Onset Of Complete Heart Block Research Articles

Anesthetic challenges in a pregnant patient with post mitral valve replacement, complete heart block, and coagulopathy coming for emergency cesarean section: A case report

A 24-year-old primigravida with a history of rheumatic heart disease and prosthetic mitral valve on oral anticoagulation who was lost follow-up during the third trimester presented with premature rupture of membranes. On evaluation, she had new-onset complete heart block. She was temporarily paced but developed cardiac failure. Anesthetic challenges and management of this parturient with post mitral valve replacement, complete heart block, and warfarin-induced coagulopathy for emergency cesarean delivery are discussed in this case report. Ours is the first case report of a pregnant patient with new onset of complete heart block during pregnancy several years after mitral valve replacement.

Genotypic and phenotypic predictors of complete heart block and recovery of conduction after surgical repair of congenital heart disease

Complete heart block (CHB) is a major complication that occurs after congenital heart surgery. We hypothesized that genetic and clinical factors are associated with the development of postoperative CHB and recovery of atrioventricular (AV) conduction. The purpose of this study was to identify predictors of CHB and recovery after congenital heart surgery. Patients undergoing congenital heart surgery at our institution from September 2007 through June 2015 were prospectively enrolled in a parent study of postoperative arrhythmias. Patients with onset of CHB within 48 hours postoperatively were included in the study. Daily rhythm assessment was performed until demonstration of 1:1 conduction or pacemaker implantation. Of 1199 subjects enrolled, 56 (4.7%) developed postoperative CHB. In multivariate analysis, preoperative digoxin exposure (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.3-4.4), aortic cross-clamp time (OR 1.08, 95% CI 1.04-1.11), ventricular septal defect closure (OR 2.2, 95% CI 1.2-4.1), and a common polymorphism in the gene encoding connexin-40 (GJA5 rs10465885 TT genotype; OR 2.1, 95% CI 1.2-3.8) were independently associated with postoperative CHB. Junctional acceleration (JA) (OR 4.0, 95% CI 1.1-15.1) and intermittent conduction noted during complete AV block (OR 9.1, 95% CI 1.0-80) were independently associated with 1:1 AV conduction recovery. Use of a multivariate model including both JA and intermittent conduction demonstrated good discrimination with a positive predictive value of 86% (95% CI 67%-96%) in predicting 1:1 conduction recovery. Preoperative factors, including a missense polymorphism in GJA5, are independently associated with increased risk for CHB. JA and intermittent conduction may prove useful in predicting recovery of AV conduction among patients with CHB after congenital heart surgery.

Abstract 9589: Conduction Abnormalities in Pediatric Patients with Restrictive Cardiomyopathy

Introduction: Pediatric restrictive cardiomyopathy (RCM) carries a poor prognosis secondary to a high risk of sudden cardiac death. Sudden death in pediatric patients has previously been attributed to ventricular tachyarrhythmias. There are many reasons why patients with RCM might develop conduction system disease and it is conceivable that in the acute setting, this might be a triggering event for sudden death. Methods: A single center, retrospective chort of pediatric patients with RCM, diagnosed between April 1994 and April 2011 was analyzed for conduction system abnormalities and potential triggering events for sudden death. Patient demographic, cardiac and electrocardiographic characteristics were reviewed. Incidence of sudden cardiac events was determined (defined as death or an episode of acute hemodynamic compromise felt to be secondary to a cardiac arrhythmia). Non-parametric statistical methods were used to determine associations between clinical characteristics and sudden cardiac events. Results: Fifteen patients (1 - 17 years) were reviewed; there were 5 sudden cardiac events including 4 deaths. Two of the deaths were precipitated by the abrupt onset of complete heart block. Another patient with syncope had intermittent heart block and survived as a result of the defibrillator pacing features. Sudden cardiac events were statistically associated with an older age ( p <0.01 ). On initial presentation, the median PR interval (222 vs. 140 msec; p < 0.01 ) and the median QRS duration (111 vs. 73.5; p = 0.01 ) was significantly longer in those having an acute cardiac event. No other functional or echocardiographic variables were associated with a sudden cardiac event. Conclusion: Pediatric patients with RCM are at risk for acute high grade heart block and bradycardic events may represent a significant portion of all arrhythmic events. Since PR interval prolongation and wider QRS complex were associated with acute cardiac events, these findings suggest increased monitoring for bradyarrhythmic episodes with consideration for prophylactic pacemaker implantation in certain patients. Particular care should be taken in patients with RCM and evidence of conduction system disease.

Late Onset of Heart Block After Open Heart Surgery for Congenital Heart Disease

Late onset of complete heart block is a potentially dangerous complication after open heart surgery for congenital heart disease. The characteristics of patients with late-onset heart block have not been well described. A retrospective review of a pacemaker database was done to identify patients who presented with new onset heart block between 1988 and 2006, after they had been discharged from the hospital after open heart surgery with normal AV conduction. Fifteen patients were identified. The age at the time of the last surgery before the onset of heart block was 2.0 +/- 3.2 years (range: 3 days to 10 years). Nine had a ventricular septal defect repair, four had an atrioventricular canal, and two other patients had other types of heart defect. The last EKG available for analysis before the onset of heart block had been obtained 5.1 +/- 6.5 years (range: 7 days to 16 years) after surgery. The symptoms at the time of presentation were variable. Four patients presented with fatigue or exercise intolerance, two with syncope, two with congestive heart failure, and one with irritability, and the remaining six patients were diagnosed during routine follow-up. The time between open heart surgery and placement of a permanent pacemaker was 6.8 +/- 7.3 years (range: 2 months to 19 years). There were seven patients in whom the onset of heart block was more than 6 years after surgery. Late onset of complete heart block after open heart surgery could be dangerous when presenting without warning. These data would support the notion that patients should be followed for life after repair of congenital heart defects, with special attention to the conduction system, particularly after repair of septal defects.

Impact of PercuSurge GuardWire Device on Prevention and Reduction of Recovery Time From Complete Heart Block in Patients With Acute Inferior Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Second-degree heart block or complete heart block (CHB) is a relatively frequent complication of acute inferior wall myocardial infarction (AIWMI). This study investigated whether the PercuSurge device can prevent procedure-related CHB or can shorten CHB recovery time in patients with AIWMI undergoing primary percutaneous coronary intervention (PCI). Between May 2002 and April 2005, a PercuSurge device was utilized in 113 patients (study population, group 1) with AIWMI due to obstruction of the right coronary artery (RCA) with a reference lumen diameter (RLD) > or = 3.5 mm. The control subjects (group 2) consisted of 119 patients who experienced AIWMI due to RCA obstruction with a RLD > or = 3.5 mm from May 2000 to April 2002. The combined incidence of new onset of CHB following the interventional procedure was significantly higher in group 2 than in group 1. Additionally, recovery time from CHB to first-degree heart block or normal sinus rhythm was remarkably longer in group 2 than in group 1. Furthermore, the duration of hospitalization in group 2 was significantly longer than in group 1. Multiple stepwise analyses demonstrated that the PercuSurge device was the only independent predictor of preventing new onset of CHB during the procedure. Additionally, this mechanical device along with final TIMI-3 flow and final myocardial blush grade > or = 2 was independently associated with reducing recovery time from CHB. In conclusion, the PercuSurge device can prevent procedure-related CHB and shorten the recovery time for CHB in patients with AIWMI undergoing primary PCI.

Early onset of complete heart block in Pearson syndrome

Journal of Inherited Metabolic DiseaseVolume 23, Issue 7 p. 753-754 Article Early onset of complete heart block in Pearson syndrome S. Rahman, S. Rahman Biochemistry, Endocrinology and Metabolism Unit, Institute of Child Health, 30 Guilford Street, London, WC1N 1EN UKSearch for more papers by this authorJ. V. Leonard, J. V. Leonard Biochemistry, Endocrinology and Metabolism Unit, Institute of Child Health, 30 Guilford Street, London, WC1N 1EN UKSearch for more papers by this author S. Rahman, S. Rahman Biochemistry, Endocrinology and Metabolism Unit, Institute of Child Health, 30 Guilford Street, London, WC1N 1EN UKSearch for more papers by this authorJ. V. Leonard, J. V. Leonard Biochemistry, Endocrinology and Metabolism Unit, Institute of Child Health, 30 Guilford Street, London, WC1N 1EN UKSearch for more papers by this author First published: 01 November 2000 https://doi.org/10.1023/A:1005611803306Citations: 6AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume23, Issue7November 2000Pages 753-754 RelatedInformation

Congenitally corrected transposition of the great arteries: clinical features, diagnosis and prognosis

Congenitally corrected transposition of the great vessels occurs rarely with an incidence of approximately 0.02 per 1000 live births. Two embryologic errors, atrioventricular discordance and ventriculo-arterial discordance, result in physiologically corrected blood flow. Although some patients may present without additional cardiac anomalies, commonly associated lesions include complete heart block, ventricular septal defect, pulmonary stenosis and tricuspid valve anatomic abnormalities which can result in tricuspid regurgitation. Distinguishing features of clinical presentation, physical exam, electrocardiogram and chest X-ray are detailed. Diagnosis can currently be made non-invasively by echocardiography, including fetal, transthoracic and transesophageal modalities. Cardiac catheterization carries a significant risk of the induction of temporary or permanent complete heart block and is therefore only indicated for hemodynamic, electrophysiologic and angiographic assessment of associated abnormalities in symptomatic individuals when surgical intervention is anticipated. Prognosis for patients with corrected transposition of the great vessels depends on the severity of associated lesions. Since the onset of complete heart block occurs at a rate of 2% per year, and arrhythmia-related deaths are not uncommon, early pacemaker placement is indicated. Concern regarding the ability of the right ventricle to function as the long-term systemic pump has led to the recent concept of double switch repair as opposed to intracardiac repair of associated lesions, particularly in those patients with systemic right ventricular failure and tricuspid regurgitation. Due to the complexity of this congenital heart defect, recommendations for intervention must remain highly individualized.

DUAL‐CHAMBER PACING VIA A PERSISTENT LEFT SUPERIOR VENA CAVA IN A PATIENT WITH TURNER'S SYNDROME

SUMMARY Persistent left superior vena cava often occurs with other cardiovascular malformations, and may complicate positioning of intravenous pacing electrodes. The previously unreported association with coarctation of the aorta and Turner's syndrome is documented in a 50‐year‐old patient needing a dual‐chamber pacemaker after the onset of complete heart block.

Prognostic factors in atrioventricular block complicating acute myocardial infarction.

Summary: Atrioventricular block (A-V block) was documented in 150 (13.8%) of 1083 patients with acute myocardial infarction. Those with A-V block differed significantly from the remainder, being older, having higher peak levels of serum lactic dehydrogenase and a greater incidence of left ventricular failure and of death in hospital. These differences were due mainly to the inclusion of 90 patients with complete heart block (CHB). Among those patients whose CHB complicated anterior infarction there was a significantly greater incidence of previous infarction. Lesser grades of A-V block and right bundle branch block (RBBB) commonly heralded the onset of CHB, which occurred more frequently in those with inferior infarction. Markers of death in those with CHB were anterior infarction, RBBB, and a slow subsidiary pacemaker with a wide ventricular complex. Pacing is recommended for all patients with CHB and for those with RBBB; the reasons for this are presented in detail.

Late onset complete heart block: Newly recognized sequela of cardiac surgery

Two children who had undergone definitive repair of tetralogy of Fallot suddenly had sustained complete heart block 3 and 4 years, respectively, after operation. Review of the literature and a nationwide survey revealed similar experiences in additional 18 cases. Ten of the patients had tetralogy of Fallot, 5 had endocardial cushion defects, 4 had isolated ventricular septal defects, and 1 had transposition of the great vessels. The interval between time of operation and documentation of the block ranged from 1 month to 14 years. The data indicate a need for careful evaluation of postoperative conduction disturbances. Delayed onset of complete heart block is a possibility in all patients but particularly in those with evidence of damage to one or both bundle branches.

Complete bundle-branch block complicating acute myocardial infarction.

Bundle-branch block complicated 68 out of 806 cases of acute myocardial infarction managed in a coronary-care unit and was associated with a mortality of 56 per cent. Twenty-five out of 48 patients with right-bundle-branch block, and 13 of 20 patients with left-bundle-branch block died. In 21 of the 68 patients complete heart block subsequently developed, and in 13 of these an idioventricular pacemaker failed to emerge. Bilateral bundle-branch block preceded the onset of complete heart block in 15 patients. Transvenous pacing electrodes were inserted prophylactically in the last 31 consecutive cases of bundle-branch block. This procedure was associated with a high proportion of life-threatening arrhythmias, and pacing did not reduce subsequent mortality in the nine patients in whom complete heart block developed.

Complete heart block in acute myocardial infarction: A clinical evaluation of the intracardiac bipolar catheter pacemaker

The incidence of complete heart block is probably greater than recognized in earlier studies. It is suggested that modern technics of constant cardiac monitoring would indicate that the discrepancy could have resulted from at least two sources. Complete heart block may be transient in some patients and appear to be of little consequence. However, patients presenting in this manner may be more likely to have periods of asystole later in the hospital course. The ability to immediately re-institute electrical pacing may be lifesaving. The onset of complete heart block may be closely followed by cardiac arrest during the interval preceding establishment of a lower intrinsic pacemaker. Periodic electrocardiograms would be unlikely to document complete heart block in either of these circumstances. Complete heart block occurs most frequently in infarctions resulting from occlusion of the right coronary artery associated with the electrocardiographic picture of inferior infarction. Complete heart block developing in the setting of acute myocardial infarction frequently is accompanied by other complications of infarction, especially congestive heart failure and shock. This combination results in an especially poor prognosis. The absence of congestive heart failure was the best prognostic sign in our series of patients, being associated with no mortality. Patients without shock had a 28 per cent mortality, and patients without cardiac arrest, a mortality of 29 per cent. Cardiac arrest poses a serious threat to survival. The insertion of a pacemaker catheter within 15 minutes after onset of complete heart block will reduce the incidence of this complication. Pacemaker insertion is not a benign procedure in the setting of acute myocardial infarction. The type of catheter currently in use can be difficult to manipulate and may cause significant arrhythmias during insertion. This technic also requires movement of the patient to nonpatient areas for visualization of the catheter during insertion. This is usually at a time in the course of infarction when as little movement as possible is desirable. For these reasons, we currently consider it to be in the best interest of the patient not to insert a pacemaker catheter unless complete heart block intervenes. Second degree heart block was noted to develop in about 8.7 per cent of all of our patients with acute infarction; less than half of these went into complete heart block. On the other hand, 2 patients were documented to develop complete heart block directly from normal sinus rhythm. When intracardiac catheter stimulation is utilized, the patient is not aware of artificial pacing, and the use of the external jugular system allows the patient complete freedom of movement during pacing. The incidence of complete heart block persisting in survivors of our study is greater than previously reported. This probably represents the survival of patients who would otherwise have succumbed from atrioventricular nodal infarction. Modern methods of management preclude the acceptance of “death” as an end-point in acute myocardial infarction. Thirty-seven per cent of patients suffering cardiac arrest after complete heart block developed in myocardial infarction survived their infarction to return to normal life. The role of an intracardiac catheter pacemaker was felt to be essential in a significant number of these patients. The role of the catheter pacemaker as a preventive measure against cardiac arrest would also appear valuable provided its use is limited to certain clinical situations. At present it would appear to be a useful adjunct in patients who experience complete heart block during acute myocardial infarction, provided proper facilities are available for insertion and that the physician is adept in handling problems that may arise during insertion or while the catheter is in place inside the heart.