Complete Heart Block In Patient Research Articles

Frequency of Reversibility of Complete Heart Block in Acute Myocardial Infarction

Objective The aim of current study was to evaluate the frequency of reversibility of complete heart block in patients of acute myocardial infarction. Methods Total one hundred and thirty eight patients with complaint of syncope and atypical chest pain presented at emergency ward of Punjab Institute of Cardiology, Lahore. All patients underwent conventional coronary angiogram to roll out the ischemic etiology of underlying bradyarrhythmias. Among them more than 90% patients have mild coronary artery disease and they were kept on medical management. But all patients remained TPM dependant for two weeks which were then treated with permanent pacemakers. Results Results of the current study revealed that the mean age of patients was 51.48 ± 15.46 with minimum age 18 and maximum was 65 years. Out of 138 patients, 84(61%) were male while 54(39%) were female., 52(37.7%) patients diagnosed of diabetes mellitus, 75(54.3%) patients of hypertension and 58(42.03%) patients were smoker, 41(29.7%) have family history, 47(34.1%) patients have dyslipidemia and only 50(36.2%) obese patients. Patients divided into two groups; patients with complete heart block in the age grouped between 16-35 years, only 6(4.3%) as compare with age grouped 36-65 years only 10(7.2%) have complete heart block, male 8(5.8%), only 5(3.6%) hypertensive patients and 4(2.9%) diabetic patients suffering complete heart block, 2(1.4%) patients presented during 1-12 hours compare with 7(5.1%) presented between 13-24 hours, results showed statistically insignificant as p-value > 0.05. 2nd Degree AV Block and complete heart block showed significant difference between troponin level as p-value <0.05 in patients diagnosed with ACS. Conclusion Atrioventricular block is frequently reversible in people with AMI. As a result, in situations with AMI permanent pacemaker installation should be postponed.

Unraveling the invisible demon: a study of the oxidative stress markers, antioxidant activities and inflammatory markers in patients admitted with complete heart block

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Despite the recent advancements in the management of Complete Heart Block (CHB), the aetiology of CHB is still idiopathic in most of the cases. Our study explores this hitherto untouched aspect of complete heart block. Purpose We aimed to assess the aetiological profile of Complete Heart Block patients in our study. Methods The study population consisted of 60 patients with complete heart block aged between 30 to 80 years, attending as an inpatient in ER. Oxidative stress was measured by serum MDA, serum GSH, serum Catalase activity and serum SOD activity. Antioxidant activity was obtained by measuring the levels of serum total antioxidant capacity. Inflammatory stress was measured by IL-5 and TNF-alpha levels. These values were compared to 30 healthy controls with no prior history of smoking and diabetes mellitus. Results The mean age of the patient was 62.48 ± 7.98 years and the gender distribution was 37 males and 23 females out of 60 patients. The mean value of serum MDA (ng/mL) in cases is 1451.26 ± 206.32, and in controls, the mean value is 1197.98 ± 234.71 (p=<0.001). The mean value of serum GSH (mcg/mL) in cases is 46.982 ± 18.613, and in controls, the mean value is 54.155 ± 10.762 (p=0.027). The mean value of serum Catalase Activity (U/min/mg protein) in cases is 10.763 ± 4.038 and in controls, the mean value is 19.878 ± 7.787 (p=0.003). The mean value of serum SOD Activity (U/g) in cases is 24.950 ± 5.4565, and in controls, the mean value is 46.214 ± 14.6309 (p=0.891). The mean value of serum Total Antioxidant Capacity (U/mL) in cases is 5.546 ± 0.620 and in controls, the mean value is 8.346 ± 2.781 (p=0.025). The mean value of serum IL-5 (pg/mL) in cases is 481.442 ± 28.8995, and in controls, the mean value is 67.347 ± 20.445 (p<0.001). The mean value of serum TNF-ALFA (pg/mL) in cases is 196.741 ± 73.771, and in controls, the mean value is 144.530 ± 42.599 (p= 0.081). Conclusions During a complete heart block, SOD (p=0.891), CAT (p=0.003), GSH (p=0.027) and total antioxidant (TAOC) (p=0.025) were significantly decreased in cases, compared to healthy controls, thus suggesting that the elevated levels of oxidative free radicals causes endothelial dysfunctioning. The increase in ROS was observed by a highly significant increase of malondialdehyde (MDA) (p=<0.001) showing high ROS-mediated tissue damage. Besides damage by oxidative stress, our study suggests that there are certain inflammatory markers like TNF-α and IL-5 that actively participate in causing heart block. There was a significant increase in the concentration of IL-5 (p<0.001) in the cases as compared to the controls.

Variation in the Expression of Interstitial Cell of Cajal-like Cell (CD117) Across Congenital Pelvic-ureteric Junction Obstruction and its Renal Sonological and Functional Correlation: A Prospective Observational Study.

This study aims to study the variation in the expression of CD117-positive interstitial cells of Cajal-like cells (ICC-LC) across the upper urinary tract region in children presenting with pelvic-ureteric junction obstruction (PUJO) and its association with renal functional and sonological parameters of patients. A prospective observational study was done on 20 children with congenital PUJO who underwent dismembered pyeloplasty. All children underwent renal sonography (anteroposterior pelvic diameter [APPD], pelvicalyceal ratio [P/C ratio], Mid polar renal parenchymal diameter [MPPD]) and functional imaging scan (LLEC scan or DTPA scan). Three specimens were taken intraoperatively from above PUJ, at the level of PUJ, and below PUJ. Those were examined immunohistochemically using CD117 to count ICC-LC using standard criteria. Variation in the expression of CD117-positive ICC-LC was correlated with the abovestated parameters. The number of CD117-positive ICC-LC showed a continuous decreasing trend above downward. P/C ratio and APPD showed a parallel trend with ICC-LC distribution, whereas split renal function (SRF) showed an inverse relationship with the expression of ICC-LC. Children with lesser severity of obstruction (APPD <30 mm and SRF >40%) showed a uniform decreasing trend in the number of CD117-positive ICC-LC across PUJ. Children with more severe obstruction (APPD >30 mm and SRF <40%) showed a decrease in the expression of ICC-LC up to the level of PUJO followed by a sudden relatively increased expression of ICC-LC below the obstruction. The expression of ICC-LC shows a uniformly decreasing trend across obstruction when the severity of obstruction is less. Resurgence in the number of ICC-LC below PUJ in subjects with severe obstruction hints at the emergence of a new pacemaker area below severely blocked PUJ akin to that seen in complete heart block patients and deserves early attention.

Incidence of morbidity and mortality in a cohort of congenital complete heart block patients followed over 40 years.

Congenital complete heart block (CCHB) is seen in 1:15,000-20,000 births and commonly requires pacemaker placement by young adulthood. There is limited understanding of cardiac morbidity and mortality. The purpose of this study was to determine the long-term incidence of cardiac morbidity and mortality in subjects with CCHB and identify associated risk factors. Retrospective cohort analysis of subjects with CCHB at Children's Hospital of Philadelphia between 1976 and 2018 was performed. The primary outcome was a composite of death, left ventricular systolic dysfunction, heart failure, cardiomyopathy, or cardiac resynchronization therapy (CRT). Cox proportional hazard models assessed independent risk factors for the primary outcome and its components (death, heart failure and/or cardiomyopathy, CRT). One-hundred fourteen subjects (58% female; median age at last visit 15.2 years) were included. Eighty-eight (77%) underwent pacemaker implantation (median age at placement 1.9 years; interquartile range [IQR] 0.1-8.0 years). Twenty-six subjects (23%) reached the primary outcome; 7 (6%) died and 14 (12%) were diagnosed with heart failure and/or cardiomyopathy. Median time from diagnosis to primary outcome was 3.1 years (IQR 0.0-10.8 years). There were no significant associations between age at diagnosis <1 year (hazard ratio [HR] 1.5; 95% confidence interval [CI] 0.6-3.9), fetal diagnosis (HR 2.3; 95% CI 0.96-5.6), or maternal antibody positivity (HR 2.4; 95% CI 0.9-6.6) and the primary outcome. Fetal diagnosis had a higher associated hazard of heart failure and/or cardiomyopathy (HR 4.5; 95% CI 1.3-15.0). In 114 subjects with CCHB, 23% reached the composite outcome of cardiac morbidity and mortality, with no significant association between age at diagnosis, fetal diagnosis, and maternal antibody status with composite cardiac morbidity and mortality.

Frequency of Complete Heart Block in Patients with Acute Inferior Wall Myocardial Infarction

Background: Acute MI is the leading health issue globally affecting many lives. Aim: To determine the frequency of complete heart block in patients with acute inferior wall myocardial infarction. Study Design: Cross-sectional study. Methodology: All newly diagnosed inferior wall MI patients were included. Detailed history followed by detailed clinical examination was done. ECGs were done. Complete heart block was evaluated. It was considered as third degree AV block and was diagnosed when there was no AV nodal conduction and the P wave was completely dissociated from the QRS complexes. All this information was recorded on Performa. Data was analyzed using SPSS version 25. Cardiogenic shock was stratified among age and gender by applying chi square test. Results: Age as mean ± SD was 62 ± 8.04 years. Enrolled males were 59% while females were 41% in present study. Results showed that 19% patients had complete heart block while 81% were without it. Conclusion: It was concluded that frequency of complete heart block was high (19%) in patients with inferior wall MI Keywords: Complete Heart Block, Myocardial Infarction and Frequency

Randomized Pragmatic Trial of Pacemaker Versus Implantable Cardiac Monitor in Syncope and Bifascicular Block.

In this study, the authors tested whether a strategy of empiric permanent pacing reduces major composite events more effectively than acting on the results of an implantable cardiac monitor (ICM). Syncope may be caused by intermittent complete heart block in patients with bifascicular heart block, but competing diagnoses coexist. Whether empiric permanent pacing or acting on investigative results provides best care is unknown. This was a multinational, randomized, pragmatic clinical trial of patients≥50 years of age with bifascicular block, preserved left ventricular function, and≥1 syncope in the preceding year. The primary composite outcome measure comprised cardiovascular death, syncope, bradycardia resulting in pacemaker insertion, and device complications. There were 57 and 58 subjects randomized to receive a pacemaker or ICM. A total of 41 patients had left bundle branch block and 74 had right bundle branch block and a left fascicular block. Patients were followed for a median 33months. There were fewer composite primary outcomes in patients randomized to pacemaker compared with ICM, respectively (20 [35%] vs 44 [76%]; chi square P< 0.0001), with lower actuarial probabilities of a primary outcome (0.45 and 1.00; P< 0.001). Syncope was as likely in the groups randomized to receive a pacemaker or ICM (29% vs 26%, chi-square P = 0.95). Empiric permanent pacing compared with ICM reduced major adverse events but not syncope in older patients with bifascicular block and recent syncope. There remains a substantial likelihood of syncope recurrence in patients who receive a permanent pacemaker likely caused by vasodepressor syncope. (Syncope: Pacing or Recording in the Later Years [SPRITELY]; NCT01423994).

MAGIC OF ADVANCED IMAGING AND IMMUNOTHERAPY IN CARDIAC SARCOIDOSIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: This case report emphasizes the role of advanced imaging and immunotherapy in the diagnosis and management of cardiac sarcoidosis (CS). CASE PRESENTATION: A 52-year-old healthy male presented with near-syncope for 5 days. He had a blood pressure of 164/67 mmHg and a heart rate of 43 bpm. Electrocardiogram revealed complete-heart-block (CHB) with a ventricular rate of 38/min. Troponin T and electrolytes were normal, and Lyme's serology was negative. Echocardiogram was normal. Cardiac magnetic resonance imaging (CMR) revealed late gadolinium enhancement (LGE) affecting the mid inferior segment at the right ventricle (RV) insertion site (Figure 1). A cardiac and whole-body 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed focal areas of increased FDG uptake in the LV involving mid and basal anteroseptal segments, mid inferoseptal segment, basal inferolateral, and basal inferior segments with normal perfusion (Figure 2). The scan also revealed hypermetabolic bilateral hilar and mediastinal lymphadenopathy. A diagnosis of CS was made. An Implantable-Cardioverter-defibrillator (ICD) was placed and the patient was discharged on 40mg of prednisone and 20mg of leflunomide. Within 4 months, he went from 100% RV pacing to 0%. Eventually, the corticosteroid was tapered off. At follow-up after 1.5 years, RV pacing remained 0% on Leflunomide 20mg. DISCUSSION: One should always suspect CS in young patients with high-grade AV block. During the workup of CHB (Figure 3), the 2017 Japanese Circulation Society Working Group Criteria for diagnosing CS was followed (1). The patient had 2 characteristic findings strongly suggestive of sarcoidosis: (a) hilar lymphadenopathy and (b) significant tracer accumulation in the myocardium and hilar lymph nodes on FDG-PET scan. He also met 2 major criteria strongly suggestive of CS: (a) LGE on CMR and (b) abnormal myocardial FDG uptake. These findings, per the criteria, establish the clinical diagnosis of CS. The mainstay of treatment for CS is corticosteroids +/- steroid-sparing agents to decrease intra-cardiac inflammation (1). CHB patients with CS have a high risk of ventricular arrhythmias, hence should receive ICD (2). The addition of antimetabolite adjuvants is more effective than corticosteroids alone (3). They may reduce the total time of glucocorticoid therapy and keep patients in remission. CONCLUSIONS: Clinical diagnosis of CS can be established with FDG-PET imaging and CMR. CS patients with advanced heart block should receive ICD. Corticosteroids are the mainstay of treatment. Immunotherapy is an effective adjunct that can help taper the glucocorticoids and keep patients in remission. Early introduction of these agents should be considered in these patients. REFERENCE #1: 1. Trivieri MG et al. Challenges in Cardiac and Pulmonary Sarcoidosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2020;76:1878-1901 REFERENCE #2: 2. Nordenswan H-K et al. Outcome of Cardiac Sarcoidosis Presenting With High-Grade Atrioventricular Block. Circulation: Arrhythmia and Electrophysiology 2018;11:e006145 REFERENCE #3: 3. Nagai S, Yokomatsu et al. Treatment with methotrexate and low-dose corticosteroids in sarcoidosis patients with cardiac lesions. Intern Med 2014;53:427-33. DISCLOSURES: No relevant relationships by Roy Chung, source=Web Response No relevant relationships by Sachin Kumar, source=Web Response No relevant relationships by Raunak Nair, source=Web Response

Complete heart block in patients infected with SARS-CoV-2: A case series from a developing country

Coronavirus Disease 19 (COVID-19) has led to a global pandemic and has been the center of attention across the entire medical community. This novel virus was initially thought to affect primarily the respiratory system, but now it is evident that it has a multitude of effects on the human body. Our point of interest is to establish the effect of COVID-19 infection on the conducting system of the heart. We present a case series of four patients who developed complete heart block (CHB) shortly after being infected with COVID-19 without any previous known risk factors of complete heart block. There have only been a few previous case reports on the occurrence of CHB in COVID-19 patients highlighting the importance and the need of our case series to the literature of cardiovascular outcomes in COVID-19 patients. Our case series highlight that COVID-19 can indeed affect the conduction system of the heart and cause CHB in patients who then recovered spontaneously further elucidating the transient nature of cardiovascular effects caused by the novel virus.

Complete Heart Block as a Clinical Feature in Critically Ill Coronavirus Disease 2019 (COVID-19) Patients: A Case Series of Three Cases

Background. Novel coronavirus-19 disease (COVID-19) is associated with significant cardiovascular morbidity and mortality. However, there have been very few reports on complete heart block (CHB) associated with COVID-19. This case series describes clinical characteristics, potential mechanisms, and short-term outcomes of critically ill COVID-19 patients complicated by CHB. Case Summary. We present three cases of new-onset CHB in critically ill COVID-19 patients. Patient 1 is a 41-year-old male with well-documented history of Familial Mediterranean Fever (FMF) who required mechanical ventilator support for acute hypoxic respiratory failure from severe COVID-19 pneumonia. He developed new-onset CHB without a hemodynamic derangement but subsequently had acute coronary syndrome complicated by cardiogenic shock. Patient 2 is a 77-year-old male with no past medical history who required intubation for severe COVID-19 pneumonia acute hypoxic respiratory failure. He developed CHB with sinus pause requiring temporary pacing but subsequently developed multiorgan failure. Patient 3 is 36-year-old lady 38 + 2 weeks pregnant, gravida 2 para 1 with no other medical history, who had an emergency Lower Section Caesarean Section (LSCS) as she required intubation for acute hypoxic respiratory failure. She exhibited new-onset CHB without hemodynamic compromise. The CHB resolved spontaneously after 24 hours. Discussion. COVID-19-associated CHB is a very rare clinical manifestation. The potential mechanisms for CHB in patients with COVID-19 include myocardial inflammation or direct viral infiltration as well as other causes such as metabolic derangements or use of sedatives. Patients diagnosed with COVID-19 should be monitored closely for the development of bradyarrhythmia and hemodynamic instability.

Early Outcomes of Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy in Children With Noonan Syndrome

Noonan syndrome (NS) is a genetic syndrome causing obstructive hypertrophic cardiomyopathy (HCM) in infants. Studies of cardiac surgery in pediatric HCM patients with NS (NS-HCM) are lacking. We aim to characterize the early disease course of young NS-HCM patients before adolescence and assess their complications and survival condition after septal myectomy. Pediatric obstructive HCM patients who underwent septal myectomy at age 10 years or under were enrolled consecutively between 2009 and 2019. Ten patients with NS and 43 non-NS patients were enrolled in our study. NS-HCM patients were diagnosed at a younger age (5.00 ± 7.48 months vs. 18.73 ± 26.96 months) and more often had biventricular outflow tract obstruction (90.00% vs 30.23%). The surgical treatment can significantly reduce the pressure gradient of the outflow tract. More NS-HCM patients had biventricular reconstruction (70.00% vs 25.58%). The overall survival rates in all patients were 98.04% during 5-year follow-up, respectively. Complete heart block (CHB) was the most prevalent complication in patients with NS and tended to be more common than in non-NS patients (20% vs 7.32%). No sudden cardiac death (SCD) occurred in CHB patients who had pacemaker implantation. Biventricular reconstruction was the risk factor for CHB. Septal myectomy is safe and effective surgery to relieve obstruction in young age pediatric obstructive NS-HCM patients. Postoperative CHB is a common complication, especially in patients who underwent biventricular reconstruction. The implantation of pacemaker can protect CHB patients from SCD and improve their prognosis.

Complete Heart Block after open Heart Surgery in Children with Congenital Cardiac Diseases Feasibility of more waiting time before PPM administration

Introduction: Congenital cardiac disorders are the most prevalent congenital disorders which require interventional or surgical treatments. The most common causes of complete heart block (CHB) are degeneration of cardiac conduction system, acute myocardial infarction and congenital cardiac disorders. CHB after congenital heart surgery is of paramount importance which causes post-operation death and heart failure. Application of a pacemaker is a standard treatment for CHB. The purpose of this paper is to study the frequency of early postoperative CHB in patients with congenital cardiac diseases and also the need for temporary (TPM) and permanent (PPM) pacemakers. Materials and methods: This descriptive-analytical and cross-sectional study was conducted on children with congenital heart defects who had undergone open-heart surgery in Tabriz’s Shahid Madani Hospital from 2011 to 2016. Patients with early postoperative CHB were included in the study. Those who had improved on their own and those who needed TPM and PPM were identified and at the end, the frequency of CHB and the need for TPM and PPM were assessed. Results: Of the 2100 operated patients, 109 patients developed early postoperative heart block. The frequency of early CHB after open heart surgery was 5.19%. Of the 109 patients, 69 patients (63.3%) with early postoperative CHB needed TPM, 9 patients needed PPM and 22 patients improved without pacemaker. Conclusion: The prevalence of early CHB in patients operated for congenital cardiac diseases was 5.19%. The need for TPM was high and most of the patients had improved cardiac rhythm with no need for PPM or TPM.

Electrophysiology studies for predicting atrioventricular block in patients with syncope: A systematic review and meta-analysis

Syncope may be caused by intermittent complete heart block in patients with bundle branch block. Electrophysiology studies (EPS) testing for infra-Hisian heart block are recommended by the European Society of Cardiology syncope guidelines on the basis of decades-old estimates of their negative predictive values (NPVs) for complete heart block. The aim of this study was to determine the NPV of EPS for complete heart block in patients with syncope and bundle branch block. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL without language restriction from database inception to October 2019 for Medical Subject Headings terms and keywords related to "syncope," "heart block," and "programmed electrical stimulation." A random effects meta-analysis was conducted with a primary outcome of the proportion of patients with a negative EPS who later presented with complete heart block, diagnosed with surface electrocardiographic (ECG) recordings vs continuous implantable cardiac monitor (ICM). Ten reports contained 12 cohorts with 639 patients who met the inclusion criteria. The mean age was 69 ± 7 years; 35%±10% were women; and 85% of patients had bifascicular block. Seven cohorts recorded clinical outcomes with external ECG recordings, and 5 cohorts featured ICMs. The mean prespecified His-to-ventricle interval criterion was ≥70 ms. In studies featuring surface ECG recordings, there were 7% (95% confidence interval 7%-17%) patients who developed complete heart block compared with 29% (95% confidence interval 24%-35%) in the studies featuring ICM (P = .0001). The NPV of EPS in patients with syncope and bundle branch block is 0.71, sufficiently low to question its use.

Transient Third-degree Heart Block Secondary to Asymptomatic COVID-19 Infection

COVID-19 predominantly affects the lungs manifesting as respiratory illnesses including pneumonia and acute respiratory distress syndrome. Cardiac manifestations are also being increasingly reported such as pericardial disease, myocardial injury and dysfunction, arrhythmias and conduction abnormalities. A 70-year-old male with asymptomatic COVID-19 infection developed a transient episode of complete heart block just prior to his planned discharge from hospital. There are only few case reports purporting the development of a transient complete heart block in patients with moderate to severe COVID-19 infection. However, to date, this is the first report of incidentally detected, asymptomatic COVID-19 infection manifesting as third degree heart block.

Abstract 15900: Incidence of Mortality and Morbidity in a Cohort of Congenital Complete Heart Block Patients Followed for Over 40 Years

Introduction: Congenital complete heart block (CCHB) is rare, 1:15,000 - 1:20,000 live births. The most important risk factors for mortality and cardiac morbidities in this population are not clear. Our CCHB population with structurally normal hearts is uniquely suited to evaluate natural history, impact of chronic pacing, and associated morbidities. Methods: We performed a retrospective cohort study of all identifiable subjects at the Children’s Hospital of Philadelphia from 1/1/1970-4/3/2018 with a CCHB ICD-9 or 10 code and confirmed CCHB by medical record review. We excluded those with structural congenital heart disease, genetic, or acquired cardiac conditions. The primary outcome was a composite of death, cardiomyopathy (CM), heart failure (HF), echocardiographic systolic dysfunction (SD), or cardiac resynchronization therapy (CRT). We applied univariate analysis using chi-square, ANOVA, and determined relative risk. Results: The cohort includes 114 subjects, 58% female, 68% white, 65% diagnosed in the first year of life, with 1571 person-years of follow-up. Maternal antibody testing was positive in 49 subjects (42%). Sixteen (14%) were paced on first day of life and 88 (77%) had at least one permanent pacemaker implanted. Median age at first implant was 1.9 years (IQR 0.1-7.9) and median paced duration 11.8 years (IQR 5.8-16.2). Of those born before 2000, 92% received a pacemaker; 66% born since 2000 have a pacemaker. Pacemaker lead fracture or dislodgement occurred in 28 (32% of paced subjects, 28 per 1000 pacemaker-years). Twenty-five (22%, 16 per 1000 person-years) reached the composite outcome, 23 with cardiac dysfunction (HF, CM or SD); 5 received CRT. Seven of the 25 subjects died. Pacing on first day of life and male sex had relative risks of 3.6 (95% CI 1.9-6.8) and 2.6 (95% CI 1.3-5.2), respectively, of reaching the primary outcome. Maternal antibody positivity, in utero diagnosis, age at diagnosis, birth decade, and duration of pacing were not associated with a higher risk of the primary outcome. Conclusions: The rate of a composite outcome of death, cardiac dysfunction, or CRT was 16 per 1000 person-years in a cohort of 114 subjects with CCHB. Pacing on first day of life and male sex were associated with a higher risk of the composite outcome.

Diagnostic accuracy of cardiac magnetic resonance imaging for cardiac sarcoidosis in complete heart block patients implanted with magnetic resonance-conditional pacemaker

BackgroundCardiac magnetic resonance (CMR) imaging has become the principal noninvasive imaging modality for the diagnosis of cardiac sarcoidosis (CS) patients. This study aimed to determine the diagnostic performance of CMR imaging for CS in new-onset complete heart block (CHB) patients implanted with magnetic resonance-conditional pacemaker (MRCP). MethodsFifty CHB patients implanted with MRCP were enrolled in this study. Clinical CS was diagnosed if there was a histological diagnosis of extra-cardiac sarcoidosis in patients with CHB based on the consensus statement; clinical CS was the reference standard. The diagnostic performance of CMR sequences, including cine magnetic resonance imaging (MRI), increased T2-weighted signal (T2WS), and late gadolinium enhancement (LGE), for clinical CS was investigated. We also compared the diagnostic performance of CMR sequences between the entire left ventricle (LV) and the basal septum, which involves the electrical pathway of atrioventricular conduction. ResultsIn total, 8 of the 50 patients with CHB were confirmed to have extra-cardiac sarcoidosis and were diagnosed with clinical CS. The accuracy, sensitivity, and specificity of LGE in the basal septum and entire LV were 94%, 100%, and 93% and 80% (p = 0.023), 100% (p = 1.00), and 76% (p = 0.023), respectively. The accuracy, sensitivity, and specificity of increased T2WS and cine MRI in the basal septum were 94%, 75%, and 98% and 90%, 38%, and 100%, respectively. There was no statistical difference between the entire LV and the basal septum for the diagnostic performance of increased T2WS and cine MRI. ConclusionsCMR can be a diagnostic tool for evaluating clinical CS in patients with CHB implanted with MRCP. LGE in the basal septum might provide the overall best diagnostic performance for clinical CS with CHB.

Predictive role of ventricular repolarization parameters for the occurrence of complete heart block in patients undergoing transcatheter aortic valve implantation.

BackgroundWe investigated the role of ventricular repolarization parameters to predict complete atrioventricular block in patients undergoing transcatheter aortic valve implantation (TAVI).MethodsA total of 150 patients undergoing TAVI due to severe aortic stenosis were included in this retrospective cohort study. Patients were assigned in two groups based on the presence (n: 49) or absence (n: 101) of complete atrioventricular block after TAVI. Ventricular repolarization intervals (QT, QTc, JT, JTc, TP‐E), indices (QT dispersion), and ratios (TP‐E/QT, TP‐E/QTc, TP‐E/JTc) were measured.ResultsElectrocardiographic repolarization parameters such as Tp‐e interval: 74.2 ± 5.1 versus 59.2 ± 6.1 ms, p < .001; QTc interval: 397.6 ± 3.4 versus 368.1 ± 7.8 ms, p < .001; JTc interval: 317.4 ± 11.3 versus 291.1 ± 6.7 ms, p < .001; Tp‐e/QT ratio: 0.28 ± 0.04 versus 0.20 ± 0.04, p < .001; Tp‐e/QTc ratio: 0.29 ± 0.04 versus 0.19 ± 0.03, p < .001; Tp‐e/JT ratio: 0.32 ± 0.03 versus 0.23 ± 0.03, p < .001; Tp‐e/JTc ratio: 0.30 ± 0.02 versus 0.2 ± 0.03, p < .001; and QT dispersion: 34.4 ± 3.0 versus 17.8 ± 3.6 ms, p < .01 were significantly higher in post‐TAVI permanent pacemaker group. In a univariate regression analysis, pulmonary artery pressure, heart rate, coronary artery disease, Tp‐e/QTc, Tp‐e/JTc, and PR interval were significantly associated with complete heart block. Tp‐e/JTc (OR 0.373, p = .067) and PR interval (OR 0.898, p = .079) were found to be independent predictors of these type of arrhythmias in a multivariate analysis. But it is not statistically significant.ConclusionOur results suggest that repolarization parameters may play a role in predicting complete atrioventricular block. Tp‐e/JTc was found to be potential independent risk marker for this setting.

Permanent pacemaker implantation after pediatric heart transplantation: Risk factors, indications, and outcomes.

Permanent pacemaker (PPM) placement in adults following orthotopic heart transplantation (OHT) has been well documented. However, studies concerning the need for PPM implantation in pediatric heart transplant recipients are less common. Institutional transplant and pacing databases as well as patient medical records were reviewed for all pediatric patients undergoing OHT (n=314; all with bicaval connection) at our institution between January 2000 and March 2018. A total of 16 patients (5.1%) were implanted with a pacemaker after transplantation. Donor age was the only significant risk factor for post-transplant PPM implantation, with a median age of 28.5years (7.0-49.0) in the pacing group vs 15.5years (0.4-56.0) in the non-pacing group (P=0.009). Indication for pacemaker insertion was more often complete heart block (CHB) (12/16, 75%) than sinus node dysfunction (SND) (4/16, 25%). There was no significant difference in mortality between recipients who received a PPM and those who did not (log-rank test; P=0.345). Increasing donor age is associated with increased PPM placement following pediatric heart transplantation. Interestingly, a high proportion of CHB patients recovered sinus rhythm, and long-term outcomes for paced patients are similar to other heart transplant recipients.

Clinical Characteristics and Outcomes of Patients with Ischemic and Non-Ischemic Complete Heart Block.

IntroductionThird degree or complete heart block (CHB) is a medical emergency and usually requires permanent pacemaker placement. CHB can be caused by cardiac ischemia or non-ischemic conditions such as infiltrative diseases or fibrosis. The purpose of this study is to identify the baseline clinical characteristics associated with ischemic versus non-ischemic causes of complete heart block and compare their outcomes.Materials and methodsAn institutional review broad approval was granted by the Cleveland Clinic Health System. In our study, 216 patients with CHB presenting to Fairview Hospital between January 2014 and June 2016 were initially identified using the International Classification of Disease (ICD) codes at discharge. Only the patients with a new diagnosis of complete heart block (CHB) were included in the study (total N=62), which led to the exclusion of 154 patients. The patients were characterized into non-ischemic and ischemic groups based on cardiac marker elevation, electrocardiogram changes and/or cardiac catheterization findings. In all the patients, data including the following was collected: demographics such as age, gender, ethnicity and body mass index; pre-existing comorbidities such as hypertension, chronic kidney disease, diabetes mellitus, thyroid disease, previous coronary artery disease, history of cancer; use of nodal blocking agents, electrolyte abnormalities on admission, echocardiographic parameters such as ejection fraction (EF), right ventricular systolic pressure (RVSP), left ventricular end diastolic and systolic volumes (LVEDV and LVESV, respectively). The primary outcome was all-cause mortality and the secondary outcome was pacemaker placement. Categorical variables were analyzed using chi-square and continuous variables using ANOVA.ResultsOut of 62 patients (N=62), 48 had non-ischemic and 14 had ischemic CHB. The mean age was 67 years (95% CI, 60.55-74.73) in the ischemic group and 75 years (95% CI, 71.52-78.80) in the non-ischemic group, p=0.04. Patients with ischemic CHB had a lower mean EF of 49.6% (95% CI, 42.04%-57.23%) compared to 57.42% in non-ischemic CHB patients (95% CI, 53.97%-60.87%), p=0.05. History of coronary artery disease was present in 71.4% (10/14) patients with ischemic CHB compared to 37.5% (18/48) patients with non-ischemic CHB, p=0.02. There was no statistically significant difference between the two groups in terms of gender, diabetes, hypertension, thyroid dysfunction, chronic kidney disease, nodal blocking agents, electrolyte abnormalities or smoking status. For outcomes, 6/48 (12.5%) of patients with non-ischemic CHB had died compared to 3/14 (21.4%) ischemic CHB (p=0.327). Permanent pacemaker was implanted in 45/48 patients (93.75%) of the non-ischemic CHB compared to 6/14 (42.83%) in the ischemic group (p<0.001).ConclusionsPatients with ischemic CHB are younger, and they have a lower ejection fraction but they are less likely to get a pacemaker compared to non-ischemic CHB. Further studies with a bigger sample size are required to understand the long term mortality outcomes of patients with CHB.

Isoprenaline in complete heart block patients during ambulance transport

Results 98 (69 male and 29 female) such patients were transported, and 13 were on Temporary Pacemakers. 97 were inter-hospital transfers. 43 (44.3%) patients were transported with Isoprenaline (average dose 2.7 mcg/min, range 1 to 8.2mcg/min); 8 with Dopamine, and 7 on external cardiac pacing. 30 patients were on Isoprenaline and 8 on Dopamine in previous hospitals, and the same drug with similar dose was initially continued in the ambulance. Out of the 84 patients transported without temporary pacemaker, 60 patients were transported within 20 km (travel time less than 30 minutes), 22 from distance between 50 to 100 km (average travel time 90 minutes) and 3 patients were transported beyond 100kms. The longest distance patients travelled with Isoprenaline infusion was 525 km (travel time 26 hours). 6 (14%) patients with Isoprenaline showed side effects and dose had to be reduced. Isoprenaline was replaced by Dopamine in one of them. 4 of them travelled distance between 60 to 70 km and 2 beyond 100 km. 34 (79%) patients with Isoprenaline achieved heart rates above 60/min.

Ventricular dyssynchrony with VVI pacemakers – Does complete heart block patients differs from sinus node dysfunction?

Ventricular dyssynchrony with VVI pacemakers – Does complete heart block patients differs from sinus node dysfunction?