Cases Of Atrioventricular Block Research Articles

A Case of 2:1 Atrio-Ventricular Block- Unravelled by Exercise Testing

: We present a case of 75-year-old lady with effort intolerance and baseline ECG showing 2:1 atrio-ventricular block, in whom it was unclear as to requirement of permanent pacing, even after long term ECG monitoring. She underwent a tread mill test during which her QRS became wide and developed complete heart block within 2 minutes of the test. Thus, a simple exercise test helped in confirming level of block to be infra nodal without need for invasive study. In patients with exertional symptoms, even in elderly, and in those where ECG masquerades as a benign entity, exercise testing is useful to differentiate benign cases of atrio-ventricular block from the more serious cases that mandate a pacemaker implantation.

Electrocardiogram analysis in patients with sickle cell disease and thalassemia

This study is an analysis of the electrocardiograms (ECGs) of 52 adult patients with a hemoglobinopathy (sickle cell disease and/or thalassemia). We examined the electrocardiograms (ECG) of 52 consecutive patients (> 14 years old) with ahemoglobinopathy (sickle cell disease and/or thalassemia) monitored at the Casablanca Ibn Rochd Hospital between February 2017 and July 2018. The mean age was 24.19 ± 9.55; 50.9 percent were men. Forty-six percent of all patients had abnormal ECGs. Among the 52 electrocadiograms, 17 had left ventricular hypertrophy, one patient had left bundle branch block and 5 patients had right bundle branch block. The corrected QT interval was prolonged in 3 patients. T wave abnormalities were recorded in 9 cases (inverted T wave in 8 cases and peaked T wave in 1 case). There was one case of atrial fibrillation, and no cases of atrioventricular block or ST segment abnormalities were recorded. The most observed electrical abnormalities were left ventricular hypertrophy, left and right branch block, and prolongation of the Qtc interval.

Intracardiac echocardiography guided left bundle branch pacing

Objective To investigate the role and method of intracardiac echocardiography (ICE) in left bundle branch pacing. Methods A total of 12 patients who underwent ICE guided left bundle branch pacing from February 2018 to June 2018 in department of cardiology of the First People’s Hospital of Yunnan Province. The patients’ sex, age, weight, disease history, and the results of color Doppler echocardiography were recorded before surgery.The duration of surgery, X-ray exposure, pacing parameters (threshold, perception, impedance) , electrocardiogram (ECG) characteristics, pacing parameters, clinical symptoms and echocardiographic results were recorded after surgery. Results The left bundle branch pacing guided by ICE was successfully in all 12 patients. There were 4 cases of sick sinus syndrome, 6 cases of atrioventricular block, 2 cases of atrial fibrillation with long R-R interval.The mean operation time was (1.75±0.28) hours, and the X-ray exposure was (61.2±13.6) mGy. The implantation time of left bundle branch electrode was (1.23±0.24) hours, X-ray exposure of left bundle branch electrode implantation was (48.9±12.3) mGy. There was no electrode dislocation, pneumothorax or infection after operation. Two of them had a small hematoma of the pacemaker pocket, hematoma disappeared after compression. Conclusion Feasibility of ICE guidance for left bundle branch pacing, which may increase the success rate and reduce the risk of surgery. Key words: Cardiac pacing, artificial; Intracardiac echocardiography; Left bundle branch

Intracardiac echocardiography-guided left bundle branch pacing

Background: The aim of this study is to investigate the role and method of intracardiac echocardiography (ICE) in left bundle branch pacing. Subjects and Methods: A total of 12 patients who underwent ICE-guided left bundle branch pacing from February 2018 to June 2018 in the Department of Cardiology of the First People's Hospital of Yunnan Province were enrolled in this observational case analysis. The study was approved by the Institutional Ethical Committee of the First People's Hospital of Yunnan Province, China (approval No. KHLL2019-KY018). The patients' sex, age, weight, disease history, and the results of color Doppler echocardiography were recorded before surgery. The duration of surgery, X-ray exposure, pacing parameters (threshold, perception, and impedance), electrocardiogram characteristics, pacing parameters, clinical symptoms, and echocardiographic results were recorded after surgery. Results: The left bundle branch pacing guided by ICE was successfully in all 12 patients. There were four cases of sick sinus syndrome, six cases of atrioventricular block, and two cases of atrial fibrillation with long R-R interval. The mean operation time was 1.75 ± 0.28 hours, and the X-ray exposure was 61.2 ± 13.6 mGy. The implantation time of left bundle branch electrode was 1.23 ± 0.24 hours, and X-ray exposure of left bundle branch electrode implantation was 48.9 ± 12.3 mGy. There was no electrode dislocation, pneumothorax, or infection after operation. Two of them had a small hematoma of the pacemaker pocket, and hematoma disappeared after compression. Conclusion: This study demonstrates the feasibility of ICE guidance for left bundle branch pacing, which may increase the success rate and reduce the risk of surgery.

Left Septal Slow Pathway Ablation for Atrioventricular Nodal Reentrant Tachycardia.

Immunohistochemistry studies suggest that the anatomic substrate of the slow pathway in atrioventricular nodal reentrant tachycardia (AVNRT) is the left inferior nodal extension. We hypothesized that slow pathway ablation from the left septum is an effective alternative to right-sided ablation. We analyzed our databases of AVNRT in search of cases that had used slow pathway ablation from the left septum because of failure of right septal ablation, and then prospectively subjected consenting patients to a left septal-only procedure. Of 1342 patients subjected to right septal slow pathway ablation for AVNRT, 15 patients, 11 with typical and 4 with atypical AVNRT, had a left septal approach after unsuccessful right-sided ablation (R+L group). Eleven patients were subjected to a left septal-only approach for slow pathway ablation without a previous right septal attempt (L group). Fluoroscopy times in the R+L and L groups were 30.5 (21.0-44.0) and 20.0 (17.0-25.0) minutes, respectively (P=0.061), and radiofrequency current delivery times were 11.3 (5.0-19.1) and 10.0 (7.0-12.0) minutes, respectively (P=0.897). There was no need for additional ablation lesions at other anatomic sites in either group, and no cases of atrioventricular block were encountered. Recurrence rates of the arrhythmia for the R+L and L groups were 6.7% and 0%, respectively, in the 3 months after ablation (P=1.000). Left septal ablation at the anatomic site of the left inferior nodal extension is an alternative for ablation of both typical and atypical AVNRT when ablation at the right posterior septum is ineffective.

Lacosamida asociada a bloqueo de alto grado en un paciente con neuralgia del trigémino

Lacosamide is an antiepileptic drug whose exact mechanism of action remains unknown. It acts by increasing the slow inactivation of the voltage-dependent sodium channels of the cell membranes. It is indicated in the treatment of focal seizures with or without secondary generalisation and is occasionally used as adjunct treatment in neuropathic pain. Although the most frequent side effects are mild (dizziness, diplopia, blurred vision, headache, tremor, etc.), others such as supraventricular tachyarrhythmias, changes in repolarisation, atrioventricular blocks and even cardiac arrest or sudden death have been reported. A 74-year-old male, diagnosed with classic trigeminal neuralgia treated with 200 mg/12 h of carbamazepine, who visited due to a worsening of the pain in the trigeminal V1-V2 region. On the sixth day after admission, after adjusting the carbamazepine treatment to a descending regime, 400 mg/24 h of eslicarbazepine and 100 mg/12 h of intravenous lacosamide, he presented a complete atrioventricular block with extreme bradycardia that required the placement of a pacemaker. Voltage-dependent sodium channel blockade mainly affects non-sinusal cardiac tissue. An alteration in the atrioventricular or infrahisian node is more consistent with its mechanism of action. Other cases of atrioventricular block in this kind of polytherapy have been reported. Precaution is advised in the concomitant use of antiepileptic drugs, above all among those that prolong the PR interval, and they should be contraindicated in patients with a history of atrioventricular block, ischaemic heart disease or heart failure. Before starting, a baseline electrocardiogram and regular electrocardiographic monitoring are advised during the first few weeks.

Catheter Ablation of Atypical Atrioventricular Nodal Reentrant Tachycardia.

Because of its low prevalence, data on atypical atrioventricular nodal reentrant tachycardia (AVNRT) are scarce, and the optimal ablation method has not been established. Our study aimed at assessing the efficacy and safety of conventional slow pathway ablation, as applied for typical cases, in atypical AVNRT. We studied 2079 patients with AVNRT subjected to slow pathway ablation. In 113 patients, mean age 48.5±18.1 years, 68 female, atypical AVNRT or coexistent atypical and typical AVNRT without other concomitant arrhythmia was diagnosed. Ablation data and outcomes were compared with a group of age- and sex-matched control patients with typical AVNRT. Fluoroscopy and radiofrequency current delivery times were not different in the atypical and typical groups, 20.3±12.2 versus 20.8±12.9 minutes (P=0.730) and 5.9±5.0 versus 5.5±4.5 minutes (P=0.650), respectively. Slow pathway ablation was accomplished from the right septum in 110 patients, and from the left septum in 3 patients, in the atypical group. There was no need for additional ablation lesions at other anatomic sites, and no cases of atrioventricular block were encountered. Recurrence rates of the arrhythmia were 5.6% in the atypical (6/108 patients) and 1.8% in the typical (2/111 patients) groups in the next 3 months following ablation (P=0.167). Conventional ablation at the anatomic area of the slow pathway is the therapy of choice for symptomatic AVNRT, regardless of whether the typical or atypical form is present.

Should the Aortic Root Be the Preferred Route for Ablation of Focal Atrial Tachycardia Around the AV Node?: Support From Intracardiac Echocardiography.

The purpose of this study was to determine the optimal approach to focal atrial tachycardia originating from around the atrioventricular node. Focal atrial tachycardia (FAT) demonstrating earliest activation around the atrioventricular (AV) node during right atrial (RA) mapping has been eliminated by ablation at the RA para-Hisian region, from the left atrium (LA) or the noncoronary aortic cusp (NCC). However the optimal approach has not been determined. We conducted a retrospective analysis of a consecutive series of 148 patients undergoing catheter ablation for FAT between 2006 and 2014 in our institution. Earliest activation was recorded in the peri-AV nodal region during RA mapping in 34 patients (23%). Of these, 7 patients (20.5%) had successful ablation at the RA septum, using either radiofrequency (n= 4) or cryoenergy (n= 3). Seven FATs (20.5%) were ablated from the LA at the region of the aortomitral continuity, and 20 patients (59%) had successful ablation in the NCC, including 1 patient with a recurrence after a temporarily successful cryoablation from the RA. The proportion of the 3 approaches in this series showed a significant temporal evolution and overall frequency favoring ablation in the NCC (p= 0.011 for time trend and 0.013 for actual vs. expected frequencies). Intracardiac echocardiography proved superior catheter stability with the NCC approach. There were 2 cases of atrioventricular block and 1 recurrence after RA ablation versus no complications or recurrent FAT with NCC and LA approaches. Most peri-AV nodal FATs can be safely and effectively ablated from the NCC. The strategy of preferential NCC approach avoids RA para-Hisian ablation with the accompanying risk of AV block.

Bloc auriculoventriculaire transitoire aigu chez l’africain : résultats d’une première série chez des drépanocytaires

Background Even though sickle cell disease has a high prevalence amongst the black race and despite its well known potential of micro-infarction, there have been only a few reports regarding the acute myocardial damage during vaso-occlusive crisis. The risk of atrio-ventricular block during these crises has never been described in a large survey. Methods and results The survey was conducted in 4 cardiac ICUs in France between 1990–2010. Ten patients (six men and four women, mean age 39 years old) were hospitalized for an acute atrio-ventricular block. The patients were all African or Caribbean natives. Three patients were found with a heterozygous phenotype for hemoglobin S (sickle trait) and seven were found with a homozygous phenotype. The most common symptoms were asthenia (7 cases), shortness of breath (2 cases) and acute coronary syndrome (1 case) (syncope was not reported). Four patients had a second-degree atrio-ventricular block and six patients had third-degree block. The treatment involved bed rest, intravenous hydration, and pain relief with opiates. All the cases of atrio-ventricular block were only transitory and none of the patients underwent a pacemaker implantation. Conclusion This report is the largest survey regarding transitory acute atrio-ventricular block in patients with sickle cell disease. A local ischemic event affecting the AV node and His bundle area can explain the conduction abnormalities. Sickle cell disease must be ruled out in black patients with an AV block.

Bloc auriculo-ventriculaire transitoire aigu dans la drépanocytose. Première série

BackgroundEven though sickle cell disease has a high prevalence amongst the black race and despite its well known potential of micro infarction, there have been only a few reports regarding the acute myocardial damage during vaso-occlusive crisis. The risk of atrio ventricular block during these crises has never been described in a large survey. Patients and resultsTen patients (six men and four women, mean age 39 years old) were hospitalized for an acute atrio ventricular block. The patients were all African or Caribbean natives. Three patients were found with a heterozygous phenotype for hemoglobin S (sickle trait) and seven were found with a homozygous phenotype. The most common symptoms were asthenia (10 cases), shortness of breath (8 cases) and acute coronary syndrome (1 case) (syncope was not reported). Four patients had a second degree atrio ventricular block and six patients had third degree block. The treatment involved bed rest, intravenous hydration, and pain relief with opiates. All the cases of atrio ventricular block were only transitory and none of the patients underwent a pacemaker implantation. ConclusionThis report is the largest survey regarding transitory acute atrio ventricular block in patients with sickle cell disease. A local ischemic event affecting the AV node and Hiss bundle area can explain the conduction abnormalities. Sickle cell disease must be ruled out in black patients with an AV block.

Diagnosis, characterization and outcome of congenitally corrected transposition of the great arteries in the fetus: a multicenter series of 30 cases

To describe the anatomy, associated anomalies and outcome of 30 cases of congenitally corrected transposition of the great arteries (ccTGA) detected prenatally. This was a retrospective observational study of the 30 cases of ccTGA confirmed at autopsy or postnatal echocardiography seen at one of three referral centers from 1994 to 2003. The following data were considered: gestational age at diagnosis, cardiac anatomy, associated cardiac and extracardiac anomalies and fetoneonatal outcome. All fetuses underwent fetal echocardiography and a detailed anomaly scan, with follow-up scans at 3-4-week intervals until delivery. The diagnosis was confirmed at autopsy or after delivery. Follow-up data were retrieved from the clinical files of the patients. The mean gestational age at diagnosis was 25.5 weeks. Intracardiac defects associated with the ccTGA included a ventricular septal defect in 21 cases, pulmonary outflow obstruction in 12 cases, an abnormal tricuspid valve in 10 cases, ventricular hypoplasia in five cases and dextro/mesocardia in five cases. The karyotype was normal in all 24 newborns, and unknown in the cases which resulted in termination of pregnancy (n = 5) or intrauterine death (n = 1). There were associated extracardiac anomalies in four cases only. Three of the four cases of atrioventricular block (AV block) developed in the third trimester, while the fourth appeared after birth. There were nine deaths (five terminations, two perinatal deaths and two infant deaths). The remaining 21 (70%) newborns were alive at a median follow-up time of 32 months, 11 of them after various surgical procedures. Our data suggest that in fetuses with ccTGA the risk of chromosomal and extracardiac anomalies is low, in accordance with postnatal data. The spectrum of associated cardiac lesions is consistent with that reported in the pediatric literature. These data may be of use during prenatal counseling since no figures regarding survival and/or outcome of ccTGA in the fetus have been reported so far.

Cardiovascular involvement in relapsing polychondritis

Relapsing polychondritis is an inflammatory disease that characteristically involves cartilagenous tissues. Cardiovascular involvement is a fairly common complication and the second most frequent cause of mortality in this disease. The case of a man with a progressive cardiac involvement, aortic incompetence, mitral regurgitation, and finally complete atrioventricular block offered the opportunity of reviewing the cardiovascular complications in relapsing polychondritis. The most frequent abnormalities are aortic regurgitation and aortic aneurysm. Furthermore, several cases of atrioventricular block, mitral regurgitation, and acute pericarditis have been reported. For early diagnosis and treatment of these severe complications, periodic cardiovascular examination is mandatory in these patients.

Late results after repair of aortic insufficiency associated with ventricular septal defect

The late results of 70 patients aged 1.96 to 35.9 (mean 10.1) years who had repair of ventricular septal defect and aortic insufficiency from 1968 to 1988 were reviewed. The ventricular septal defect was subcristal in 50 and subpulmonary in 20 patients. Two thirds were situated immediately below some part of the right coronary leaflet with prolapse of that leaflet. Most of the remainder were below the right commissure or the anterior part of the noncoronary leaflet with prolapse of one or both adjacent leaflets. Associated structural defects, usually including some fusion at a commissure, were present in 18 of the 70 patients and occurred more often with a ventricular septal defect in or below the commissure between the right and noncoronary leaflets (p less than 0.001). Follow-up ranged from 1.9 to 19.6 (mean 9.8) years. There were no early deaths or cases of atrioventricular block, but there were two late deaths. Patient survival rate was 96% at 10 years. Freedom from valvuloplasty failure and freedom from reoperation were 76% and 85%, respectively, at 10 years. The major predictor for failure by multivariate analysis was the presence of an associated structural defect (p less than 0.01). Age at repair and position of the ventricular septal defect were not significant risk factors. We conclude that aortic valvuloplasty produces good palliation in most children. The few failures occurred early and chiefly in patients with associated structural valve defects that occurred more frequently in children who had a ventricular septal defect in the right commissure, where both the right and noncoronary leaflets may be affected.

Intra-hisian 2:1 atrioventricular block secondary to Lyme disease

We describe a case of Lyme carditis with intra-hisian 2:1 atrioventricular (AV) block documented by electrophysiological study. To our knowledge, only two cases of AV block at the level of the His bundle has been described in the literature. Sinus rhythm was restored after 4 days of i.v. ceftriaxone.