Diagnosis Of Complete Heart Block Research Articles

Abstract 15372: The Lewis Lead

The Lewis lead is a modified ECG configuration that can enhance the amplitude of the atrial electrical activity and is useful when the atrial activity cannot be discerned in the standard ECG. The configuration involves applying the right arm electrode on the manubrium, left arm electrode to the 5th intercostal space on the right sternal border, left leg electrode over the right lower costal margin and right leg electrode in the standard position. The ECG is then interpreted in lead I and II. Herein we present a case where the Lewis lead aided in the diagnosis of complete heart block with underlying atrial fibrillation. Case Presentation: A 75 year old female with severe tricuspid regurgitation was admitted for tricuspid valve replacement. She had previous paroxysmal atrial fibrillation status post pulmonary vein isolation. The preoperative ECG revealed normal sinus rhythm. Postoperatively, ECG demonstrated a narrow complex ventricular rhythm at 70 beats per minute. No atrial activity could be clearly discerned (Image 1). The epicardial atrial wire placed intraoperatively was not functioning, therefore atrial electrogram could not be obtained. It was unclear from repeat ECGs if there was sinus arrest or atrial fibrillation in the atria. The Lewis lead was then utilized and revealed underlying atrial fibrillation (Image 1); together, this was consistent with atrial fibrillation and complete heart block with a junctional escape rhythm. The rhythm did not recover and there was progressive conduction system disease with widening of the QRS and episodes of severe bradycardia. She underwent pacemaker implantation. Discussion: By utilizing the Lewis lead we were able to establish the atrial rhythm and differentiate between atrial fibrillation and sinus arrest. The Lewis lead can also help narrow the differential for wide complex tachycardia by magnifying the p wave, thus making it easier to detect ventriculoatrial dissociation, a hallmark feature of ventricular tachycardia.

Abstract 16716: Clinical Parameters Associated With Temporary Transvenous Pacing for Patients Presenting With Complete Heart Block

Introduction: Patients presenting with Complete Heart Block (CHB) are emergently referred for placement of a temporary transvenous pacemaker (TTVP) for hemodynamic stability. Data on the immediate management and outcomes of such patients are lacking. Methods: Data collected through retrospective chart review of patients presenting to the Emergency Department (ED) at 3 regional referral hospitals from 10/2017 to 9/2022 with a diagnosis of new CHB; included age, sex, clinical, laboratory and ECG data, medications, interventions and length of stay(LOS). Results: There were 230 patients (106 women), mean age 77 years. Of these 94 were on beta blockers, 55 on calcium channel blockers. Syncope, dizziness and dyspnea were common symptoms. Pause > 3 seconds was seen in 50 patients. Sympathomimetics were used in 55 patients and 179 patients were admitted to the ICU. There was no statistical difference in demographics, clinical features, ICU utilization and LOS. A TTVP was placed in 72(31%) and a Permanent Pacemaker (PPM) prior to discharge in 182 patients, a median of 1 day from ED presentation. By site, there were 71, 74 and 85 patients of whom TTVP was placed in 38%, 15% and 40% and a PPM in 76%, 82% and 79% in the 3 regional centers. The median LOS was 3 days. Univariate logistic regression was used to assess for predictors of TTVP placement (SAS® Version 9.4, Cary, NC). Syncope, Initial SBP, Shock, Pause > 3 seconds, Acute MI, and Serum K were associated with higher odds of patients getting TTVP. SBP > 160mmHg was associated with lower odds of needing TTVP. Conclusions: TTVP was infrequently needed (31%) among patients presenting to the ED with CHB. Initial SBP, Shock, Acute MI, Pause > 3sec and Serum K were associated with TTVP placement. Higher SBP was associated with lower odds of needing a TTVP. There seems to be a difference in TTVP utilization rate between centers. Prospective data related to the acute management of CHB is needed to identify variations in utilization of TTVP between centers.

Abstract 12071: Emergent Temporary Transvenous Pacemakers Were Infrequently Needed for Patients Presenting With Complete Heart Block at a Regional Hospital

Introduction: Patients presenting with Complete heart block (CHB) are emergently referred for placement of a temporary transvenous pacemaker (TTVP) for hemodynamic stability. Data on the immediate management and outcomes of such patients are lacking. Methods: Data collected; through retrospective chart review of patients presenting to the Emergency Department (ED) at a regional hospital from October 2017 to January 2021 with a diagnosis of new CHB; included age, sex, clinical, laboratory and ECG data, medications, interventions and length of stay. Results: There were 71 patients (31 women) of whom 19 were on beta blocker or Calcium channel blockers. Data (see Table 1) for all variables was available in 68 patients. Syncope, lightheadedness and dyspnea were common symptoms. The median age was 77 years. The median heart rate was 41bpm. Atropine was used in 13 patients. Five patients with initial Systolic Blood Pressure (SBP) < 100mmHg received sympathomimetics. Syncope with pause occurred in 3 patients. A TTVP was placed in 12 patients. Among 22 patients with initial SBP > 160mmHg one patient with a recent TAVR had a TTVP placed. All but five were managed in the ICU setting. On Univariate logistic regression (R statistical software 3.6.1) initial SBP, SBP < 100mmHg and Initial Serum K level were clinically significant. In multivariate analysis, SBP was significant with a lower SBP predicting need for a TTVP [OR 0.96 (CI 0.91 - 0.99, p = 0.019)]. A permanent pacemaker (PPM) prior to discharge was placed in 64 patients on average in 1.6 days from presentation. 3 patients with STEMI and TTVP did not need a PPM. 1 transitioned to hospice and 1 patient died of sepsis. In 1 it was attributed to COVID-19 infection. Conclusions: TTVP was infrequently needed (16.66%) among patients presenting to the ED with CHB. Initial SBP and Serum K were clinically relevant factors. Prospective data related to the acute management of CHB is needed to identify predictors that can improve the care for such patients.

Pulmonary hypertension associated with auto-immune complete heart block in neonates: Unrecognized manifestation of neonatal lupus

Auto-immune complete heart block (CHB) is a well-defined consequence of antenatal exposure to maternal anti-SSA/Ro and/or anti-SSB/La antibodies. After birth, the persistence of maternal anti-SSA and/or anti-SSB antibodies passively transferred to the foetus can cause skin rash, vascular, hepatic or neurologic manifestations. Pulmonary involvement is infrequent in a such condition in neonates while pulmonary hypertension (PH) is a common complication of systemic lupus erythematosus (SLE) in adulthood. We report a series of 4 neonates referred to our institution for prenatal diagnosis of auto-immune CHB who developed pulmonary hypertension after birth. Two patients were paced at the time of PH diagnosis and 2 patients weren’t. PH was suspected by transthoracic echocardiography after a PH-free interval ranging from 10 days to 3 months. PH was confirmed by right heart cath (RHC) in all, all had a lung CT-pulmonary angiography and one patient had a pulmonary biopsy at the time of pacemaker implantation. At the RHC all the patients presented a pre-capillary PH (PAPm > 25 mmHg, PWAP < 15 mmHg). All our patients presented a vasoreactivity at the O 2 /NO test performed during the RHC. Lung CT showed ground glass opacities in all patients. The one biopsy showed medial hypertrophy without intimal proliferation. Clinical, hemodynamical, CT scan and even pulmonary biopsy findings were consistent with a lung disease cause for PH. Based on the adult management of PH in SLE patients, immunosuppression therapy with intravenous immunoglobulin and with corticosteroids has been proposed to all but one patient. In 2 cases, it has been necessary to add a treatment with pulmonary vasodilator. By 6 months PH normalized in all patients. This series demonstrated the potential pulmonary involvement in neonatal lupus. The prognostic of PH associated with auto-immune CHB in paediatrics patients seams good if adequately diagnosed and treated.

Early outcome of permanent pacemaker implantation

Background: Permanent pacemaker implantation (PPI) is considered the most effective and safe procedure for treatment of symptomatic bradyarrythmia. In this study we evaluated incidence of intraoperative and early postoperative (three month) outcome of PPI in our center.&#x0D; Method: This is a cross sectional study carried out over a period twenty months between Jan 2017 and August 2018. All patients undergoing PPI at Nobel Medical College were enrolled in the study. Details of demographic data, medical history, hardware used and complications were recorded. Prospective follow up was done in outpatient department upto three months.&#x0D; Result: A total of seventy-six patients were enrolled in the study. Fifty-one (67%) were male and twenty-five (33%) were female. Ninety percent of the patient was above the age of sixty-five years. Fifty-five (71%) received single chamber and twenty-one (28%) received dual chamber pacemaker. Majority of the patient (87%) had a diagnosis of complete heart block. There was no mortality unto 3 months. Majority (92%) of the patient had no complications at all. Two patients had pocket site infection. Lead dislodgment was noted in three patients. Lead perforation and acute temponade occurred during intraoperative period in one case, which was successfully managed by pericardiocentesis.&#x0D; Conclusion: In summary permanent pacemaker implantation was effective and relatively safe procedure in our center with no mortality.

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.

Complete Heart Block Complicating ST-Segment Elevation Myocardial Infarction: Temporal Trends and Association With In-Hospital Outcomes

ObjectivesThe purpose of this study was to determine the association of complete heart block (CHB) with outcomes and to examine temporal trends in the incidence and outcomes of CHB complicating ST-segment elevation myocardial infarction (STEMI). BackgroundThere are limited data available on the incidence and outcomes of CHB in STEMI patients who undergo contemporary management. MethodsWe used the 2003 to 2012 National Inpatient Sample databases to identify all patients age ≥18 years hospitalized with STEMI. Patients with a concomitant diagnosis of CHB were then identified. Multivariable logistic regression was used to analyze the association of CHB with outcomes and to examine the temporal trends in incidence and outcomes of CHB complicating STEMI. ResultsOf 2,273,853 patients with STEMI, 49,882 (2.2%) had CHB. The incidence of CHB increased from 2.1% in 2003 to 2.3% in 2012 (adjusted odds ratio [OR] per year: 1.02; 95% confidence interval [CI]: 1.02 to 1.03). STEMI patients with CHB had higher in-hospital mortality than those without CHB (20.4% vs. 8.7%; adjusted OR: 2.47; 95% CI: 2.41 to 2.53). The higher mortality associated with CHB was independent of the location of STEMI; however, the magnitude of this association was greatest in patients with anterior STEMI. In patients with CHB complicating STEMI, although permanent pacemaker implantation rates declined (adjusted OR per year: 0.96; 95% CI: 0.95 to 0.97), in-hospital mortality remained unchanged during the study period (adjusted OR per year: 1.00; 95% CI: 0.99 to 1.01). ConclusionsThe incidence of CHB complicating STEMI has increased slightly over the last decade, although the absolute incidence remains quite low. CHB remains associated with higher in-hospital mortality in STEMI patients even in the current era of prompt reperfusion therapy. In patients with CHB complicating STEMI, there was no change in risk-adjusted in-hospital mortality during the study period.

Lyme Carditis and Complete Heart Block: An Unusual Case of a Young Student

Lyme carditis is a relatively uncommon medical condition in young people. It can be accompanied by myalgias, sweating episodes, fever and chest pain for several weeks. It sometimes has certain manifestations masquerading as pericarditis. Varying degrees of atrioventricular (AV) block accompanied by rhythm abnormalities are not uncommon. We describe an unusual case of a young male college student presenting with shortness of breath and evidence of complete heart block secondary to the rare diagnosis of complete heart block due to Lyme disease causing cardiac conduction abnormalities. This condition completely resolved with intravenous antibiotic therapy. This case represents a relevant and unique clinical scenario which is an important education point highlighting prompt diagnosis in a reversible cause of complete heart block. J Med Cases. 2014;5(8):435-436 doi: http://dx.doi.org/10.14740/jmc1841w

Lyme Carditis and Complete Heart Block: An Unusual Case of a Young Student

Lyme carditis is a relatively uncommon medical condition in young people. It can be accompanied by myalgias, sweating episodes, fever and chest pain for several weeks. It sometimes has certain manifestations masquerading as pericarditis. Varying degrees of atrioventricular (AV) block accompanied by rhythm abnormalities are not uncommon. We describe an unusual case of a young male college student presenting with shortness of breath and evidence of complete heart block secondary to the rare diagnosis of complete heart block due to Lyme disease causing cardiac conduction abnormalities. This condition completely resolved with intravenous antibiotic therapy. This case represents a relevant and unique clinical scenario which is an important education point highlighting prompt diagnosis in a reversible cause of complete heart block. J Med Cases. 2014;5(8):435-436 doi: http://dx.doi.org/10.14740/jmc1841w

Index of Suspicion

Index of Suspicion

Prenatal Diagnosis of Complete Heart Block and Congenitally Corrected Transposition of the Great Arteries

Prenatal Diagnosis of Complete Heart Block and Congenitally Corrected Transposition of the Great Arteries

The Pathology of the heart conduction system in congenital heart block

The incidence of congenital complete heart block is estimated in 1 of 2500 – 20,000 births. Many cases are isolated (found in an otherwise normal heart) and the pathology of the heart conduction system is variable. We report a 51-year-old man with the diagnosis of complete heart block, with a permanent pacemaker. No family history of rhythm disturbances was available. The patient presented and endocarditis after replacement of the pacemaker battery. The prognosis was poor and the patient died three months later. Autopsy examination showed signs of shock, of septic origin. The heart was hypertrophic (450 g) and the left ventricle thickened. Histopathological examination of the heart conduction system showed that the sinus and atrioventricular nodes were normal, but the His bundle was interrupted and replaced by fibrous tissue. No inflammatory signs were present. Loss of conducting fibres and their replacement by fibrous tissue is the most common pathological process in complete heart block. In this case His bundle was mostly affected, different to Lev’s disease where the process is more distal (branching atrioventricular bundle) and to Lenegre’s disease, which shows a diffuse damage in the conducting system.

Optimally Timed Rate-adaptive Atrioventricular Delay in AV Sequential Pacing

Background and Objectives:The impetus for the spectacular advances in pacemaker technology has been a shift in the aims of pacemaker therapy from ensuring survival of patients with conduction defects to optimizing hemodynamic function. Now, optimization of the system through rate adaptive AV sequential pacing and adjusting the appropriate time of the AV interval is the main goal. At lower levels of exercise, the relative importance of an appropriately timed atrial contraction in maintaining optimal cardiac output is now well established in patients with normal and abnormal ventricular function. The purpose of this study is to define the optimal AV delay patterns in AV sequential pacing in association with heart rate changes. Materials and Methods:Eleven patients who had been treated with dual chamber pacemakers under the diagnosis of complete heart block or sick sinus syndrome were included. During the study, the pacemaker was programmed to the atrial triggered ventricular pacing mode. The heart rates were increased from 50 beats/minute to 80 beats/min by 5 beats/minute's interval. At each heart rate, the AV delay was programmed to 100, 125, 150, 175, 200 ms and the time velocity integral was measured by a continuous wave Doppler echocardiography. Results:When the heart rate changes were not considered, time velocity integral was the greatest with an AV delay of 150 ms (p<0.0001). There were no significant differences between AV delays regarding the time velocity integrals in rate responsive optimal fixed AV delay. The average r-value of linear regressions for optimal AV delay was -0.54. Individually programmed AV delay showed that the optimal AV delays were at 125 ms in two cases, 150 ms in five cases, 175 ms in three cases, and 200 ms in one case. The most unfavorable AV delays were at 100 ms in four cases, 150 ms in one case, 175 ms in two cases, and 200 ms in three cases. The r-values of linear regression for individualized optimal AV delay showed very wide range (-2.5-0.89). Conclusion:The optimal AV delay within the range of 50-80 bpm of heart rates is 150 ms. The average r-value of linear regression for optimal AV delay was -0.54. However there were wide variations in optimal AV delay individually, we should consider a patient-specific AV delay algorithm. (Korean Circulation J 2000;30(3):310-317)

Early prevention and management of ischemic heart disease: Focus on hypertension

The purpose of this study was to determine the association of complete heart block (CHB) with outcomes and to examine temporal trends in the incidence and outcomes of CHB complicating ST-segment elevation myocardial infarction (STEMI).There are limited data available on the incidence and outcomes of CHB in STEMI patients who undergo contemporary management.We used the 2003 to 2012 National Inpatient Sample databases to identify all patients age ≥18 years hospitalized with STEMI. Patients with a concomitant diagnosis of CHB were then identified. Multivariable logistic regression was used to analyze the association of CHB with outcomes and to examine the temporal trends in incidence and outcomes of CHB complicating STEMI.Of 2,273,853 patients with STEMI, 49,882 (2.2%) had CHB. The incidence of CHB increased from 2.1% in 2003 to 2.3% in 2012 (adjusted odds ratio [OR] per year: 1.02; 95% confidence interval [CI]: 1.02 to 1.03). STEMI patients with CHB had higher in-hospital mortality than those without CHB (20.4% vs. 8.7%; adjusted OR: 2.47; 95% CI: 2.41 to 2.53). The higher mortality associated with CHB was independent of the location of STEMI; however, the magnitude of this association was greatest in patients with anterior STEMI. In patients with CHB complicating STEMI, although permanent pacemaker implantation rates declined (adjusted OR per year: 0.96; 95% CI: 0.95 to 0.97), in-hospital mortality remained unchanged during the study period (adjusted OR per year: 1.00; 95% CI: 0.99 to 1.01).The incidence of CHB complicating STEMI has increased slightly over the last decade, although the absolute incidence remains quite low. CHB remains associated with higher in-hospital mortality in STEMI patients even in the current era of prompt reperfusion therapy. In patients with CHB complicating STEMI, there was no change in risk-adjusted in-hospital mortality during the study period.

Complete Heart Block as the Sole Presentation of Lyme Disease

We report a case of Lyme myocarditis presenting solely as complete heart block in a previously healthy 32-year-old white man. Indium cardiac antimyosin scan showed diffuse uptake (2+, on a scale of 0 to 4+) during the acute phase of the illness. The electrocardiogram and the indium cardiac antimyosin scan were normal 6 weeks after completion of tetracycline and prednisone treatment. Lyme carditis should be considered in the differential diagnosis of complete heart block of unclear origins, even in patients presenting without other signs or symptoms suggestive of Lyme disease.

Echocardiography and fetal heart sounds in the diagnosis of fetal heart block

A 32-week fetus was demonstrated phonocardiographically and echocardiographically to have a regular atrial rate of 150 per minute and a regular ventricular rate of 39 per minute, indicating complete heart block. The diagnosis was suspected when two groups of heart sounds at two distinct rates were heard on auscultation, and was confirmed by the postnatal ECG. The maternal history was significant for the presence of systemic lupus erythematosus. The basis for the echocardiographic diagnosis of complete heart block, the presence of atrial heart sounds in complete heart block, and the relationship of maternal SLE to congenital heart block are discussed.

Complete heart block: procrastination suggested in using pacemaker.

To the Editor.— Complete heart block is a relative uncommon finding. During the past ten years, 15 patients having a diagnosis of complete heart block were admitted to this hospital. This is an incidence of about 0.05% in 30,805 consecutive admissions. The present study was initiated primarily because it seemed that most of the patients, who had a diagnosis of complete heart block, did well on medical management alone, whereas many reports have described large numbers of patients who received pacemakers. In order to evaluate complete heart block in this hospital, the electrocardiograms of all patients recorded during the preceding ten years—20,000 in number—were reviewed. There were 15 instances of complete heart block. The records and ECGs of these patients were carefully examined to determine (1) what happened to the patient; (2) what happened to the complete heart block; (3) the etiology of the complete heart block; and (4) the

PRENATAL DIAGNOSIS OF COMPLETE CONGENITAL HEART BLOCK

About seventy cases of congenital heart block have been recorded. Yater's 1 review of cases prior to 1929 included only thirty cases of well established block. The criteria used by him and in subsequent reviews were auriculoventricular dissociation proved by a graphic method in a relatively young person, development of bradycardia at a fairly early age, and absence of a history of infection which might cause heart block. In 1934 Hays 2 collected twelve additional cases. Since then about twenty-six additional cases have been reported. The age at which the diagnosis of heart block has been made varies from birth up to 20 years. Only five cases including our case have been diagnosed before birth. Yater, 1 Witt, 3 Heubner 4 and Ottow 5 have made a prenatal diagnosis of complete heartblock. The diagnosis of heart block before birth has also been made by White, Eustis and Kerr, 6

VISUAL METHODS IN DIAGNOSIS OF HEART-BLOCK.II. A REPLY.

In availing myself of the opportunity of making a rejoinder to Dr. Hirschfelder's criticism of my recent communication I wish first to say that I think his criticism is partly right and partly wrong. The diagnosis of complete heart-block with the auricle beating four or five times as fast as the ventricle can undoubtedly, as he says, be made without instruments of any kind. In partial heart-block, however, which probably always precedes the complete form, the problem is entirely different. We may not have bradycardia in these cases, but only an irregularity caused by an occasional "block" of the auricular impulse. These cases, the recognition of which is so important, can scarcely be detected without the aid of suitable instruments. It might, of course, be possible in favorable cases to<i>feel</i>an omission of the radial pulse or apex beat and<i>see</i>that a conspicuous venous pulsation continued without interruption.