Left Anterior Hemiblock Research Articles

Myocardial Injury in Patients With Acute and Subacute Chagas Disease in the Brazilian Amazon Using Cardiovascular MagneticResonance.

BackgroundChagas disease is a neglected tropical disease that is still considered a global health emergency. In the Amazon region, most of the reports are of acute cases that are associated with oral transmission. This study aimed to evaluate myocardial injury in patients with acute Chagas disease before and after treatment.Methods and ResultsWe evaluated 23 patients with acute Chagas disease in 3 different stages of progression. Group 1 had 12 patients evaluated during the acute phase, at the time of diagnosis, and 1 year after treatment, and Group 2 had 11 patients in the late postacute phase who were evaluated 5.2 years on average after diagnosis and treatment. ECGs with the Selvester score, 24‐hour Holter exam, and cardiovascular magnetic resonance imaging were performed. The mean age of the 23 patients was 44.3±18.9 years, and they were mostly men (15/65.24%) from Amazonas state (22/95.6%). In 69.6% (n=16) of the patients, some ECG alterations were found, the most frequent being left anterior fascicular block and ventricular repolarization. In Group 1, the 24‐hour Holter exam showed atrial tachycardia in 3 (25%) patients and ventricular extrasystoles in 2 (16.7%) patients. In Group 2, 1 patient had ventricular extrasystoles. Myocardial injury was observed in 7 patients (58.3%) at the acute phase and in 5 (50%) patients at the 1‐year follow‐up in Group 1 and in 2 (18.2%) patients in Group 2.ConclusionsThis article describes, for the first time, myocardial injury shown by cardiovascular magnetic resonance imaging in a group of patients with acute Chagas disease and reveals the importance of early detection and follow‐up of the cardiac impairment in these patients.

P319 SOMETHING MORE OF SIMPLE CARDIAC CONDUCTION DISORDERS

Abstract Background Cardiac amyloidosis (CA) is an infiltrative disease caused by extracellular deposition of amyloid fibrils. Possible cardiac manifestations include heart failure with preserved ejection fraction (EF), aortic valve stenosis, microvascular coronary artery disease, atrial fibrillation (AF), ventricular arrhythmias, and cardiac conduction disorders (CCD). We report a case of advanced CCD in a patient first diagnosed with wild–type transthyretin amyloidosis (ATTRwt). Case Report An 88–year–old man went to Emergency Room for chest pain with minimal elevation of troponin I and increase in NTproBNP. The patient reported a recent syncope with ribs fractures. The medical history showed hypertension, paroxysmal AF, carotid atherosclerosis, vascular encephalopathy and prostate cancer. Troponin I monitoring showed plateau values and there were no clinical signs of heart failure. ECG showed regular sinus rhythm with marked first degree atrioventricular block, right bundle branch block and left anterior fascicular block (Fig. 1A). Cardiac telemetry recorded brief phases of atrioventricular dissociation (AVD). Transthoracic echocardiography showed severe left ventricular concentric hypertrophy (LVCH) with granular–sparkling appearance and preserved EF, reduced global longitudinal strain with apical sparing (Fig. 1B), mitral–aortic valve degeneration and dilation of the ascending aorta. Given the advanced CCD with AVD and the recent syncope, the patient underwent a dual–chamber pacemaker implantation. In consideration of the echocardiographic suspicion of CA, following Gillmore’s diagnostic algorithm (GDA), serum electrophoresis and assay of serum free light chains were performed and resulted normal, while 99mTc–DPD bone scintigraphy was positive for significant radiotracer cardiac uptake (Perugini grade 3) (Fig. 1C). Based on this result, we carried out the search for transthyretin gene mutations which resulted negative, and therefore the diagnosis of ATTRwt was made. Discussion Advanced CCD in patients with transthyretin CA are present in about 9.5% of cases at the time of diagnosis, especially in older patients. It is therefore essential, in case of concomitant LVCH, to suspect the presence of CA as the cause of CCD by searching for the disease red flags and following the GDA to non–invasively confirm or exclude the diagnosis of CA. A correct and timely diagnosis of CA makes it possible to treat the disease and its complications, improving the prognosis.

Predicting permanent pacemaker implantation following transcatheter aortic valve replacement: A contemporary meta-analysis of 981,168 patients.

BackgroundHeart block requiring permanent pacemaker (PPM) implantation is a relatively frequent complication of transcatheter aortic valve replacement (TAVR).ObjectiveThe purpose of this study was to perform a contemporary meta-analysis to provide an updated assessment of clinically useful predictors of PPM implantation post-TAVR.MethodsMedline and EMBASE searches were performed to include all studies reporting PPM post-TAVR between 2015 and 2020. Pertinent data were extracted from the studies for further analysis. RevMan was used to create forest plots and calculate risk ratios (RRs).ResultsWe evaluated 41 variables from 239 studies with a total of 981,168 patients. From this cohort, 17.4% received a PPM following TAVR. Strong predictors for PPM implant were right bundle branch block (RBBB) (RR 3.12; P <.001) and bifascicular block (RR 2.40; P = .002). Intermediate factors were chronic kidney disease (CKD) (RR 1.53; P <.0001) and first-degree atrioventricular block (FDAVB) (RR 1.44; P <.001). Weak factors (RR 1–1.50; P <.05) were male gender, age ≥80 years, body mass index ≥25, diabetes mellitus (DM), atrial fibrillation (AF), and left anterior fascicular block (LAFB). These factors along with increased left ventricular outflow tract (LVOT) area (>435 mm2) and/or aortic annulus diameter (>24.4 mm) were incorporated to propose a new scoring system to stratify patients into high- and low-risk groups.ConclusionMale gender, age ≥80 years, FDAVB, RBBB, AF, DM, CKD, Medtronic CoreValve, transfemoral TAVR, increased LVOT, and aortic annulus diameter were significant predictors of post-TAVR PPM implantation. Preprocedural assessment should consider these factors to guide clinical decision-making before TAVR. Validation of our scoring system is warranted.

Risk of conduction disturbances following different transcatheter aortic valve prostheses: the role of aortic valve calcifications.

OBJECTIVESTo assess the impact of prosthesis choice and aortic valve calcifications on the occurrence of conduction disturbances after transcatheter aortic valve implantation (TAVI).METHODSWe retrospectively analyzed the preoperative clinical characteristics, electrocardiograms, contrast-enhanced multidetector computed tomography scans and procedural strategies of patients who underwent TAVI in our center between January 2012 and June 2017. Quantification of calcium volume was performed for each aortic cusp above (aortic valve) and below (left ventricular outflow tract, LVOT) the basal plane. Multivariate analysis was performed to evaluate risk factors for the onset of new bundle branch block (BBB), transient and permanent atrioventricular block (tAVB, pAVB).RESULTSA total of 569 patients were included in the study. Six different prostheses were implanted (Edwards Sapien XT, n = 162; Edwards Sapien 3, n = 240; Medtronic CoreValve, n = 27; Medtronic CoreValve Evolut R, n = 21; Symetis Acurate, n = 56; Symetis Acurate neo, n = 63). The logistic regression analysis for BBB showed association with baseline left anterior hemiblock. The logistic regression for tAVB, found the prior valvuloplasty and the balloon post-dilatation associated with the outcome. Baseline left and right BBB, degree of oversizing, and LVOT calcification beneath the non-coronary cusp were associated with pAVB. Neither the prosthesis model, nor the use of a self-expandable prosthesis showed statistical significance with the above-mentioned outcomes on univariate analysis. CONCLUSIONSLVOT calcification beneath the non-coronary cusp, baseline left anterior hemiblock, right BBB, balloon post-dilatation, prior valvuloplasty and oversizing are independently associated with postprocedural conduction disturbances after TAVI. Use of a self-expandable prosthesis may show a lower incidence of AVB, if applied in lower calcified aortic valves.

Electrocardiogram abnormalities in chronic Chagas cardiomyopathy correlate with scar mass and left ventricular dysfunction as assessed by cardiac magnetic resonance imaging

Electrocardiographic (ECG) abnormalities are frequently identified in Chronic Chagas cardiomyopathy (CCC) patients and advanced abnormalities are related to a worse prognosis. Cardiac Magnetic Resonance (CMR) can precisely assess ventricular systolic dysfunction and quantify myocardial fibrosis (MF), both identified as prognostic factors. We sought to investigate if ECG abnormalities in CCC patients were associated with more severe myocardial involvement as evaluated by CMR. MethodsCCC patients with 12‑lead ECG and CMR closely obtained were included. ECG analysis evaluated rhythm, presence, and type of intraventricular conduction disturbances (IVCD) and, ventricular premature beats (VPB). CMR short-axis cine and late gadolinium enhancement images were evaluated to obtain left and right ventricular ejection fractions and MF mass, respectively. Statistical significance was set in 5%. Results194 CCC patients (98 women, 56 ± 14 years) were evaluated, and no IVCD was detected in 71. The most common IVCD was the association of right bundle branch block and left anterior fascicular block (RBBB+LAFB) in 58 patients, followed by isolated RBBB in 34, isolated LAFB in 17, and left bundle branch block (LBBB) in 14 patients. Of patients with no IVCD, 63% had MF and the burden of fibrosis (no IVCD - 7.4 ± 8.6%; RBBB - 6.6 ± 6.5%; p = 1.00), as well as left ventricular ejection fraction (LVEF) (no IVCD - 52 ± 14%; RBBB - 55 ± 10%; p = 1.00) were similar to patients with isolated RBBB. Left conduction system impairment was associated with lower LVEF (LAFB - 39 ± 15%; RBBB+LAFB- 41 ± 15%; and LBBB - 35 ± 15%; p < 0.001) and more MF (RBBB+LAFB - 12.2 ± 10.4%; LBBB - 10.6 ± 7.5%; and LAFB - 12.0 ± 7.0%; p < 0.001). The univariable model showed that the presence of MF was related to RBBB+LAFB (OR 5.0; p = 0.001) and VPB (OR 6.3; p = 0.014). After adjustment for age, gender, and different risk factors in a multivariable model, the same findings were still significantly related to CMR myocardial fibrosis (RBBB+LAFB OR 5.0; p = 0.002 / VPB OR 6.9; p = 0.015). ConclusionsECG without IVCD does not exclude serious cardiac abnormalities in CCC, and isolated RBBB seems to have a benign course. The presence of VPB and left branch conduction impairment, especially LAFB associated with RBBB, indicate a more severe cardiac involvement.

Transitory R wave growth in the midst of ST-segment elevation myocardial infarction: A case of left septal fascicular block with atypical electrocardiographic presentation

We report the case of a patient who presented with angina and ST-segment elevation in the precordial leads owing to a proximal occlusion of the left anterior descending coronary artery. Serial electrocardiography (ECG) showed signs consistent with the left septal fascicular block (LSFB). The latter was observed in conjunction with a pre-existing left anterior fascicular block and presented atypical ECG features, such as intermittent prominent anterior QRS forces (prominent R wave) in V2 only and preserved septal q waves in I and aVL. In the discussion, we present an overview of the electrocardiographic criteria for the diagnosis of the LSFB together with reasons for which LSFB may present with an atypical ECG picture.

Bifascicular Block with Electrocardiographic Sisiisiii Pattern in Mild Covid-19 Pneumonia with Slight Pleural Effusion; Differentiation versus Outcome

Rationale: Cardiovascular and chest involvement in a pandemic COVID-19 virus infection may be vital.Bifascicular heart block is affecting the conduction delay or block below the AVN in two of the three fascicles. There is a correlation between mortality with sudden cardiac death (SCD) and bifascicular block. SISIISIII pattern is meaning that the S-waves of amplitude is more than 1.5 mm in I, II, and III. It is a variable prognostic electrocardiographic finding. Patient concerns: A 67-year-old, retired officer, smoker, married, Egyptian male patient was admitted to the intensive care unit with right bundle branch block, left anterior fascicular block, and mild COVID-19 pneumonia with slight pleural effusion. Diagnosis: Bifascicular block with ECG SISIISIII pattern in mild COVID-19 pneumonia with slight pleural effusion. Interventions: Electrocardiography, oxygenation, non-contrast chest CT, and echocardiography. Outcomes: Good response and better outcomes despite the presence of several remarkable risk factors were the results. Lessons: Associated hypoxia in the current COVID-19 pneumonia may play an essential role in the present new bifascicular heart block. SISIISIII pattern represents a variable prognostic ECG finding such as RVH, pulmonary embolism, and congenital heart disease. The presence of left ventricular septal hypertrophy is considered another risk. The presence of the elderly male sex, heavy smoker, COVID-19 pneumonia, pleural effusion, bifascicular heart block, SISIISIII pattern, and interventricular septal hypertrophy are prognostic factors for the severity of the disease.

BIFASCICULAR BLOCK REVEALING STEINERTS MYOTONIC DYSTROPHY

Steinerts disease or myotonic dystrophy type 1 is a genetic neuromuscular disorder with autosomal dominant transmission. It leads to multisystemic damage, including a cardiac localization that is life-threatening.We report the case of a 55 year old patient, without cardiovascular risk factors, with a history of distal muscle damage since the age of 25 years, in his family history we find a brother followed for an unlabelled skeletal muscle damage.He consulted for exertional dyspnea and lipothymic discomfort. The clinical examination revealed a decrease in muscle strength in the lower limbs with amyotrophy. Walking is difficult with the help of crutches and the patient uses a wheelchair. The neurological investigation concluded in Steinerts myotonic dystrophy on the electromyogram.The patients ECG showed a bifascicular block consisting of a left anterior hemiblock and a complete right bundle branch block. The echocardiography did not show any structural abnormalities but found a disturbance of the LV relaxation on the mitral profile.The electrophysiological exploration carried out for the measurement of infrahisical conduction revealed a long HV at 100ms indicating the implantation of a double chamber stimulation.The interest of reporting this case was to underline the importance of screening for cardiac damage of rhythmic origin. But also to inform with the help of literature data the incidence of these forms and the place of cardiac stimulation in the prevention of sudden death in steinerts myotonia.

Sex-Related Differences in Patients With Unexplained Syncope and Bundle Branch Block: Lower Risk of AV Block and Lesser Need for Cardiac Pacing in Women.

ObjectiveTo analyze if there are sex-related differences in patients with unexplained syncope and bundle branch block (BBB).BackgroundDespite increasing awareness that sex is a major determinant of the incidence, etiology, and the outcomes of different arrhythmias, no studies have examined differences in presentation and outcomes between men and women with syncope and BBB.MethodsCohort study of consecutive patients with unexplained syncope and BBB was included from January 2010 to January 2021 with a median follow-up time of 3.4 years [interquartile range (IQR) 1.7–6.0 years]. They were evaluated by a stepwise workup protocol based on electrophysiological study (EPS) and long-term follow-up with an implantable cardiac monitor (ICM).ResultsOf the 443 patients included in the study, 165 (37.2%) were women. Compared with men, women had less diabetes (25.5 vs. 39.9%, p = 0.002) and less history of ischemic heart disease (IHD; 13.3 vs. 25.9%, p = 0.002). Left bundle branch block (LBBB) was more frequent in women (55.2 vs. 27.7%, p < 0.001) while right bundle branch block (RBBB) was more frequent in men (41.5 vs. 67.7%, p < 0.001). His to ventricle (HV) interval in the EPS was shorter in women (58 ms [IQR 52–71] vs. 60 ms [IQR 52–73], p = 0.035) and less women had an HV interval longer than 70 ms (28.5 vs. 38.1%, p = 0.039), however, EPS and ICM offered a similar diagnostic yield in both sexes (40.6 vs. 48.9% and 48.4% vs. 51.1%, respectively). Women had a lower risk of developing atrioventricular block (AVB) (adjusted odds ratio [OR] 0.44–95% CI 0.26–0.74, p = 0.002) and of requiring permanent pacemaker implantation (adjusted hazard ratio [HR] 0.72–95% CI: 0.52–0.99, p = 0.046). The mortality rate was lower in women (4.5 per 100 person-years [95% CI 3.1–6.4 per 100 person-years] vs. 7.3 per 100 person-years [95% CI 5.9–9.1 per 100 person-years]).ConclusionsCompared to men, women with unexplained syncope and BBB have a lower risk of AVB and of requiring cardiac pacing. A stepwise diagnostic approach has a similar diagnostic yield in both sexes, and it seems appropriate to guide the treatment and avoid unnecessary pacemaker implantation, especially in women.

Fascicular heart blocks and risk of adverse cardiovascular outcomes: Results from a large primary care population.

Fascicular heart blocks can progress to complete heart blocks, but this risk has not been evaluated in a large general population. The purpose of this study was to investigate the association between various types of fascicular blocks diagnosed by electrocardiographic (ECG) readings and the risk of incident higher degree atrioventricular block (AVB), syncope, pacemaker implantation, and death. We studied primary care patients referred for ECG recording between 2001 and 2015. Cox regression models were used to estimate hazard ratios (HRs) as well as absolute risks of cardiovascular outcomes. Of 358,958 primary care patients (median age 54 years; 55% women), 13,636 (3.8%) had any type of fascicular block. Patients were followed up to 15.9 years. We found increasing HRs of incident syncope, pacemaker implantation, and third-degree AVB with increasing complexity of fascicular block. Compared with no block, isolated left anterior fascicular block (LAFB) was associated with 0%-2% increased 10-year risk of developing third-degree AVB (HR 1.6; 95% confidence interval [CI] 1.25-2.05), whereas right bundle branch block combined with LAFB and first-degree AVB was associated with up to 23% increased 10-year risk (HR 11.0; 95% CI 7.7-15.7), depending on age and sex group. Except for left posterior fascicular block (HR 2.09; 95% CI 1.87-2.32), we did not find any relevant associations between fascicular block and death. We found that higher degrees of fascicular blocks were associated with increasing risk of syncope, pacemaker implantation, and complete heart block, but the association with death was negligible.

Perioperative complications following major vascular surgery. Correlations with preoperative clinical, electrocardiographic and echocardiographic features.

Background and aim:We investigated the incidence rate of perioperative complications following major vascular surgery, as well as identified the risk factors and preoperative clinical, electrocardiographic and echocardiographic determinants, related to these complications.Methods:We studied 241 patients with asymptomatic intact abdominal aortic aneurysm (AAA) subjected to open surgical repair, 182 with critical carotid stenosis subjected to endarterectomy (CEA), and 158 with severe symptomatic occlusive peripheral artery disease subjected to aortofemoral bypass (AFB). Preoperatively, all subjects provided a medical history and underwent physical, laboratory examinations, a standard ECG, and transthoracic echocardiography.Results:Overall, the perioperative mortality rate was 1.2%. The highest rate of complications was observed in the AAA group (p<0.01). Cardiac, respiratory, renal, gastrointestinal, and vascular complications were critically higher in the AAAs. Neurological complications were more common in the CEA compared to AAAs (p<0.01). Diabetic decompensation was more frequent in the AFB compared to the others (p<0.05). Mortality was correlated with left atrial enlargement and uricemia (p<0.03 respectively). Cardiac complications were correlated with heart rate (p<0.04), QT interval (p<0.001) and left ventricular mass (p<0.03), pulmonary with high levels of glycaemia (p<0.05) and overt diabetes (p<0.04), while renal insufficiency with hypertension (p<0.03), diabetes (p<0.01), previous myocardial infarction (p<0.01) and left anterior hemiblock (p<0.01), and neurological with hypertension (p<0.04) and overweight (p<0.01).Conclusions:We report a high rate of perioperative complications in vascular patients undergoing surgical revascularization. Cardiac, respiratory, renal, hematological, and gastrointestinal complications were predominant in the AAA group. Mortality appears significantly related to left atrial dimension and uricemia. (www.actabiomedica.it)

Beyond the wrist: Using a smartwatch electrocardiogram to detect electrocardiographic abnormalities

When worn on the wrist, smartwatch electrocardiograms may provide important but incomplete information. We sought to evaluate the added benefit of placing the smartwatch on the ankle and on the chest to diagnose various electrocardiographic abnormalities compared with 12-lead electrocardiograms. Two hundred and sixty patients with (n=189) or without (n=71) known cardiac disorders underwent 12-lead electrocardiogram and smartwatch electrocardiogram recordings of lead I (AW-I) and of leads I and II and pseudo chest leads V1 and V6 (AW-4). AW-I and AW-4 diagnoses (three-cardiologist consensus) were compared with 12-lead electrocardiogram diagnoses (three-cardiologist consensus) to calculate sensitivity and specificity. AW-I showed high accuracy for the diagnoses of atrial fibrillation (96% sensitivity, 91% specificity) and complete bundle branch block (85% sensitivity, 98% specificity). Compared with AW-I, AW-4 improved detection of an abnormal 12-lead electrocardiogram (91% vs. 80% sensitivity; P<0.01), atrial flutter/tachycardia (69% vs. 25% sensitivity; P=0.04), T-wave abnormalities (77% vs. 34% sensitivity; P<0.01), pathological Q-waves (41% vs. 7% sensitivity; P<0.01) and left anterior hemiblock (70% vs. 0% sensitivity; P=0.02). AW-4 also enabled better differentiation between atrioventricular block and sinus bradycardia (from 81% to 95% correct; P=0.03) and between atrial fibrillation and atrial flutter/tachycardia (from 71% to 89% correct; P=0.02), but not between bundle branch blocks (from 82% to 87% correct; P=0.57). A smartwatch electrocardiogram on the wrist accurately diagnoses atrial fibrillation and bundle branch block. Recording additional leads significantly improves the accuracy of detecting an abnormal electrocardiogram and repolarization changes, and also allows for better differentiation of brady- and tachyarrhythmias.

31 Cardiac magnetic resonance findings in patients with Type 1 myotonic dystrophy

Abstract Aims Heart disease is a major determinant of prognosis in type 1 myotonic dystrophy (DM1), second only to respiratory complications. Cardiac imaging, possibly including cardiac magnetic resonance (CMR), is recommended in patients with DM1. However, limited information is available on CMR findings and their prognostic significance in DM1. Methods and results We identified all patients with DM1 evaluated from 2009 to 2020 in a CMR laboratory with an established collaboration with a Neuromuscular Disorder Unit. Thirty-four patients were retrieved (21 males, aged 45 ± 12). By the time of CMR examination, 90% had neuromuscular symptoms (mean duration 17 ± 13 years), 13 (38%) had previous reports of atrioventricular block (n = 12 1st degree, n = 1 2nd degree type 1), 30 (88%) of intraventricular conduction disturbances (n = 5 left bundle branch block, n = 5 right bundle branch block, n = 3 left anterior fascicular block, n = 17 other non-specific or incomplete intraventricular conduction delay), 4 (12%) of atrial fibrillation or flutter. No patient had a device. At CMR, 5 (15%) patients had left ventricular (LV) systolic dysfunction [LV ejection fraction (LVEF) &amp;lt;50%] and 4 (12%) a depressed right ventricular (RV) function (RVEF &amp;lt;50%). Compared to age- and sex-specific reference values for our laboratory (Figure 1 left), 12 (35%) patients showed a decreased LV end-diastolic volume index (LVEDVi), 7 (21%) a decreased LV mass index (LVMi), and 29 (85%) a decreased LVMi/LVEDVi ratio. Nine (26%) patients had mid-wall late gadolinium enhancement (LGE, mean extent 4.5 ± 2.0% of LVM; n = 8 septal, n = 4 inferolateral, n = 2 inferior, n = 1 anterolateral, see Figure 1 middle), and 14 (41%) some areas of fatty infiltration (n = 9 involving the LV, n = 13 the RV). Native T1 in the interventricular septum (1,041 ± 53 ms) approached the upper reference limit (1089 ms), and the extracellular volume was slightly increased (33 ± 2%, reference values &amp;lt;30%). Over a median follow-up of 2.5 years (interquartile interval: 1.5–4.0), 2 (6%) patients died for infectious and respiratory complications, 5 (15%) underwent device implantation (n = 4 PM; n = 1 ICD), and 4 (12%) had a documentation of high-risk (Lown class ≥4) ventricular ectopic beats (VEBs). Among all CMR variables collected, higher values of LVMi/LVEDVi ratio emerged as univariate predictor of all-cause death (P = 0.044). At logistic regression analysis, anteroseptal wall thickness was associated with the need for device implantation (P = 0.028), while LGE mass was associated with high-risk VEBs (P = 0.026) (Figure 1 right). Conclusions Patients with DM1 display several structural and functional cardiac abnormalities, with variable degrees of cardiac muscle hypotrophy, fibrosis, and fatty infiltration. The possibility to predict the need for device implantation, ventricular arrhythmias, and all-cause or cardiovascular mortality should be verified in larger cohorts.

Abstract 17047: Nintedanib And Cardiomyopathy: A Vascular Failure?

Description of the Case: Patient 1 is a 61-year-old woman with a history of rheumatoid arthritis-related interstitial lung disease (ILD). Six months after initiation of nintedanib, she was diagnosed with new-onset heart failure. Cardiac magnetic resonance imaging (CMR) was consistent with nonischemic cardiomyopathy (NICM) with ejection fraction (EF) of 15-25%. EKG showed new bifascicular block (right bundle branch block and left anterior fascicular block). Nintedanib was discontinued, and four months later, echocardiogram showed recovered EF (50-54%). EKG abnormalities resolved with biventricular pacing. Patient 2 is a 57-year-old-man with a history of scleroderma-related ILD and stable diastolic heart failure (EF = 55-60%). Six months after initiation of nintedanib, he was admitted for heart failure exacerbation. CMR showed NICM with EF = 35%, and EKG showed prolonged QRS (130 ms). Given the rapid progression of cardiomyopathy, nintedanib was discontinued. Discussion: We report two patients with underlying connective tissue disease who developed significant nonischemic cardiomyopathy in temporal association with initiation of nintedanib. Nintedanib is a tyrosine kinase inhibitor, antagonizing three angiogenic signaling pathways mediated by vascular endothelial growth factor receptor (VEGFR), fibroblast growth factor receptor (FGFR), and platelet derived growth factor receptor (PDGFR). The nintedanib-treated cohorts of the TOMORROW and INPULSIS trials for idiopathic pulmonary fibrosis showed a high incidence of myocardial infarction (MI). With the recent SCENSIS trial, nintedanib was approved in 2019 for ILD associated with systemic sclerosis. There are likely multifactorial effects of this triple angiokinase inhibitor, seeing that it inhibits multiple growth factors essential for vascular homeostasis, the balance between mesenchymal and endothelial cell fates. Thus, there may be multiple pathways for cardiomyopathy due to “vascular failure,” including MI and importantly, cardiac fibrosis. Based on our observations, we urge other clinicians to report their experience with nintedanib use in patients with underlying connective tissue disease and to carefully monitor these patients for adverse cardiovascular effects.

Evaluation of the Predictive Value of Left Anterior Fascicular Block on Determination of Left Main and/or Proximal Left Anterior Descending Coronary Artery Disease in Patients with Stable Angina: A Propensity Score Matching Analysis

Evaluation of the Predictive Value of Left Anterior Fascicular Block on Determination of Left Main and/or Proximal Left Anterior Descending Coronary Artery Disease in Patients with Stable Angina: A Propensity Score Matching Analysis

Impact of new-onset left bundle branch block on clinical and echocardiographic outcomes after TAVR with SAPIEN-3 valve

Abstract Background New left bundle branch block (LBBB) is a common finding after transcatheter aortic valve replacement (TAVR) that can result in worse outcomes after TAVR. We aim to investigate the impact of new-onset LBBB after TAVR using the SAPIEN-3 (S3) valve. Methods Consecutive patients who underwent transfemoral-TAVR with S3 valve between April 2015 and December 2018 were included. Exclusion criteria included pre-existing LBBB, right bundle branch block, left anterior hemiblock, left posterior hemiblock, wide QRS ≥120 msec, prior permanent pacemaker (PPM), and non-transfemoral access. Results Among 612 patients, 11.4% developed new-onset LBBB upon discharge. Implantation depth was the only predictor of new-onset LBBB (OR 1.294; 95% CI 1.121–1.493; p&amp;lt;0.001). The median (IQR) length of stay was longer with new-onset LBBB [3 (2–5) days vs. 2 (1–3) days; p&amp;lt;0.001]. New-onset LBBB was associated with higher thirty-day PPM requirement (18.6% vs. 5.4%; p&amp;lt;0.001) including those implanted after discharge (4.3% vs. 0.9%; p=0.02). There was no difference in 3-year all-cause mortality between both groups (30.9% vs. 30.6%; log-rank p=0.829). Further, new-onset LBBB was associated with lower left ventricular ejection fraction (LVEF) at both 30 days (55.9±11.4% vs. 59.3±9%; p=0.026) and 1 year (55±12% vs. 60.1±8.9%; p=0.002) despite no differences at baseline. These changes were still present when we stratified patients according to baseline LVEF (≥50% or &amp;lt;50%). We also noted higher mean LV end-diastolic volume index (51.4±18.6 vs. 46.4±15.1 ml/m2; p=0.036), and LV end-systolic volume index (23.2±14.1 vs. 18.9±9.7 ml/m2; p=0.009) with new-onset LBBB at 1 year. Lastly, there were significantly higher rates of heart failure readmissions at 1 year with new-onset LBBB (10.7% vs. 4.4%; log-rank p=0.033). Conclusion Among our cohort of S3 recipients, new-onset LBBB was associated with higher PPM requirement, worse LVEF, higher LV volumes and increased risk of heart failure hospitalizations. However, it did not affect mortality in the short-to-intermediate post-TAVR period. Funding Acknowledgement Type of funding sources: None. Figure 1. All-cause Survival

S1137 The Impact of Electrocardiogram Parameters on Cardiovascular Complications at Time of Liver Transplantation

Introduction: Electrocardiogram (ECG) is an integral component of cardiovascular assessment in patients evaluated for liver transplant (LT). However, despite its centrality, there is paucity of data linking ECG interval and rhythm assessment to peri-LT cardiovascular events. Methods: In this retrospective study, the ECG of all patients receiving LT at our institution between 2010-2018 (n=651) were reviewed independently by two cardiologists blinded to clinical data according to the Minnesota classification. Primary outcome included cardiac arrest, new-onset cardiac arrythmia or known arrhythmia requiring change in medication that occurred within 4 weeks of LT. Results: The mean age was 56±10 years and consisted mainly of males (n=478) and Whites (n=469). Leading etiology of cirrhosis was hepatitis C (n=276), followed by NASH (n=120) and alcohol-related liver disease (n=104). At LT evaluation, 633 patients were in sinus rhythm, while atrial fibrillation or flutter was present in 18 subjects. The most common abnormal ECG findings included prolonged QTc (n=347), left ventricular hypertrophy (n=58), right bundle branch block (n=28), and left bundle branch block (n=6). Patients with NASH were more likely to have atrial fibrillation/flutter (5.8% vs. 2.1%; p=0.03), interventricular conduction delay (13.3% vs. 5.1%; p=0.003), and left anterior fascicular block (5.8% vs. 1.3%; p=0.007). The likelihood of primary outcome was 17.3% with the most common arrhythmia being atrial fibrillation (n=53, 8.1%), followed by bradycardia (n=22, 3.4%), supraventricular tachycardia (n=10, 1.5%), and sinus tachycardia (n=9, 1.4%). Primary outcome was more common among patients with dyslipidemia (24.3% vs. 15.5%, p=0.01) and CAD (23.6% vs. 15.0%, p=0.008). After adjusting for gender, BMI, beta blocker use, diabetes, dyslipidemia, statin use, and presence of CAD, age (HR 1.06, p=0.001) and male gender (HR 1.97, p=0.04) were associated with increased risk of post-LT arrythmias. While aspirin (HR 0.37, P=0.02) and prolonged QRS (HR 0.49, p=0.04) were associated with lower risk of cardiovascular events. Conclusion: ECG abnormalities are common among patients with cirrhosis, particularly NASH cirrhosis. It is likely perturbation the bio-clinical profile (older, diabetic, obese, electrolyte abnormalities) that predispose them to developing peri-transplant arrhythmias. Well designed mechanistic studies are required to better understand the pathophysiology to implement targeted peri-transplant therapy to mitigate this risk.

Rhythm and Conduct Disorders Associated With Aortic Stenosis: A North African Study

Introduction: The location of the conduction pathways and their intimate anatomical relationship with the aortic valve provide insight into the occurrence of arrhythmias and conduction disorders during aortic stenosis. These disorders have an important prognostic impact. our work proposes to determine and describe the rhythm and conduction disorders encountered in aortic stenosis in a Moroccan population group while recalling the causes and the prognostic and therapeutic impacts of this association. Materials and methods: This is a retrospective study of 148 patients with aortic stenosis hospitalized at the cardiology center of the HMIMV over a period of 24 months during which we analyzed the clinical and electrocardiographic data in order to describe and analyze the rhythm and conduction disorders encountered in this pathology. Statistical analysis was performed with SPSS software, version 18. Results: The mean age of the population was 65 (57, 74) years, the sex ratio was 1.21 with male predominance. Smoking (current or former) reported in 38.5% of patients was the main modifiable cardiovascular risk factor, followed by hypertension in 35.8% of patients. Dyspnea of effort was the most frequent reason for consultation at 81% of which 64% (of these) were at least of the functional class III of the NYHA. Palpitations and lipothymia or syncope accounted for 21% and 16.2% of the series. The aortic stenosis was tight overall with a mean aortic area of 0.8 [O, 6; 1] cm². Aortic stenosis was rarely isolated. In 36% of cases, it was associated with rhythm and conduction disorders. Among these disorders, atrial fibrillation was the most frequent (36.5%), followed by left anterior hemiblock (17%), LBBB (13.5%) and RBBB (9.5%). Finally there was 9.4% of complete atrioventricular block. Conclusion: The occurrence of arrhythmias and conduction disorders during aortic stenosis is frequent and due to multifactorial mechanism. In the literature, their prevalence is variable ......

Trypanocidal therapy among children infected by Trypanosoma cruzi. Serological and electrocardiographic changes over a mean twenty-five-years follow-up period

This study compared the serological and electrocardiographic evolution among patients with chronic T. cruzi infection treated during childhood or left untreated. A retrospective cohort study was conducted during a mean follow-up period of 25 years in 82 patients: half of them underwent treatment (nifurtimox 8, benznidazole 33) before being 15 years old, whereas the other half remained untreated. During the follow-up, negative seroconversion occurred in 92.7% of the treated children, while all the untreated ones remained positive for conventional serology. At baseline, 2 patients from each group had electrocardiographic abnormalities. During the study period, 4/41 (9.75%) and 9/41 (21.95%) of treated and untreated patients displayed an altered electrocardiogram, respectively. In multivariate analyses, the probability of developing electrocardiographic abnormalities was significantly reduced among treated patients (OR = 0.18, 95% CI = 0.04-0.79; p = 0.023). Electrocardiographic abnormalities attributable to Chagas cardiomyopathy were seen in 3 patients from the untreated group (complete right bundle branch block + left anterior fascicular block, frequent ventricular extrasystole, and left anterior fascicular block). The remarkable seronegativization seen in Benznidazole and Nifurtimox recipients underlines the parasiticidal effect of both compounds. Such demonstration along with the fact that CCC-related alterations were only present in the untreated group, reinforces the view of trypanocidal treatment in chronically T. cruzi-infected children as decreasing the risk for cardiomyopathy development.

Predictors of Permanent Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement - A Systematic Review and Meta-Analysis.

BackgroundAs transcatheter aortic valve replacement (TAVR) technology expands to healthy and lower‐risk populations, the burden and predictors of procedure‐related complications including the need for permanent pacemaker (PPM) implantation needs to be identified.Methods and ResultsDigital databases were systematically searched to identify studies reporting the incidence of PPM implantation after TAVR. A random‐ and fixed‐effects model was used to calculate unadjusted odds ratios (OR) for all predictors. A total of 78 studies, recruiting 31 261 patients were included in the final analysis. Overall, 6212 patients required a PPM, with a mean of 18.9% PPM per study and net rate ranging from 0.16% to 51%. The pooled estimates on a random‐effects model indicated significantly higher odds of post‐TAVR PPM implantation for men (OR, 1.16; 95% CI, 1.04–1.28); for patients with baseline mobitz type‐1 second‐degree atrioventricular block (OR, 3.13; 95% CI, 1.64–5.93), left anterior hemiblock (OR, 1.43; 95% CI, 1.09–1.86), bifascicular block (OR, 2.59; 95% CI, 1.52–4.42), right bundle‐branch block (OR, 2.48; 95% CI, 2.17–2.83), and for periprocedural atriorventricular block (OR, 4.17; 95% CI, 2.69–6.46). The mechanically expandable valves had 1.44 (95% CI, 1.18–1.76), while self‐expandable valves had 1.93 (95% CI, 1.42–2.63) fold higher odds of PPM requirement compared with self‐expandable and balloon‐expandable valves, respectively.ConclusionsMale sex, baseline atrioventricular conduction delays, intraprocedural atrioventricular block, and use of mechanically expandable and self‐expanding prosthesis served as positive predictors of PPM implantation in patients undergoing TAVR.