Conduction Abnormalities Research Articles

Reduced plakoglobin increases the risk of sodium current defects and atrial conduction abnormalities in response to androgenic anabolic steroid abuse.

Androgenic anabolic steroids (AAS) are commonly abused by young men. Male sex and increased AAS levels are associated with earlier and more severe manifestation of common cardiac conditions, such as atrial fibrillation, and rare ones, such as arrhythmogenic right ventricular cardiomyopathy (ARVC). Clinical observations suggest a potential atrial involvement in ARVC. Arrhythmogenic right ventricular cardiomyopathy is caused by desmosomal gene defects, including reduced plakoglobin expression. Here, we analysed clinical records from 146 ARVC patients to identify that ARVC is more common in males than females. Patients with ARVC also had an increased incidence of atrial arrhythmias and Pwave changes. To study desmosomal vulnerability and the effects of AAS on the atria, young adult male mice, heterozygously deficient for plakoglobin (Plako+/-), and wild type (WT) littermates were chronically exposed to 5α-dihydrotestosterone (DHT) or placebo. The DHT increased atrial expression of pro-hypertrophic, fibrotic and inflammatory transcripts. In mice with reduced plakoglobin, DHT exaggerated Pwave abnormalities, atrial conduction slowing, sodium current depletion, action potential amplitude reduction and the fall in action potential depolarization rate. Super-resolution microscopy revealed a decrease in NaV1.5membrane clustering in Plako+/- atrial cardiomyocytes after DHT exposure. In summary, AAS combined with plakoglobin deficiency cause pathological atrial electrical remodelling in young male hearts. Male sex is likely to increase the risk of atrial arrhythmia, particularly in those with desmosomal gene variants. This risk is likely to be exaggerated further by AAS use. KEY POINTS: Androgenic male sex hormones, such as testosterone,might increase the risk of atrial fibrillation in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC), which is often caused by desmosomal gene defects (e.g. reduced plakoglobin expression). In this study, we observed a significantly higher proportion of males who had ARVC compared with females, and atrial arrhythmias and Pwave changes represented a common observation in advanced ARVC stages. In mice with reduced plakoglobin expression, chronic administration of 5α-dihydrotestosterone led to Pwave abnormalities, atrial conduction slowing, sodium current depletion and a decrease in membrane-localized NaV1.5 clusters. 5α-Dihydrotestosterone, therefore, represents a stimulus aggravating the pro-arrhythmic phenotype in carriers of desmosomal mutations and can affect atrial electrical function.

The Role of Immune Cells Driving Electropathology and Atrial Fibrillation.

Atrial fibrillation (AF) is the most common progressive cardiac arrhythmia worldwide and entails serious complications including stroke and heart failure. Despite decades of clinical research, the current treatment of AF is suboptimal. This is due to a lack of knowledge on the mechanistic root causes of AF. Prevailing theories indicate a key role for molecular and structural changes in driving electrical conduction abnormalities in the atria and as such triggering AF. Emerging evidence indicates the role of the altered atrial and systemic immune landscape in driving this so-called electropathology. Immune cells and immune markers play a central role in immune remodeling by exhibiting dual facets. While the activation and recruitment of immune cells contribute to maintaining atrial stability, the excessive activation and pronounced expression of immune markers can foster AF. This review delineates shifts in cardiac composition and the distribution of immune cells in the context of cardiac health and disease, especially AF. A comprehensive exploration of the functions of diverse immune cell types in AF and other cardiac diseases is essential to unravel the intricacies of immune remodeling. Usltimately, we delve into clinical evidence showcasing immune modifications in both the atrial and systemic domains among AF patients, aiming to elucidate immune markers for therapy and diagnostics.

Prediction Model of Post-TAVR Complication Using a Medical Twin Web Navigator

Transcatheter aortic valve replacement (TAVR) has been introduced as an alternative to surgical aortic valve replacement for patients with severe aortic valve disease and is expanding into a universal treatment. However, complications after TAVR can have devastating consequences for patients and must be predicted. By designing a TAVR medical twin architecture based on real-world data (RWD), we can minimize complications and achieve optimal clinical outcomes through analysis and simulation results in a virtual environment that can predict complications. The simulation phase utilizes machine learning algorithms for complication prediction to predict patients with conduction abnormalities, a complication of TAVR, and provides the prediction results through a web-based monitoring system. We also conduct research to identify factors that influence complications, so that complication prediction in a virtualized environment on a medical twin architecture can serve as a guide for personalized care design for patients undergoing TAVR.

The utility and impact of outpatient telemetry monitoring in post-transcatheter aortic valve replacement patients

BackgroundConduction disturbances are a common complication of transcatheter aortic valve replacement (TAVR). Mobile Cardiac Telemetry (MCT) allows for continuous monitoring with near “real time” alerts and has allowed for timely detection of conduction abnormalities and pacemaker placement in small trials. A standardized, systematic approach utilizing MCT devices post TAVR has not been widely implemented, leading to variation in use across hospital systems. ObjectivesOur aim was to evaluate the utility of a standardized, systematic approach utilizing routine MCT to facilitate safe and earlier discharge by identifying conduction disturbances requiring permanent pacemaker (PPM) placement. We also sought to assess the occurrence of actionable arrhythmias in post-TAVR patients. MethodsUsing guidance from the JACC Scientific Expert Panel, a protocol was implemented starting in December 2019 to guide PPM placement post-TAVR across our health system. All patients who underwent TAVR from December 2019 to June 2021 across four hospitals within Northwell Health, who did not receive or have a pre-existing PPM received an MCT device at discharge and were monitored for 30 days. Clinical and follow-up data were collected and compared to pre initiative patients. ResultsDuring the initiative 693 patients were monitored with MCT upon discharge, 21 of whom required PPM placement. Eight of these patients had no conduction abnormality on initial or discharge ECG. 59 (8.6 %) patients were found to have new atrial fibrillation or flutter via MCT monitoring. There were no adverse events in the initiative group. Prior to the initiative, 1281 patients underwent TAVR over a one-year period. The initiative group had significantly shorter length of stay than pre-initiative patients (2.5 ± 4.5 vs 3.0 ± 3.8 days, p < 0.001) and lower overall PPM placement rate within 30 days post-TAVR (16 % vs 20.5 %, P = 0.0125). ConclusionsIn our study, implementation of a standardized, systematic approach utilizing MCT in post-TAVR patients was safe and allowed for timely detection of conduction abnormalities requiring pacemaker placement. This strategy also detected new atrial fibrillation and flutter. Reduction in post TAVR pacemaker rate and length of stay were also noted although this effect is multifactorial.

Syncope in older adults: challenges, approach and treatment.

Syncope can have devastating consequences, resulting in injuries, accidents or even death. In our ageing society, the subsequent healthcare usage, such as emergency room presentations, surgeries and hospital admissions, forms a significant and growing socioeconomic burden. Causes of syncope in the older adult include orthostatic hypotension, carotid sinus syndrome, vasovagal syncope, structural cardiac abnormalities, cardiac arrhythmias and conduction abnormalities. As stated in the recently published World Falls Guidelines, syncope in older adults often presents as falls, which is either due to amnesia for loss of consciousness, or pre-syncope leading to a fall, especially in those prone to falls with several other risk-factors for falls present. This difference in presentation can hinder the recognition of syncope. In patients with unexplained falls, or in whom the history comprises red flags for potential syncope, special attention to (pre)syncope is therefore warranted. When syncope is mistaken for other causes of a transient loss of consciousness, such as epileptic seizures, or when syncope presents as falls, patients are often referred to multiple specialists, which may in turn lead to excessive and unnecessary diagnostic testing and costs. Specialist services that are able to provide a comprehensive assessment can improve diagnostic yield and minimise diagnostic testing, thus improving patient satisfaction. Comprehensive assessment also leads to reduced length of hospital stay. Increasingly, geriatricians are involved in the assessment of syncope in the older patient, especially given the overlap with falls. Therefore, awareness of causes of syncope, as well as state-of-the-art assessment and treatment, is of great importance.

A Mutational Hotspot in The LAMP2 Gene: Unravelling Intrafamilial Phenotypic Variation and Global Distribution of The c.877C>T Variant: A Descriptive Study.

Danon disease is defined by a clinical trio of cardiomyopathy, skeletal myopathy, and cognitive impairment. It results from the lysosomal-associated membrane protein-2 (LAMP2) gene variants. The aim of study is determination of genotype and phenotype of a newly diagnosed Iranian family with a unique phenotype due to a pathogenic variant of the LAMP2 gene along with a phenotypic comparison of all reported patients. In this descriptive study, we evaluated the demographic data, clinical features, management procedures, as well as genetic analysis of both patients in this newly diagnosed family. Whole genome sequencing (WGS) and in silico structural and functional predictions were applied. A comprehensive search of the c.877C>T variant in LAMP2 was conducted using the PubMed, Google Scholar, VarSome, ClinVar, Human Gene Mutation Database (HGMD), and Franklin databases to identify any genotype-phenotype correlations. Nine patients were carriers of the c.877C>T variant. All patients were male, and displayed variable degrees of left ventricular hypertrophy (LVH) that ranged from mild to severe. All patients exhibited typical cardiac conduction abnormalities consistent with Danon disease. Four underwent heart transplants and survived. Skeletal muscle involvement and cognitive impairment were observed in four patients each. The mean age of onset was 14 years. The proband in this study exhibited an earlier onset of cardiac symptoms. Genetic analysis is the preferred diagnosis approach for Danon disease and can assist families in managing affected patients, identify carriers, and assist with future family planning. This study highlights the intrafamilial phenotypic variability of Danon disease. It is possible that variants of this gene may be frequent in Iran.

Post-TAVR conduction abnormalities leading to permanent pacemaker implantation: Risk factors, prevention, and management.

Transcatheter aortic valve replacement (TAVR) often leads to conduction abnormalities, necessitating pacemaker implantation. This review of 38 meta-analyses identified preexisting right bundle branch block(RBBB), LAHB, and new-onset left bundle branch blockas key risk factors, with a higher PPM risk in male and older patients. Procedural factors like transfemoral access and self-expandable valves also increase this risk. Prevention focuses on tailoring TAVR to individual electrophysiological and anatomical profiles. However, there's a lack of consensus in managing these conduction disturbances post-TAVR, highlighting the need for further research and standardized treatment strategies.

A Report of Two Cases with Caseous Annular Calcification of the Mitral Valve.

Introduction: Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annulus calcification, a chronic and degenerative mitral valve fibrous ring process. It usually carries a benign prognosis. The prevalence of CCMA is about 0.06%-0.07% of the population. CCMA is generally diagnosed incidentally and can be confused with other intracardiac masses such as cardiac tumors, abscesses, vegetation, or calcified thrombi. Multimodality imaging, including TEE, cardiac computed tomography, and cardiac magnetic nuclear resonance, can easily differentiate CCMA from other masses and help avoid unnecessary surgery. CCMA is typically located in the basal area of the posterior mitral valve, and the calcification seems like a round, large, soft mass with a central echo-dense location. CCMA may have a benign course, but it may sometimes be complicated with mitral valvular dysfunction, systemic embolization, or conduction abnormalities in the scenarios mentioned above, as well as when the diagnosis is unclear, surgery is indicated. Mitral valve replacement should be preferred compared to mitral valve repair.&#x0D; Conclusions: It is important to note that the decision for mitral valve replacement, including CAC cases, should be individualized based on various factors, including the patient's clinical condition, symptoms, severity of valve disease, and associated comorbidities.&#x0D; As scientific understanding and research progress, there may be ongoing developments and refinements in the conservative and surgical management of CCMA.

In-hospital outcomes of septal myectomy vs. alcohol septal ablation for hypertrophic cardiomyopathy with outflow tract obstruction: An update and insights from the national inpatient sample from 2011 to 2019.

Septal Myectomy (SM) and Alcohol Septal Ablation (ASA) improve symptoms in patients with Hypertrophic Cardiomyopathy with outflow tract obstruction (oHCM). However, outcomes data in this population is predominantly from specialized centers. The National Inpatient Database was queried from 2011 to 2019 for relevant international classification of diseases (ICD)-9 and -10 diagnostic and procedural codes. We compared baseline characteristics and in-hospital outcomes of patients with oHCM who underwent SM vs ASA. A p-value < 0.001 was considered statistically significant. We identified 15,119 patients with oHCM who underwent septal reduction therapies, of whom 57.4% underwent SM, and 42.6% underwent ASA. Patients who underwent SM had higher all-cause mortality (OR: 1.8 (1.3-2.5)), post-procedure ischemic stroke (OR: 2.3 (1.7-3.2)), acute kidney injury (OR: 1.4 (1.2-1.7)), vascular complications (OR: 3.6 (2.3-5.3)), ventricular septal defect (OR: 4.4 (3.2-6.1)), cardiogenic shock (OR: 1.7 (1.3-2.3)), sepsis (OR: 3.2 (1.9-5.4)), and left bundle branch block (OR: 3.5 (3-4)), compared to ASA. Patients who underwent ASA had higher post-procedure complete heart block (OR: 1.3 (1.1-1.4)), right bundle branch block (OR: 6.3 (5-7.7)), ventricular tachycardia (OR: 2.2 (1.9-2.6)), supraventricular tachycardia (OR: 1.6 (1.4-2)), and more commonly required pacemaker insertion (OR: 1.4 (1.3-1.7)) (p < 0.001 for all) compared to SM. This nationwide analysis evidenced that patients undergoing SM had higher in-hospital mortality and periprocedural complications than ASA; however, those undergoing ASA had more post-procedure conduction abnormalities and pacemaker implantation. The implications of these findings warrant further investigation regarding patient selection strategies for these therapies.

The rise of counterfeit medication: an emerging threat?

Madam, Heart failure (HF) is a multifaceted clinical syndrome arising from a functional or structural cardiac condition that hampers the adequate filling or expulsion of blood into the systemic circulation. It is estimated that heart failure affects around 26 million people globally and significantly adds to healthcare expenditures on a worldwide scale1. Furthermore, in 2016, approximately 16 percent of deaths in Pakistan were due to heart related disorders. This number grew to 29 percent in 20222. HF can greatly diminish the functional capability of a patient and heighten the risk of mortality. Therefore, it is essential to accurately diagnose and proficiently manage this condition to improve the quality of life of the patient. Spironolactone, the first mineralocorticoid receptor antagonist (MRA) to be developed, is prescribed for the management of hypertension, primary hyperaldosteronism, and peripheral oedema linked to cardiac failure3. When HF occurs and cardiac output decreases, it stimulates the renin-angiotensin-aldosterone system (RAAS) which in turn causes salt and water reabsorption and thus increases venous return to the heart which further contributes to congestive heart failure and heart fails to pump the additional fluid and pooling occurs. Here MRAs are very affective as they inhibit the function of aldosterone and hence fluid retention does not occur. Unfortunately, the beneficial effects of spironolactone do not occur without substantial adverse effects. Firstly, spironolactone is associated with sexual adverse events due to its affinity for androgen and progesterone receptors. There have been reports of male patients experiencing gynecomastia and breast pain. Secondly, spironolactone has been classified as potassium sparing diuretic hence hyperkalemia (defined as serum K+ &gt; 5.5 mEq/L) is a common side effect3. Hyperkalemia can manifest as muscle weakness or paralysis, metabolic acidosis, cardiac conduction abnormalities, and life-threatening cardiac arrhythmias4. These cardiac arrythmias can have serious consequences, including cardiac arrest and stroke. In conclusion heart failure, if not treated immediately, can be fatal. Spironolactone is a drug used for management of heart failure; however, it has some detrimental effects on the cardiovascular system such as development of serious cardiac arrythmias. Hyperkalemia, due to potassium sparing nature of MRAs, is the primary cause of these life-threatening effects thus it is recommended to assess serum potassium levels and renal function of a patient with heart failure before prescribing spironolactone. Moreover, patients who are being treated with spironolactone should be periodically monitored to prevent any casualty.

Donor Electrocardiogram Associations With Cardiac Dysfunction, Heart Transplant Use, and Survival: The Donor Heart Study

BackgroundPotential organ donors often exhibit abnormalities on electrocardiograms (ECGs) after brain death, but the physiological and prognostic significance of such abnormalities is unknown. ObjectivesThis study sought to characterize the prevalence of ECG abnormalities in a nationwide cohort of potential cardiac donors and their associations with cardiac dysfunction, use for heart transplantation (HT), and recipient outcomes. MethodsThe Donor Heart Study enrolled 4,333 potential cardiac organ donors at 8 organ procurement organizations across the United States from 2015 to 2020. A blinded expert reviewer interpreted all ECGs, which were obtained once hemodynamic stability was achieved after brain death and were repeated 24 ± 6 hours later. ECG findings were summarized, and their associations with other cardiac diagnostic findings, use for HT, and graft survival were assessed using univariable and multivariable regression. ResultsInitial ECGs were interpretable for 4,136 potential donors. Overall, 64% of ECGs were deemed clinically abnormal, most commonly as a result of a nonspecific St-T-wave abnormality (39%), T-wave inversion (19%), and/or QTc interval >500 ms (17%). Conduction abnormalities, ectopy, pathologic Q waves, and ST-segment elevations were less common (each present in ≤5% of donors) and resolved on repeat ECGs in most cases. Only pathological Q waves were significant predictors of donor heart nonuse (adjusted OR: 0.39; 95% CI: 0.29-0.53), and none were associated with graft survival at 1 year post-HT. ConclusionsECG abnormalities are common in potential heart donors but often resolve on serial testing. Pathologic Q waves are associated with a lower likelihood of use for HT, but they do not portend worse graft survival.

Contemporary mechanics of conductive hearing loss

The middle ear plays a critical role for the conversion of acoustic energy to mechanical vibrations that subsequently enter the cochlea. It is middle ear impedance matching through ossicular coupling that has enabled land-dwelling vertebrates to hear soft airborne sounds. Conductive hearing loss may result from damage to the delicate middle ear structures following infection, trauma or rapid pressure changes. An understanding of the mechanics of the middle ear significantly improves the oto-surgeon's ability to effectively diagnose conductive hearing loss, localize the responsible lesion and then effectively correct the conduction abnormality. This article reviews some of the basic knowledge of middle ear mechanics for sound transmission, highlights recent advances in developing new techniques to assist in diagnosis of middle ear disease, and finally sheds light on future research aimed at improving the diagnosis and management of middle ear pathology.

His bundle pacing in a patient with atrioventricular conduction abnormalities, persistent atrial flutter at high thromboembolic and bleeding risk after hybrid coronary revascularization and left atrial appendage closure - case report

We present a case of a 78-year-old patient with persistent atrial &amp;#64258; utter, history of atrial &amp;#64257; brillation and atrioventricular conduction disturbances, including &amp;#64257; rst-degree atrioventricular block (AVB) and paroxysmal complete AVB. Echocardiography revealed mildly reduced left ventricular ejection fraction (LVEF, 44%). The patient had high thromboembolic risk, had previous ischemic stroke, suffered from chronic coronary artery disease treated with hybrid coronary revascularization (minimally invasive direct coronary artery bypass grafting and subsequent percutaneous coronary intervention) as well as left atrial appendage closure. Because of high bleeding risk, double antiplatelet therapy (acetylsalicylic acid and clopidogrel) combined with low dose of low-molecular-weight heparin after cardiac surgery were introduced. Due to persistent atrial &amp;#64258; utter, complete AVB, lack of intraventricular conduction abnormalities, mildly reduced LVEF and expected high right ventricle pacing burden, the patient was referred for dual-chamber pacemaker implantation using conduction system pacing (CSP), preferentially His bundle pacing (HBP). The procedure was performed with good outcome and CSP was utilized via HBP. After reassessment of thromboembolic and bleeding risk, the patient was discharged home on reduced dose of dabigatran. Short-term follow-up showed stable HBP parameters along with no additional symptoms. Despite good short-term outcomes and no complications in studied patient, large randomized controlled trials are needed to verify long-term safety and ef&amp;#64257; cacy of HBP to optimize clinical care of patients with atrioventricular conduction abnormalities using a personalized approach.&amp;nbsp;

Comparing Complication Rates of Transcatheter Aortic Valve Replacement to Surgical Aortic Valve Replacement

Background/Objective: Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are the two procedures used to treat severe symptomatic aortic stenosis. One of the most feared outcomes of both procedures is stroke. Conduction abnormalities and arrhythmias after TAVR are relatively common, but few studies have been done comparing the rate of these events between TAVR and SAVR. The objective of our study is to find if there are any differences between the rates of stroke, conduction abnormalities, and arrhythmias between patients that have undergone TAVR and patients that have undergone SAVR. Methods: The CRC/Sidus Real World Evidence Cardiology Dataset was used to obtain samples for this project. Patients who underwent TAVR and SAVR were identified using CPT codes. These two cohorts of patients were tracked for complications between 0 to 30 days after the procedure and between 0 days to 1 year after the procedure using ICD-10 codes. Results: Patients who underwent TAVR (n=3621) were much more likely to have conduction disorders and arrhythmias both in the 0-30 day range and 0 days-1 year range after the procedure compared to patients who underwent SAVR (n=2137). Cerebral infarction and transient cerebral ischemic attack rates were also higher in the TAVR group. Mortality rates for TAVR were lower than mortality rates for SAVR, both 30 days and 1 year after the procedure. Conclusion/Impact: TAVR has revolutionized aortic valve replacement and allowed many patients with aortic stenosis (many of whom are at high surgical risk) a minimally invasive option to improve their quality of life. Finding ways to reduce the rates of stroke, arrhythmias, and conduction abnormalities; for example, through improved devices and techniques, and improvedanti-thrombotic therapy, is extremely important as TAVR becomes more and more widely utilized.

Safety and Efficacy of His Bundle Area (Para-Hisian) Pacing Using a Mathematical Cross-Correlation Cardiac Synchrony Index

Background: The deleterious effects of right ventricular (RV) apical pacing promoted the need for more physiological pacing techniques, such as conduction system, His bundle area, and mid-septal ventricular pacing. We aimed to compare permanent mid-septal and His bundle area pacing (HBAP) vs RV apical pacing to determine which is more physiological and to assess lead stability and pacing thresholds. Methods: We retrospectively analyzed 137 consecutive patients undergoing permanent pacing (63% men, mean age 61 ± 24 years). Seventy-one (52%) had a baseline QRS of &lt; 120 ms, with no evidence of intraventricular conduction abnormalities, 37 (27%) had right bundle branch block, and 29 (21%) had left bundle branch block. The ventricular lead was implanted at the RV apex in 54 patients, at the His bundle area in 66, and at the mid interventricular septum in 17. Twelve-lead electrocardiogram was recorded, and electrical synchrony was assessed using the Synchromax® crosscorrelation cardiac synchrony index (CSI). Results: QRS duration was prolonged in all pacing sites. There was no correlation between QRS duration and the CSI (r = 0.028, p = 0.79). The CSI was significantly improved only in patients undergoing HBAP, despite a slight widening of the QRS complex. There was no difference in pacing thresholds and sensed R wave voltage. Lead dislodgment occurred in only 1 lead implanted at the His bundle area. Conclusions: HBAP successfully captures the conduction system, normalizing the CSI despite producing a wider QRS, meaning that coordination is more important than duration for achieving optimal cardiac synchrony

Blunt chest trauma-induced myocardial infarction: a case of sudden death by homicide

BackgroundBlunt cardiac injuries, which are typically the result of blunt chest trauma, are not particularly significant clinically. It is vital never to underestimate blunt chest injuries, especially when they occur in the anterior thoracic area. Blunt trauma to the chest is one of the rarest causative factors of myocardial infarction (MI). Blunt cardiac injury encompasses different medical emergency conditions such as gradual damage to the myocardium leading to myocardial ischemia, injuries to the great vessels of the heart, pericardial tamponade, septum or wall ruptures, pump failure, conduction abnormalities, and atrial and ventricular fibrillations. The most common cause of blunt chest trauma is a road traffic accident (RTA), followed by a sports injury. Mostly blunt trauma chest injuries occur below the age group of 45 years.Case presentationA 45-year-old male with a history of physical assault was brought to the emergency department by his neighbor. He was allegedly kicked by his relative over the chest during an altercation sustained blunt-force trauma to the chest and collapsed immediately. On admission, he was given cardiopulmonary resuscitation and declared dead. On autopsy, there were no signs suggestive of external injury or any shoeprints/footprints on the chest. On histopathological examination, a diffuse area of discoloration consistent with an extensive myocardial infarction was noted. Old healed infarcts were seen in the free wall of the left ventricle, left posterior papillary muscle, and left apex. The coronaries showed atheromatous plaque with lumen narrowing and focal calcification.ConclusionsIt is the task of the forensic pathologist to ascertain and record evidence as to whether the myocardial infarction was caused by the alleged blunt trauma to the chest during the autopsy. This is important as it will determine the type of prosecution the accused is likely to be charged with and the extent of the punishment that he will likely receive under the Indian Penal Code.

Tricuspid regurgitation burden following transcatheter aortic valve replacement requiring early pacemaker implantation

Background Conduction abnormality requiring the implantation of a permanent pacemaker (PPM) is a well-known and clinically important complication of transcatheter aortic valve replacement (TAVR). However, PPM implantation may result in lead-associated tricuspid valve regurgitation (TR). This study sought to determine the incidence and progression of TR following PPM implantation after TAVR. Methods This was a retrospective review of all echocardiograms of patients who underwent PPM following TAVR at the Baylor Scott & White hospitals from 2012 to 2021. The primary endpoint was TR progression at 30 days and 1 year. A subanalysis comparing the change in TR progression between small and large TAVR devices was also conducted. Secondary outcomes included all-cause death at 30 days and 1 year. Results Out of the 2744 patients who underwent TAVR between April 2012 and August 2021, 177 patients (6.5%) subsequently received a new PPM. There was a statistically significant progression of TR at 1-year follow-up (McNemar’s P value = 0.02). TR progression rates were comparable between the small and large valve groups at 1-year follow-up (4% vs 11%, P = 0.09, respectively). Conclusion In this single healthcare system study, we demonstrated a significant progression of TR in patients with PPM post TAVR at 1 year.

Variation in prenatal surveillance and management of anti-SSA/Ro autoantibody positive pregnancies

Objective To describe international surveillance and treatment strategies for managing anti-SSA/Ro autoantibody positive pregnancies. Study Design An electronic REDCap questionnaire was distributed to Fetal Heart Society and North American Fetal Therapy Network members which queried institution-based risk stratification, surveillance methods/frequency, conduction abnormality treatments, and postnatal anti-SSA/Ro pregnancy assessment. Results 101 responses from 59 centers (59% US, 17% international) were collected. Most (79%) do not risk stratify pregnancies by anti-SSA/Ro titer; those that do use varied cutoff values. Many pregnant rheumatology patients are monitored for cardiac abnormalities regardless of maternal anti-SSA/Ro status. Surveillance strategies were based on maternal factors (anti-SSA/Ro status 85%, titer 25%, prior affected child 79%) and monitoring durations varied. Most respondents treat 2° and 3° fetal atrioventricular block, commonly with dexamethasone and/or IVIG. Conclusions Wide variation exists in current fetal cardiac surveillance and treatment for anti-SSA/Ro autoantibody positive pregnancies, highlighting the need for evidence-based protocols to optimize care.

“Unveiling Lyme Carditis: ThirdDegree Heart Block as the Initial Presentation

Background: Lyme disease is a tick-borne bacterial disease caused by spirochetes within the Borreliaceae family. Lyme carditis is a manifestation of the early disseminated stage of Lyme disease and typically arises one to two months after the initial infection. Case presentation: We present the case of a previously healthy 31-year-old man admitted to the emergency department with a thirddegree atrioventricular block. Lyme carditis was diagnosed based on positive serology and Western immunoblot assay results, despite the absence of the characteristic erythema chronicum migrans skin lesion. Following initiation of appropriate antibiotic treatment with doxycycline, there was a complete reversal of the atrioventricular block. Conclusion: Lyme carditis, a manifestation of the early disseminated stage of Lyme disease, should be considered in patients presenting with conduction abnormalities. Prompt antibiotic therapy offers a favorable prognosis, allowing for the avoidance of unnecessary permanent pacemaker implantation.

Leopard syndrome without lentigenes: A rare presentation and literature review

Abstract: Leopard syndrome (LS) has presentations of lentigines, conduction abnormalities in the heart, hypertelorism of the eyes, stenosis of the pulmonary artery, cryptorchidism, mental retardation, and sensorineural deafness. Another condition known as Noonan syndrome (NS) has many overlapping symptoms. LS is due to germ-line mutations in the PTPN11 gene. The same genetic mutation also leads to NS. Here, we described a 10-year-old male child presented with failure to thrive, decreased appetite, large atrial septal defect, and developmental delay and later on diagnosed with LS by whole-genome sequencing. In this case, characteristic lentigines are absent, which puts the pediatrician in a dilemma. However, by using the diagnostic criteria set by Voron since 1976, we are able to reach a clinical diagnosis of LS.