurred in 24 patients and the secondary outcome in 11 patients. All-cause mortality was 17%, corresponding to an annual mortality rate of 4.3%. Ten patients died for non-cardiovascular causes and one for advanced heart failure. No patient in the study died from sudden death. During the follow-up, 10 patients (16.1%) underwent AICD implantation due to VT relapse. At 36 months, between study and control groups, there was no difference in either the primary composite outcome (HR 1.03, 95% CI 0.45-2.21, p = 0.98) or in the secondary outcome (HR 1.4, 95% CI 0.48-4.54, p = 0.49). Conclusions Patients with well-tolerated SMVT, SHD and LVEF over 30% represent a subgroup of patients at lower risk that can benefit of RF ablation as a first-choice therapy. Delay in AICD implantation, after a possible VT relapse or clinical worsening, appears to represent a safe therapeutic strategy. Therefore, it is ethical and desirable to start a prospective randomized clinical trial to evaluate the benefit and cost-effectiveness of this strategy, as an alternative to AICD implantation.

Gender, ethnic difference in arrhythmic risks and prognosis in patients with non-ischaemic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background The mortality benefits of Automatic Intracardiac Defibrillator (AICD) in non-ischaemic cardiomyopathy patients is less clear. Subgroup analysis of Definite trial showed that female patients favoured medical treatment. Ethnic difference in arrhythmic risk also not known. Method 447 patients with heart failure and reduced left ventricular ejection fraction (LVEF &amp;lt;40%) due to non-ischemic cardiomyopathy, all have coronary angiogram to exclude significant coronary artery disease (&amp;gt;70% stenosis). Continuous variables were compared by Student t tests and categorical variables compared by use of the Fisher exact test. Composite endpoints include death, sudden cardiac death (SCD), ventricular arrhythmias (VA ) and hospitalisations for heart failure. P&amp;lt;0.05 was denoted as statistical significant. Results Mean age 63.07 ± 14.19 years, male patients 314 (70%), 360 Chinese and 87 non-chinese. Mean age of male and female patients were 61.21 ± 13.65 and 67.46 ± 14.52 years old respectively. Patients with diabetes mellitus 38%, hypertension 76%, atrial fibrillation 38%, stroke 9%. LDL 2.78 ± 1.04 mmol/l, HbA1c 6.56 ± 1.62%, baseline creatinine 98.43 ± 37.27umol/l. Patients taking ivabradine 9%, b-blocker 88%, Angiotensin inhibitors/Angiotensin Receptor Blocker 66%, Sacubitrial/ Valsartan 26%, spironolactone 57%, SGLT-2 inhibitor 9%. Mean follow-up duration of 6.18 ± 4.16 years. There were 61 deaths (13%, 2.20% death/ year, 20 females and 41 males). 38 SCD, 22 VA, 218 hospitalisation for heart failure There was a significant increase in LVEF from 24.88 ± 8.17 to 39.92 ± 13.88% and 22.05 ± 8.52 to 36.14 ± 8.17 % in female and male patients respectively (p=0.023). 190 patients (43%) have LVEF increased to or more than 35%. 40 patients (9%) received device therapy (AICD and Cardiac resynchronization therapy), 19% secondary prevention, 81% for primary prevention. The median time from diagnosis of NICMP to appropriate device therapy for VT/ VT storms was 85.5 months (interquartile range 35-131). 18/21 patients (86%) noted to have appropriate therapy for VT/ VT storms were males. HR for males 8, 95% CI (1.06, 60.34, p=0.044). All the device therapy occurred in patients with LVEF&amp;lt; 35%. There is also gender difference in composite endpoints (p=0.0022) LVEF improved from 23.31± 8.67 to 38.10 ±15.20 and 21.63 ±7.57 to 33.74 ±12.92% respectively (p=0.014) in Chinese and non-Chinese patients respectively. There are no significant difference in the VA or primary composite endpoints. Conclusions The study showed progressive improvement of the therapeutic regimens improve mortality by improving LVEF regardless of gender or ethnicity. The ventricular tachyarrhythmic risk, composite endpoints are significantly higher in male than female patients with non-ischaemic cardiomyopathy. There is no ethnic difference in clinical endpoints.

P31 PERCUTANEOUS LEFT STELLATE GANGLION BLOCK AS PRE–TREATMENT STRATEGY FOR HIGH–RISK PATIENTS WHO ARE CANDIDATES FOR INVASIVE PROCEDURES POTENTIALLY ASSOCIATED WITH ADRENERGIC STIMULATION: AN HYPOTHESIS–GENERATING CASE REPORT

Abstract Introduction Percutaneous left stellate ganglion block (PLSGB) has been reported as a safety and effective procedure for the management of refractory arrhythmic storm (AS). In this report we present a case of a man with refractory AS effectively treated with PLSGB, subsequently candidate for an invasive procedure potentially associated with adrenergic stimulation and propose the use of this technique as pre–treatment strategy in this clinical setting. Case presentation A 57–year–old man was admitted to our hospital for AS. Past medical history revealed that two years earlier he had been treated with primary percutaneous coronary intervention for ST–segment elevation myocardial infarction. Four months before admission he underwent coronary artery bypass graft surgery with concomitant mechanical mitral valve replacement, closure of an interventricular defect and, considering the severe left ventricular disfunction, he was implanted with an automatic defibrillator in primary prevention. At the time of admission, he was treated with lidocaine infusion with remission of arrhythmic events. Comprehensive diagnostic workup revealed no overt triggers for AS. Five days after admission, the patient experienced recurrence of ventricular arrhythmias (VA), refractory to amiodarone, lidocaine, and magnesium infusion, increased pacing rate, and sedation with dexmedetomidine. PLSGB was then attempted with the injection of lidocaine and ropivacaine using an anatomical approach with complete remission of arrhythmic events. After a week free from VAs, a new AS was observed and PLSGB was repeated using the same modality with complete arrhythmic resolution. Considering the advanced heart failure, the patient was candidate to heart transplantation (HT) and, before undergoing gastro– and colonoscopy required for inclusion in the HT program, with the aim to reduce the risk of VA recurrences triggered by potential adrenergic stimulation, we pre–treated the patient with PLSGB using only ropivacaine, with successful induction of temporary Horner syndrome (Fig. A). The endoscopy procedures were performed successfully with no VA events and the patient was then discharged waiting for HT. Conclusion We propose the use of PLSGB as a pre–treatment strategy for patients at high–risk of VAs who are candidates for invasive procedures potentially associated with adrenergic stimulation. This report could be hypotheses–generating for further studies on this topic.

P168 A RARE CASE OF HYPERTROPHIC CARDIOMYOPATHY WITH HIGH RISK OF SUDDEN CARDIAC DEATH: WHAT CAN WE DO UNTIL MIECTOMY?

Abstract A 43–year–old Indian man with obstructive hypertrophic cardiomyopathy (HCMO) and a family history of sudden death presented with heart palpitations associated with chest discomfort and syncope during moderate physical activity despite beta–blocker therapy at maximum dose (New York Heart Association–NYHA III). Transthoracic echocardiography demonstrated ejection fraction 55% and ventricular septum (SIV) (23 mm) and posterior wall hypertrophy (12 mm). There was evidence of dynamic left ventricular outflow tract obstruction (maximum LVOT gradient 30 mmHg at baseline and 45 mmHg after Valsalva) and systolic anterior movement of the amterior mitral flap responsible of moderate regurgitation. It also showed a bicuspid aortic valve with fusion of the right and left cusps and mild regurgitation. ECG Holter showed sporadic supraventricular premature ectopic beats and abnormality of the ventricular repolarization that were accentuated during exercise. Exercise stress test showed 3 mm ST depression in V4–V5 leads. Cardiac magnetic resonance (CMR) and Cardio–CT confirmed HCMO diagnosis and showed a junctional origin of the coronaries, a bifurcated interventricular artery, coronaries free from significant stenosis, intramural late gadolinium enhancement (LGE) of the mid–ventricular SIV and sub–endocardium LGE of the basal SIV. The high HCM– Sudden Cardiac Death Risk score and the presence of LGE on CMR identified a high–risk status and prompt consideration for primary prevention automatic implantable cardioverter defibrillator (AICD) therapy. Thus, in order to treat major life–threatening ventricular arrhythmias, AICD was placed (ESC guidelines 2014 Class IIa). Invasive treatment is indicated for symptomatic patients, NYHA class III and IV refractory to optimized medication and who have gradients in the LVOT. Aortic transvalvular–myectomy is the procedure with the longest experience and considered the gold standard. However, in this case surgical treatment was temporarily postponed. So a sequential rhythm pacing with reduced A–V delay was set up in order to induce a left bundle branch block and a “paradoxical” movement of the SIV with reduction of LVOT gradient. After 2 weeks the LVOT gradient was 20 mmHg and the symptoms were improved. This case suggests the usefulness of a single device for the treatment of different aspects in HCMO waiting to undergo surgical treatment: prevention of sudden cardiac death and improvement of symptoms refractory to medical therapy.

P30 CARDIAC ARRESTS IN SPORTS: WHAT IS DIFFERENT COMPARED TO OTHER PUBLIC PLACES?

Abstract Introduction Cardiac arrests in sports can involve professional athletes, amateurs, but also spectators of sports competitions. Sports facilities are the only ones for which the current law provides for the presence of an automatic external defibrillator (AED) and trained personnel, unlike other public places (schools, work, street, station, general public buildings) where it is only recommended. Objective To compare patient characteristics, presentation rhythm, bystander cardiopulmonary resuscitation (CPR), AED use before emergency medical services (EMS) arrival, and return of spontaneous circulation (ROSC) longer than 30 seconds in the Utstein category of out–of–hospital cardiac arrests (OHCAs) in sports compared to events in other public places. Materials and Methods We considered all the OHCAs occurred from 01/01/2015 to 31/12/2020 in the provinces of Pavia, Lodi, Cremona, Mantua and Varese (2400000 inhabitants), excluding the OHCAs occurred at home, in long–term care facilities and witnessed by the EMS. Results During the study period, 22 OHCAs occurred in sports and 552 in other public places (school, work, street, station, public buildings). The age is similar in the two groups [sport 59 years (IQR 53.5–66.7) vs other 63 years (IQR 51–75), p = 0.2]. In sports, there is a trend in favor of shockable rhythms (13/22=59% vs 185/552=33%, p = 0.1). The percentage of CPR performed by bystanders in sports is significantly higher than in other public places (20/22=91% vs 299/552=54%, p = 0.003), as the bystander AED use (11/22=50% vs 64/552=12%, p &amp;lt; 0.001) and bystander AED shock (7/22=31% vs 27/552=5%, p &amp;lt; 0.001) before EMS arrival. A ROSC greater than 30 seconds was obtained in 59% of OHCAs in sports, with a statistically significant difference compared to events in other public places (13/22=59% vs 166/552=30%, p = 0.015). Conclusions During sports competitions there is a greater ability to intervene in case of cardiac arrest, which determines a higher probability of obtaining ROSC, although in terms of age or presentation rhythm the patients are comparable to OHCA victims in other places public. These results suggest the need for an AED and trained personnel in other public places as well.

The impact of the italian law mandating an automatic external defibrillation in all sports venues on sudden cardiac arrest survival

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The chances of surviving a sport-related cardiac arrest depend strictly on resuscitation efforts. Since 2015, all Italian recreational and competitive sport venues must be equipped with automated external defibrillators (AEDs), and trained staff must be present during competitions. The aim of the study was to evaluate the incidence and survival rates of cardiac arrests in sport Venues in the Lombardia region of Italy before and after 2015. Methods We collected retrospectively data regarding all sudden cardiac arrests of presumed cardiac origin that involved both athletes and non-athletes (coaches, referees, spectators, etc.) and which occurred in sports venues of the Lombardia region in the period 2015-2019 versus those that occurred in the period 2011-2014, when automatic external defibrillators were not mandatory yet. All cases have been gathered thanks to the database built by the regional territorial emergency service (AREU) of the Lombardia region and consulting the news reported by the local and national press. Results Between 2015 and 2019, the incidence of cardiac arrest of presumed cardiac origin which affected athletes in sports venues of the Lombardia region was 0.19 per 100,000 inhabitants/year, versus 0.28 per 100,000 inhabitants/year in the period 2011-2014 (p&amp;lt;0.005). The average age of the victims was 49.9 years in 2015-2019 and 52 years in 2011-2014 (p=0.96). After the enactment of the "compulsory AED law", the proportion of cardiac arrests treated with onsite AEDs increased from 15% to 42.1% (p&amp;lt;0.001) and the return of spontaneous circulation (successful resuscitation) increased from 67% to 80% (p&amp;lt;0.05). The association between mandatory presence of AEDs in sports venues and resuscitation success in terms of ROSC was found significant (p&amp;lt;0.05). Conclusions Cardiac arrest in sports venues is a rare event and involves mainly male athletes older than 30 years old. A nationwide law mandating the presence of AEDs in all sport venues significantly increased the proportion of individuals suffering cardiac arrest who received defibrillation before the emergency medical system arrival and favorably influenced survival rates.