Branch Block Research Articles

Left bundle branch area pacing in the setting of cardiac amyloidosis: a case series

Abstract Background Cardiac amyloidosis (CA) is a highly prevalent cause of congestive heart failure. It often requires cardiac pacing due atrioventricular conduction (AV) system disorders, often with cardiac resynchronization (CRT) to prevent development/deterioration of left ventricular (LV) dysfunction. Left bundle branch area pacing (LBBAP) is an emerging alternative to CRT, offering a strict physiological LV activation and very limited use of iodinated contrast. The feasibility of LBBAP in CA is considered limited due to the presence of septal pseudohypertrophy which theoretically limits left-sided conduction system engagement. Purpose To evaluate the feasibility and effectiveness of LBBAP in cardiac amyloidosis. Methods Consecutive patients with CA (both light-chain -AL- or wild-type transtiretin -wtATTr) with a pacing indication for AV conduction disorders were enrolled. Patients underwent baseline echocardiographic examination. LBBAP was achieved by means of stylet-driven leads advanced transeptally (right ventricle (RV) to LV) via dedicated delivery systems, with continuous monitoring of 12-lead electrocardiographic morphology and impedance until a typical QRS morphology in V1 was obtained (usually rSr’ or Sr’). Standard measures for left bundle (LB) capture were used (stimulus to peak R in V6 – S-RV6, V6-V1 interpeak interval, presence of transition in these measures during threshold testing, presence of fascicular signal during spontaneous QRS). Results Between January 2022 and June 2023, among 63 patients undergoing LBBAP, 7 patients (11%) had CA, 2 AL (28%) and 5 (72%) wtATTR. Patients were prevalently old (78±7 y) males (6, 85%); LV mean septal thickness was 17±2 mm (min 16, max 20 mm) and mean LV ejection fraction (LVEF) was 45±6%. Indications were PR prolongation in 3, bradycardic atrial fibrillation and LB branch block (LBBB) in 2, primary LBBB in 1 and chronic RV pacing in 1. Baseline QRS duration was 145±47 ms (QRS<120 ms: 97±15 ms, QRS>120 ms: 182±13 ms). LBBAP success was 100%. Fascicular electrograms were observed in ¾ of patients without LBBB; S-RV6 interval was 74 ±11 ms (³70 ms in 3), RV6-RV1 interpeak interval was 47±9 ms (³ 30 ms in 6 patients). DQRS in baseline broad QRS was -52 ms and +32 ms in narrow. No complications were observed. Over a short follow up of 6 months, an increase in average LVEF was observed (LVEF at 6 months: 51±3%, p<0.05). Conclusions In patients with CA, LBBAP is easily achievable with stylet-driven systems with frequent selective engagement of conduction system. QRS narrowing in baseline broad QRS is significant while QRS broadening in baseline narrow QRS is limited. Early results regarding follow-up of surrogate endpoint such as LVEF are promising.

Intraoperative Corticosteroids and Pacemaker Implantation After Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis. However, conduction disturbances leading to pacemaker implantation remain a common complication, increasing morbidity and mortality in these patients. Hence, measures to lower its incidence should be taken, and corticosteroid therapy could be effective by reducing inflammation caused by direct mechanical trauma to the conduction system. A retrospective cohort study was conducted at the Centro Hospitalar de Vila Nova de Gaia/Espinho, analyzing the medical records of patients with native severe aortic stenosis who underwent transfemoral TAVR in 2022. The Chi-square test was used to compare the rate of pacemaker implantation in patients who received corticosteroids with patients who didn't. The statistical significance was considered for a p-value <0.05. A total of 341 patients were included in this study. Monitored anesthesia care was the preferred anesthetic technique (99.1%). Sixty-three point three percent (63.3%) of patients received corticosteroids at the beginning of the procedure. Corticosteroid administration did not significantly affect the incidence of permanent pacemaker implantation (p=0.277), vascular complications on the access site (p=0.765), or in-hospital mortality (p=0.909). Male gender, 1st-degree atrioventricular block, and right branch block were the only identified predictors of permanent pacemaker implantation after transfemoral TAVR (p=0.041 <0.001 and <0.001, respectively). Corticosteroid administration at the beginning of TAVR doesn't seem to influence the incidence of permanent pacemaker implantation, which can suggest that other factors play a more important role in the development of conduction disturbances leading to pacemaker implantation.

TBACkp: HER2 expression status classification network focusing on intrinsic subenvironmental characteristics of breast cancer liver metastases

The HER2 expression status in breast cancer liver metastases is a crucial indicator for the diagnosis, treatment, and prognosis assessment of patients. And typical diagnosis involves assessing the HER2 expression status through invasive procedures like biopsy. However, this method has certain drawbacks, such as being difficult in obtaining tissue samples and requiring long examination periods. To address these limitations, we propose an AI-aided diagnostic model. This model enables rapid diagnosis. It diagnoses a patient's HER2 expression status on the basis of preprocessed images, which is the region of the lesion extracted from a CT image rather than from an actual tissue sample. The algorithm of the model adopts a parallel structure, including a Branch Block and a Trunk Block. The Branch Block is responsible for extracting the gradient characteristics between the tumor sub-environments, and the Trunk Block is for fusing the characteristics extracted by the Branch Block. The Branch Block contains CNN with self-attention, which combines the advantages of CNN and self-attention to extract more meticulous and comprehensive image features. And the Trunk Block is so designed that it fuses the extracted image feature information without affecting the transmission of the original image features. The Conv-Attention is used to calculate the attention in the Trunk Block, which uses kernel dot product and is responsible for providing the weight for the self-attention in the process of using convolution induced deviation calculation. Combined with the structure of the model and the method used, we refer to this model as TBACkp. The dataset comprises the enhanced abdominal CT images of 151 patients with liver metastases from breast cancer, together with the corresponding HER2 expression levels for each patient. The experimental results are as follows: (AUC: 0.915, ACC: 0.854, specificity: 0.809, precision: 0.863, recall: 0.881, F1-score: 0.872). The results demonstrate that this method can accurately assess the HER2 expression status in patients when compared with other advanced deep learning model.

Impact of short-term exercise training on QT dispersion and double product in diabetic patients after surgical aortic valve replacement

Abstract Background QT dispersion (QTd) represents the heterogeneity in the repolarization of the ventricular myocardium and electrical instability of the myocardium, reflecting the increased tendency towards ventricular arrhythmias. Abnormally high QTd has been correlated with risk of cardiac death. Purpose The aim of this study was to establish the influence of short-term exercise training on QT dispersion and double product (DP), in diabetic patients after surgical aortic valve replacement (SAVR). Methods The study involved 147 patients after SAVR, in the sinus rhythm without AV blocks or branch blocks. Average age of patients was 59.3 years. 45 patients were with diabetes mellitus, and 102 were without diabetes. Patients were similar as to age and baseline stress test duration. In all subjects clinical examination, standard ECG and exercise test on treadmill according to Bruce protocol, were performed and after that patients were included in program of physical training for three weeks. Patients were instructed to follow a training program using the bicycle ergometer (10 min, 2 times a day), gymnastic exercises and walking. The patients continued to take the same medicaments in same doses. From standard ECG corrected QT dispersion (QTdc) was calculated. Results Before starting with the program of physical training, patients with diabetes had significantly higher values of QTdc (83.4 ± 15.3 vs 74.6 ± 16.9 ms; p&amp;lt;0.005) in comparison to those without diabetes. After three weeks, significant reduction of QTdc was found (from 83.4 ± 15.3 to 77.3 ± 15.4 ms; p&amp;lt;0.02 in patients with diabetes and from 74.6 ± 16.8 to 68.7 ± 17.1 ms; p&amp;lt;0.005 in patients without diabetes). After three weeks, significant reduction of DP was found (from 11763.8 ± 779.9 to 11314.8 ± 635.8 beat/min x mmHg; p&amp;lt;0.005 in patients with diabetes and from 114376.4 ± 792.3 to 10034.2 ± 521.3 beat/min x mmHg; p&amp;lt;0.001 in patients without diabetes). In diabetic patients, after program of physical training, significant reduction of glycemia was found (from 7.0 ± 2.3 to 5.9 ± 1.5 mmol/L; p&amp;lt;0.005), of total cholesterol from 5.2 ± 1.3 to 4.6 ± 1.1 mmol/L (p&amp;lt;0.025), of LDL cholesterol from 3.2 ± 0.8 to 2.8 ± 0.6 mmol/L (p&amp;lt;0.05). After three weeks, both groups of patients in the exercise test reached a significantly longer time (p&amp;lt;0.001). Conclusions The study showed that patients with diabetes have a higher value QTdc, probably due to diffuse interstitial fibrosis. Short-term exercise training has favourable effects on QT dispersion and double product in patients after SAVR. In patients without diabetes physical training had more favourable effects on the followed parameters. Physical training led to the significant decrease of myocardial oxygen uptake at rest and probably decreased the possibility of arrhythmia events.

Predictors of Side Branch Obstruction Following Stenting of the Main Vessel in Coronary Bifurcation Lesions

INTRODUCTION: Percutaneous coronary intervention (PCI) of bifurcation lesions is complicated by the presence of side branch blockage, which contributes to a low procedural success rate and an elevated rate of adverse cardiac events. A shift in the position of the carina and plaque buildup have been proposed as possible causes of SB occlusion. 1,2 It is estimated that between 15-20% of PCI procedures are done to address lesions at coronary bifurcations.3-5 Multiple randomized clinical trials have concluded that an interim stenting procedure should be used for routine bifurcation stenting. 6-11 &#x0D; AIM AND OBJECTIVE: To assess the predictors of side branch obstruction following stenting of the main vessel in coronary bifurcation lesions.&#x0D; MATERIAL AND METHODS: Total 300 patients were enrolled with coronary bifurcation lesions who were undergoing PCI and had at least one major SB. Major SB definition was the same as what had been found in other studies: diameter ?2.0mm. Patients with SB stenting before MV stenting, LMS disease, or in-stent restenosis were excluded. Using quantitative coronary analysis (QCA) software, all of the baseline and procedure characteristics were analyzed. The Student's t-test was used to compare continuous data. A p-value &lt; 0.05 was considered significant.&#x0D; RESULTS: Out of 300 patients, side branch blockage was found in 23 (7.6%) of the patients. The patients were distributed into two groups based on whether they had SB occlusion (SBO) or not. Mean age (years) in the study was 50.36+12.54 in SBO group and 50+30.34 in no-side-branch occlusion (NSBO) group. There were 19(82%) male and 4(18%) female patients in SBO group and 215(77%)male and 62(23%) female in NSBO group. Diameter stenosis of side branch before MV stenting (55%+20 vs30+25%), side branch diameter (2.1+0.3 vs2.2+0.2), bifurcation angle (70+20degree vs 45+22 degree, p=&lt;0.01) and lower TIMI flow in side branch were found significant predictors of major side branch occlusion.&#x0D; CONCLUSION: The bifurcation angle, diameter stenosis of the SB, side branch diameter before to main vessel stenting, and TIMI flow grade of the SB prior to MV stenting were all predictive of severe SB occlusion following MV stenting. As a result, these criteria should be considered when designing PCI for bifurcation lesions in order to increase procedure success.&#x0D; KEYWORDS: Side branch obstruction, stenting, coronary bifurcation lesions.

Nonsurgical Interventional Spine Pain Procedures

Nonsurgical interventional spine pain procedures provide an additional treatment option for lower back pain at the traditional bifurcation of conversative vs. operative management. Transforaminal epidural steroid injections, radiofrequency ablations, intrathecal drug delivery, and spinal cord stimulation were found to be effective and safe techniques when applied to their specific indication. Thermal annuloplasty and minimally invasive lumbar decompression showed mixed support. Discography, sacroiliac joint injections, and spinous process spacers lacked sufficient evidence to support efficacy. Medial branch blocks and facet joint injections were found to be useful diagnostic tools.

Changes in QT Interval in Maintenance Hemodialysis Patients: Pre-Dialysis, One Hour after Initiation of Dialysis, and Post-Dialysis

Introduction: This study aimed to evaluate the effects of dialysis on change of QT interval in pre-dialysis, 1 h after dialysis initiation, and post-dialysis period in patients on maintenance dialysis (MHD). Methods: An observational prospective study was conducted, including 61 patients, on thrice-weekly MHD ≥3 months, and without acute diseases, at the Nephrology-Dialysis Department of a tertiary hospital in Vietnam. The exclusive criteria were atrial fibrillation, atrial flutter, branch block, prolonged QT recorded in medical history, and taking antiarrhythmic drugs lengthening QT interval before entering the study. Twelve-lead electrocardiographs and blood chemistries were done simultaneously before, 1 h after initiation, and after the dialysis session. Results: The proportion of patients with prolonged QT interval increased significantly from 44.3% in pre-dialysis to 77% 1 h after dialysis initiation and 86.9% in post-dialysis session. Immediately after dialysis, the QT and QTc intervals on all 12 leads were significantly longer. Post-dialysis levels of potassium, chloride, magnesium, and urea decreased significantly from 3.97 (0.7), 98.6 (4.7), 1.04 (0.2), and 21.4 (6.1) to 2.78 (0.4), 96.6 (2.5), 0.87 (0.2), and 6.33 (2.8) mmol/L, respectively, whereas the calcium increased significantly from 2.19 (0.2) to 2.57 (0.2) mmol/L. There were significant differences in the potassium level at the dialysis initiation and its speed of reduction between the group without and with prolonged QT interval. Conclusions: There was an increased risk of prolonged QT interval in MHD patients regardless of the absence of the previous abnormal QT interval. Notably, this risk increased rapidly 1 h after the initiation of dialysis.

Can Ultrasound-Guided Medial/Lateral Branch Blocks Be Used to Select Patients for Fluoroscopically-Guided Radiofrequency Neurotomy?

Can Ultrasound-Guided Medial/Lateral Branch Blocks Be Used to Select Patients for Fluoroscopically-Guided Radiofrequency Neurotomy?

Performance metrics of AI-enhanced single lead EKG maintained after entry of organised clustered data

Abstract Background Our experience in creating innovative Artificial Intelligence-guided single lead EKG methodologies for ST-Elevation Myocardial Infarction (STEMI) detection within complex EKG records has been previously validated. Purpose By expanding the intricate variables of our previously tested algorithm input, we seek to further improve our STEMI detecting tool. Methods 11,567 12-lead EKG records (10-s length, 500 Hz sample frequency) derived from the Latin America Telemedicine Infarct Network database from April 2014 to December 2019. From these records, we included the following balanced classes: angiographically confirmed and unconfirmed STEMI (divided by wall affected), branch blocks, non-specific ST-T changes, normal, and abnormal (Remaining 200+ CPT codes). Cardiologist annotations ensured precision (Ground truth). Determined classes were “STEMI” and “Not-STEMI”. A 1-D Convolutional Neural Network model was trained and tested for each lead with dataset proportions of 90/10, respectively. The last dense layer outputs a probability for each record being STEMI/Not-STEMI. The analysis also included performance metrics and false-negative reports. Results Overall, the most promising Single lead for STEMI detection was V2 (91.2% Accuracy, 89.6% Sensitivity, and 92.9% Specificity). 55% of false negatives were inferior wall STEMI (Table 1). Conclusion Appreciable progress of our new methodology compared to our previous experiences in AI-guided Single Lead for STEMI detection, especially for lead V2. By performing a thorough analysis of false-negative reports, we aspire to identify potential areas of STEMI detection weakness which will become the focus of future ventures. Funding Acknowledgement Type of funding sources: None.

864 ISOLATED CARDIAC METASTASIS FROM CARCINOMA OF THE CERVIX: RARE CASE OF ACS-NSTE. CASE REPORT

Abstract Introduction The heart is a rare site of tumor metastasis. Although rarely, cardiac metastases may be secondary to a primary intra-abdominal tumor. Aim we report the case of a 60-years-old woman, ante-mortem finding of an isolated cardiac metastasis from cervical carcinoma presented as ACS-NSTE, who was evaluated in our Division of Cardiology. Materials and methods electrocardiogram, transthoracic echocardiography, angioTC, cardiac surgery and histopathologic analysis were performed. Results electrocardiogram showed incomplete right branch block with diffuse negative T waves. On the echocardiogram evidence of a voluminous hypo-isoechoic formation almost completely occupying the cavity of the right ventricule (RV) which appeared dilated and dysfunctional; D-shape aspect of the left ventricule as from the overload of the right sections and with moderate pericardial effusion, mildly reduced ejection fraction (EF50%Q). An urgent Angio-CT was performed and revealed a voluminous solid neoformation with inhomogeneous content and progressive contrast enhancement in the right ventricule. Following admission, the patient's haemodynamic status gradually worsened. Therefore, urgent cardiac surgery was performed. After drainage of abundant serum/haematic effusion, probably neoplastic infiltration of RV was seen. Therefore, given the extension it was decided to perform only multiple biopsies. Histopathological examination revealed moderately differentiated squamous cell carcinoma, as from metastasis from K. cervix. Conclusions there is no standardized therapy for the treatment of cardiac metastases, it is necessary to evaluate on a case-by-case basis. The most important prognostic factors are the obstructive effect of the intracardiac mass and the extent of any pericardial effusion. In fact, they can adversely affect hemodynamic stability.

Prevalence of new Onset Right Bundle Branch Block in Acute Myocardial Infarction and its Coronary Angiographic Findings in Patients Attending NICVD

Background and Aim: Acute myocardial infarction patients with left and right bundle branch block significantly contributes to higher risk of mortality. Right bundle branch block (RBBB) has clinical implications in acute myocardial infarction setting. The present study aimed to determine the prevalence of new onset RBBB in acute myocardial infarction and its association with coronary angiographic findings. Methodology: This cross-sectional study was conducted on 82 acute myocardial infarction (AMI) patients in National Institute of Cardiovascular Diseases (NICVD), Karachi from January 2022 June 2022. Study protocol was approved from the institution research and ethical committee. All the patients of either gender with an age range 25 years to 85 years having acute myocardial infarction were included. Written informed consent was taken. Patients with previous RBBB, had implanted pacemaker, and presentation of symptoms &gt;24 hours were excluded. Detailed history and clinical examination of each individual was done. Patients’ angiographic findings after eligibility based on coronary angiography was done and recorded. All the data were entered into pre-designed profroma. SPSS version 26 was used for data analysis. Results: Of the total 82 AMI patients, there were 48 (58.5%) male and 34 (41.5%) females. Age-wise distribution of AMI patients were as follows; 17 (20.7%) 25-45 years, 28 (34.2%) 46-65 years, and 37 (45.1%) 66-85 years. The overall mean age was 54.62±6.82 years. The prevalence of new onset RBBB and without RBBB was 17 (20.7%) and 65 (79.3%) respectively. Of the 17 AMI with RBBB patients, the incidence of single vessel disease, double vessel disease, triple vessel disease, and left main stem disease was 3 (17.6%), 5 (29.4%), 6 (35.3%) and 3 (17.6%) respectively. Majority of patients aged 46 years to 65 years had RBBB in 9 (32.1%), followed by 6 (16.2%) in patients 66-85 years and 2 (11.8%) in patients aged 25-45 years. Conclusion: The present study concluded that the prevalence of new onset RBBB was 20.7% among acute myocardial infarction patients. The incidence of triple vessel disease was prominent in acute myocardial infarction patients with RBBB followed by double vessel disease. Also, elderly patients of acute myocardial infarction patients were more susceptible to RBBB than younger one. Keywords: Right bundle branch blockage, Acute myocardial infarction, Coronary angiography

Artificial intelligence-guided, single-lead EKG may be a game-changer for symptom-to-balloon time reduction in ST-elevated myocardial infarction

Abstract Background Over decades, efforts to shave off life-saving minutes from ST-Elevated Myocardial Infarction (STEMI) care centred on reducing door-to-needle and door-to-balloon times. We firmly believe that symptom-to-balloon time should prove a better focus to this end. Challenges come with this goal as it heavily relies on a patient's perception and initiative to seek care, which we deem intelligent and wearable Artificial Intelligence (AI)-driven Single Lead EKG technologies as an attractive solution in modern-day cardiology. Purpose To provide an accurate, accessible, and cost-effective AI-driven Single Lead STEMI detection algorithm that can be embedded into wearable devices and employed in a self-administered fashion. Methods Database: EKG records from Mexico, Colombia, Argentina, and Brazil from April 2014 to December 2019. Dataset: A total of 11,567 12-lead EKG records of 10[s] length with a sampling frequency of 500 Hz, including the following balanced classes: angiographically confirmed and unconfirmed STEMI, branch blocks, non-specific ST-T abnormalities, normal and abnormal (200+ CPT codes, excluding those mentioned above). Cardiologists manually checked the label of each record to ensure precision. Pre-processing: We discard the first and last 250 samples as they may contain a standardisation pulse. The study applied a digital low pass filter of order 5 with a frequency cut-off of 35 Hz. The mean was subtracted from each Lead. Classification: The determined classes were “STEMI” (Including STEMI in different locations of the myocardium – anterior, inferior, and lateral); and “Not-STEMI” (Combination of randomly sample, branch blocks, non-specific ST-T changes, and abnormal records – 25% of each). Training and Testing: A 1-D Convolutional Neural Network was trained and tested with a dataset proportion of 90/10, respectively. A different model was trained and tested for each Lead, using the central 4,500 samples of the records. The last dense layer outputs a probability for each report of being STEMI or Not-STEMI. Lead V2 showed the best overall results. The model was further tested through the same methodology using the best Lead with a subset of the previous data, excluding the unconfirmed STEMI EKG records (Total 7,230 12-lead EKG records for Confirmed Only STEMI dataset). Performance metrics were reported for each experiment and compared. Results Combined STEMI data: Accuracy: 91.2%; Sensitivity: 89.6%; Specificity: 92.9%. Confirmed STEMI Only dataset: Accuracy: 92.4%; Sensitivity: 93.4%; Specificity: 91.4% (Figure 1). Conclusion By assiduously improving the quality of the model's input, we continue to assess our algorithm's performance and reliability for future clinical validation as a potential remote monitoring and early STEMI detection device. Funding Acknowledgement Type of funding sources: None.

Performance metrics of AI-enhanced single lead EKG maintained after entry of organised clustered data

Abstract Background Our experience in creating innovative Artificial Intelligence-guided single lead EKG methodologies for ST-Elevation Myocardial Infarction (STEMI) detection within complex EKG records has been previously validated. Purpose By expanding the intricate variables of our previously tested algorithm input, we seek to further improve our STEMI detecting tool. Methods 11,567 12-lead EKG records (10-s length, 500 Hz sample frequency) derived from the Latin America Telemedicine Infarct Network database from April 2014 to December 2019. From these records, we included the following balanced classes: angiographically confirmed and unconfirmed STEMI (divided by wall affected), branch blocks, non-specific ST-T changes, normal, and abnormal (Remaining 200+ CPT codes). Cardiologist annotations ensured precision (Ground truth). Determined classes were “STEMI” and “Not-STEMI”. A 1-D Convolutional Neural Network model was trained and tested for each lead with dataset proportions of 90/10, respectively. The last dense layer outputs a probability for each record being STEMI/Not-STEMI. The analysis also included performance metrics and false-negative reports. Results Overall, the most promising Single lead for STEMI detection was V2 (91.2% Accuracy, 89.6% Sensitivity, and 92.9% Specificity). 55% of false negatives were inferior wall STEMI (Table 1). Conclusion Appreciable progress of our new methodology compared to our previous experiences in AI-guided Single Lead for STEMI detection, especially for lead V2. By performing a thorough analysis of false-negative reports, we aspire to identify potential areas of STEMI detection weakness which will become the focus of future ventures. Funding Acknowledgement Type of funding sources: None.

Atrial Flutter in PRKAG2 Syndrome: Clinical and Electrophysiological Characteristics.

PRKAG2 syndrome is a rare autosomal dominant disease, a phenocopy of hypertrophic cardiomyopathy characterized by intracellular glycogen accumulation. Clinical manifestations include ventricular preexcitation, cardiac conduction disorder, ventricular hypertrophy, and atrial arrhythmias. To compare the clinical and electrophysiological characteristics observed in patients with atrial flutter, with and without PRKAG2 syndrome. An observational study comparing patients with atrial flutter: group A consisted of five patients with PRKAG2 syndrome from a family, and group B consisted of 25 patients without phenotype of PRKAG2 syndrome. The level of significance was 5%. All patients in group A had ventricular preexcitation and right branch block, and four had pacemakers (80%). Patients in group A were younger (39±5.4 vs 58.6±17.6 years, p=0.021), had greater interventricular septum (median=18 vs 10 mm; p<0.001) and posterior wall thickness (median=14 vs 10 mm; p=0.001). In group A, four patients were submitted to an electrophysiological study, showing a fasciculoventricular pathway, and atrial flutter ablation was performed in tree. All patients in group B were submitted to ablation of atrial flutter, with no evidence of accessory pathway. Group B had a higher prevalence of hypertension, diabetes mellitus, coronary artery disease and sleep apnea, with no statistically significant difference. Patients with PRKAG2 syndrome presented atrial flutter at an earlier age and had fewer comorbidities when compared to patients with atrial flutter without mutation phenotype. The occurrence of atrial flutter in young individuals, especially in the presence of ventricular preexcitation and familial ventricular hypertrophy, should raise the suspicion of PRKAG2 syndrome.

SUCCESSFUL ABLATION IN PEDIATRIC PATIENT WITH SURGICAL REPAIR OF RASTELLI AV CANAL TYPE SECUNDARY TO REFRACTORY VENTRICULAR TACHYCARDIA

TYPE: Late Breaking Case Report TOPIC: Critical Care INTRODUCTION: The management of the patient with post surgical cardiac pathology is complex, frecuently requiring critical care and multidisciplinary interventions to have success. We present a complicated clinical case with complicated ventircular tachycardia treated with ablation of the ventricular arrhythmogenic focus. CASE PRESENTATION: 5-Year-old female with down syndrome and rastelli type “A” av channel weight 18 kg. It is admitted in picu for corrective repair, presenting as a complication of refractory ventricular tachycardia under medical management. With post-surgical echocardiogram without residual defects, lvef of 79%. Extubed in its first 48 post-surgical hours, shows collapse rhythm, beginning amiodarone, lidocaine and even electric cardioversion, ventilatory support and vasoactive without improvement. Cardiac and myocardial profile: troponin i: 300 ckmb: 24 myoglobin: 311, probnp: 2501. ecg: monomorphic ventricular fibrillation, abnormal axis deviation, incomplete right branch block, right ventricular hypetrophy. Undergo catheterism with ablation of arrhythmogenic focus in anterior lateral wall of the left ventricle. DISCUSSION: Transcathether ablation by radio frequency constitutes a curative therapeutic alternative for different cardiac tachyarrhythmias already proven in pediatric patients, it has demonstrated a high effectiveness of the problem resolution. CONCLUSIONS: Radiofrequency ablation is an excellent therapeutic tool in critical medicine for surgical complications such as ventricular tachycardia refractria with ventricular arrithmogenic focus. DISCLOSURE: Nothing to declare. KEYWORD: refractory ventricular tachycardia

THE INFLUENCE OF SHORT-TERM EXERCISE TRAINING ON ARTERIAL BLOOD PRESSURE AND QT DISPERSION IN PATIENCE AFTER SURGICAL AORTIC VALVE REPLACEMENT

Objective: The aim of this study was to establish the influence of short-term exercise training on arterial blood pressure and QT dispersion in patients after surgical aortic valve replacement (SAVR). Design and method: The study involved 103 patients after SAVR, in the sinus rhythm without AV blocks or branch blocks. Average age of patients was 60.8 years. Patients were randomly divided into the physical training group (training group: 85 patients) and control group (non-training group: 18 patients). Patients were similar as to age and baseline stress test duration. In all subjects clinical examination, standard ECG and exercise test on treadmill according to Bruce protocol were performed and after that training group patients were included in physical training program for three weeks. Training group patients were instructed to follow a training program using the bicycle ergometer (10 min, 2 times a day), gymnastic exercises and walking. The patients continued to take the same medicaments in same doses. From standard ECG corrected QT dispersion (QTdc) was calculated. Results: After three weeks, we have found significant reduction of QTdc from 79.1 ± 19.7 to 70.8 ± 20.4 ms; p &lt; 0.02 in the training group. Also, in the training group, we have found significant reduction of heart rate from 78.6 ± 7.1 to 65.9 ± 6.1 beats/min (p &lt; 0.001), of systolic blood pressure from 137.4 ± 13.1 to 127.7 ± 11.5 mmHg (p &lt; 0.025), of diastolic blood pressure from 87.8 ± 8.9 to 84.2 ± 7.5 mmHg (p &lt; 0.01) and of double product from 11996.7 ± 1162.4 to 10518.8 ± 794.3 beat/min x mmHg; p &lt; 0.001. In contrast, the non-training group showed no significant changes. Conclusions: The study showed that short-term exercise training have favourable effects on arterial blood pressure and QT dispersion in patients after SAVR. Physical training led to the significant decrease of myocardial oxygen uptake at rest and probably decreased the possibility of arrhythmia events in patients after SAVR.

P120 A STRANGE HEART MURMUR

Abstract An 38–year–old man was referred to our hospital for chest pain. He was a smoker but had no other cardiovascular risk factors and had no history of relevant diseases. On cardiovascular examination, a rough grade IV/V systolic murmur was present at the mesocardium. His electrocardiogram showed sinus tachycardia and complete right branch block. On laboratory tests, cardiac biomarkers were negative. A transthoracic echocardiogram showed left ventricle cavity–sized at the upper limits with preserved systolic function and mild concentric hypertrophy. The aortic root was ectatic with tricuspid valve and mild regurgitation. In addition, there was a great spheric cavity in the region of the right sinus of Valsalva that was communicating with the aortic lumen with turbulent flow inside. The Pulmonary Trunk was dilated and there was a strange turbulent flow within it that extended towards the aortic valve. A chest computed tomography (CT) scan was performed in emergency which ruled out an aortic dissection and revealed the presence of an aneurysm of the right sinus of Valsalva. The following day, a transesophageal echocardiogram was performed which confirmed the aneurysm of the right sinus Valsalva and the presence of systodiastolic flow between it and the right ventricular outflow compatible with a fistula. For this reason, the patient was transferred to the Cardiac Surgery Department of another hospital. He underwent cardiac surgery of resection of aneurysmatic tissue, direct suture of the fistula by the combined transaortic / transpulmonary route and reductive plastic surgery of the pulmonary trunk. Aneurysms of sinus of Valsalva are rare cardiac anomalies, which may be either acquired or congenital. A congenital lack of continuity between the aortic media and annulus fibrosis may initiate aneurysm formation. Acquired aneurysms may result from trauma, endocarditis, syphilis, Behcet, Marfan’s syndrome and senile–type dilatation. In our case, the etiology of the aneurysm is not well understood. It could be a congenital aneurysm that has fissured over time creating a fistula with the right ventricular outflow. This fistula caused a significant left–to–right shunt resulting in haemodynamic changes such as pulmonary trunk dilation. We report this case because the concomitant presence of an aneurysm of the right Valsalva sinus and a fistula between it and the right ventricular outflow represents an extremely rare and poorly described event in the literature.

Left Bundle Branch Pacing: Unexpected Resynchronization Effect of Anodal Capture.

Anodal capture can provide a resynchronization effect on biventricular pacing. However, evidence of such an effect remains unclear in left bundle branch pacing (LBBP). We report a patient with a baseline sinus rhythm with complete atrioventricular block and a ventricular escape rhythm with a right bundle branch (RBB) block QRS morphology and left axis deviation who received LBBP for cardiac resynchronization therapy (CRT), and its anodal capture stimulation (ANS) rendered a near-normal QRS morphology. The resolution of the RBB pattern during bipolar pacing in this patient resulted from a fusion of LBBP and right ventricular septal capture from ANS. In conclusion, CRT can be achieved during LBBP by ANS in patients who do not have retrograde RBB activation.

Long-Term Electrocardiographic Follow-Up of a Patient with Light-Chain Cardiac Amyloidosis

Amyloid light-chain (AL) cardiac amyloidosis can cause restrictive cardiomyopathy, which has a poor prognosis. Although electrocardiography (ECG) is useful for its diagnosis and management, there are few reports on the long-term follow-up of electrocardiographic changes in affected patients. The present patient was a 62-year-old woman who visited our hospital for assessment of palpitations and lower leg edema. A chest radiograph showed cardiac enlargement, and ECG revealed sinus rhythm, first-degree atrioventricular block, low QRS voltage in the limb leads and a pseudo-myocardial infarction pattern in the precordial leads. Echocardiography revealed left ventricular hypertrophy with systolic and diastolic dysfunction. Immunoelectrophoresis demonstrated M-protein (IgGλ), and bone marrow biopsy suggested IgGλ-type plasmacytoma. Myocardial biopsy findings were compatible with cardiac amyloidosis. On the basis of these findings, we diagnosed AL cardiac amyloidosis. Melphalan-prednisolone (MP) therapy was started in conjunction with treatment for non-sustained ventricular tachycardia and congestive heart failure. Two years and 4 months later, the sinus rhythm converted to atrial tachycardia. At a follow-up examination at 4 years and 8 months, right branch block appeared. After that, intraventricular conduction worsened, and the low voltage in the limb leads was not observed. Seven years after diagnosis, she was hospitalized for treatment of pneumonia and heart failure with tachycardia. On the seventh day of hospitalization, heart rhythm changed to atrial stand-still with escaped ventricular rhythm and she died of cardiac arrest. These ECG changes are valuable information regarding the pathophysiological changes that occur in AL cardiac amyloidosis.

Venous Thromboembolic Disease in the Cardiology Department of the Nianakoro Fomba Hospital in Segou (HNF)

Venous thromboembolic disease (VTE) is a nosological group that consists mainly of deep vein thrombosis (DVT) and pulmonary embolism (PE). The objective of our study was to determine the hospital prevalence of VTE in this Nianakoro Fomba Regional Hospital (HNF) in Ségou, Mali, to describe the sociodemographic aspects of these patients and the therapeutic possibilities in this locality. Materials and Methods: We conducted a prospective descriptive study from June 2019 to June 2020 in the cardiology department of the HNF of Ségou. All patients of all ages and both sexes who had VTE on clinical and paraclinical criteria (pulmonary Angio scan and/or venous Doppler echo) during the study period were included. Result: 31 patients were included out of 366 hospitalized patients, with a hospital prevalence of 8.47%. The 41-60 and 61 - 80 age groups were both dominant with 35.48% of cases each. The female sex was the most represented with 58.06% of cases and a sex ratio of 0.97. High blood pressure (hypertension) was the preeminent cardiovascular risk factor in 32.2% of cases and predisposing factors for VTE were dominated by immobilization (41.94%), peripartum (16.13%) and heart failure (16.13%). Dyspnea and chest pain were the frequent reasons for consultation with 93.54% and 83.87% of cases respectively and 6 patients (19.35%) had calf pain. More than 3/4 of the patients had tachypnea or 90.32% and tachycardia in nearly 74.19%. The clinical probability of VTE was intermediate at 51.61% according to the Wells score. D-Dimers were elevated in 38.70%, or all 12 patients who performed it. The electrocardiogram (ECG) recorded a sinus rhythm in 93.54% of cases, a right branch block and atrial fibrillation (AF) in 35.48% and 6.45% of cases, respectively. Dilation of the right ventricle was present in 64.51% of cases with PAH in 61.29% on cardiac Doppler ultrasound. In the majority of cases (82.15%) it was a massive bilateral proximal and distal pulmonary embolism. Treatment was based on low molecular weight heparin (HPBM) and antivitamin K (AVK) in all patients (100%). No bleeding incidents; the average hospital stay was 10 days and an intra-hospital mortality rate of 29%.