Conduction Abnormalities In Patients Research Articles

Advanced Cardiac Conduction Abnormalities in Patients on Ibrutinib Therapy

Background: Bruton tyrosine kinase inhibitors, such as ibrutinib, are medications that are actively used for Chronic Lymphocytic Leukemia (CLL) and several lymphomas. They work by inhibiting Bruton’s tyrosine kinase therefore affecting B cell proliferation. Ibrutinib itself is associated with multiple cardiotoxicities including atrial fibrillation, ventricular arrhythmias, heart failure, and bleeding. There are well-established studies that show the incidence of atrial fibrillation with ibrutinib therapy. However, only a few reports show an association between ibrutinib therapy and advanced heart block. Case presentation: We present two unique cases of patients who presented to the emergency room with syncope while being on ibrutinib therapy for CLL. At presentation, the patients were found to have conduction abnormalities seen on their EKG that included complete heart block in one patient and sick sinus syndrome in the other. Ultimately, each patient was treated with a pacemaker, ibrutinib therapy was discontinued, and they were started on alternative therapy for their CLL. Discussion: No clear mechanism has been established for how ibrutinib therapy causes these conduction abnormalities. This case series proposes a possible mechanism of advanced conduction abnormalities that is caused by ibrutinib therapy that is associated with the NOTCH gene. We propose that the downregulation of the NOTCH gene may prevent cardiac myocyte remodeling and therefore can cause conduction abnormalities as seen in our patients along with others that presented with advanced heart block with ibrutinib therapy.

Temporary-Permanent Pacemakers in the Management of Conduction Abnormalities in Patients Undergoing Transcatheter Aortic Valve Replacement

BackgroundInjury to the cardiac conduction system requiring a permanent pacemaker (PPM) implantation is a known adverse outcome of transcatheter aortic valve replacement (TAVR). Temporary-permanent pacemakers (TPPM) have been used as a bridge to PPM implantation in patients with systemic infection; however, there are only a few reports of its routine use in patients undergoing TAVR. This study aimed to assess the utility of routine use of TPPM in patients undergoing TAVR with a high risk of needing a PPM or those who develop high-grade conduction abnormalities during/after TAVR. MethodsBetween April 2015 and December 2021, 978 patients underwent TAVR at our institution, of whom 111 patients had TPPM placed before or during/after TAVR during the study period. In total, 89 patients were included in the final analysis. ResultsThe median age was 78 years (IQR, 71-84 years); 52 (58.4%) patients with preexisting native conduction disease were considered high risk for advanced heart block and had TPPM placed before TAVR. In addition, 37 (41.6%) patients had TPPM placed during/after TAVR. Of the 89 patients who received TPPM, 51 (57.3%) were treated with a balloon-expandable valve and 38 (42.7%) with a self-expandable valve. Of the patients who underwent TPPM placement, only 49 (55.1%) required a PPM, and TPPM was removed in 40 (44.9%) patients. TPPM was in place for a median of 6 days (IQR, 2-11 days). Only 1 of the 89 patients (1.1%) who received a TPPM had lead dislodgment. No other complications were noted. Median length of stay was 3 days (IQR, 2-4 days). ConclusionsIn patients with high-risk baseline conduction abnormalities before TAVR and those who develop new high-grade conduction abnormalities during/after TAVR, TPPM provides a feasible and safe method for pacing that could allow early ambulation, facilitate early discharge, and prevent unnecessary PPM implantations in some patients.

PO-03-108 TEMPORAL COURSE OF CONDUCTION ABNORMALITIES AFTER PERCUTANEOUS AND SURGICAL AORTIC VALVE REPLACEMENT

Aortic valve replacement is an increasingly common procedure. With the advent of trans-catheter aortic valve implantation (TAVI), patients that would have previously been denied valve replacement are able to undergo intervention. The anatomic proximity of the aortic valve and the native conduction system can lead to significant conduction abnormalities requiring permanent pacemaker (PPM) implantation. This retrospective study aimed to compare the incidence, temporality and eventual recovery of conduction abnormalities in patients undergoing PPM implantation post TAVI and surgical aortic valve replacement (SAVR). During the 5-year study period, 1012 patients had aortic valve replacement, 746 underwent SAVR and 266 patients underwent TAVI. In this group, patients were screened for pacemaker implantation within 14 days post procedure and were included if the pacemaker implantation was due to new AV conduction abnormalities. Patients were excluded if they had a pacemaker prior to surgery or had alternate reasons for pacemaker implantation such as complications from infective endocarditis. The incidence of new AV conduction abnormalities requiring pacemaker implantation post-operatively was 5.3% (n=14) in TAVI patients and 3.4% (n=26) in SAVR patients. In the TAVI group PPM implantation occurred on average at 3.2 ± 2.1 days (median 3 days) post procedure. In the SAVR group the average time to implantation was 6 ± 3.1 days (median 5 days). To determine conduction recovery 36 patients had complete follow up, 26 patients in SAVR and 10 patients in TAVI group. After a mean follow-up of 3 months, 50% of patients in the TAVI group and 36.1% in SAVR group recovered 1:1 conduction. At 12 months, 60% of patients in the TAVI group and 41% in the SAVR group had improved conduction and by 24 months it was 50% and 34.5%, respectively. In patients who undergo PPM implant post TAVI a high rate of conduction recovery is observed during follow-up, probably emphasizing the need for better selection of pacing candidates.

Cardiac arrhythmias and conduction abnormalities in patients with type 2 diabetes

The association between type 2 diabetes (T2D) and the development of cardiac arrhythmias and conduction disturbances has not been extensively studied. Arrhythmia was defined as atrial fibrillation and flutter (AF/AFl), ventricular tachycardia (VT) and ventricular fibrillation (VF), and conduction abnormality as sinus node disease (SND), atrioventricular (AV) block or pacemaker implantation, and intraventricular conduction blocks (IVCB). Incidence rates and Cox regression were used to compare outcomes, and to assess optimal levels for cardiometabolic risk factors and risk associated with multifactorial risk factor control (i.e., HbA1c, LDL-C, systolic blood pressure (SBP), BMI and eGFR), between patients with versus without T2D. The analyses included data from 617,000 patients with T2D and 2,303,391 matched controls. Patients with diabetes and the general population demonstrated a gradual increase in rates for cardiac conduction abnormalities and virtually all age-groups for AF/AFI showed increased incidence during follow-up. For patients with versus without T2D, risks for cardiac arrhythmias were higher, including for AF/AFl (HR 1.17, 95% CI 1.16–1.18), the composite of SND, AV-block or pacemaker implantation (HR 1.40, 95% CI 1.37–1.43), IVCB (HR 1.23, 95% CI 1.18–1.28) and VT/VF (HR 1.08, 95% CI 1.04–1.13). For patients with T2D who had selected cardiometabolic risk factors within target ranges, compared with controls, risk of arrythmia and conduction abnormalities for T2D vs not were: AF/AFl (HR 1.09, 95% CI 1.05–1.14), the composite of SND, AV-block or pacemaker implantation (HR 1.06, 95% CI 0.94–1.18), IVCB (HR 0.80, 95% CI 0.60–0.98), and for VT/VF (HR 0.97, 95% CI 0.80–1.17). Cox models showed a linear risk increase for SBP and BMI, while eGFR showed a U-shaped association. Individuals with T2D had a higher risk of arrhythmias and conduction abnormalities than controls, but excess risk associated with T2D was virtually not evident among patients with T2D with all risk factors within target range. BMI, SBP and eGFR displayed significant associations with outcomes among patients with T2D.

Epicardial conduction abnormalities in patients with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) and mutation positive healthy family members - A study using electrocardiographic imaging.

The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) in early stages is challenging. The aim of this study was therefore to investigate whether electrocardiographic imaging (ECGI) can detect epicardial conduction changes in ARVC patients and healthy mutation-carriers (M-carriers). Twelve ARVC patients, 20 M-carriers and 8 controls underwent 12-lead ECG, signal-averaged ECG, 2-dimensional echocardiography, 24-hours Holter monitoring and ECGI (body surface mapping and computer tomography with offline analysis of reconstructed epicardial signals). Total and Right Ventricular Activation Time (tVAT and RVAT respectively), area of Ventricular Activation during the terminal 20 milliseconds (aVAte20) and the activation patterns were compared between groups. In ARVC patients the locations of aVAte20 were scattered or limited to smaller parts of the right ventricle (RV) versus in controls, in whom aVAte20 was confined to right ventricular outflow tract (RVOT) and left ventricle (LV) base (+/- RV base). ARVC patients had smaller aVAte20 (35cm2 vs 87cm2, p<0.05), longer tVAT (99msec vs 58msec, p<0.05) and longer RVAT (66msec vs 43msec, p<0.05) versus controls. In 10 M-carriers (50%), the locations of aVAte20 were also eccentric. This sub-group presented smaller aVAte20 (53cm2 vs 87cm2, p = 0.009), longer RVAT (55msec vs 48msec, p = 0.043), but similar tVAT (65msec vs 60msec, p = 0.529) compared with the M-carriers with normal activation pattern. ECGI can detect epicardial conduction abnormalities in ARVC patients. Moreover, the observation of localized delayed RV epicardial conduction in M-carriers suggests an early stage of ARVC and may be a useful diagnostic marker enhancing an early detection of the disease.

Predictors of post-TAVI conduction abnormalities in patients with bicuspid aortic valves

ObjectivesThis study evaluates predictors of conduction abnormalities (CA) following transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valves (BAV).BackgroundTAVI is associated with CA that commonly necessitate a permanent...

Abstract 193: Major Adverse Cardiovascular Events And Conduction Abnormalities In Patients With ANCA-Associated Vasculitis: Retrospective Analysis From A Tertiary Referral Center

Objective: Our aim was to determine the association of major adverse cardiovascular events (MACE) and cardiac conduction abnormalities in patients with history of ANCA-associated vasculitis. Methods: We retrospectively reviewed patients with ANCA vasculitis (n=125) from 2017-2020. Charts were reviewed to assess cardiovascular (CV) risk factors which included history of smoking, hypertension, hyperlipidemia, diabetes mellitus and chronic kidney disease. Incidence of MACE such as myocardial infarction (MI), stroke, heart failure (HF) was calculated retrospectively after the diagnosis of ANCA vasculitis. Similarly, the incidence of cardiac conduction abnormalities [atrial fibrillation (AF), first degree atrioventricular block (1AVB), and advanced heart block (ADVB)] was analyzed. Chi square and modified Poisson regression were used to calculate the incidence rate ratio (IRR) for MACE and conduction abnormalities. Results: Of 125 total patients, 77 (61.6%) had granulomatosis with polyangiitis (GPA), 37 (29.6%) had eosinophilic granulomatosis with polyangiitis (EGPA), and 11 (8.8%) had microscopic polyangiitis (MPA). Females were 68%. Mean age of the cohort was 58 +/- 15 with a mean BMI of 29.4 +/- 6.4 kg/m 2 . The unadjusted and adjusted (for age, gender, and CV risk factors) IRR for stroke was significantly lower in patients with EGPA and MPA vs. GPA (p&lt;0.05), while IRR for HF was higher in EGPA vs. GPA (p&lt;0.05) [Table 1]. IRR for AF was higher in patients with EGPA vs. GPA (p&lt;0.02), while for ADVB it was lower (p&lt;0.04) [Table 2]. The adjusted IRRs for MI and HF were higher in patients with EGPA and MPA but were not statistically significant [Table 1]. Conclusion: Incidence of stroke is higher in GPA patients compared with EGPA and MPA, while EGPA is more likely to lead to heart failure compared to GPA. Atrial fibrillation is more commonly seen in patients with EGPA, and advanced heart block is less common in EGPA compared with GPA.

IDENTIFYING PREDICTIVE RISK FACTORS FOR PACEMAKER NEED IN PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT

BACKGROUND Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients suffering with aortic stenosis. However, there remains some uncertainty on the risk factors associated with TAVR and conduction disturbances requiring permanent pacemaker insertion (PPI) following the procedure. The aim of this study was to identify risk factors for post-TAVR pacemaker need and examine the effect of PPI on long-term outcomes. METHODS AND RESULTS A retrospective study was performed on all consecutive patients who underwent TAVR at the Saint John Regional Hospital between 2010-2018, excluding those with an existing pacemaker. Risk factors capable of independently predicting post-procedure PPI were identified using two-tailed t-test, χ-square test, and hierarchical logistic regression model. Kaplan-Meier survival analysis was performed to compare all-cause mortality between patients who did or did not receive a pacemaker. A total of 377 patients with no previous pacemaker were included in the study. A total of 42 (11.1%) required PPI post-TAVR and were compared to patients who did not. Univariate analysis suggested that larger valves (>29cm) (p=0.05), renal insufficiency (p=0.03), and ECG abnormalities (p < 0.0001) including right bundle branch block (RBBB) (p < 0.0001), QRS duration >200ms (p=0.0003), and heart rate < 50bpm (p=0.01) were associated with increased PPI. After multivariable analysis, only ECG abnormalities as a combined outcome (OR 5.19, CI 2.52-11.04, p < 0.0001) was identified as an independent predictive risk factor of PPI (Table 1). Valve type was not a predictive risk factor for PPI in our study, with 10.7% of patients with balloon-expanding and 13.6% of patients with self-expanding valves requiring pacemakers post-procedure (p=0.88). Kaplan-Meier survival analysis demonstrated post-TAVI pacemaker insertion had no significant impact on all-cause mortality (Figure 1). CONCLUSION Our study illustrates that permanent pacemaker use in TAVR remains high (>10%) and identifies several ECG abnormalities as the most robust predictors of pacemaker need post-TAVR, in particular RBBB. However, our limited study suggests that post-TAVR pacemaker insertion is not associated with all-cause mortality after discharge. As TAVR becomes a treatment option for lower surgical risk patients, considerations for the need for post-procedural pacemaker insertion may affect clinical decision making and warrant screening for conduction abnormalities in patients undergoing TAVR. Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients suffering with aortic stenosis. However, there remains some uncertainty on the risk factors associated with TAVR and conduction disturbances requiring permanent pacemaker insertion (PPI) following the procedure. The aim of this study was to identify risk factors for post-TAVR pacemaker need and examine the effect of PPI on long-term outcomes. A retrospective study was performed on all consecutive patients who underwent TAVR at the Saint John Regional Hospital between 2010-2018, excluding those with an existing pacemaker. Risk factors capable of independently predicting post-procedure PPI were identified using two-tailed t-test, χ-square test, and hierarchical logistic regression model. Kaplan-Meier survival analysis was performed to compare all-cause mortality between patients who did or did not receive a pacemaker. A total of 377 patients with no previous pacemaker were included in the study. A total of 42 (11.1%) required PPI post-TAVR and were compared to patients who did not. Univariate analysis suggested that larger valves (>29cm) (p=0.05), renal insufficiency (p=0.03), and ECG abnormalities (p < 0.0001) including right bundle branch block (RBBB) (p < 0.0001), QRS duration >200ms (p=0.0003), and heart rate < 50bpm (p=0.01) were associated with increased PPI. After multivariable analysis, only ECG abnormalities as a combined outcome (OR 5.19, CI 2.52-11.04, p < 0.0001) was identified as an independent predictive risk factor of PPI (Table 1). Valve type was not a predictive risk factor for PPI in our study, with 10.7% of patients with balloon-expanding and 13.6% of patients with self-expanding valves requiring pacemakers post-procedure (p=0.88). Kaplan-Meier survival analysis demonstrated post-TAVI pacemaker insertion had no significant impact on all-cause mortality (Figure 1). Our study illustrates that permanent pacemaker use in TAVR remains high (>10%) and identifies several ECG abnormalities as the most robust predictors of pacemaker need post-TAVR, in particular RBBB. However, our limited study suggests that post-TAVR pacemaker insertion is not associated with all-cause mortality after discharge. As TAVR becomes a treatment option for lower surgical risk patients, considerations for the need for post-procedural pacemaker insertion may affect clinical decision making and warrant screening for conduction abnormalities in patients undergoing TAVR.

Patients With Primary Hyperparathyroidism Have Shorter QT/QTc Intervals

Background: Previous studies suggest that patients with primary hyperparathyroidism (PHPT) have subclinical cardiovascular disease, but data regarding cardiac conduction abnormalities are limited. The aim of this study was to assess cardiac conduction abnormalities in patients with PHPT compared to controls with thyroid disease (TD). Method: We conducted a retrospective analysis of patients over 40 years of age who underwent parathyroidectomy or thyroidectomy at a single tertiary institution between 2013 and 2018. Demographics and EKG parameters from pre-operative EKG reports were compared using the Mann-Whitney U and Chi Square tests. Regression was used to compare EKG differences between the PHPT and control groups adjusted for sex, age, and other variables found to be significant on univariate analysis. Results: A total of 1181 patients were analyzed, 51% in the PHPT group (n=602) and 49% in the TD group (n=579). The median age was 60.5 years (IQR 53.5–67.9) and there was no difference in sex between the cohorts. PHPT patients had a higher prevalence of hyperlipidemia (HLD, 49% vs 36%, p<0.001) and hypertension (HTN, 50.7% vs 42.1%, p<0.01), but had no differences in EKG rhythm patterns or prevalence of arrhythmia compared to TD patients. As expected, mean serum calcium levels were higher for the PHPT group, 10.74 (0.66) vs 9.53 (0.44). However, the PHPT group included both normocalcemic and hypercalcemic patients. The PHPT group had a lower median QT interval compared to the TD group, 386ms (IQR 368–406) vs 398ms (IQR 376–418), p<0.001 and a higher median PR value, 158ms (IQR 144–174.5) vs 156ms (IQR 143.5–171), p<0.05. More PHPT patients (n=21, 3.5%) had a short QTc interval (<360ms males/<370ms females), compared to TD controls (n=1, 0.2%). Among PHPT patients with a short QT interval, the proportion of patients with hypercalcemia (95%) was higher than that of the PHPT group overall (75%). On multivariable analysis, PHPT patients had a shorter QT interval than TD controls after controlling for sex, age, HLD, HTN. There was no difference between PHPT and TD when serum calcium was included in the model, suggesting that calcium mediates the relationship between QT interval and disease status. Conclusion: PHPT patients have shorter QT/QTc intervals compared to TD controls, but no increased prevalence of arrythmia at baseline. While the QT interval was associated with degree of serum calcium elevation, these findings in a large cohort suggest that PHPT is not associated with arrythmia at baseline among those undergoing parathyroidectomy.

Cardiac conduction abnormalities in patients with degenerated bioprostheses undergoing transcatheter aortic valve-in-valve implantations and their impact on long-term outcomes

BackgroundThe relationship between preoperative cardiac conduction abnormalities (CCA) and long-term outcomes after transcatheter aortic valve-in-valve implantation (TAVI-VIV) remains unclear. The aim of the study was to evaluate the effects of preoperative CCA on mortality and morbidity after TAVI-VIV and to estimate the impact of new-onset CCA on postoperative outcomes. MethodsBetween 2011 and 2020, 201 patients with degenerated aortic bioprostheses were qualified for TAVI-VIV procedures in two German heart centers. Cases with previously implanted permanent rhythm-controlling devices were excluded (n = 53). A total of 148 subjects met the eligibility criteria and were divided into 2 study groups according to the presence of preexisting CCA (CCA (n = 84) and non-CCA (n = 64), respectively). Early and late mortality and morbidity were evaluated. Follow-up functional status was assessed according to New York Heart Association (NYHA) classification. ResultsThere were no procedural deaths. TAVI-VIV related new-onset CCAs were observed in 35.8% patients. The 30-day permanent pacemaker implantation rate was 1.6% in non-CCA vs 9.5% in CCA group (p = 0.045). Preexisting right bundle-branch block (OR:5.01; 95%CI, 1.05–23.84) and first-degree atrioventricular block (OR:4.55; 95%CI, 1.10–18.73) were independent predictors of new pacemaker implantation. One-year and five-year probability of survival were comparable in CCA and non-CCA groups: 90.3% vs 91.8% and 68.2% vs 74.3%, respectively. Surviving patients with preexisting and new-onset CCA had a worse functional status according to NYHA classification at follow-up. ConclusionPreexisting and new-onset postoperative CCAs did not affect early and late mortality after TAVI-VIV procedures, however, they may have a negative impact on late functional status.

Sinoatrial conduction abnormalities - an underestimated cardiac complication in women with systemic sclerosis.

IntroductionIt has been claimed that patients with systemic sclerosis (SSc) have an increased risk of developing cardiac arrhythmias and atrioventricular conduction disorders, but it is unknown whether SSc may be a cause of sinoatrial conduction abnormalities.AimTo establish the incidence of sinoatrial conduction abnormalities in patients with SSc and verify the relationship of these disorders with various clinical descriptors of SSc.Material and methodsForty women with systemic sclerosis of varying duration and severity underwent 24-hour ambulatory ECG monitoring. The occurrence of type I second-degree sinoatrial block (SA-block) and calculation of sinoatrial conduction time (SACT) were evaluated to establish the incidence of sinoatrial conduction abnormalities. The measurements of SACT were obtained using spontaneous atrial premature beats. The effect of various clinical descriptors on sinoatrial conduction abnormalities was assessed.ResultsThe mean ± SD SACT for the 40 patients was 150 ±15 ms. Prolonged (> 150 ms) SACT was found in 20 patients. In 14 (35%) patients SA-block occurred during ambulatory ECG monitoring. The discriminant analysis identified the severity of SSc cutaneous manifestation as an independent marker for developing SA-block (p < 0.005) and SACT prolongation (p < 0.0002).ConclusionsPatients with SSc are at an increased risk of developing type I second-degree sinoatrial block and prolonged sinoatrial conduction time. The occurrence of these abnormalities is related to the severity of skin involvement. Therefore, cardiological diagnosis using 24-hour ambulatory ECG in this group of patients should be focused also on this type of disorders. Prospective, controlled studies are needed to assess their prognostic role.

Phenytoin-Induced Cardiac Conduction Abnormalities

AbstractPhenytoin possesses electrophysiological effects consistent with those of the Vaughan–Williams 1B classification. As such, phenytoin may widen the QRS complex but would not be expected to result in QTc prolongation or ST elevation. The reported case demonstrates these unexpected electrophysiological effects with supratherapeutic concentrations of phenytoin when no other potential cause could be elucidated. No contributing factors present in the case, compared with previously published reports of electrophysiological effects of supratherapeutic phenytoin concentrations, could be elucidated. The report suggests that clinicians should monitor for potential conduction abnormalities in patients with elevated phenytoin concentrations.

Conduction defect rates in high risk surgical patients undergoing TAVR with or without PCI during a single hospitalization: a nationwide study

Abstract Introduction Since the first documented transaortic valve replacement (TAVR) by Cribier et. al. in 2002 as a less invasive treatment approach for severe aortic stenosis (AS) and following the landmark PARTNER 1 trial, the Food and Drug Administration (FDA) approved TAVR in 2012 for patients deemed to be at high surgical risk. In recent years, there has been an expansion of indications to include low surgical risk candidates. Risk factors associated with aortic stenosis overlap with those for coronary artery disease, and up to 40–70% of patients referred for replacement have incidental obstructive coronary lesions. The best timing of intervention for concurrent pathology has been a subject of debate; recommendations support combined TAVR and percutaneous coronary intervention (PCI) for treatment of ostial/proximal lesions or in unstable patients. TAVR is not free of complications and a concern has been on post-deployment alterations of the heart's electrical system that may result in need for permanent pacemaker (PPM) implantation. Purpose To secure the aortic valve in place during a TAVR, there is a known risk of inducing a conduction disturbance. This study examined conduction abnormalities in patients undergoing a concurrent TAVR and PCI during the same hospitalization. Methods The patient population was obtained from the Nation Inpatient Sample database, which is a stratified systematic random sample of 20% hospital admissions in the USA. ICD-9 Revision-Clinical Modification procedure codes were used to identify all patients undergoing PCI and TAVR during the same admission between 2011 and 2014. Patients 50 years and older were included. Those with a history of a PPM were excluded. Outcomes of interest included new PPM, left bundle branch block (LBBB), first degree/second degree/complete AV bock, all-cause in-hospital mortality, and length of stay. Multivariate logistic regression analysis was used while adjusting for patient and procedural confounders. Results Between 2011 and 2014, 29,998 patients underwent TAVR, of which 1070 had a concurrent PCI during the same hospital admission. There was no noted increase in odds of PPM (OR 0.42 95% CI: 0.010–1.72), LBBB (OR 1.89 95% CI 0.65–5.49), second degree AV block (OR 1.49 95% CI: 0.21–10.50), complete AV block (OR: 1.44, 95% CI: 0.57–3.63), atrial fibrillation (OR 0.95 95% CI: 0.46–1.94), or atrial flutter (OR 1.75 95% 0.38–7.94) in those undergoing PCI+TAVR compared to TAVR alone. The odds of all cause, in-hospital mortality was 4.44 (95% CI: 1.25–15.8) times greater in those with a PCI+TAVR during the same admission compared to TAVR alone. Length of stay was 7.5 days (95% CI: 7.25–7.75) in those undergoing a TAVR compared to 12.4 days (95% CI: 10.67–14.15) in those with a TAVR+PCI, p&amp;lt;0.0001. Conclusion Periprocedural PCI and TAVR during the same hospitalization does not further increase risk of major conduction defects or rates of pacemaker implantation. Funding Acknowledgement Type of funding source: None

Automatic Multi-Label ECG Diagnosis of Impulse or Conduction Abnormalities in Patients with Deep Learning Algorithm: A Cohort Study

Background: Electrocardiography (ECG) is a fundamental diagnostic tool, frequently used in clinical practice, for testing heart conditions. Recently, computer-aided ECG interpretation has become more widely investigated. However, researches on concurrent ECG diagnosis for multiple heart abnormalities are limited and therefore a market-applicable multi-label automatic diagnosis framework that covers a wide range of arrhythmias, with better-than-human accuracy in diagnosing ECGs with multi-labels, has not yet been developed. We therefore aimed to engineer a deep learning approach for the automated multi-label diagnosis of impulse or conduction abnormalities by realtime ECG analysis. Methods: We utilized a dataset with 70,692 patients, consisting of adults with age ≥18 years. 180112 ECGs (standard 10-second and 12-lead format) with 21 distinct rhythm classes, including various impulse or conduction abnormalities, were used for the diagnosis of arrhythmias in multi-label and single-label level. Base rhythm labels were assessed by trained personnel under the supervision of cardiologists. We ensured that each abnormality had a sample size of at least 4,000 ECGs, except idioventricular rhythm (1,780 ECGs due to the rarity of said disease), for compiling a balanced dataset. We allocated ECGs to a training or a validation dataset for the multi-label diagnostic model training, and evaluated model performance on a test dataset by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC) curve, as well as quantifying accuracy, sensitivity, specificity, and the F1 score. The test dataset was annotated by the consensus of a committee of board-certified actively-practicing cardiologists. Validation of results for the test dataset were compared to diagnoses made by 53 ECG cardiologists who have a wide range of ECG interpretation experience (range=0-12+ years). Findings: We demonstrated that in multi-label level, our convolutional neural network (CNN) approach toward diagnosing heart abnormalities resulted in AUC scores above 0.913 for most of the diseases, with an average score of 0.985 (95% confidence interval (CI) 0.988-0.994). The model obtained an average F1 score of 0.890 (95% CI0.877- 0.903), sensitivity of 0.869 (95% CI 0.851-0.887), specificity of 0.995 (95% CI 0.994- 0.996). The average F1 score computed from our deep learning model exceeded the score from human cardiologists regardless of ECG interpretation experience (0 12 years: 0.829). The CNN outputs also showed identical or increased performance with respect to average sensitivity and accuracy as compared to the cardiologists. In single-label level, the CNN achieved an average F1 of 0.918, higher than the average level of the cardiologists 0.798. Interpretation: Our automatic ECG diagnosis system is better than human cardiologists to classify particular waveforms into clinically defined categories accurately, to distinguish a wide range of distinct arrhythmias, and to apply both single label and multiple label ECGs. Our study is therefore a promising foundation for the deployment of computational decision-support systems in practical clinical applications. Funding Statement: Project supported by the Major International (Regional) Joint Research Project, the Ministry of Management Science, the National Natural Science Foundation of China (Grant No. 71520107003). Declaration of Interests: Dr. Yuan reports grants from National Natural Science Foundation of China, during the conduct of the study; In addition, Dr. Yuan has a patent An automatic ECG classification method, system and equipment based on deep learning algorithm pending to Ye Yuan, Xiaoyun Yang, Hongling Zhu, Yiran Wang, Cheng Cheng, Xingyi Li, Hang Yin, Jingyi Wang. There are no other conflicts of interest. Ethics Approval Statement: To protect patients’ privacy, we used anonymized data as to prevent breaches. Accordingly, a written informed consent was not required for this study, since the ECG samples were appropriately anonymized and de-identified, as according to the Health Insurance Portability and Accountability Act Safe Harbor provision. The study design was evaluated and exempted from full review by the Huazhong University of Science and Technology Institutional Review Board.

Osteogenic circulating endothelial progenitor cells are linked to electrocardiographic conduction abnormalities in rheumatic patients.

Osteogenic circulating endothelial progenitor cells (EPC) play a pathogenic role in cardiovascular system degeneration through promulgating vasculature calcification, but its role in conduction disorders as part of the cardiovascular degenerative continuum remained unknown. To investigate the role of osteocalcin (OCN)-expressing circulating EPCs in cardiac conduction disorders in the unique clinical sample of rheumatoid arthritis (RA) susceptible to both abnormal bone metabolism and cardiac conduction disorders. We performed flow cytometry studies in 134 consecutive asymptomatic patients with rheumatoid arthritis to derive osteogenic circulating OCN-positive (OCN+) CD34+KDR+ vs. CD34+CD133+KDR+ conventional EPC. Study endpoint was the prespecified combined endpoint of electrocardiographic conduction abnormalities. Total prevalence of cardiac conduction abnormality was 9% (n=12). All patients except one had normal sinus rhythm. One patient had atrial fibrillation. No patient had advanced atrioventricular (AV) block. Prevalence of first-degree heart block (>200ms), widened QRS duration (>120ms) and right bundle branch block were 6.7%, 2.1%, and 2.2% respectively. Circulating osteogenic OCN+ CD34+ KDR+ EPCs were significantly higher among patients with cardiac conduction abnormalities (p=0.039). Elevated OCN+ CD34+ KDR+ EPCs> 75th percentile was associated with higher prevalence of cardiac conduction abnormalities (58.3% vs. 20.02%, p=0.003). Adjusted for potential confounders, elevated OCN+ CD34+ KDR+ EPCs> 75th percentile remained independently associated with increased risk of cardiac conduction abnormalities (OR=4.4 [95%CI 1.2-16.4], p=0.028). No significant relation was found between conventional EPCs CD34+CD133+KDR+ and conduction abnormalities (p=0.36). Elevated osteogenic OCN+ CD34+ KDR+ EPCs are independently associated with the presence of electrocardiographic conduction abnormalities in patients with rheumatoid arthritis, unveiling a potential novel pathophysiological mechanism.

CLO19-052: Incidence of Ribociclib-Associated Cardiac Conduction Abnormalities in Patients With Hormone Receptor-Positive HER2-Negative Metastatic Breast Cancer: A Combined Analysis of 3 Phase III Randomized Controlled Trials

Introduction: Ribociclib, a cyclin-dependent kinase 4/6 inhibitor, has improved survival in patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER 2)-negative advanced breast cancer. Despite remarkable efficacy, potential cardiac toxicities remain a concern. We undertook a combined analysis of randomized controlled trials (RCT) to estimate the incidence of prolongation of corrected QT interval (QTcF) associated with ribociclib. Methods: We performed systematic search of Embase, MEDLINE, and meeting abstracts till September 30, 2018, to find all phase 3 RCTs comparing ribociclib with other agents or placebo in patients with advanced breast cancer and reporting QTc prolongation as adverse event. Mantel-Haenszel method was used to calculate the pooled risk ratio (RR) and absolute risk difference (RD) with 95% CI. Fixed effects model was applied. Heterogeneity was assessed using I2 statistic. Results: Three phase III studies with 2,062 participants were included. Randomization ratio was 1 to 1 in MONALEESA-2 and 7 studies and 2 to 1 in MONALEESA-3 study. I2 statistic was 0, suggesting homogeneity across studies. Prolongation of QTcF &gt;60 msec from baseline was observed in 72 patients (61 had post-baseline QTcF &gt;480 msec) in ribociclib arm, compared to 7 in control arm. Pooled RR for prolongation of QTcF was 7.956 (95%CI: 3.683–17.187; P&lt;.001) and RD was 0.055 (95%CI: 0.040–0.070; P&lt;.001). The risk of having a post-baseline QTcF &gt;480 msec was significantly higher with ribociclib vs control (pooled RR, 4.002; 95%CI: 2.161–7.412; P&lt;.001; and RD, 0.039; 95%CI: 0.024–0.055; P&lt;.001). A total of 16 (1.38%) patients in the ribociclib arm had dose reduction, interruption, or discontinuation due to QTcF prolongation, as opposed to 3 (0.33%) in control arm. Pooled RR and RD were statistically significant at 4.204 (95%CI: 1.333–3.260; P=.014) and 0.012 (95%CI: 0.004–0.021; P=.006), respectively. Conclusion: Advanced breast cancer patients may have cardiac dysfunction due to prior cardiotoxic chemotherapies. In our meta-analysis, ribociclib was associated with significantly higher risk of QTc prolongation and the resultant dosing inconsistencies and discontinuation. Early detection of this potential adverse event and timely intervention are critical.

A case of catecholaminergic polymorphic ventricular tachycardia diagnosed as having long QT syndrome 25 years ago

The aim of this study is to describe electrocardiographic changes and conduction abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI).76 patients who underwent TAVI using Edwards Sapien 3 prosthesis were included, comparing electrocardiographic registries at admission, post-procedure and before discharge.Patients after TAVI presented a longer PR interval, a wider QRS, and a longer corrected QT, with a left deviation of QRS axis and T waves; reversible changes that tended to correct in the following days after TAVI. Complete atrioventricular block incidence was 2.9%. New-onset left bundle branch block (LBBB) incidence was 39%, although solved in almost half of patients before discharge.TAVI was associated with different reversible electrocardiographic changes that suggest a transient impact on the conduction system. One of every five patients presented permanent LBBB after valve implant.

Role of Late Sodium Current in Experimental Torsade de Pointes

The aim of this study is to describe electrocardiographic changes and conduction abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI).76 patients who underwent TAVI using Edwards Sapien 3 prosthesis were included, comparing electrocardiographic registries at admission, post-procedure and before discharge.Patients after TAVI presented a longer PR interval, a wider QRS, and a longer corrected QT, with a left deviation of QRS axis and T waves; reversible changes that tended to correct in the following days after TAVI. Complete atrioventricular block incidence was 2.9%. New-onset left bundle branch block (LBBB) incidence was 39%, although solved in almost half of patients before discharge.TAVI was associated with different reversible electrocardiographic changes that suggest a transient impact on the conduction system. One of every five patients presented permanent LBBB after valve implant.

The magic of Lidocaine load in extreme Long QT with 2:1 functional AV block

The aim of this study is to describe electrocardiographic changes and conduction abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI).76 patients who underwent TAVI using Edwards Sapien 3 prosthesis were included, comparing electrocardiographic registries at admission, post-procedure and before discharge.Patients after TAVI presented a longer PR interval, a wider QRS, and a longer corrected QT, with a left deviation of QRS axis and T waves; reversible changes that tended to correct in the following days after TAVI. Complete atrioventricular block incidence was 2.9%. New-onset left bundle branch block (LBBB) incidence was 39%, although solved in almost half of patients before discharge.TAVI was associated with different reversible electrocardiographic changes that suggest a transient impact on the conduction system. One of every five patients presented permanent LBBB after valve implant.

A Difference between the Depolarization Time and QRS Duration in Heart Failure Patients with LBBB: A Simulation Study

The aim of this study is to describe electrocardiographic changes and conduction abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI).76 patients who underwent TAVI using Edwards Sapien 3 prosthesis were included, comparing electrocardiographic registries at admission, post-procedure and before discharge.Patients after TAVI presented a longer PR interval, a wider QRS, and a longer corrected QT, with a left deviation of QRS axis and T waves; reversible changes that tended to correct in the following days after TAVI. Complete atrioventricular block incidence was 2.9%. New-onset left bundle branch block (LBBB) incidence was 39%, although solved in almost half of patients before discharge.TAVI was associated with different reversible electrocardiographic changes that suggest a transient impact on the conduction system. One of every five patients presented permanent LBBB after valve implant.