INTRODUCTION:Pulmonary capillary wedge pressure (PCWP) and right atrial pressure (RAP) are key haemodynamic indicators of cardiac congestion. Atrial fibrillation (AF) often coexists with several heart diseases, making it challenging to determine AF's independent contribution to atrial pressure elevation. Therefore, the impact of AF on PCWP and RAP requires clarification. We sought to quantify the contribution of AF on PCWP and RAP within patients with various chronic heart diseases. METHODS:We performed a single-center retrospective analysis on 1452 patients (age: 68.0 ± 13.6 years, 58.7% male, 26% AF) with chronic heart diseases undergoing right heart catheterization (RHC). PCWP and RAP were measured during RHC, and the underlying AF or sinus rhythm (SR) was annotated. To isolate AF effect from clinical, haemodynamic, and echocardiographic confounders, two propensity score matching analyses yielded two balanced cohorts for PCWP (n = 496) and RAP (n = 494) analysis. RESULTS:After matching, PCWP was higher in the AF than the SR group (18.4 ± 0.49 mmHg vs 15.7 ± 0.49 mmHg; P < .001). Similarly, RAP was higher in the AF than the SR group (8.7 ± 0.34 mmHg vs 7.5 ± 0.34 mmHg; P = .02). The findings were highly robust for PCWP (E-value = 10.8) and moderately robust for RAP (E-value = 2.78) to unmeasured confounders. Additionally, patients in the SR cohort with a prior history of AF had significantly higher PCWP and RAP compared to patients with no AF history. CONCLUSION:In our cohort, AF increased PCWP by 2.6 mmHg and RAP by 1.1 mmHg. Furthermore, a previous history of AF is linked to higher atrial pressures in patients later in SR.
INTRODUCTION:Left bundle branch area pacing (LBBAP) has emerged as a physiologic alternative to conventional right ventricular and biventricular pacing, yet large real-world evidence remains limited. We aimed to assess changes in ventricular function and symptoms after LBBAP in patients with different clinical indications. METHODS AND RESULTS:Consecutive patients discharged with confirmed LBBAP across 29 Italian centers underwent evaluation of echocardiographic parameters and New York Heart Association (NYHA) functional class at follow-up. A total of 697 patients were included: 532 with a bradycardia indication and 165 with a heart failure (HF) indication, assessed at a median follow-up of 12.4 months. In the bradycardia group, left ventricular ejection fraction (LVEF) showed a slight improvement from 55% (interquartile range, 50-60) to 56% (52-60) (p = 0.027). Paced-induced cardiomyopathy (PICM), defined as a ≥ 10% absolute LVEF reduction to < 50%, occurred in 3% of patients. Loss of LBBAP capture (p = 0.025) and lower LBBAP percentage (p = 0.024) were independent predictors of PICM. In the HF group, LVEF improved from 35% (30-41) to 45% (36-52) (p < 0.001). Overall, 61.8% were classified as responders (LVEF increase ≥ 5%), rising to 73.8% among patients with ≥ 12 months of follow-up. Higher LBBAP pacing percentage and absence of coronary artery disease independently predicted response. NYHA functional class improved significantly in both groups. CONCLUSIONS:In this large real-world cohort, LBBAP was associated with meaningful improvements in ventricular function and symptoms in both bradycardia and HF populations. A high percentage of effective LBBAP capture is essential for optimizing outcomes, supporting its role as an effective physiologic pacing strategy.
BACKGROUND:Biologic therapies for severe T2-high asthma demonstrated oral corticosteroid-sparing effects, but evidence on the harmlessness of de-escalating inhaled corticosteroids and other in patients controlled with dupilumab remains limited. OBJECTIVE:To evaluate, in a real-world setting, the clinical impact of de-escalating high-dose ICS, LAMA and LTRA in patients with severe asthma controlled with dupilumab. METHODS:We conducted a retrospective bicentric observational study including 54 patients with severe asthma who initiated dupilumab between January 2022 and December 2023. Changes in maintenance therapy during the first year were classified as de-escalation, continuation, or never treated. Primary outcomes at 18 months included ACT score, acute exacerbation rate (AER), FEV1, their variation from baseline, chronic OCS use and clinical remission. RESULTS:Dupilumab significantly improved asthma control, lung function, AER, and OCS use. The proportion of patients receiving high-dose ICS decreased from 85.1% at baseline to 47.1% at 18 months (p < 0.001). Similar trends for LAMA and LTRA. Primary outcomes at 18 months did not differ significantly between patients who de-escalated maintenance therapy and those who continued treatment. Clinical remission was achieved in 53.7% of patients at 12 months and 63.4% at 18 months. Maintenance therapy de-escalation did not affect the likelihood of achieving clinical remission, although nearly half of patients in remission remained on low-to-medium dose ICS. CONCLUSIONS:In patients with severe asthma controlled with dupilumab, de-escalation of high-dose ICS, LAMA, or LTRA was not associated with clinical deterioration and did not preclude achievement of clinical remission.
Respiratory Distress Syndrome (RDS) is the most common respiratory problem of preterm newborns. The preferred way to manage RDS is with Less Invasive Surfactant Administration (LISA), which involves direct laryngoscopy in spontaneously breathing infants. Despite its widespread diffusion, the optimal sedation protocol for LISA remains unclear. Dexmedetomidine, an α2-adrenergic agonist, offers sedative and analgesic properties with minimal respiratory depression. This pilot study aims to evaluate dexmedetomidine for LISA procedure focusing on the frequency of adequate sedation (defined as N-PASS score −2 to −5) and analgesia (NIPS score < 4) and adverse events related to dexmedetomidine. This is a prospective observational study conducted in our tertiary Italian NICU from May 2021 to July 2024. We enrolled preterm neonates aged between 26+0 to 36+6 weeks, diagnosed with RDS who required LISA. We also analyzed the study population into two groups based on a cut-off of 32 weeks to understand possible differences in adverse events and sedation and analgesia scores, even if this was not our prior aim. Dexmedetomidine (1 µg/kg) was administered intravenously before LISA. Primary outcomes included pain control assessed by Neonatal Infant Pain Scale (NIPS) score, sedation adequacy assessed by Neonatal Pain, Agitation, and Sedation Scale (N-PASS), and success rate of the procedure (such as laryngoscopy conditions assessed by Goldberg score and number of attempts). We also assessed the safety of the procedure evaluating adverse events, such as intubation rates, apneas/desaturations, bradycardia, and hypotension. Forty-seven preterm newborns received dexmedetomidine. The median (IQR) gestational age (weeks/days), birth weight (grams) and age (hours) at LISA were respectively 29+6 (28+5, 33+1) weeks, 1421 (1069–2074) g, 3 (2.5–6) hours. Pain scores indicated adequate pain control during the procedure (NIPS < 4 in 76
