Right Bundle Branch Block Research Articles

Impact of Quantitative ST-T Analysis in Patients With Suspected Myocardial Infarction Presenting With Right Bundle Branch Block

BackgroundWhile left bundle branch block (LBBB) is a well-known risk feature in patients with acute myocardial infarction, and a rapid invasive management is recommended, data supporting this strategy for patients with right bundle branch block (RBBB) is less robust. MethodsIn total, 2139 patients with suspected ST-elevation myocardial infarction (STEMI) were triaged to acute coronary angiography based on a prehospital 12-lead electrocardiogram (ECG). Sensitivity and specificity for STEMI-ECG criteria were compared in RBBB and non-BBB patients. Adjusted hazard ratios for 1-year overall mortality were computed. ResultsSTEMI was adjudicated in 1832/2139 (85.6%) of all patients and in 102/117 (87.2%) of RBBB patients. ST-segment deviation followed typical ST-T patterns in most RBBB patients. Of 17 RBBB patients without significant ST changes, STEMI was adjudicated in 14 (82%). Diagnostic accuracy of STEMI criteria was comparable in RBBB and non-RBBB patients for inferior (sensitivity: 51.1% vs 59.1%, P = .14; specificity: 66.7% vs 52.1%, P = .33) and anterior STEMI (sensitivity: 35.2% vs 36.6%, P = .80; specificity: 58.3% vs 49.5%, P = .55). Diagnostic performance was lower for lateral STEMI in RBBB patients (sensitivity: 14.8% vs 4.4%, P = .001; specificity: 75.0% vs 98.4%, P < .001). Patients with RBBB had higher 1-year mortality compared with non-BBB patients (hazard ratio 2.3%; 95% confidence interval, 1.25-4.21. ConclusionECG criteria used for detection of STEMI showed comparable diagnostic accuracy in RBBB and non-BBB patients. However, STEMI was frequently present in RBBB patients not fulfilling diagnostic ECG criteria. RBBB patients showed poorer outcome after 1 year. Consequently, the presence of RBBB in suspected STEMI cases signifies a high-risk feature, aligning with established guidelines.

Longitudinal ECG changes in tetralogy of Fallot and association with surgical repair.

ECG abnormalities have been linked to adverse changes in right ventricular (RV) morphology and poor clinical outcomes in repaired Tetralogy of Fallot (rTOF). Our aim was to describe how ECG changes progress in early and intermediate follow-up and whether types of surgical strategy at the time of primary repair affected these changes. We studied patients with rTOF born 2000-2018 operated at our institution. Seven time points in relation to primary repair, follow-up, and pulmonary valve replacement (PVR) were identified. Patients correct with valve sparing repair (VSR), trans-annular patch (TAP) including with a monocusp valve (TAP + M) and with at least 3 ECGs were included. PQ interval, QRS duration, dispersion, and fragmentation, QTc duration and dispersion, JTc as well as presence of a right bundle branch block (RBBB) were analyzed. Medical records were reviewed for demographic and surgical data. Two hundred nineteen patients with 882 ECGs were analyzed with a median follow-up time of 12.3 years (8.4, 17) with 41 (19%) needing PVR during the study period. QRS duration increased at time of primary repair to discharge from 66 msec (IQR 12) to 129 msec (IQR 27) (p < 0.0001) and at 1- and 6- year follow-up but showed only a modest and temporary decrease after PVR. QTc increased at the time of primary repair as well as prior to PVR. PQ interval showed a small increase at the time of primary repair, was at its highest prior to PVR and decreased with PVR. Type of surgical repair affected mainly QTc and JTc and was consistently longer in the TAP + M group until PVR. In VSR, QTc and JTc were prolonged initially compared to TAP but were similar after 1 year. After PVR, there were no differences in adverse ECG changes between surgical groups. PQ interval and QRS duration best correspond to the assumed volume load whereas the relationship with QTc and JTc is more complex, suggesting that these represent more complex remodeling of the myocardium. Before PVR, QTc and JTc are longer in the TAP + M group which may be due to a longer surgical incision.

Correlation of ECG and cardiac MRI for assessment of ventricular hypertrophy and dilatation in adults with repaired tetralogy of Fallot

BackgroundSurgically repaired Tetralogy of Fallot (rTOF) is associated with progressive right ventricular hypertrophy (RVH) and dilation (RVD). Accurate estimation of RVH/RVD is vital for the ongoing management of this patient population. The utility of the ECG in evaluating patients with rTOF with pre-existing right bundle branch block (RBBB) has not been studied. We aimed to determine the sensitivity/specificity of currently established ECG criteria in detecting RVH/RVD in this patient population. MethodsWe included consecutive patients diagnosed with rTOF who underwent CMR performed at our regional referral centre between January 2012 and December 2019. Each CMR was assessed for LVH, LVD, RVH and or RVD. The ECG corresponding to the CMR was then used to determine RVH/LVH for specificity and sensitivity analysis. ResultsOur study included 163 consecutive rTOF patients. The specificity for ECG-based criteria for LVH was 100.00% (95% C.I. (87.75, 100.00)), and the sensitivity was 7.19% (95% C.I. (3.15, 12.83)). When RBBB was present, specificity for RVH was 100.00% (95% C.I. (84.56, 100.00)), and sensitivity was 7.69% (95% C.I. (3.75, 13.69)). When RBBB was absent, specificity for RVH was 100.00% (95% C.I. (15.81, 100.00)), and sensitivity was 0.00% (95% C.I. (0.00, 33.63)). A regression model with the entire group of 163 ToF patients, based on the Sokolow-Lyon criterion (sum of R in V1 + S in V5/V6), produced a new suggested criterion for the diagnosis of RVH in patients with rTOF, which was a sum of R in V1 + S in V5/V6 greater than 13.25 mm. This model's sensitivity for RVH detection was 69.1%, and specificity was 36.8%. ConclusionsStandard ECG voltage criteria have poor sensitivity for detecting right and left ventricular chamber hypertrophy and dilatation in patients with rTOF, so current ECG criteria should not be used to monitor RVH/RVD in this patient population.

Bidirectional gated recurrent unit with auto encoders for detecting arrhythmia using ECG data

Heartbeat irregularity or arrhythmia of a patient with serious congestive cardiovascular breakdown is distinguished in this article, and the class not really settled utilizing long haul ECG information. Several existing methods on arrhythmia detection are utilized, which does not accurately classify the Arrhythmia and it takes higher computational time. Morphological filtering and Extended Empirical wavelet transformation preprocess the input data to remove noises and base line. Then these pre-processed data is fed to Ternary Pattern and Discrete Wavelet Transform (TP-DWT) related feature extracting to take relevant feature. Then, the extracted features are given to Bidirectional Gated Recurrent Unit with Auto Encoder (BiGRU-AE) to classify Arrhythmia into Normal, Atrial Fibrillation (AF), First-degree atrioventricular block (1-AVB), Left Bundle Branch (LBBB), Right Bundle Branch Block (RBBB), Premature Atrial Contraction (PAC), Premature Ventricular Contraction (PVC), ST-segment depression (STD) and ST-segment elevation (STE). The proposed BiGRU-AE-AD-ECG is activated in Python and its efficiency is measured under certain metrics, like sensitivity, precision, f-measure, specificity, accuracy, error rate, ROC and computational time. Here, CPSC 2018 dataset is used to validate the efficiency of the BiGRU-AE-AD-ECG method. The performance of BiGRU-AE-AD-ECG method provides 23.40 %, 18.78 % and 28.05 % higher accuracy, 20.41 %, 27.07 % and 18.80 % higher precision, 32.01 %, 27.40 % and 28.95 % higher sensitivity and 28.05 %, 23.41 % and 31.34 % higher specificity analyzed with existing models, like automatic cardiac arrhythmias categorization based on CNN and attention-based RNN network (CNN-RNN-AD-ECG), a multiple lead-branch fusion network under 12-Lead ECG for multiple class arrhythmia categorization (MLBFNet-AD-ECG), analysis of ECG-based arrhythmia identification scheme using machine learning (SVM-AD-ECG)respectively.

Transient complete right bundle branch block due to lung contusion: case report

Introduction: Right bundle branch block (RBBB) may occur in lung diseases and cardiovascular diseases. Case Report: A 25-year-old male patient was admitted to emergency department after a motorcycle accident. Contusion was detected in bilateral lungs, and pneumothorax with laceration were detected in the right lung. ECG revealed 103 bpm, right axis deviation, and complete RBBB. ECG revealed 83 bpm, complete RBBB continued at the 6th hour after tube thoracostomy, and high sensitive TnI was normal. Chest X-ray was normal on the 4th day of hospitalization, and ECG revealed 74 bpm, normal sinus rhythm. Conclusion: In thoracic trauma, ECG changes may develop as a result of lung contusion. ECG findings improve as the lung contusion heals.

Ultra-high-frequency ECG volumetric and negative derivative epicardial ventricular electrical activation pattern

From precordial ECG leads, the conventional determination of the negative derivative of the QRS complex (ND-ECG) assesses epicardial activation. Recently we showed that ultra-high-frequency electrocardiography (UHF-ECG) determines the activation of a larger volume of the ventricular wall. We aimed to combine these two methods to investigate the potential of volumetric and epicardial ventricular activation assessment and thereby determine the transmural activation sequence. We retrospectively analyzed 390 ECG records divided into three groups-healthy subjects with normal ECG, left bundle branch block (LBBB), and right bundle branch block (RBBB) patients. Then we created UHF-ECG and ND-ECG-derived depolarization maps and computed interventricular electrical dyssynchrony. Characteristic spatio-temporal differences were found between the volumetric UHF-ECG activation patterns and epicardial ND-ECG in the Normal, LBBB, and RBBB groups, despite the overall high correlations between both methods. Interventricular electrical dyssynchrony values assessed by the ND-ECG were consistently larger than values computed by the UHF-ECG method. Noninvasively obtained UHF-ECG and ND-ECG analyses describe different ventricular dyssynchrony and the general course of ventricular depolarization. Combining both methods based on standard 12-lead ECG electrode positions allows for a more detailed analysis of volumetric and epicardial ventricular electrical activation, including the assessment of the depolarization wave direction propagation in ventricles.

The Transcatheter Aortic Valve Replacement-Conduction Study: The Value of the His-Ventricular Interval in Risk Stratification for Post-TAVR Atrioventricular-Block

BackgroundThere is no clear consensus regarding the optimal risk stratification of high-degree atrioventricular block (HDAVB) after transcatheter aortic valve replacement (TAVR). MethodsThis prospective study sought to determine the utility of the pre- and post-TAVR His-ventricular (HV) interval in the risk stratification of post-TAVR HDAVB. One hundred twenty-one patients underwent an electrophysiology study before and after TAVR. The primary outcome was HDAVB requiring pacemaker implantation within 30 days post-TAVR. A separate retrospective cohort was analyzed to determine the postoperative interval at which the risk of HDAVB is reduced to <5%. ResultsHDAVB occurred in 12 (10%) patients. Baseline right bundle branch block (RBBB) (odds ratio [OR]: 13.6), implant depth >4 mm (OR: 3.9), use of mechanically- or self-expanding valves (OR: 6.3), and post-TAVR HV > 65 ​ms (OR: 4.9) were associated with increased risk of HDAVB, whereas PR intervals and pre-TAVR HV were not. In patients without baseline RBBB or new persistent left bundle branch block (LBBB), not one patient with post-TAVR HV < 65 ​ms developed HDAVB. In the separate retrospective cohort (N = 1049), the risk of HDAVB is reduced (<5%) on postoperative days 4 and 3 in patients with pre-TAVR RBBB and post-TAVR persistent LBBB, respectively. ConclusionsBaseline RBBB, new persistent LBBB, implant depth >4 mm, and a post-TAVR HV ≥ 65 ​ms were associated with a higher risk of post-TAVR HDAVB, whereas an HV ≤ 65 ​ms was associated with a lower risk. The pre-TAVR HV was not associated with our outcome, and the delta HV did not have practical incremental prognostic value. Among those without pre-TAVR RBBB or post-TAVR persistent LBBB, no patients with post-TAVR HV < 65 ​ms developed HDAVB.

Discrimination between ventricular tachycardia and wide-QRS preexcited tachycardia.

To develop a new algorithm to differentiate ventricular tachycardia (VT) from preexcited tachycardia (pre-ET) according to left bundle branch block (LBBB) and right bundle branch block (RBBB) patterns. This study included 67 electrocardiograms (ECGs) with VT and 63 ECGs with pre-ET, collected from our hospital and through PubMed. Of those, 64 were allocated to the derivation cohort and the rest to the validation cohort. The diagnoses of the ECGs were confirmed using an electrophysiological study. Parameters and classifiers from prior algorithms along with the propagation speeds in the early portion of the QRS complex (initial deflection index) in leads V1, V6, aVR, II, and III were manually measured. The performance of the new algorithm was compared with that of prior algorithms. The initial deflection index in lead III was the strongest predictor of pre-ET in LBBB-pattern wide-QRS tachycardia (p = 0.003, AUC 0.805). The initial deflection index in lead V1 was the most powerful predictor of pre-ET in RBBB-pattern wide-QRS tachycardia (p = 0.001, AUC 0.848). Compared to earlier algorithms, those using the initial deflection indexes: lead III in LBBB patterns (cutoff value >0.3) and lead V1 in RBBB patterns (cutoff value ≤0.48), demonstrated superior performance in screening VT, with AUC values of 0.828. The initial deflection indexes proved effective as discriminators between VT and pre-ET in the validation cohort. In LBBB-pattern wide-QRS tachycardia, the early propagation speed of pre-ET was faster than that in VT. Conversely, in RBBB-pattern wide-QRS tachycardia, it was slower.

Application of echocardiography in transcatheter aortic valve replacement in patients with severe aortic regurgitation and correlation analysis of postprocedural complications.

Transcatheter aortic valve replacement (TAVR) is gradually becoming an alternative therapy for patients who cannot adapt to surgical treatment or have contraindications. The purpose of this study was to investigate the value of echocardiography in the evaluation of severe AR patients treated with TAVR and to analyze the correlations with postprocedural complications to improve the evaluation and screening of patients. We retrospectively analyzed clinical and echocardiographic data of 70 patients with severe AR. Periaortic valve structures were carefully measured by esophageal echocardiography (TEE) and compared with the multilayer slice computed tomography (MSCT) findings. Real-time three-dimensional esophageal echocardiography (RT-3D TEE) was monitored during the operation, and a 30-day postprocedural follow-up was performed. The relationship between postprocedural complications and patients' clinical data or periaortic valve structures was analyzed by multifactorial analysis to identify relevant predictors of complications. The TEE measurements of periaortic valve structures were in good agreement with the MSCT measurements. Among the patients who underwent successful operations, both left atrial (LA) and left ventricular (LV) diameters were reduced, and the left ventricular ejection fraction (LVEF) was improved 30 days after TAVR compared with the preprocedural period (P<.05). Permanent pacemakers were implanted in 15 patients. The presence of preprocedural right bundle branch block (RBBB) (OR: 2.93; 95% CI: 1.18-12.70; P=.01) was an independent factor for permanent pacemaker implantation after TAVR. Echocardiography plays an extremely important role in TAVR procedures. The presence of preprocedural RBBB can be an independent predictor of postprocedural pacemaker implantation.

An interesting dynamic retrograde His bundle potential during the transventricular-septal process for left bundle branch pacing in a patient with right bundle branch block: A case report.

A 67-year-old male presented with symptomatic bradycardia caused by atrial fibrillation and underwent His bundle pacing (HBP) and left bundle branch pacing (LBBP). Electrocardiography (ECG) revealed a complete right bundle branch block (RBBB). John Jiang's connecting cable was used during the transventricular septal process. An interesting dynamic retrograde His bundle potential (RHP) was recorded with uninterrupted lead screws.

Incidence and Outcomes of New-Onset Right Bundle Branch Block Following Transcatheter Aortic Valve Replacement.

The incidence and prognosis of right bundle branch block (RBBB) following transcatheter aortic valve replacement (TAVR) are unknown. Hence, we sought to characterize the incidence of post-TAVR RBBB and determine associated risks of permanent pacemaker (PPM) implantation and mortality. All patients 18 years and above without preexisting RBBB or PPM who underwent TAVR at US Mayo Clinic sites and Mayo Clinic Health Systems from June 2010 to May 2021 were evaluated. Post-TAVR RBBB was defined as new-onset RBBB in the postimplantation period. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. The risks of PPM implantation (within 90 days) and mortality following TAVR were compared for patients with and without post-TAVR RBBB using Kaplan-Meier analysis and Cox proportional hazards modeling. Of 1992 patients, 15 (0.75%) experienced new RBBB post-TAVR. There was a higher degree of valve oversizing among patients with new RBBB post-TAVR versus those without (17.9% versus 10.0%; P=0.034). Ten patients (66.7%) with post-TAVR RBBB experienced high-grade atrioventricular block and underwent PPM implantation (median 1 day; Q1, 0.2 and Q3, 4), compared with 268/1977 (13.6%) without RBBB. Following propensity score adjustment for covariates (age, sex, balloon-expandable valve, annulus diameter, and valve oversizing), post-TAVR RBBB was significantly associated with PPM implantation (hazard ratio, 8.36 [95% CI, 4.19-16.7]; P<0.001). No statistically significant increase in mortality was seen with post-TAVR RBBB (hazard ratio, 0.83 [95% CI, 0.33-2.11]; P=0.69), adjusting for age and sex. Although infrequent, post-TAVR RBBB was associated with elevated PPM implantation risk. The mechanisms for its development and its clinical prognosis require further study.

How to assess and treat right ventricular electromechanical dyssynchrony in post-repair tetralogy of Fallot: insights from imaging, invasive studies, and computational modelling.

Right bundle branch block (RBBB) and resulting right ventricular (RV) electromechanical discoordination are thought to play a role in the disease process of subpulmonary RV dysfunction that frequently occur post-repair tetralogy of Fallot (ToF). We sought to describe this disease entity, the role of pulmonary re-valvulation, and the potential added value of RV cardiac resynchronization therapy (RV-CRT). Two patients with repaired ToF, complete RBBB, pulmonary regurgitation, and significantly decreased RV function underwent echocardiography, cardiac magnetic resonance, and an invasive study to evaluate the potential for RV-CRT as part of the management strategy. The data were used to personalize the CircAdapt model of the human heart and circulation. Resulting Digital Twins were analysed to quantify the relative effects of RV pressure and volume overload and to predict the effect of RV-CRT. Echocardiography showed components of a classic RV dyssynchrony pattern which could be reversed by RV-CRT during invasive study and resulted in acute improvement in RV systolic function. The Digital Twins confirmed a contribution of electromechanical RV dyssynchrony to RV dysfunction and suggested improvement of RV contraction efficiency after RV-CRT. The one patient who underwent successful permanent RV-CRT as part of the pulmonary re-valvulation procedure carried improvements that were in line with the predictions based on his Digital Twin. An integrative diagnostic approach to RV dysfunction, including the construction of Digital Twins may help to identify candidates for RV-CRT as part of the lifetime management of ToF and similar congenital heart lesions.

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.

Classification feasibility test on multi-lead electrocardiography signals generated from single-lead electrocardiography signals.

Nowadays, Electrocardiogram (ECG) signals can be measured using wearable devices, such as smart watches. Most wearable devices provide only a few details; however, they have the advantage of recording data in real time. In this study, 12-lead ECG signals were generated from lead I and their feasibility was tested to obtain more details. The 12-lead ECG signals were generated using a U-net-based generative adversarial network (GAN) that was trained on ECG data obtained from the Asan Medical Center. Subsequently, unseen PTB-XL PhysioNet data were used to produce real 12-lead ECG signals for classification. The generated and real 12-lead ECG signals were then compared using a ResNet classification model; and the normal, atrial fibrillation (A-fib), left bundle branch block (LBBB), right bundle branch block (RBBB), left ventricular hypertrophy (LVH), and right ventricular hypertrophy (RVH) were classified. The mean precision, recall, and f1-score for the real 12-lead ECG signals are 0.70, 0.72, and 0.70, and that for the generated 12-lead ECG signals are 0.82, 0.80, and 0.81, respectively. In our study, according to the result generated 12-lead ECG signals performed better than real 12-lead ECG.

Feasibility of Conduction System Pacing in Patients with Baseline Bundle Branch Block-A Single-Center Mid-Term Follow-Up Study.

The primary prerequisite for a successful conduction system pacing (CSP) procedure is the integrity of the conduction system, which may be impaired if a baseline bundle branch block (BBB) is present. This study aimed to evaluate the feasibility and mid-term performance of permanent CSP in patients with baseline BBB and to compare the results between left bundle branch block (LBBB) and right bundle branch block (RBBB) patterns. A total of 101 patients with typical BBB and an attempt at CSP were retrospectively reviewed. Procedural characteristics, pacing, sensing parameters, and complications at baseline and after a mid-term follow-up were analyzed. The global procedural success for CSP was 93%. His bundle pacing (HBP) had a significantly lower success rate than left bundle branch area pacing (LBBAP) (50.5% vs. 86%). The paced QRS duration was significantly narrower with HBP. The pacing and sensing thresholds were significantly better with LBBAP. Procedural complications occurred only in the LBBAP group (two acute perforations in the LV cavity and one acute chest pain during lead fixation) without long-term sequelae. The HBP and the LBBAP procedural success rates were higher in the RBBB versus the LBBB group (62.5% vs. 44.9% and 100% vs. 81.5%, respectively). Baseline QRS duration, atrial volumes, and right ventricular diameters were significantly associated with HBP procedural failure. The follow-up pacing and sensing thresholds were similar to the baseline values for all pacing methods and BBB morphology. Only one device-related complication leading to pacing interruption was recorded. In patients with bundle branch blocks, CSP is a feasible procedure associated with a high success rate, stable pacing and sensing parameters, and low complication rates over a mid-term follow-up.

Electrocardiographic predictors of left ventricular scar in athletes with right bundle branch block premature ventricular beats.

Right bundle branch block (RBBB) morphology non-sustained ventricular arrhythmias (VAs) have been associated with the presence of non-ischaemic left ventricular scar (NLVS) in athletes. The aim of this cross-sectional study was to identify clinical and electrocardiogram (ECG) predictors of the presence of NLVS in athletes with RBBB VAs. Sixty-four athletes [median age 39 (24-53) years, 79% males] with non-sustained RBBB VAs underwent cardiac magnetic resonance (CMR) with late gadolinium enhancement in order to exclude the presence of a concealed structural heart disease. Thirty-six athletes (56%) showed NLVS at CMR and were assigned to the NLVS positive group, whereas 28 athletes (44%) to the NLVS negative group. Family history of cardiomyopathy and seven different ECG variables were statistically more prevalent in the NLVS positive group. At univariate analysis, seven ECG variables (low QRS voltages in limb leads, negative T waves in inferior leads, negative T waves in limb leads I-aVL, negative T waves in precordial leads V4-V6, presence of left posterior fascicular block, presence of pathologic Q waves, and poor R-wave progression in right precordial leads) proved to be statistically associated with the finding of NLVS; these were grouped together in a score. A score ≥2 was proved to be the optimal cut-off point, identifying NLVS athletes in 92% of cases and showing the best accuracy (86% sensitivity and 100% specificity, respectively). However, a cut-off ≥1 correctly identified all patients with NLVS (absence of false negatives). In athletes with RBBB morphology non-sustained VAs, specific ECG abnormalities at 12-lead ECG can help in detecting subjects with NLVS at CMR.

Complete Heart Block Secondary to Section Concomitant Use of Metoprolol and Fluoxetine in a Case of Chronic Depression and Systemic Hypertension: A Case Report

Bradyarrhythmia can be brought on by intrinsic or extrinsic causes that disrupt the cardiac conduction system, with iatrogenic drug usage being the most common extrinsic cause. Atrioventricular (AV) block is frequently brought on by beta-blockers, calcium channel blockers, anti-arrhythmics, and digoxin. The first course of treatment for heart block involves stopping the problematic medications. Psychotropic medications have the potential to cause cardiotoxic adverse effects that affect the heart. In a patient with a pre-existing cardiac disorder, psychotropic drugs can manifest with dangerous arrhythmias. It is yet unknown what intricate processes cause these effects. A variety of arrhythmias may be brought on by or made worse by many commonly used drugs. Hereby, the authors present a case report of 56-year-old hypertensive male, a known case of chronic depression with chest heaviness. The Electrocardiogram (ECG) revealed Complete Heart Block (CHB) with Right Bundle Branch Block (RBBB). The patient was on fluoxetine and beta-blockers for his mental illness and hypertension. Three days after withholding the drugs, the CHB resolved, and his baseline ECG remained as RBBB. The present case highlights the interaction of drugs leading to CHB in present patient. Therefore, the importance of a detailed drug history in such cases becomes imperative.

Coronary Artery Bypass Graft Effect on Cardiogoniometry Characteristic in Patients with Coronary Heart Disease

Abstract Context: Cardiogoniometry (CGM) is a noninvasive technique for quantitative three-dimensional vectorial analysis of myocardial depolarization and repolarization. We describe a method of surface electrophysiological cardiac assessment using CGM performed at rest to detect variables helpful in identifying coronary artery disease (CAD) and interplaying factors in patients who underwent coronary artery bypass graft (CABG). Materials and Methods: In this study, all patients with CAD undergoing CABG were enrolled. Echocardiography, CGM, and electrocardiography (ECG) were obtained before surgery and a month later. The ECG and CGM alterations were compared before and after CABG and the accuracy of those two methods was evaluated. Results: In this study, 50 patients were enrolled, of which 33 (66%) were male versus 17 (44%) female, with a mean age of 39.12 ± 60 years. The mean ejection fraction before and after surgery was 44.3 ± 7.9% (range: 20–55) and 40.9 ± 12.5% (20–50), respectively. Before surgery, all patients had sinus rhythm, five cases had left bundle-branch block (LBBB), and one case was with right bundle-branch block (RBBB). Subsequently, after surgery, five cases had LBBB, and two cases were found to have RBBB. The rate of postoperation bleeding was 20%. There was no significant change in echocardiographic characteristics before and after operation (P = 0.81); likewise, no significant change was seen in ECG criteria before and after operation (P = 0.96). A significant correlation was seen regarding CGM characteristics before and after CABG (P = 0.003). Conclusions: A significant association was seen regarding CGM characteristics before and after undergoing an operation. In addition, the specificity and sensitivity of the CGM and ECG before and after operation improved well.

Systemic Sclerosis Sine Scleroderma Presenting as Pulmonary Arterial Hypertension - A Case Report

A 60-year-old married male farmer with a significant medical history, including STElevation Myocardial Infarction (STEMI), coronary artery bypass grafting (CABG), and Raynaud’s disease, presented to the emergency department with sudden-onset syncope and progressive shortness of breath on exertion. The syncope episode involved an abrupt loss of consciousness, with spontaneous recovery and no associated symptoms like jerky movements or tongue biting. The shortness of breath had been gradually worsening over several weeks, becoming noticeable even during minimal exertion. On examination, the patient appeared chronically ill but had stable vital signs cardiovascular examination revealed bilateral pedal edema, while respiratory assessment and Neurological evaluation were normal. Blood tests indicated normal full blood count (FBC) and urea and electrolytes (U+E), but slight elevations in CRP 29 mg/L and ESR 20 mm/hr. Troponin levels remained stable, but brain natriuretic peptide (BNP) was markedly elevated at 2061 pg/mL. The electrocardiogram (ECG) showed right axis deviation and incomplete right bundle branch block (RBBB). A CT scan of the brain ruled out any acute pathology, such as stroke or hemorrhage. A previous echocardiogram (ECHO) had shown a left ventricular ejection fraction (LVEF) of 50-55%, indicating good left ventricular function. Given the findings, the patient was started on Furosemide 40 mg daily and advised to follow a fluid restriction regimen to prevent worsening of overload symptoms. A repeat echocardiogram revealed deterioration in right ventricular (RV) function with a significantly (RVSP) of 80 mmHg, suggesting severe pulmonary hypertension (PHTN). A D-dimer test was negative for pulmonary embolism (PE). Cardiology consultation raised concerns about possible chronic thromboembolic disease, leading to further testing, including a computed tomography pulmonary angiogram (CTPA) and an autoimmune screen, along with potential right heart catheterization (RHC). The CTPA was negative for PE, but the autoimmune screen returned positive results for antinuclear antibodies (ANA &gt;1200) and anticentromere antibodies. Right heart catheterization confirmed pre-capillary pulmonary hypertension (PAH) with pulmonary artery pressure exceeding 44 mmHg and no nitrate response. A rheumatology review, in light of the patient’s history of Raynaud’s disease, positive ANA, and confirmed PAH, led to the diagnosis of Systemic Sclerosis Sine Scleroderma–a form of systemic sclerosis without skin involvement. The patient was initiated on Tadalafil, (PDE-5) for PAH management and prescribed home oxygen therapy, particularly during exertion. He was discharged with a plan for multidisciplinary followup involving rheumatology, cardiology, and pulmonology to manage his complex condition. Conclusion: Multidisciplinary is essential for optimizing outcomes in SSc and PAH.

Qualitative and Quantitative Electrocardiogram Parameters in a Large Cohort of Children with Duchenne Muscle Dystrophy in Comparison with Age-Matched Healthy Subjects: A Study from South India.

Electrocardiography (ECG) remains an excellent screening tool for cardiac assessment in Duchenne muscular dystrophy (DMD), but an accurate interpretation requires comparison with age-matched healthy controls. We examined various ECG parameters in children with DMD, in comparison with age-matched controls. Standard 12-lead ECG tracings of serial patients were screened for quality and selected. Controls were healthy, age-matched school-going children. Both quantitative and qualitative ECG parameters were analyzed. After screening, ECGs from 252 patients with DMD (8.32 ± 3.12 years, 2-21 years) and ECGs from 151 age-matched healthy controls (9.72 ± 2.23, 4-19 years) were included. A significantly higher heart rate, shorter R-R interval, and taller R wave in V1 were seen across all age group of DMD in comparison to controls, with the difference increasing with age. While QT prolongation was seen in all age groups of DMD, QTc prolongation was seen only at 10 years or more. Incomplete right bundle branch block (RBBB) and pathological Q waves in inferolateral leads were exclusive in DMD, with the latter declining with age. Evidence for left ventricular (LV) pathology, such as tall R in V5/V6, increase in SV1 + RV6 height, and QRS complex duration, were seen only in the age group of 10 years or more. Stratification based on age and comparison with age-matched healthy subjects showed that several ECG parameters were influenced by age, and it also identified age-dependent evidence for LV pathology and QTc prolongation in DMD.