Auriculoventricular Block Research Articles

HV interval measure immediately before TAVI with SEV for predicting pacemaker implantation

Abstract Introduction Although improvements, new onset persistent disturbances in electrocardiogram (ECG) after transcatheter aortic valve implantation (TAVI) remains up to 34% at hospital discharge (1), needing permanent pacemaker implantation (PPM) in self-expanding valves (SEV) as high as 15-27% (2,3). In post TAVI scenario, European Society of Cardiology guidelines recommend an electrophyisiologic study centered in His-ventricular electrogram (HV) interval measure for assessing risk of progression to high auriculoventricular block (AVB), if abnormal a PPM is indicated (4,5). We aim to predict PPM through basal HV interval measurement prior TAVI with SEV. Furthermore, we aim to compare different current SEV with basal HV interval and the distinct rate of PPM before discharge. Methods and Results Single-center prospective cohort study, patients with severe aortic stenosis scheduled for TAVI, sinus rhythm at intervention day, without PPM or history of PPM indication were included. At time of TAVI, contralateral venous puncture to femoral arterial access was made, a tetrapolar catheter was advanced and placed at the septal aspect of tricuspid valve searching for His electrogram. A mobile polygraph was used to measure ECG parameters and HV interval before TAVI. Then, a tetrapolar catheter was advanced to ventricle to perform rapid stimulation as part of habitual valve implantation protocol. After procedure, we performed rhythm surveillance for at least >48-72 hours and based in electrical evolution one of three decisions was made: 1)PPM implant, 2)late post TAVI HV interval re-measure or 3)clinical daily ECG vigilance, if this last was normal, unchanged from basal or with new but stable conduction disturbances, discharge were indicated following ESC guidelines. A total of 41 patients were enrolled, median age 84±4 years, 24 females (54.5%), PR mean 198±42ms, QRS mean 112±30ms. 18 had a 1st degree AVB (40.9%) of whom 13 (72.5%) had a PR ˂240ms. EPS data showed prior HV interval mean of 55±9ms. A Mild abnormal HV interval (56-69ms) were seen in 21 patients (51.2%), of whom 12 had a narrow QRS. SEV implanted were 11 (25%) Medtronic CoreValve Evolut+, 5 (11.4%) Biosensors Allegra, 25 (56.8%) Abbott Navitor. Post TAVI procedure, 5 (12.2%) women and 8 (19.5%) men met criteria for PPM implantation before discharge. One woman was implanted 6 days after discharge due to high AVB (66ms HV interval prior TAVR). In a multivariate analysis including sex, age, PR, QRS and HV interval >55ms, valve type the RR (IC 95% 1.37-30.99) risk of PPM was 6.52 folds higher (p=0.019). Conclusions An HV interval >55ms before TAVI with SEV increases risk of PPM after TAVI and before hospital discharge. There was no difference in PPM implantation after TAVI between different SEV types in our center.

Predictors of permanent pacemaker implantation for transcatheter self-expandable aortic valve implant in the cusp overlap era.

Predictors of permanent pacemaker implantation (PPMI) after self-expanding transcatheter aortic valve implant (TAVI) were described. Is unknown if PPMI predictors remain in the era of high implants using the cusp overlap (COP). Single-center, prospective, consecutive case series of patients undergoing self-expanding TAVI with the COP approach. The status of PPMI and other clinical events were ascertained at 30 days. A total of 261 patients were included (84% with Evolut, n = 219). Implant depth >4 mm was infrequent (13.8%). TAVI depth (OR 1.259; p = 0.005), first or second-degree auriculo-ventricular block (OR 3.406; p = 0.033), right-bundle (OR 15.477; p < 0.0001), and incomplete left-bundle branch block (OR 7.964; p = 0.036) were found to be independent predictors of PPMI. The risk of PPMI with deep implant and no electrical disturbances was 3%, and 0% with high implant and no prior electrical disturbances. Those who received PPMI had no statistically significant increased risk of death, myocardial infarction, stroke, bleeding events, or vascular complications at 30 days, but longer hospital stay (mean difference 1.43 days more, p = 0.003). Implant depth and prior conduction abnormalities remain the main predictors of PPMI using self-expanding TAVI in the COP era. Patients with high implants and no prior conduction abnormalities may be candidates for early discharge after uneventful self-expanding TAVI, while the rest may need inpatient monitoring regardless of achieving a high implant. The need for PPMI was associated with longer hospital stays.

A rare presentation of infective endocarditis: Phase 4 block of the left bundle branch as key for the diagnosis. A case report

Definitive diagnosis of infective endocarditis (IE) is mainly based on microbiological and imaging criteria. In a minority of cases, particularly when perivalvular area is involved, cardiac conduction disorders (CCD) may appear, which implies worse prognosis. In this scenario, different degrees of auriculoventricular block can occur, but development of bundle branch block is rare. Herein, we present a case of IE with negative initial imaging tests, where the occurrence of phase 4 bundle branch block after a sequence of type I second degree AV block was crucial to establish a definitive diagnosis and an optimal therapeutic approach.

Value of basal HV Interval prior TAVR as predictor of permanent pacemaker implantation

Abstract Background/Introduction Transfemoral aortic valve replacement (TAVR) is an effective and safe treatment for severe aortic stenosis (SAoS) even in low risk patients (1,2). As population ages, the volume of TAVR procedure increases and although improvements in technology and technique, new onset persistent disturbances in the electrocardiogram (ECG) are present up to 34,8% of patients at hospital discharge(3) and the secondary need of permanent pacemaker implantation (PPM) remains high, being of 4-24% with balloon-expanding valves (BEV) and 14.7-26.7% with self-expanding valves (SEV)(3). According to ESC guidelines, an electrophyisiologic study (EPS) centered in HV interval measure with a cutoff of ≥70ms is a useful tool to assess the risk of progression to high auriculoventricular block (HAVB) in specific groups with persistent ECG abnormalities to consider PPM(4-5), but this only applies in post TAVR scenario. Measuring HV interval at the intervention day prior procedure could help optimize and assess risk for PPM post TAVR. Purpose To measure basal HV interval prior TAVR and correlate it to risk of PPM implantation before discharge and 30 days after discharge. Methods Single-center prospective cohort study, patients with SAoS scheduled for TAVR, sinus rhythm at intervention day, without PPM or history of PPM indication were included. At time of TAVR, a tetrapolar catheter was placed at the septal aspect of tricuspid valve. A mobile polygraph was used to measure ECG parameters and HV interval before TAVR. Then, tetrapolar catheter was advanced to ventricle to perform rapid stimulation as part of habitual valve implantation protocol. After procedure, a rhythm monitorization for &amp;gt;48-72 hrs, was made to decide, PPM, HV interval measure or clinical daily ECG vigilance with posterior discharge was performed. A 30-day post discharge follow up was expected. Results 38 patients were enrolled, median age 83.5 ± 5.5 years, 23 females (60,5%). 37 patients had SEV implanted and 1 patient had BEV implanted. Median HV interval was 54.4ms. 18 patients (47.4%) had a mild abnormal HV interval, of whom 11 had a narrow QRS. Post TAVR procedure, 15 patients (39.5%) persisted with "de novo" LBB at discharge. 5 women and 7 men, had PPM implanted before discharge. 1 woman was implanted 6 days after discharge due to HAVB (66ms HV interval prior TAVR). In a multivariate analysis including sex, age, PR, QRS and HV interval &amp;gt;55ms, the RR (IC 95% 1.9-70.3) risk of PPM was 13.42 folds higher (p=0.008). At a bivariate quantitative HV analysis, a higher HV period persisted significantly related to PPM outcome (p=0.001). Conclusions In our study population, a pre-existing mild to moderate prolongation of HV interval prior TAVR substantially elevates the risk of requiring PPM before discharge. 61.1% of these basal mild prolongation HV interval patients had a narrow QRS prior TAVR.HV measure prior TAVR in narrow QRSTable 1

Electrical, Echocardiographic and Coronary Artery Characteristics of Right Ventricular Infarction: Experience of the Cardiology Department of the CHU Mohammed VI Marrakech

Introduction: Coronary heart disease is the main cause of morbidity and mortality worldwide. Right ventricular (RV) infarction is often difficult to diagnose and has a poor prognosis due to rhythmic and hemodynamic complications.&#x0D; Objective: The study of electrical, ultrasonographic, and coronarographic features of the VD Infarction.&#x0D; Materials and Methods: Retrospective study of patients hospitalized in the Cardiology Department of the Mohammed VI University Hospital in Marrakech over a period of 24 months for MDI extended to the RV.&#x0D; Results: 120 patients were hospitalized during this period for MI with extension to the VD. Atypical clinical presentation was noted in 10% of cases. Clinical examination on admission revealed signs of right heart failure in 18% of cases, including 6% complicated by cardiogenic shock. Thrombolysis was performed in 10% of the patients, 67% of them successfully. The ECG found an isolated extension to the V3R leads in 76% of the cases and in association with a V4R overshoot in 45% of the cases, conduction disorders were noted in 28% of the cases, presented essentially by first degree auriculoventricular block. Echocardiography showed impaired LV function in 82% of cases, and longitudinal systolic dysfunction of the LV in 65%. Coronary angiography was performed in 91% of the cases, half of which underwent coronary angioplasty. The combination of both CD and IVA damage was found in 40% of the cases, and damage to the middle DC was the most common in almost half of the cases. The most frequent complications were rhythmic and conductive disorders in 38% of cases, and the evolution was fatal in 8% of cases.&#x0D; Conclusion: Involvement of the RV during MI is characterized by a very critical initial phase, once overcome, the overall prognosis becomes favorable in the long term.

Improved understanding of the respiratory drive pathophysiology could lead to earlier spontaneous breathing in severe acute respiratory distress syndrome

Optimisation of the respiratory drive, as early as possible in the setting of severe acute respiratory distress syndrome (ARDS) and not its suppression, could be a new paradigm in the management of severe forms of ARDS. Severe ARDS is characterised by tachypnoea and hyperpnoea, a consequence of a high respiratory drive. Some patients require endotracheal intubation, controlled mechanical ventilation (CMV) and paralysis to prevent overt ventilatory failure and self-inflicted lung injury. Nevertheless, intubation, CMV and paralysis do not address per se the high respiratory drive, they only suppress it. Optimisation of the respiratory drive could be obtained by a multimodal approach that targets attenuation of fever, agitation, systemic and peripheral acidosis, inflammation, extravascular lung water and changes in carbon dioxide levels. The paradigm we present, based on pathophysiological considerations, is that as soon as these factors have been controlled, spontaneous breathing could resume because hypoxaemia is the least important input to the respiratory drive. Hypoxaemia could be handled by combining positive end-expiratory pressure (PEEP) to prevent early expiratory closure and low pressure support to minimise the work of breathing (WOB). ‘Cooperative’ sedation with alpha-2 agonists, supplemented with neuroleptics if required, is the pharmacological adjunct, administered immediately after intubation as the first-line sedation regimen during the multimodal approach. Given relative contraindications (hypovolaemia, auriculoventricular block, sick sinus syndrome), alpha-2 agonists can help attenuate or moderate fever, increased oxygen consumption VO2, agitation, high cardiac output, inflammation and acidosis. They may also help to preserve microcirculation, cognition and respiratory rhythm generation, thus promoting spontaneous breathing. Returning the physiology of respiratory, ventilatory, circulatory and autonomic systems to normal will support the paradigm of optimised respiratory drive favouring early spontaneous ventilation, at variance with deep sedation, extended paralysis, CMV and use of the prone position as therapeutic strategies in severe ARDS. GLOSSARY Glossary and Abbreviations_SDC, http://links.lww.com/EJAIC/A55

Severe bradycardia in a teenager as the initial manifestation for Guillain Barr\xe9 syndrome: a case report

BackgroundGuillain-Barré syndrome is the most common cause of flaccid paralysis, with multiple known clinical variants. Autonomic dysfunction, although frequently reported in the clinical course, is often overlooked in the pediatric population and is usually not the initial presenting symptom in this age groupCase presentationWe present the case of a previously healthy 17-year-old who arrived at the Emergency Department complaining of gastrointestinal symptoms associated with lipothymia. An initial electrocardiogram (ECG) showed sustained sinus bradycardia subsequently associated with arterial hypertension. Structural and inflammatory cardiac pathology were ruled out, as well as auriculoventricular conduction block and posterior reversible encephalopathy syndrome. On the ninth day after initial symptoms, the patient presented sensory and motor nerve disturbances with the cerebrospinal fluid analysis showing a clear albumin-cytologic dissociation, consistent with an atypical presentation of GBS with autonomic dysfunction. Immunoglobulin therapy was administered, developing subsequent aseptic meningitis, that required discontinuation of previous therapy and treatment with plasmapheresis. Clinical improvement was achieved with full motor function recovery.ConclusionThis case illustrates a Guillain-Barré syndrome variant in which autonomic dysfunction preceded neurologic deficit, a finding uncommon in children, emphasizing this as an important differential diagnosis for severe bradycardia in pediatric patients.

Unilateral pulmonary edema associated factors after minimally invasive mitral valve surgery.

In recent years, minimally invasive cardiac surgery (MICS) has been developed and applied to a greater number of pathologies, especially in mitral valve surgeries, as it obtains results comparable to those of conventional techniques while entailing lower surgical trauma and shorter recovery time. MICS requiring one-lung ventilation has been associated to the appearance of unilateral pulmonary edema (UPE), which is a potentially serious complication. The objective is determining the incidence of UPE after mitral MICS and its development associated factors. Observational descriptive and single-center study analyzing data from patients undergoing mitral valve MICS (right mini-thoracotomy) consecutively collected between the years 2015 and 2017. A total of 93 patients were included and 26 presented UPE. The most common complications after mitral valve MICS were atrial fibrillation (38.7%), UPE (28%) and transient and/or definitive second- or third-degree auriculoventricular block (19.4%). The UPE group had longer ICU stay (3.3 ± 8.0 vs. 1.84 ± 2.23 days) and longer total hospitalization length-of-stay (15.5 ± 34.7 vs. 10.6 ± 7.5 days). The mortality in the UPE group was 3.9%. A significant association was found between the following collected variables and the development of postoperative UPE: preoperative baseline pulse oximetry, preoperative use of ACE inhibitors, postoperative atrial fibrillation and 24 first-hours cumulative chest tube drainage volume on the first 24 h. The incidence of UPE is high and its appearance is associated with a longer ICU and total length of stay. More studies are required to understand its pathophysiology and apply measures to help decreasing its appearance.

Factores asociados al edema pulmonar unilateral después de la cirugía mínimamente invasiva de la válvula mitral

Background and objectivesIn recent years, minimally invasive cardiac surgery (MICS) has been developed and applied to a greater number of pathologies, especially in mitral valve surgeries, as it obtains results comparable to those of conventional techniques while entailing lower surgical trauma and shorter recovery time. MICS requiring one-lung ventilation has been associated to the appearance of unilateral pulmonary edema (UPE), which is a potentially serious complication. The objective is determining the incidence of UPE after mitral MICS and its development associated factors. Material and methodsObservational descriptive and single-center study analyzing data from patients undergoing mitral valve MICS (right mini-thoracotomy) consecutively collected between the years 2015 and 2017. ResultsA total of 93 patients were included and 26 presented UPE. The most common complications after mitral valve MICS were atrial fibrillation (38.7%), UPE (28%) and transient and/or definitive second- or third-degree auriculoventricular block (19.4%). The UPE group had longer ICU stay (3.3±8.0 vs. 1.84±2.23 days) and longer total hospitalization length-of-stay (15.5±34.7 vs. 10.6±7.5 days). The mortality in the UPE group was 3.9%. A significant association was found between the following collected variables and the development of postoperative UPE: preoperative baseline pulse oximetry, preoperative use of ACE inhibitors, postoperative atrial fibrillation and 24 first-hours cumulative chest tube drainage volume on the first 24h. ConclusionsThe incidence of UPE is high and its appearance is associated with a longer ICU and total length of stay. More studies are required to understand its pathophysiology and apply measures to help decreasing its appearance.

Predicting pacemaker dependency after TAVI with pre-procedural MSCT

Abstract Background and aim High degree conduction disturbances is a burdensome complication of transcatheter aortic valve implantation (TAVI). There is limited data whether such disorders are permanent or reversible. Anatomic surrogates, such as membranous septum [MS, a distance marker from aortic annulus to His-bundle surge] and calcium distribution within aortic valve have been associated with pacemaker (PM) implantation. The aim of our study was to assess predictors of long-term pacemaker dependency following TAVI. Methods Single center prospectively included patients that underwent pacemaker implantation following TAVI (March 2017 to September 2020). Patients who were lost to follow up, with bicuspid aortic valve, previously implanted PM and non-available or low quality MSCT exam were excluded. On MSCT, MS length was measured on modified coronal view, the aortic-valvular complex (AVC) was characterized by leaflet sector and calcium distribution was assessed on a J-score threshold of 850-Hounsfield units. Pacemaker dependency was assessed by reducing ventricular pacing to 30 bpm and defined by subsequent complete AV dissociation in patients in sinus rhythm or an escape rhythm &amp;lt;50 bpm in atrial fibrillation, in addition of &amp;gt;90% pacing percentage since implantation. Results From the 352 patients with inclusion criteria, 67 underwent PM implantation (19%) and 55 included in the analysis (male 33.9%, median age=85) (Figure). Median time for pacemaker implantation was 3 days [interquartile range (IQR) 3–5 days], mostly due to complete auriculo-ventricular block (76.4%, N=42). PM dependency occurred in 14 out of 55 (25.5%) patients at mean follow up of 500±363 days. Patients with PM dependency tended to have deeper implantation depth, (6.2 mm vs 5.5 mm, p=0.096) and a significantly shorter MS (5.8 mm vs 6.8 mm, P-value = 0.031) (Table). Increasing MS length was independently associated with a lower risk of PM dependency [odds ratio (OR) 0.58 per mm; 95% CI: 0.35–0.98, p=0.04] regardless prosthesis choice. MS length under 5 mm had 97.6% specificity (95% CI: 87.1–99.9) and 85.7% positive predictive value for pacemaker dependency (AUC=76.7; 95% CI 63.3–87). Conclusion Our findings highlight the importance of MSCT-derived MS length to stratify the risk of long term need for pacemaker. Patients with short MS (&amp;lt;5mm) in addition to conduction abnormality following TAVI had a high likelihood of PM dependency on the long term and should be considered for prompt PM implantation. Funding Acknowledgement Type of funding sources: None.

Predictors of early and late re-hospitalization and mortality in non-ST elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Regarding prognosis, acute coronary syndromes (ACS) are heterogeneous. Non-ST elevation myocardial infarction (NSTEMI) is a subtype of ACS. In-hospital (IH) and post-hospitalization (PH) risk stratification is crucial. Objective To identify predictors of IH and PH mortality (early and late), as well as predictors of early and late re-admission (RA) in our center population suffering NSTEMI, using real-life data. Methods Based on a single-center retrospective study, data collected from admissions between 1/01/2018 and 11/12/2019. Patients (pts) who survived the ACS and were discharged from the hospital were included. Concerning prognosis, we assessed 1-month M and RA (1mM and 1mRA), 6-month M and RA (6mM and 6mRA), 1-year M and RA (1yM and 1yRA). Results 268 pts with ACS, 59.7% were males and mean age was 66.4 ± 12.5 years old. NSTEMI was the diagnosis in 66.4% and ST elevation myocardial infarction (STEMI) in 31%. Mean creatinine was 1.2 ± 1ml/min, mean sodium was 138 ± 3mmol/L, mean blood urea nitrogen (BUN) was 21 ± 12mg/dL and mean haemoglobin (Hb) was 13.6 ± 1.9g/dL. 88.2% of the pts presented in Killip-Kimball class (KKC) 1, 5.7% in KKC 2, 5.7% in KKC 3 and 0.4% in KKC IV; furthermore, 4.1% of the pts presented de novo AF. Concerning coronary artery disease, 250 were submitted to coronary angiography – 18.8% had no lesions or non-significant lesions (stenosis &amp;lt;50%), 34.8% had one significant lesion, 23.2% had 2 significant lesions and 23.2% had 3 or more. Regarding left ventricle (LV) function, 70.5% of the pts had no LV dysfunction, 15.7% had mild LV impairment (LVI), 9.3% moderate LVI and 4.5% had severe LVI. 8.4% of the patients experienced IH complications, such as auriculoventricular block, heart failure, ventricular tachycardia, stroke, cardiorespiratory arrest and major haemorrhage, during hospitalization. 1mM rate was 1.9% and 1yM rate was 7.8%. KKC (p = 0.001), BUN (p = 0.007), LV function (p= 0.001) and de novo AF (p = 0.46) were predictors of 1mM. Age (p = 0.004), KKC (p = 0.031), BUN (p = 0.002), sodium (p = 0.037), creatinine (p = 0.001), Hb (p = 0.003), LV function (p &amp;lt; 0.001), de novo AF (p &amp;lt; 0.001) and occurrence of IH complications (p &amp;lt; 0.001) were predictors of 1yM. Age (p = 0.010), male gender (p = 0.19), Hb (p = 0.031), de novo AF (p &amp;lt; 0.001) and occurrence of IH complications (p = 0.001) were predictors of 1mRA. Age (p = 0.004), smoking (p = 0.040), hypertension (p = 0.040), glycemia at admission (p = 0.031), Hb (p = 0.004), LV function (p = 0.019), de novo AF (p &amp;lt; 0.001) and occurrence of IH complications (p &amp;lt; 0.001) were predictors of 1yRA. Conclusion This study suggests that de novo AF and occurrence of IH complications are very important prognosis factors regarding early and late mortality and readmission rates.

Etiology and prognosis of patients with unexplained syncope and mid-range left ventricular dysfunction

Syncope in patients with mid-range left ventricular ejection fraction (LVEF) can be due to potentially serious arrhythmic causes. However, there is no clear consensus on the best way to manage these patients. The objectives of this study were to determine the causes of syncope and assess the diagnostic yield and safety of a stepwise workup protocol in this population. This was a prospective observational study. A stepwise workup protocol was applied to patients with LVEF 35%-50% and unexplained syncope after the initial assessment (step 1). One hundred four patients were included {median age 75.6 years; (interquartile range [IQR] 67.6-81.2 years); median LVEF 45% (IQR 40%-48%); median follow-up 2.0 years (IQR 0.7-3.3 years). In 71 patients (68.3%), a diagnosis was reached: 55 (77.5%) in step 2 (hospital admission and electrophysiology study) and 16 (36.5%) in step 3 (implantable cardiac monitor). Arrhythmic causes were the most common etiology (45.2% auriculoventricular block and 9.6% ventricular tachycardia). Sixty patients (57.7%) required the implantation of a cardiac device and 11 had a defibrillation function. Patients diagnosed in step 3 had a higher global risk of recurrence of syncope (hazard ratio 6.5; 95% confidence interval 2.3-18.0). The mortality rate was 8.1 per 100 person-years, and the sudden or unknown death rate was 0.9 per 100 person-years. In patients with mid-range left ventricular dysfunction and syncope of unknown cause, a systematic diagnostic strategy based on electrophysiology study and/or implantable cardiac monitor implantation allows a diagnosis to be reached in a high proportion of cases and guides the treatment. Arrhythmia is the most common cause of syncope in this population, particularly auriculoventricular block.

Device therapy guided by implantable loop recorders: predictors of bradyarrhythmic events

Abstract Background Implantable loop recorders (ILR) improved diagnostic yield in unexplained syncope patients (pts). Data on possible predictive factors for bradycardia requiring device implantation in these pts is limited. We aim to identify clinical predictors for device implantation due to a significant bradyarrhythmia in patients who underwent ILR insertion for the study of syncopal/presyncopal (S/pS) events. Methods Single-center retrospective study of patients who implanted an ILR for the study of unexplained S/pS episodes between 2013 and 2018. The primary endpoint was a documented bradyarrhythmia requiring device implantation during the follow-up. Results A total of 251 pts were included. Mean age was 68±15 years and 53% were female. The majority of pts (220; 88%) had normal ejection fraction. Fifty-two (21%) pts had atrial fibrillation (AF). Regarding basal electrocardiographic characteristics, 34 (14%) pts had 1st degree auriculo-ventricular block (AVB), 31 (12%) pts had left bundle branch block (L-BBB), 22 (9%) pts had R-BBB and 13 (5%) pts had bifascicular block. During a median follow-up of 20 (IQR 9–34) months, 74 (29%) pts required device implantation because of a significant bradyarrhythmia (92% pacemaker, 4% CRT, 4% ICD). Median duration from ILR until device implantation was 5 (IQR 1–10) months. The indications were sick-sinus-syndrome in 47 (64%) pts, advanced AV block in 23 (31%) pts and symptomatic slow AF in 4 (5%) pts. Patients who required device implantation were older (73±12 vs 66±15 years, p &amp;lt;0.001), had more hypertension (73% vs 59% p=0.048), a higher prevalence of AF (34% vs 15% p=0.001) and a lower glomerular filtration rate (GFR&amp;lt;60 ml/min: 32% vs 21%, p=0.047). They also had more 1st AVB (22% vs 11%, p=0.026) and intraventricular conduction disturbances (38% vs 25%, p=0.025). There was a trend for a higher device implantation in pts with concomitant 1st AVB and left anterior fascicular block (7% vs 2%, p=0.063) In a logistic regression model, age &amp;gt;75 years (HR: 1.7; 95% CI: 1.1–2.8) and the presence of AF (HR: 1.8; 95% CI: 1.1–3.0) were independent predictors for device implantation. Conclusion An older age and the presence of AF were independent predictors for device therapy in pts who implanted an ILR for the study of S/pS. These factors may identify a higher risk group and should be considered in the initial workup of these pts. Funding Acknowledgement Type of funding source: None

Maternal complications induced by digoxin treatment of fetal tachycardia: A retrospective series of 18 cases

ObjectiveTo evaluate maternal tolerance to digoxin, used alone or associated to other antiarrhythmic drugs in the management of fetal tachycardia. Patients and MethodsThis retrospective study was conducted at Rouen University Hospital between January 2009 and July 2016. All women who have received a treatment by either digoxin alone or associated with another antiarrhythmic drug for fetal tachycardia were included in the study. Maternal cardiac and extracardiac adverse effects were reported and comparisons between electrocardiograms before and during treatment with digoxin alone were performed. ResultsEighteen women were treated by digoxin, either alone or associated with another antiarrhythmic (sotalol, flecainide or amiodarone). During treatment, digoxin overdosing (>2ng/mL) was observed in 11 women (61%), among which 4 women had toxic levels of digoxinemia (>3ng/mL) that was symptomatic in 3 women. Cardiac complications such as sinus bradycardia, first-degree auriculo-ventricular block and Mobitz I second-degree auriculo-ventricular block were reported in four women (18.2%). Extracardiac side effects i.e. neurosensorial or digestive were diagnosed in 35.3% of women. The parameters of the electrocardiogram were not altered before and after treatment with digoxin alone. ConclusionAntiarrhythmics can cause maternal cardiac complications and extracardiac side effects that can sometimes be severe but rapidly reversible upon treatment arrest.

Fetal complete heart block: a rare condition

Fetal auriculoventricular block may be associated with some autoimmune diseases and its prompt diagnosis might reverse the condition. It is a rare finding, where steroids treatment may have a positive effect but it is not always the case. Reports with poor prognosis where high prenatal mortality and postnatal morbidity is present are a concern, and thus remains an area of major clinical interest where future treatment alternatives are expected. We present a case of a 30 year old female with past medical history of Hashimoto thyroiditis, Sjogren syndrome and Gastrointestinal acid reflux and a 9 week spontaneous abortion at 28 years old. Daily medication included hydroxychloroquine 400 mg/day and levothyroxine 175 mcg/day. She was seen in a preconception counseling appointment where an evaluation regarding her autoimmune conditions was made. The following antibodies were elevated: antinuclear (anti SS-A and B), anticardiolipin, antiglycoprotein and antiperoxidase with an elevated TSH. The patient was advised to maintain hydroxychloroquine dosage and increase levothyroxin, add acetylsalicylic acid as well as start enoxaparin 40 mg/day when she became pregnant. During pregnancy, fetal ultrasound did not show any abnormalities until 20 weeks gestation where moderate tricuspid regurgitation was noticed and after three weeks it revealed complete atrioventricular heart block. She was started on steroids. Despite treatment, the condition showed no signs of reversibility. No fibroelastosis or hydrops fetalis development was seen, but ventricular rate was lower than 55 bpm, so it was judged with poor prognosis, ending in voluntary pregnancy termination. Indications for complete atrioventricular block treatment are controversial showing that sometimes steroids do not have a positive impact on reversing this condition. This case highlights that even with appropriate pre-conceptional counseling, medication adjustment and close follow-up, fetus may develop this rare and multifactorial disease, so new antenatal therapies are needed to change its poor outcome.

PT001 Incidence Of Subclavian Vein Obstruction Following Device Implantation

Introduction: The data about the incidence of subclavian venous (SCV) obstruction or thrombosis after transvenous device implantation is limited and it is rare following immediate period after the implantation. However, when it is neccesary to substitute defected leads or improve the funcional status by making a device upgrade, the presence of obstruction or severe stenosis can make the intervention difficult, forcing to use the opposite side to implant the new device. Objectives: We aimed to assess the incidence of venous obstruction or severe stenosis and its tortuosity after a pacemaker or ICD implantation in our population. We obtained an iodinated contrast venography study just before the elective device’s replacement due to battery discharge. Methods: A contrast venography was performed in 26 patients who were candidates to elective generator change due to battery discharge. 16 p (64%) were men, the main age was 77 11 years; 13p (50%) had Chronic Heart Failure and in 18p (72%) Ischemic cardiomyopathy was diagnosed. The mean period between the first implant and device’s replacement was 9,3 3,4 years. 17p (68%) had Diabetes Mellitus, 15p (60%) were Hypercholesterolemic, 9p (36%) were smokers and 11p (44%) were had systemic arterial hypertension. Results: The initial indication to implantation the device was AuriculoVentricular block in 11p (42%), sinus node dysfunction in 8p (32%), resynchronization therapy with or without ICD in 5p (20%), and prevention of sudden death without resynchronization therapy in 1p(4%). The generator was DDD in 11p (44%), VDD in 2p (8%), VVI in 6p (24%)%, CRT in 4p (16%), and CRT-ICD in 2p (8%). The Right Ventricular lead was implanted in the outflow tract in 14p (56%) and in 11p(44%) the site was the right ventricular apex. In 100% of the patients the leads were implanted through the Left Subclavian Vein. Venous severe stenosis or obstruction was observed with venographic study in 4p (16%) and tortuosity in 2p(8%). We didn’t find any predictor of severe stenosis or obstruction of the access veins. Conclusion: Severe stenosis, obstruction or tortuosity of the access veins after a pacemaker or ICD implantation make difficult futures upgrades and leads change. The process can be facilitated by means of doing a previous venography. In our population it is unusual in an intermediate-long term period Disclosure of Interest: None Declared

PT002 Comparison of invasive haemodynamics, Brain Natriuretic Peptide and high sensitivity Troponin T levels with right ventricular apical and right ventricular outflow tract pacing in normal hearts

Introduction: The data about the incidence of subclavian venous (SCV) obstruction or thrombosis after transvenous device implantation is limited and it is rare following immediate period after the implantation. However, when it is neccesary to substitute defected leads or improve the funcional status by making a device upgrade, the presence of obstruction or severe stenosis can make the intervention difficult, forcing to use the opposite side to implant the new device. Objectives: We aimed to assess the incidence of venous obstruction or severe stenosis and its tortuosity after a pacemaker or ICD implantation in our population. We obtained an iodinated contrast venography study just before the elective device’s replacement due to battery discharge. Methods: A contrast venography was performed in 26 patients who were candidates to elective generator change due to battery discharge. 16 p (64%) were men, the main age was 77 11 years; 13p (50%) had Chronic Heart Failure and in 18p (72%) Ischemic cardiomyopathy was diagnosed. The mean period between the first implant and device’s replacement was 9,3 3,4 years. 17p (68%) had Diabetes Mellitus, 15p (60%) were Hypercholesterolemic, 9p (36%) were smokers and 11p (44%) were had systemic arterial hypertension. Results: The initial indication to implantation the device was AuriculoVentricular block in 11p (42%), sinus node dysfunction in 8p (32%), resynchronization therapy with or without ICD in 5p (20%), and prevention of sudden death without resynchronization therapy in 1p(4%). The generator was DDD in 11p (44%), VDD in 2p (8%), VVI in 6p (24%)%, CRT in 4p (16%), and CRT-ICD in 2p (8%). The Right Ventricular lead was implanted in the outflow tract in 14p (56%) and in 11p(44%) the site was the right ventricular apex. In 100% of the patients the leads were implanted through the Left Subclavian Vein. Venous severe stenosis or obstruction was observed with venographic study in 4p (16%) and tortuosity in 2p(8%). We didn’t find any predictor of severe stenosis or obstruction of the access veins. Conclusion: Severe stenosis, obstruction or tortuosity of the access veins after a pacemaker or ICD implantation make difficult futures upgrades and leads change. The process can be facilitated by means of doing a previous venography. In our population it is unusual in an intermediate-long term period Disclosure of Interest: None Declared

Interventional therapy for trilogy of Fallot combined with Ⅲ degree auriculo ventricular block: a case report

Interventional therapy for trilogy of Fallot combined with Ⅲ degree auriculo ventricular block: a case report

Trans-catheter aortic valve implantation through the ascending aorta in a patient with previous right pneumonectomy

Methods A 74 year old male with severe aortic stenosis was referred for consideration of aortic valve replacement. He was highly symptomatic with both angina and dyspnea (NYHA class III). The echocardiogram confirmed moderate depression of LVEF. Coronary angiography demonstrated severe stenosis of the left-descending and right coronary arteries. His comorbidities included diabetes mellitus, peripheral vascular disease and left pneumonectomy, with residual poor lung function. His logistic EuroSCORE was 16.6%. Two drug eluting stents were implanted. Trans-femoral route was not feasible because of a small-caliber femoral arteries and severe peripheral vasculopathy, including subclavian severe stenosis. Trans-apical approach was also not desirable because the ventricular apex was shifted to the right and would have posed technical. Upper partial thoracotomy 5 cm far from the right border of the sternum at the second intercostal space and partial resection of the rib was performed and the ascending aorta was exposed. An 18-Fr sheath was introduced through a small puncture 6 cm over the aortic plane. Valvulotomy was performed with a 25-mm balloon and a 29-mm device was then implanted. Results A good result was obtained with minimal paravalvular leak. He did not developed heart failure or auriculo-ventricular block, but sub-acute right-sided limb ischemia appeared 72 hours from the procedure, which required percutaneous revascularization. Within one year of follow-up he remains asymptomatic from a cardiovascular point of view.

324: Women in the intensive unit care of cardiology: morbidity and mortality study

The aim of this observational study that includes 800 consecutive patients admitted in our unit intensive care of cardiology (UIC) is the evaluation of the cardiac pathology in women, and the morbidity and mortality of them compared to men. The women represent 25% of patients, they were older (mean age 66 ±5 years versus 56±7 years in men, p=0.05), and we observed more diabetes 48.6% vs 38%, p=0.003. The diagnostic of acute coronary syndrome without ST elevation were relieved in 43% of women vs 24% in men, p=0.03. STEMI were more frequent in men (24% vs 32%), the auriculo ventricular block were more frequent in women 16.8% vs 5%, p=0.002. We observed in women patient a higher incidence of cardiac arrest resuscitated (2.5% vs 1.7% p=0.05) and cardiac shock 3.2% vs 0.7%, p=0.004. Insides a better left ventricular ejection fraction (47±15% vs 40±14%, p=0.03), they presented more hemodynamic complication (6% versus 2.8% in men, p<0.01) and more rhythmic complication (8% versus 4.5% in men, p<0.01) Angiographic Coronarography were performed in 61% of women compared to 77% in men. A coronary revascularization by percutaneous transluminal coronary angioplasty were performed in 9% of women vs 11.5% in men, and only 9.6% of women beneficed of chirurgical revascularization versus 14.3% of men, p=0.004 Finaly, we observed more mortality in our study in women patients (3.2% vs 1.8%, p=0.002). The predictive factors of mortality were the level of the CRP (odds ratios and 95 percent confidence intervals =7.6, 1.1–14.3, p=0.013) and the female gender (OR at 3.8, CI at 95% a =1.2–5.4, p=0.0013) and the LVEF (OR at 1.4, CI aT 95% =1.1–7.8, p=0.012), but only the female gender was in independent predictive factor of mortality in IUC of cardiology using multiple logistic regression to estimate the adjusted odds raio (OR adjusted a 1.7, CI at 95% =1.11–5.4, P= 0.002). The women presented only the quart of the patients admitted in the intensive unit care of cardiology, but this population have a higher level of morbidity, hospital complication. More, the female gender in an independent predictive factor of mortality.