Publications by authors named "Alessandro Zorzi"

158 Publications

Exercise addiction in athletes: Comparing two assessment instruments and willingness to stop exercise after medical advice.

Psychol Assess 2021 Feb 22. Epub 2021 Feb 22.

Department of Neuroscience, University of Padua.

Exercise is overwhelmingly beneficial for physical and mental health, but for some people exercise addiction (EA) can develop and negatively impact an individual. This study sought to (a) compare the latent structure of two instruments assessing EA and (b) examine differences in attitudes toward stopping exercise, if required to on medical grounds, among exercise-addicted and non-addicted athletes. In a cross-sectional study, 1,011 athletes competing at different levels completed an anonymous on-line survey. The survey contained Exercise Dependence Scale-Revised (EDS-R), Exercise Addiction Inventory (EAI), and questions on adherence to medical prescriptions to stop exercise. We tested the latent structure of EDS-R and EAI with multigroup confirmatory factor analyses (CFA), across gender and competition level. Finally, we measured the difference of athletes' attitudes toward stopping exercise, if prescribed by a physician. Both instruments showed good fit indexes, even across gender. CFAs on EAI scores showed some violations of measurement invariance across competition level (ΔCFI = .03; ΔRMSEA = .02). On the contrary, CFAs on EDS-R scores did not show invariance violations across competition level (ΔCFI = <.01; ΔRMSEA = <.01). Finally, athletes who reached thresholds for exercise addiction, by means of EDS-R, were more prone to not follow medical prescriptions to cease exercise, independently of the competition level. These results suggest that athletes' answers on the EDS-R seem to be less affected by competition level, compared to EAI. Moreover, EDS-R outcomes could be used to identify individuals who may be unlikely to cease exercise for medical reasons, independently of their competition level. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/pas0000987DOI Listing
February 2021

Clinical correlates and outcome of the patterns of premature ventricular beats in Olympic athletes: a long-term follow-up study.

Eur J Prev Cardiol 2020 Jun 2. Epub 2020 Jun 2.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy.

Background: The pattern of premature ventricular beats, as a clue to site of origin, may help identify underlying cardiac diseases.

Aim: To assess the value of premature ventricular beat patterns in managing athletes with ventricular arrhythmias.

Methods: Athletes with 50 or more isolated premature ventricular beats/24 hours, and/or multifocal and/or repetitive premature ventricular beats at baseline, and/or exercise, and/or 24-hour electrocardiograms were selected for this analysis. Premature ventricular beats were defined as 'common' (outflow tract or fascicular origin), or 'uncommon' (other morphologies and/or multifocal or repetitive).

Results: From 4595 athletes consecutively examined, 205 (4%, 24.6 ± 6.9 years, 67% men) were included, 118 (58%) with uncommon and 87 (42%) with common premature ventricular beats. In particular, 81 (39%) showed complex patterns; 63 (31%) right/left ventricular outflow tract origin; 24 (12%) fascicular origin; 20 (10%) right bundle branch block pattern, intermediate/superior axis, wide QRS; and 17 (8%) left bundle branch block pattern, intermediate/superior axis. Uncommon premature ventricular beat patterns were predominant among men (62% vs. 38%; P < 0.001) but not among women. Uncommon premature ventricular beats were equally prevalent in endurance, mixed and skill disciplines, but lower in power sports. Cardiac diseases were detected in 11 (5%), 10 with uncommon patterns. Over a 6-year follow-up, cardiac diseases occurred in four (0.6%/year), all with uncommon patterns. Overall, cardiac diseases at baseline and during follow-up were detected in 14/118 athletes with uncommon versus one/87 with common premature ventricular beats (P = 0.003).

Conclusions: Evaluation of premature ventricular beat patterns in Olympic athletes identified cardiac diseases, requiring disqualification and/or follow-up, in 12% with uncommon versus 1% with common patterns. This result suggests that athletes with uncommon premature ventricular beat patterns should undergo comprehensive cardiac evaluation and/or serial follow-up, irrespective of gender or sporting discipline.
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http://dx.doi.org/10.1177/2047487320928452DOI Listing
June 2020

Aquatic exercise in patients with haemophilia: Electromyographic and functional results from a prospective cohort study.

Haemophilia 2021 Mar 17;27(2):e221-e229. Epub 2021 Feb 17.

Haemophilia Treatment Center (HTC) 'Cláudio Luiz Pizzigatti Corrêa', Hemocentro UNICAMP, University of Campinas, Campinas, Brazil.

Introduction: Recurrent joint bleeds in haemophilia patients often cause musculoskeletal changes leading to functional capacity impairment.

Aim: In this study, we assessed the effects of aquatic activities performed to improve functional capacity in these patients.

Methods: The interventional protocol consisted of 24 hydrotherapy sessions during three months, in comparison with 24 swimming sessions. The pre- and post-intervention assessment consisted of Functional Independence Score, haemophilia joint health score (HJHS), Pediatric Haemophilia Activities List (PedHAL), surface electromyography (SEMG) of thigh muscles to assess muscle electric activity, and load cell on extensor and flexor thigh muscles to evaluate muscular strength.

Results: Forty-seven haemophilia patients were enrolled in this study, and 32 (23 severe haemophilia A, one moderate haemophilia A and 8 severe haemophilia B), median age 12y (6 to 40y), concluded the aquatic intervention. We observed a statistically significant increase with substantial improvement in functional capacity in the pre- and post-intervention evaluation of hydrotherapy in comparison with the swimming protocol, with HJHS (p = .006 and p = .001 respectively), PedHAL (Sum score) (p = .022 and p = .001) and score FISH (p = .021). The swimming group revealed significant improvements in muscular strength, in all muscles tested (p = .005 and p = .001). SEMG signal amplitude reached significantly higher levels in all muscles evaluated after both interventions except for the vastus medialis (right) in the hydrotherapy group.

Conclusion: Our results concluded that both swimming and hydrotherapy were associated with physical improvement in haemophilia patients; however, only hydrotherapy lead to a more significant improvement in functional capacity.
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http://dx.doi.org/10.1111/hae.14275DOI Listing
March 2021

Clinical management of young competitive athletes with premature ventricular beats: A prospective cohort study.

Int J Cardiol 2021 May 12;330:59-64. Epub 2021 Feb 12.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Italy. Electronic address:

Background: Premature ventricular beats (PVBs) are not an unusual finding and their interpretation is sometimes challenging. Unfortunately, few data on the characteristics of PVBs that correlate with the risk of an underlying heart disease are available in athletes.

Objectives: The aim of this prospective study was to investigate the diagnostic and prognostic value of PVBs characteristics in competitive athletes.

Methods: From a cohort of 1751 athletes evaluated at our sports cardiology centre, we enrolled 112 competitive athletes <40 years of age (mean age 21 ± 10 years) and with no known heart disease referred for PVBs. All athletes underwent physical examination, ECG, 12‑lead ambulatory ECG monitoring, exercise testing, and echocardiography. Further investigations including cardiac magnetic resonance were performed for abnormal findings at first-line evaluation or for specific PVBs characteristics.

Results: The majority (79%) of athletes exhibited monomorphic PVBs with a fascicular or infundibular pattern (common morphologies). A definitive diagnosis of cardiac disease was reached in 26 athletes (23% of the entire population) and correlated with uncommon PVBs morphology (p < 0.001) and arrhythmia complexity (p < 0.001). The number of PVBs/24-h was lower in athletes with cardiac disease than in those with normal heart (p < 0.05). During the follow-up a spontaneous reduction of PVBs and no adverse events were observed.

Conclusions: Infundibular and fascicular PVBs were the most common morphologies observed in athletes with ventricular arrhythmias referred for cardiological evaluation. Morphology and complexity of PVBs, but not their number, predicted the probability of an underlying disease. Athletes with PVBs and negative investigation showed a good prognosis.
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http://dx.doi.org/10.1016/j.ijcard.2021.02.021DOI Listing
May 2021

The acute effects of an ultramarathon on biventricular function and ventricular arrhythmias in master athletes.

Eur Heart J Cardiovasc Imaging 2021 Feb 5. Epub 2021 Feb 5.

Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy.

Aims: Endurance sports practice has significantly increased over the last decades, with a growing proportion of participants older than 40 years. Although the benefits of moderate regular exercise are well known, concerns exist regarding the potential negative effects induced by extreme endurance sport. The aim of this study was to analyse the acute effects of an ultramarathon race on the electrocardiogram (ECG), biventricular function, and ventricular arrhythmias in a population of master athletes.

Methods And Results: Master athletes participating in an ultramarathon (50 km, 600 m of elevation gain) with no history of heart disease were recruited. A single-lead ECG was recorded continuously from the day before to the end of the race. Echocardiography and 12-lead resting ECG were performed before and at the end of the race. The study sample consisted of 68 healthy non-professional master athletes. Compared with baseline, R-wave amplitude in V1 and QTc duration were higher after the race (P < 0.001). Exercise-induced isolated premature ventricular beats were observed in 7% of athletes; none showed non-sustained ventricular tachycardia before or during the race. Left ventricular ejection fraction, global longitudinal strain (GLS), and twisting did not significantly differ before and after the race. After the race, no significant differences were found in right ventricular inflow and outflow tract dimensions, fractional area change, s', and free wall GLS.

Conclusion : In master endurance athletes running an ultra-marathon, exercise-induced ventricular dysfunction, or relevant ventricular arrhythmias was not detected. These results did not confirm the hypothesis of a detrimental acute effect of strenuous exercise on the heart.
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http://dx.doi.org/10.1093/ehjci/jeab017DOI Listing
February 2021

Papillary Muscles Abnormalities in Athletes With Otherwise Unexplained T-Wave Inversion in the ECG Lateral Leads.

J Am Heart Assoc 2021 Feb 26;10(3):e019239. Epub 2021 Jan 26.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health University of Padova Italy.

Background Papillary muscles (PMs) abnormalities may be associated with ECG repolarization abnormalities. We aimed to evaluate the relation between lateral T-wave inversion (TWI) and PMs characteristics in a cohort of athletes with no clinically demonstrable cardiac disease. Methods and Results We included 53 athletes (median age, 20 years; 87% men) with lateral TWI and no evidence of heart disease on clinical and cardiac magnetic resonance evaluation. A group of healthy athletes with normal ECG served as controls. We evaluated the PMs dimensions, such as diameters, area, volume, mass, and ratio between PMs and left ventricular mass, and the prevalence of PMs apical displacement. Compared with controls, athletes with TWI showed PMs hypertrophy with significantly increased PMs diameters, area, volume, and mass. The ratio between PMs and left ventricular mass was 4.4% in athletes with TWI and 3.0% in controls (<0.001). A PMs/left ventricular mass ratio >3.5% showed 85% sensitivity and 76% specificity for differentiating between athletes with TWI and controls. Apical displacement of PMs was found in 25 (47%) athletes with TWI versus 9 (17%) controls (=0.001). At multivariable analysis, PMs/left ventricular mass ratio and apical displacement remained independent predictors of TWI. Clinical outcome of the athletes with TWI and PMs abnormalities was uneventful despite continuation of their sports activity. Conclusions PMs hypertrophy and apical displacement may underlie otherwise unexplained lateral TWI in the athlete. Lateral TWI associated with PMs abnormalities appears as a distinct anatomo-clinical condition characterized by a favorable outcome.
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http://dx.doi.org/10.1161/JAHA.120.019239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955426PMC
February 2021

Stem cells for treatment of cardiovascular diseases: An umbrella review of randomized controlled trials.

Ageing Res Rev 2021 05 9;67:101257. Epub 2021 Jan 9.

Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy.

Aims: Stem cells are a promising therapy for various medical conditions. The literature regarding their adoption for the clinical care of cardiovascular diseases (CVD) is still conflicting. Therefore, our aim is to assess the strength and credibility of the evidence on clinical outcomes and application of stem cells derived from systematic reviews and meta-analyses of intervention studies in CVD.

Methods And Results: Umbrella review of systematic reviews with meta-analyses of randomized controlled trials (RCTs) using placebo/no intervention as control group. For meta-analyses of RCTs, outcomes with a random-effect p-value <0.05, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) assessment was used, classifying the evidence from very low to high. From 184 abstracts initially identified, 11 meta-analyses (for a total of 34 outcomes) were included. Half of the outcomes were statistically significant (p < 0.05), indicating that stem cells are more useful than placebo. High certainty of evidence supports the associations of the use of stem cells with a better left ventricular end systolic volume and left ventricular ejection fraction (LVEF) in acute myocardial infarction; improved exercise time in refractory angina; a significant lower risk of amputation rate in critical limb ischemia; a higher successful rate in complete healing in case of lower extremities ulcer; and better values of LVEF in systolic heart failure, as compared to placebo.

Conclusion And Relevance: The adoption of stem cells in clinical practice is supported by a high certainty of strength in different CVD, with the highest strength in acute myocardial infarction and refractory angina.
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http://dx.doi.org/10.1016/j.arr.2021.101257DOI Listing
May 2021

"Apical sparing" T-wave inversion in a case of mid-ventricular takotsubo syndrome.

Pacing Clin Electrophysiol 2021 Mar 18;44(3):559-563. Epub 2021 Jan 18.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy.

Previous studies showed that myocardial edema correlates with dynamic T-wave inversion and QTc prolongation in a variety of acute cardiovascular diseases including takotsubo syndrome (TTS). We reported the case of a patient with "atypical" (mid-ventricular) TTS showing a unique pattern of diffuse T-wave inversion that spared only the apical precordial leads V3-V4. Cardiac magnetic resonance (CMR) showed myocardial edema involving all mid-ventricular segments but not the apex. Both ECG and CMR normalized at follow-up evaluation. This case further reinforces the theory of an association between presence and regional distribution of acute myocardial inflammation and dynamic repolarization changes.
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http://dx.doi.org/10.1111/pace.14165DOI Listing
March 2021

Predictors of Left Ventricular Scar Using Cardiac Magnetic Resonance in Athletes With Apparently Idiopathic Ventricular Arrhythmias.

J Am Heart Assoc 2021 Jan 31;10(1):e018206. Epub 2020 Dec 31.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health University of Padova Italy.

Background In athletes with ventricular arrhythmias (VA) and otherwise unremarkable clinical findings, cardiac magnetic resonance (CMR) may reveal concealed pathological substrates. The aim of this multicenter study was to evaluate which VA characteristics predicted CMR abnormalities. Methods and Results We enrolled 251 consecutive competitive athletes (74% males, median age 25 [17-39] years) who underwent CMR for evaluation of VA. We included athletes with >100 premature ventricular beats/24 h or ≥1 repetitive VA (couplets, triplets, or nonsustained ventricular tachycardia) on 12-lead 24-hour ambulatory ECG monitoring and negative family history, ECG, and echocardiogram. Features of VA that were evaluated included number, morphology, repetitivity, and response to exercise testing. Left-ventricular late gadolinium-enhancement was documented by CMR in 28 (11%) athletes, mostly (n=25) with a subepicardial/midmyocardial stria pattern. On 24-hour ECG monitoring, premature ventricular beats with multiple morphologies or with right-bundle-branch-block and intermediate/superior axis configuration were documented in 25 (89%) athletes with versus 58 (26%) without late gadolinium-enhancement (<0.001). More than 3300 premature ventricular beats were recorded in 4 (14%) athletes with versus 117 (53%) without positive CMR (<0.001). At exercise testing, nonsustained ventricular tachycardia occurred at peak of exercise in 8 (29%) athletes with late gadolinium-enhancement (polymorphic in 6/8, 75%) versus 17 athletes (8%) without late gadolinium-enhancement (=0.002), (<0.0001). At multivariable analysis, all 3 parameters independently correlated with CMR abnormalities. Conclusions In athletes with apparently idiopathic VA, simple characteristics such as number and morphology of premature ventricular beats on 12-lead 24-hour ambulatory ECG monitoring and response to exercise testing predicted the presence of concealed myocardial abnormalities on CMR. These findings may help cost-effective CMR prescription.
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http://dx.doi.org/10.1161/JAHA.120.018206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955495PMC
January 2021

Reply to the Editor-Mexiletine in myotonic dystrophy: Beware of ventricular arrhythmias!

Heart Rhythm 2021 Apr 17;18(4):660-661. Epub 2020 Dec 17.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy.

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http://dx.doi.org/10.1016/j.hrthm.2020.12.013DOI Listing
April 2021

'Hot phase' clinical presentation in arrhythmogenic cardiomyopathy.

Europace 2020 Dec 13. Epub 2020 Dec 13.

Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35121 Padua, Italy.

Aims: The aim of this study is to evaluate the clinical features of patients affected by arrhythmogenic cardiomyopathy (AC), presenting with chest pain and myocardial enzyme release in the setting of normal coronary arteries ('hot phase').

Methods And Results: We collected detailed anamnestic, clinical, instrumental, genetic, and histopathological findings as well as follow-up data in a series of AC patients who experienced a hot phase. A total of 23 subjects (12 males, mean age at the first episode 27 ± 16 years) were identified among 560 AC probands and family members (5%). At first episode, 10 patients (43%) already fulfilled AC diagnostic criteria. Twelve-lead electrocardiogram recorded during symptoms showed ST-segment elevation in 11 patients (48%). Endomyocardial biopsy was performed in 11 patients, 8 of them during the acute phase showing histologic evidence of virus-negative myocarditis in 88%. Cardiac magnetic resonance was performed in 21 patients, 12 of them during the acute phase; oedema and/or hyperaemia were detected in 7 (58%) and late gadolinium enhancement in 11 (92%). At the end of follow-up (mean 17 years, range 1-32), 12 additional patients achieved an AC diagnosis. Genetic testing was positive in 77% of cases and pathogenic mutations in desmoplakin gene were the most frequent. No patient complained of sustained ventricular arrhythmias or died suddenly during the 'hot phase'.

Conclusion: 'Hot phase' represents an uncommon clinical presentation of AC, which often occurs in paediatric patients and carriers of desmoplakin gene mutations. Tissue characterization, family history, and genetic test represent fundamental diagnostic tools for differential diagnosis.
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http://dx.doi.org/10.1093/europace/euaa343DOI Listing
December 2020

Anatomical Predictors of Pacemaker Dependency After Transcatheter Aortic Valve Replacement.

Circ Arrhythm Electrophysiol 2021 Jan 11;14(1):e009028. Epub 2020 Dec 11.

Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy.

Background: Conduction disturbances after transcatheter aortic valve replacement (TAVR) are often transient. Limited data exist on anatomic factors predisposing to pacemaker dependency after TAVR. We sought to assess the rate and the possible predictors of pacemaker dependency after TAVR.

Methods: Consecutive patients undergoing pacemaker implantation up to 30 days after TAVR between May 2014 and September 2019 were included. Baseline electrocardiographic, computed tomography, and procedural characteristics were collected, including valve implantation depth and membranous septum length, an anatomic surrogate of the distance between the aortic annulus and the His bundle. Pacemaker dependency at 30 days and 1 year and all-cause mortality during follow-up were evaluated.

Results: Of 728 TAVR patients, 112 (53.5% men; median age, 81 years) underwent pacemaker implantation after TAVR. Of these, 44.6% (50 of 112) were pacemaker dependent at 30 days and 46.7% (36 of 77) at 1 year. By multivariate analysis, independent predictors of 30-day pacemaker dependency included left ventricular outflow tract calcifications under the left coronary cusp (odds ratio, 5.69 [95% CI, 1.45-22.31]; =0.013) and a difference between membranous septum length and implantation depth (ΔMSID) ≥3 mm (odds ratio, 7.58 [95% CI, 2.07-27.78]; =0.002). Conversely, membranous septum length and implantation depth alone were not associated with pacemaker dependency (odds ratio, 0.79 [95% CI, 0.60-1.05]; =0.11 and odds ratio, 1.11 [95% CI, 0.99-1.24]; =0.08). At a median follow-up of 28.1 (11.7-48.6) months, pacemaker-dependent patients did not show a worse survival (=0.26).

Conclusions: Less than half of the patients undergoing pacemaker implantation after TAVR are pacemaker-dependent at midterm follow-up. ΔMSID ≥3 mm and the presence of left ventricular outflow tract calcifications under the left coronary cusp, but not membranous septum length nor implantation depth alone, are predictive of long-term pacemaker dependency after TAVR, thus influencing device selection and programming.
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http://dx.doi.org/10.1161/CIRCEP.120.009028DOI Listing
January 2021

Characteristics and hospital course of patients admitted for acute cardiovascular diseases during the coronavirus disease-19 outbreak.

J Cardiovasc Med (Hagerstown) 2021 01;22(1):29-35

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padua, Italy.

Introduction: During the coronavirus disease-19 (COVID-19) outbreak in spring 2020, people may have been reluctant to seek medical care fearing infection. We aimed to assess the number, characteristics and in-hospital course of patients admitted for acute cardiovascular diseases during the COVID-19 outbreak.

Methods: We enrolled all consecutive patients admitted urgently for acute myocardial infarction, heart failure or arrhythmias from 1 March to 31 May 2020 (outbreak period) and 2019 (control period). We evaluated the time from symptoms onset to presentation, clinical conditions at admission, length of hospitalization, in-hospital medical procedures and outcome. The combined primary end point included in-hospital death for cardiovascular causes, urgent heart transplant or discharge with a ventricular assist device.

Results: A similar number of admissions were observed in 2020 (N = 210) compared with 2019 (N = 207). Baseline characteristics of patients were also similar. In 2020, a significantly higher number of patients presented more than 6 h after symptoms onset (57 versus 38%, P < 0.001) and with signs of heart failure (33 versus 20%, P = 0.018), required urgent surgery (13 versus 5%, P = 0.004) and ventilatory support (26 versus 13%, P < 0.001). Hospitalization duration was longer in 2020 (median 10 versus 8 days, P = 0.03). The primary end point was met by 19 (9.0%) patients in 2020 versus 10 (4.8%) in 2019 (P = 0.09).

Conclusion: Despite the similar number and types of unplanned admissions for acute cardiac conditions during the 2020 COVID-19 outbreak compared with the same period in 2019, we observed a higher number of patients presenting late after symptoms onset as well as longer and more complicated clinical courses.
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http://dx.doi.org/10.2459/JCM.0000000000001129DOI Listing
January 2021

Arrhythmogenic Cardiomyopathy.

Eur Heart J 2020 12;41(47):4457-4462

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy.

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http://dx.doi.org/10.1093/eurheartj/ehaa719DOI Listing
December 2020

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

Int J Cardiol Heart Vasc 2020 Oct 2;30:100625. Epub 2020 Sep 2.

Division of Cardiology, Santa Maria del Carmine Hospital, APSS, Rovereto (Tn), Italy.

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.
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http://dx.doi.org/10.1016/j.ijcha.2020.100625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7466955PMC
October 2020

Differential diagnosis of arrhythmogenic cardiomyopathy: phenocopies versus disease variants.

Minerva Med 2021 Apr 22;112(2):269-280. Epub 2020 Jul 22.

Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy -

Arrhythmogenic cardiomyopathy (ACM) is a genetic heart muscle disease caused by mutations of desmosomal genes in about 50% of patients. Affected patients may have defective non-desmosomal genes. The ACM phenotype may occur in other genetic cardiomyopathies, cardio-cutaneous syndromes or neuromuscular disorders. A sizeable proportion of patients have non-genetic diseases with clinical features resembling ACM (phenocopies). The identification of biventricular and left-dominant phenotypic variants has made differential diagnosis more difficult because of the broader spectrum of phenocopies which requires a detailed clinical study with appropriate evaluation of most prominent and discriminatory disease features. Conditions that enter into differential diagnosis of ACM include heart muscle diseases affecting the right ventricle, the left ventricle, or both. To confirm a conclusive diagnosis of ACM, these differential possibilities need to be reasonably excluded by an accurate and targeted clinical evaluation. This article reviews the clinical and imaging features of major phenocopies of ACM and provides indications for differential diagnosis. The recent etiologic classification of Arrhythmogenic Cardiomyopathies, whose common denominator is the distinctive phenotype characterized by a hypokinetic and non-dilated ventricle with a large amount of myocardial fibrosis underlying its propensity to generate ventricular arrhythmias is also addressed.
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http://dx.doi.org/10.23736/S0026-4806.20.06782-8DOI Listing
April 2021

Impact of the COVID-19 outbreak on emergency medical system missions and emergency department visits in the Venice area.

Eur J Emerg Med 2020 08;27(4):298-300

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy.

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http://dx.doi.org/10.1097/MEJ.0000000000000724DOI Listing
August 2020

Criteria for interpretation of the athlete's ECG: A critical appraisal.

Pacing Clin Electrophysiol 2020 08 30;43(8):882-890. Epub 2020 Jul 30.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy.

The electrocardiogram (ECG) is cheap and widely available but its use as a screening tool for early identification of athletes with a cardiac disease at risk of sudden cardiac death is controversial because of presumed low specificity. In the last decade, several efforts have been made to improve the distinction between physiological and pathological ECG findings in the athlete, leading to continuous evolution of the interpretation criteria. The most recent 2017 International criteria grouped ECG changes into three categories: normal, borderline, and abnormal. Borderline findings warrant further investigations only when two or more are present while abnormal changes should always be considered as the sign of a possible underlying disease. This review encompasses the evolution of the athlete's ECG interpretation criteria and highlights areas of uncertainty that will need to be addressed by further studies.
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http://dx.doi.org/10.1111/pace.14001DOI Listing
August 2020

Diagnosis of arrhythmogenic cardiomyopathy: The Padua criteria.

Int J Cardiol 2020 11 16;319:106-114. Epub 2020 Jun 16.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy.

The original designation of "Arrhythmogenic right ventricular (dysplasia/) cardiomyopathy"(ARVC) was used by the scientists who first discovered the disease, in the pre-genetic and pre-cardiac magnetic resonance era, to describe a new heart muscle disease predominantly affecting the right ventricle, whose cardinal clinical manifestation was the occurrence of malignant ventricular arrhythmias. Subsequently, autopsy investigations, genotype-phenotype correlations studies and the increasing use of contrast-enhancement cardiac magnetic resonance showed that the fibro-fatty replacement of the myocardium represents the distinctive phenotypic feature of the disease that affects the myocardium of both ventricles, with left ventricular involvement which may parallel or exceed the severity of right ventricular involvement. This has led to the new designation of "Arrhythmogenic Cardiomyopathy" (ACM), that represents the evolution of the original term of ARVC. The present International Expert Consensus document proposes an upgrade of the criteria for diagnosis of the entire spectrum of the phenotypic variants of ACM. The proposed "Padua criteria" derive from the diagnostic approach to ACM, which has been developed over 30 years by the multidisciplinary team of basic researchers and clinical cardiologists of the Medical School of the University of Padua. The Padua criteria are a working framework to improve the diagnosis of ACM by introducing new diagnostic criteria regarding tissue characterization findings by contrast-enhanced cardiac magnetic resonance, depolarization/repolarization ECG abnormalities and ventricular arrhythmia features for diagnosis of the left ventricular phenotype. The proposed diagnostic criteria need to be further validated by future clinical studies in large cohorts of patients.
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http://dx.doi.org/10.1016/j.ijcard.2020.06.005DOI Listing
November 2020

Coronary sinus and great cardiac vein electroanatomic mapping predicts the activation delay of the coronary sinus branches.

J Cardiovasc Electrophysiol 2020 08 17;31(8):2061-2067. Epub 2020 Jun 17.

Department of Cardiology, Santa Maria del Carmine Hospital, Rovereto, Italy.

Background: Implantation of left ventricular (LV) lead in segments with delayed electrical activation may improve response to cardiac resynchronization therapy (CRT). The search for the latest LV electrical delay (LVED) site can be time-consuming.

Objective: To assess if electrical mapping of coronary sinus (CS) and magna cardiac vein can help to identify the latest activated CS branch.

Methods: We retrospectively evaluated 48 consecutive patients who underwent electroanatomic mapping system-guided (EAMS)-CRT device implantation with ≥2 mapped CS branches. The activation mapping of the CS and relative branches were performed using an insulated guide wire. LVED was defined as the interval between the beginning of the QRS complex on the surface electrocardiogram and the local electrogram and expressed in milliseconds (ms).

Results: Thirty-two (67%) patients showed left bundle branch block (LBBB) and 16 (33%) non-LBBB electrocardiographic patterns. A total of 116 CS branches (mean, 2.4/patient; range, 2-5) were mapped. In the left oblique view, most patients (N = 39, 81%) showed the latest CS-LVED in lateral segments while nine (19%) showed the latest CS-LVED in anterior or posterior segments. Specifically, 94% of patients with LBBB showed the latest CS-LVED in lateral segments while CS activation among non-LBBB patients was heterogeneous. In all patients, the CS branch that demonstrated the highest LVED originated from the latest activated segment of the CS.

Conclusion: Electrical mapping of CS allows identifying the latest activated branches. This finding may contribute to simplify CRT device implantation compared to activation mapping of all the branches.
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http://dx.doi.org/10.1111/jce.14609DOI Listing
August 2020

Evaluation of mexiletine effect on conduction delay and bradyarrhythmic complications in patients with myotonic dystrophy type 1 over long-term follow-up.

Heart Rhythm 2020 11 7;17(11):1944-1950. Epub 2020 Jun 7.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy.

Background: Myotonic dystrophy type 1 (DM1) is a multisystemic disorder characterized by progressive cardiac conduction impairment, arrhythmias, and sudden death. Mexiletine is a sodium channel blocker drug used by patients with DM1 for treatment of myotonia, even though definitive proof of its safety over long-term follow-up is lacking.

Objective: The purpose of this study was to assess the impact of mexiletine for treatment of neurological symptoms on the composite endpoint of significant electrocardiogram modification (new onset or worsening of atrioventricular [AV] or intraventricular conduction delay) and bradyarrhythmic complications requiring pacemaker (PM) implantation (advanced AV block, symptomatic sinus pause >3 seconds).

Methods: This retrospective longitudinal study included a series of consecutive patients with genetically confirmed DM1 evaluated at our neurology and cardiology clinics from January 1, 2011, to January 1, 2020, who received mexiletine 200 mg twice daily. Patients with a PM, implantable cardioverter-defibrillator, or severe conduction abnormality (PQ interval ≥230 ms, complete bundle branch block, or atrial fibrillation) at enrollment were excluded.

Results: The study comprised 18 mexiletine-treated patients and 68 mexiletine-free controls. Over median follow-up of 53 months, the endpoint was reached by 4 (22%) mexiletine-treated patients and 23 (33%) non-mexiletine-treated patients (log-rank P = .45). In 3 non-mexiletine-treated patients, bradyarrhythmic complications requiring PM implantation were observed. At univariable analysis, only the presence of mild conduction delay (first-degree AV block with PQ interval <230 ms or left anterior fascicular block) at baseline predicted the endpoint (hazard ratio 2.22; 95% confidence interval 1.04-4.76).

Conclusion: Mexiletine 200 mg twice daily is safe in patients with DM1 and no severe conduction abnormality.
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http://dx.doi.org/10.1016/j.hrthm.2020.05.043DOI Listing
November 2020

Impact of exercise addiction on attitude to preparticipation evaluation and adherence to medical prescription.

J Cardiovasc Med (Hagerstown) 2020 Oct;21(10):772-778

Department of Neuroscience.

Aims: Identification of silent cardiovascular diseases by preparticipation evaluation (PPE) and disqualification from competitive sports have the potential to prevent sudden death but may induce adverse psychological consequences, particularly for exercise addicted athletes. We investigated the relationship between exercise addiction, attitude towards PPE and reaction to cardiovascular disease diagnosis.

Methods: We invited Italian competitive athletes to participate in an online questionnaire investigating exercise addiction, opinion about mandatory PPE and potential reaction to both sports disqualification and hypothetical diagnosis of different cardiovascular diseases.

Results: The survey was completed by 1011 athletes (75% men, median age 30 years) encompassing a wide range of sports disciplines and competition levels. According to the 'Exercise Dependence Scale-21', 6% were classified as exercise addicted. The vast majority of both exercise addicted and nonexercise addicted athletes agreed that PPE should be mandatory (92 and 96%, P = 0.17) and that the eligibility decision should be left to the sports medicine physician (82 and 89%, P = 0.08). In case a cardiovascular disease is identified, a higher proportion of exercise addicted athletes would undergo 'open-heart' surgery if this would allow resuming high-intensity sport (54 versus 31%, P < 0.001) and would continue exercising in case of diagnosis of a disease at risk of sudden death (57 versus 32%, P < 0.001).

Conclusion: Exercise addiction does not interfere with a general positive opinion about PPE, but is likely to impact on the adherence to medical prescription should a cardiovascular diagnosis be made. Exercise addiction should be taken into account when counselling athletes with newly diagnosed heart diseases.
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http://dx.doi.org/10.2459/JCM.0000000000000997DOI Listing
October 2020

Clinical correlates and outcome of the patterns of premature ventricular beats in Olympic athletes: a long-term follow-up study.

Eur J Prev Cardiol 2020 Jun 2:2047487320928452. Epub 2020 Jun 2.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy.

Background: The pattern of premature ventricular beats, as a clue to site of origin, may help identify underlying cardiac diseases.

Aim: To assess the value of premature ventricular beat patterns in managing athletes with ventricular arrhythmias.

Methods: Athletes with 50 or more isolated premature ventricular beats/24 hours, and/or multifocal and/or repetitive premature ventricular beats at baseline, and/or exercise, and/or 24-hour electrocardiograms were selected for this analysis. Premature ventricular beats were defined as 'common' (outflow tract or fascicular origin), or 'uncommon' (other morphologies and/or multifocal or repetitive).

Results: From 4595 athletes consecutively examined, 205 (4%, 24.6 ± 6.9 years, 67% men) were included, 118 (58%) with uncommon and 87 (42%) with common premature ventricular beats. In particular, 81 (39%) showed complex patterns; 63 (31%) right/left ventricular outflow tract origin; 24 (12%) fascicular origin; 20 (10%) right bundle branch block pattern, intermediate/superior axis, wide QRS; and 17 (8%) left bundle branch block pattern, intermediate/superior axis. Uncommon premature ventricular beat patterns were predominant among men (62% vs. 38%;  < 0.001) but not among women. Uncommon premature ventricular beats were equally prevalent in endurance, mixed and skill disciplines, but lower in power sports. Cardiac diseases were detected in 11 (5%), 10 with uncommon patterns. Over a 6-year follow-up, cardiac diseases occurred in four (0.6%/year), all with uncommon patterns. Overall, cardiac diseases at baseline and during follow-up were detected in 14/118 athletes with uncommon versus one/87 with common premature ventricular beats ( = 0.003).

Conclusions: Evaluation of premature ventricular beat patterns in Olympic athletes identified cardiac diseases, requiring disqualification and/or follow-up, in 12% with uncommon versus 1% with common patterns. This result suggests that athletes with uncommon premature ventricular beat patterns should undergo comprehensive cardiac evaluation and/or serial follow-up, irrespective of gender or sporting discipline.
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http://dx.doi.org/10.1177/2047487320928452DOI Listing
June 2020

Arrhythmic profile and 24-hour QT interval variability in COVID-19 patients treated with hydroxychloroquine and azithromycin.

Int J Cardiol 2020 10 19;316:280-284. Epub 2020 May 19.

Department of Medicine, University of Padua Medical School, Padua, Italy.

Background: Hydroxychloroquine and azithromycin combination therapy is often prescribed for coronavirus disease 2019 (COVID-19). Electrocardiographic (ECG) monitoring is warranted because both medications cause corrected QT-interval (QTc) prolongation. Whether QTc duration significantly varies during the day, potentially requiring multiple ECGs, remains to be established.

Methods: We performed 12‑lead ECGs and 12‑lead 24-h Holter ECG monitoring in all patients aged <80 years admitted to our medical unit for COVID-19, in oral therapy with hydroxychloroquine (200 mg, twice daily) and azithromycin (500 mg, once daily) for at least 3 days. A group of healthy individuals matched for age and sex served as control.

Results: Out of 126 patients, 22 (median age 64, 82% men) met the inclusion criteria. ECG after therapy showed longer QTc-interval than before therapy (450 vs 426 ms, p = .02). Four patients had a QTc ≥ 480 ms: they showed higher values of aspartate aminotransferase (52 vs 30 U/L, p = .03) and alanine aminotransferase (108 vs 33 U/L, p < .01) compared with those with QTc < 480 ms. At 24-h Holter ECG monitoring, 1 COVID-19 patient and no control had ≥1 run of non-sustained ventricular tachycardia (p = .4). No patients showed "R on T" premature ventricular beats. Analysis of 24-h QTc dynamics revealed that COVID-19 patients had higher QTc values than controls, with no significant hourly variability.

Conclusion: Therapy with hydroxychloroquine and azithromycin prolongs QTc interval in patients with COVID-19, particularly in those with high levels of transaminases. Because QTc duration remains stable during the 24 h, multiple daily ECG are not recommendable.
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http://dx.doi.org/10.1016/j.ijcard.2020.05.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235573PMC
October 2020

Axillary vein access for permanent pacemaker and implantable cardioverter defibrillator implantation: Fluoroscopy compared to ultrasound.

Pacing Clin Electrophysiol 2020 06 29;43(6):566-572. Epub 2020 May 29.

Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy.

Background: Axillary vein access (AVA) using fluoroscopic landmarks is an effective and safe approach for cardiac implantable electronic devices (CIEDs) implantation. However, it may result in a higher radiation exposure. Ultrasound-guided axillary access (USAA) is an effective alternative technique to conventional subclavian access for CIEDs implantation. Studies comparing USAA and AVA using fluoroscopic landmarks are lacking. The purpose of this study was to compare the safety, efficacy, and radiation exposure data of the USAA approach with the AVA using fluoroscopic landmarks.

Methods: The study population included 95 consecutive patients (61% male, median age 78 years [71-85 years]) referred for CIEDs implantation using AVA with fluoroscopic landmark (n = 46) or USAA (n = 49). Baseline characteristics and radiation exposure data (Air-Kerma [mGy], DAP [Gy-cm ], fluoroscopy time [seconds], and X-rays emission time [seconds]) were compared according to the technique used for the AVA.

Results: Axillary vein was successfully accessed in 45 of 49 (92%) patients using ultrasound and in 42 of 46 (91%) patients using fluoroscopic landmarks (P = 1.00). Air-Kerma, DAP, fluoroscopy time, and X-rays emission time were shorter for USAA group compared with AVA using fluoroscopic landmarks (11 mGy [8-20] vs 37 mGy [24-81], P < .00001; 3 Gy-cm [2-5] vs 10 Gy-cm [6-16], P < .00001; 97 seconds [62-163] vs 271 seconds [185-365], P < .00001; and 7 seconds [4-10] vs 21 seconds [13-39], P < .00001). There were no significant differences between the two groups in median implant procedure time (P = .55). We did not encounter any acute or long-term complications in both groups.

Conclusions: Ultrasound-guided axillary vein cannulation for CIEDs implantation is a feasible and safe alternative approach and offers a significant reduction in fluoroscopy times without increasing procedural time.
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http://dx.doi.org/10.1111/pace.13940DOI Listing
June 2020