Symptomatic Sinus Bradycardia Research Articles

Clinico-demographic Profile of Patients Receiving Permanent Pacemakers as Bradyarrhythmia Therapy: The Srinagar Registry

Introduction Cardiac conduction disorders can interrupt the normal electrical conduction in the heart and cause a decrease or cessation of pulse generation and a fall in organ perfusion in the body. This can lead to significant morbidity and mortality. This study was conceived to illustrate the clinical profile, presentation, management, and complications of bradyarrhythmia therapy in this population. Methods This descriptive cross-sectional study included prospective and retrospective data over a period of 16 years. All patient’s demographic data and data of any complications and adverse outcomes were documented. Results A total of 3489 cases having permanent pacemakers (PPMs) implanted in them were included in this study. There were 2254 (64.6%) men and 1235 (35.4%) were women. Age of the patients ranged from 25 to 100 years with a mean age of 62.9 ± 11.14 years. Mean ejection fraction of patients was 59.3 ± 2.57%. The indication for PPM implantation was complete heart block in 2079 (59.6%), sick sinus syndrome in 422 (12.1%), Mobitz type 2 heart block in 345 (9.9%), symptomatic left bundle branch block in 295 (8.5%), symptomatic bifasicular block in 176 (5.0%), symptomatic trifascicular block in 109 (3.1%), vasovagal syncope with symptomatic sinus bradycardia in 21 (0.6%), left anterior hemiblock with syncope in 3 (0.1%), and atrial fibrillation with heart block in 11 (0.3%) patients. Cardiac syncope was presented in 80%, presyncope in 15%, and 5% presented with features of chronotropic incompetence. No significant seasonal variation was observed in the incidence of PPM implantation. Single-chamber PPM was implanted in 58.8% and dual-chamber PPM in 41.2% of the cases. PPM-related complications were seen in 139 (3.98%) of the cases. Pneumothorax was seen in 21 (0.6%) of the cases, lead displacement in 39 (1.12%), lead replacement in 31 (0.89%), pocket site infection in 20 (0.57%), generator extrusion in 25 (0.70%), and lead extrusion in 3 (0.08%). Conclusion Conduction disorders affect men more than women and complete heart block is the most common form of conduction disorder in our population. There has been a significant improvement in bradyarrhythmia detection and its management, leading to wider penetration and safety of device therapy provided to the patient population.

Long-term results of cardioneuroablation evaluated by implantable loop recorder

Abstract Background Cardioneuroablation (CNA) is a catheter ablation technique based on radiofrequency application in the atrial endocardium to decrease vagal response. Since the first series publication, its use has greatly increased, with CNA being now used in vasovagal syncope (VVS), functional atrioventricular block (AVB), symptomatic sinus bradycardia (SB) and Atrial Fibrillation (AFib). There is still limited data regarding long-term follow-up (FUP) of patients who have undergone this procedure. Purpose The aim of this study was to evaluate long-term results of CNA in a single center with the use of an implantable loop recorder (ILR). Methods We performed a prospective single-center cohort study. Patients with significant documented functional bradyarrhythmias between September 2019 and October 2023 were enrolled. All patients underwent ILR implantation before ablation. CNA was performed using catheter ablation aiming at right epicardial GPs with 3-dimensional electroanatomical mapping support. A 2 mg atropine test (bolus) was carried out before and after CNA and the subsequent heart rate (HR) increase registered. Successful CNA was defined as absence of HR increase with atropine after the ablation. HR pre and post ablation was compared. Immediate and late procedure complications were assessed. Recurrence of symptoms, the presence significant vagal-induced bradyarrhythmias on ILR and the need for pacemaker (PM) implantation were also assed. Results Fifteen patients (pts) were included, with a mean age of 64 (± 12 years) and a 53.3% male prevalence. None of the pts had structural heart disease. The main indication for CNA was AFib with brady-tachy syndrome (8 pts, 53.3%), followed by VVS (4 pts, 26.7%), SB (2 pts, 13.3%) and AVB (2:1 AVB; 1 pt). The most common symptom was syncope (46.7%), followed by pre-syncope (40%) and fatigue (20%). There was a significant improvement in HR after CNA (55 ± 13 vs. 67 ± 14 bpm pos-CNA, p=0.002). The achievement of success was verified in all patients (mean HR variation with atropine before CNA 35 ± 10% vs. 2 ± 2% after CNA; p=0.001). Procedure mean time was 28 ± 12 min. During a maximum FUP of 48 months (minimum 1 month, median 5), 1 patient had recurrence of VVS with a 10s pause documentation on ILR requiring PM implantation and 1 patient had a 4s pause without translation into symptoms and a duration decreasing tendency during FUP. Freedom from recurrence of symptoms was 93.3%, freedom from pacemaker implantation was 93.3% and freedom from significant bradyarrhythmias was 86.7% – Figure 1. No immediate or long-term complications were seen. Conclusions CNA aiming at the right GPs is a safe and quick procedure for patients with functional bradyarrhythmias. This ablation technique in most patients not only reduces symptoms, but also avoids early PM implantation, therefore improving quality of life. Further randomized clinical trials are needed to support these data and refine patient selection criteria.

Cardioneuroablation for recurrent vasovagal syncope and functional sinus bradycardia: a case series

Patients with recurrent vasovagal syncope with cardioinhibitory or mixed mechanism, or with symptomatic functional sinus bradycardia or AV block can be treated with cardioneuroablation. Material and methods: A case series of 5 patients is presented – four with recurrent syncope and/or symptomatic sinus bradycardia, and one with paroxysmal atrial fi brillation and recurrent syncope. After a confi rmation of the syncope mechanism with tilt table test, and after positive atropine test, radiofrequency catheter cardioneuroablation was performed (this was adjunctive procedure for the patient with atrial fi brillation who received pulmonary vein isolation). During short-term follow-up none of the patients had syncopal recurrence. Conclusion: Catheter neuromodulation provided very good short-term results and lack of serious complications in this fi rst case series in Bulgaria.

Cardioneuroablation for successful treatment of symptomatic bradycardia in a 12-year-old child after a 6-month follow-up

BackgroundCardioneuroablation (CNA) is recognized as a promising therapeutic option for adults with severe symptomatic bradycardia caused by excessive vagal tone. However, no pediatric cases have been reported to date. Therefore, the aim of this study is to evaluate the feasibility and efficacy of CNA in children.MethodsA 12-year-old male patient was hospitalized with symptoms of fatigue, palpitations, and syncope for more than 2 months, and was definitively diagnosed with functional sinoatrial node dysfunction by using a 12-lead electrocardiogram, 24-h Holter monitoring, loading dose of atropine test (0.04 mg/kg), and treadmill exercise test. Simultaneously, whole-exome sequencing was performed on the child and his core family members. After completing the preoperative examination and signing the informed consent form, the child underwent CNA therapy.ResultsFirst, the electroanatomic structures of both atria were mapped out by using the Carto 3 system, according to the protocol of purely anatomy-guided and local fractionated intracardiac electrogram–guided CNA methods. Then, the local fractionated intracardiac electrograms of each cardiac ganglionated plexus (GP), including the GP between the aortic root and the medial wall of the superior vena cava, the GP between the posterior wall of the coronary sinus ostium and the left atrium, the GP between the anterior antrum of the right superior pulmonary vein and the superior vena cava, the GP in the superolateral area around the root of the left superior pulmonary vein, the GP around the root of the right inferior pulmonary vein, and the GP around the root of the left inferior pulmonary vein, were used as targets for ablation at a power of 30 W with an ablation index of 350–400. At a 6-month follow-up, the child's heart rhythm saw a complete restoration to sinus rhythm and clinical symptoms disappeared.ConclusionThe first application of CNA in a child with symptomatic sinus bradycardia was achieved with better clinical outcomes. CNA can be carried out cautiously in children under suitable indications.

Abstract 16739: Tricuspid Regurgitation Following Conduction System Pacing Lead Entanglement in Chordae Tendineae

Case Description: A 62-year-old male with symptomatic sinus bradycardia presented for pacemaker implantation. Conduction system pacing (CSP) was pursued using the Medtronic 3830 lead. The lead was advanced through a C315His sheath and positioned at the basal-mid ventricular septum. Passive pacing demonstrated V1 notching and aVR/aVL discordance. An attempt was made to fixate the lead but despite rapid clockwise turns at the proximal lead tip, no lead penetration was seen in the LAO projection. The lead was removed and the sheath was repositioned. A second attempt was made with similar results. When attempting to remove the lead however, the lead remained adherent to the tissue despite multiple counter-clockwise turns. Increasing traction was applied at the proximal lead tip which resulted in elongation of the fixation screw and eventual disengagement from the tissue. Upon examination of the lead tip, there was fibrinous tissue suggestive of either chordae tendineae or valve remnant. Further attempts at CSP were aborted and the patient underwent traditional RV septal lead placement. Transthoracic echocardiogram (TTE) performed following the procedure demonstrated mild-moderate eccentric tricuspid regurgitation, likely due to chordae injury. Discussion: Left bundle branch pacing (LBBP) is becoming an increasingly popular form of CSP and requires deep penetration of the septum to engage the left bundle branch. To our knowledge, this is only the second case describing tricuspid valve chordae tendineae entanglement as a result of a CSP attempt. Most often, tricuspid regurgitation due to LBBP is attributed to entrapment of the septal TV leaflet from a basal position of the pacing lead. In our case, we suspect tricuspid valve injury occurred as a direct result of entanglement of the screw into the chordae. Potential ways to mitigate this complication are to pursue a more distal implantation site or to confirm adequate passive injury current prior to fixation to ensure the screw tip engages the myocardial tissue. Most of all, it is important to recognize that when a lead is not advancing into the septum, one should abort the position early and try an alternative site to avoid complications.

Syncope and Cannabis: hypervagotonia from chronic abuse? A case report and literature review

BackgroundCannabis is the most consumed drug worldwide and number of users is increasing, particularly among youth. Moreover, cannabis potential therapeutic properties have renewed interest to make it available as a treatment for a variety of conditions. Albeit rarely, cannabis consumption has been associated with cardiovascular diseases such as arrhythmias, myocardial infarction (MI) and potentially sudden death.Case presentationA 24-year-old woman presented to the emergency department sent by her cardiologist because of a recent finding of a 16 seconds asystole on the implantable loop recorder (ILR) she implanted 7 months before for recurrent syncopes. She declared that she is a heavy cannabis user (at least 5 cannabis-cigarette per day, not mixed up with tobacco, for no less than 12 years) and all syncopes occurred shortly after cannabis consumption. After a collective discussion with the heart team, syncope unit, electrophysiologists and toxicologist, we decided to implant a dual chamber pacemaker with a rate response algorithm due to the high risk of trauma of the syncopal episodes. 24 months follow-up period was uneventful.ConclusionsCannabis cardiovascular effects are not well known and, although rare, among these we find ischemic episodes, tachyarrhythmias, symptomatic sinus bradycardia, sinus arrest, ventricular asystole and possibly death. Because of cannabis growing consumption both for medical and recreational purpose, cardiovascular diseases associated with cannabis use may become more and more frequent. In the light of the poor literature, we believe that cannabis may produce opposite adverse effects depending on the duration of the habit. Acute administration increases sympathetic tone and reduces parasympathetic tone; conversely, with chronic intake an opposite effect is observed: repetitive dosing decreases sympathetic activity and increases parasympathetic activity. Clinicians should be aware of the increased risk of cardiovascular complications associated with cannabis use and should investigate its consumption especially in young patients presenting with cardiac dysrhythmias.

Radiofrequency catheter denervation of sinus node by targetting the right anterior ganglionated plexus: towards minimizing the lesions set

Abstract Funding Acknowledgements Type of funding sources: None. Background Radiofrequency catheter (RF) ablation of the superior ganglionated plexus (RAGP) that modifies parasympathetic innervation of the sinus node (SAN) is used for the treatment of functional bradyarrhythmias. The RAGP is usually targeted from the endocardial aspect of both the right and left atria. Purpose To investigate the acute effect of a minimized biatrial set of ablation lesions aimed at denervating the SAN. Methods In patients with cardioinhibitory reflex syncope (n=25) or symptomatic functional sinus bradycardia (n=7), a minimum of 2x2 and a maximum of 2x3 RF lesions (at the discretion of the operator) were created from both sides of the superior interatrial septum with a setting of 30 W / 30 s and strictly contralateral configuration. The response to extracardiac vagus nerve stimulation (ECVS) was assessed before and after ablation. This response was quantified by the ratio of the maximum induced P-P interval and the cycle length of the current sinus rhythm (MaxPPratio). Results In 32 patients (41±13 years, 56% men), ablation of RAGP (2x3 and 2x2 lesions in 23 and 9 patients, respectively) resulted in attenuation of the response to ECVS from 7.9±3.5 s to 0.9±0.2 s (Figure, left panel). After ablation, only 9 patients had MaxPPratio >1.1 and none of the patients had MaxPPratio >1.6 (Figure, right panel). In 6 patients with MaxPPratio >1.3, the extension of original lesions easily suppressed the residual responsiveness of SAN to ECVS. Conclusion Biatrial RAGP ablation with a total RF time of 2-3 minutes resulted acutely in virtually complete SAN denervation in 72% of patients. Highly significant, but incomplete SAN denervation in remaining patients was successfully treated by extension of original ablation clusters. The long-term durability of SAN denervation associated with this ablation strategy remains to be investigated.

663 OCCURRENCE OF VENTRICULAR AND SUPRAVENTRICULAR ARRHYTHMIAS IN BRUGADA SYNDROME: RESULTS OF A TERTIARY REFERRAL CENTER EXPERIENCE

Abstract Brugada Syndrome (BrS) is one of the most common channelopathies and is related to an increased risk of ventricular arrhythmias. Current guidelines recommend the implantation of a Cardiac Defibrillator (ICD) in those patients that have a diagnostic ECG pattern and a history of aborted cardiac arrest. Nevertheless, management of asymptomatic patients, who are the majority, remains controversial as their risk stratification is often based on the results of an inductive Electrophysiologic Study (EPS) the predictive accuracy of which is debated. Furthermore, BrS has also been associated to an increased risk of supraventricular tachy- and bradyarrhythmias. Aim to describe the occurrence of ventricular and supraventricular arrhythmias in BrS patients that receive an implantable cardiac monitoring device following an EPS study Methods we retrospectively identified all BrS patients followed at our tertiary referral centre that were candidate to an EPS. Patient were candidate to EPS if: (1) they had a spontaneous diagnostic Brugada pattern at ECG and (2) they had no history of previous ventricular arrhythmias or high-risk syncope. Those patients that tested positive for induction of a sustained ventricular arrhythmia at EPS received an ICD; those that tested negative received an ILR. During the follow-up visits, implantable devices were interrogated for the occurrence of ventricular and supraventricular arrhythmias. Results We identified 87 patients matching the inclusion criteria. Of these, 31 (35.7%) received an ICD for a positive EPS while the remaining 56 (64.3%) received an ILR. Over a mean follow-up period of 34 months (IQR 5-45, 249 patient-year), only one patient in the EPS positive group experienced a ventricular arrhythmia effectively treated by the ICD (0.3 events per patient-year) compared to zero patients in the EPS negative group (100% NPV, 3.2% PPV). Notably, implanted devices allowed for the detection of supraventricular arrhythmias in 12 out of the 87 patients (14%): 5 were cases of symptomatic sinus bradycardia, with an indication to permanent pacing in two of them, and 7 were cases of atrial tachycardia/fibrillation. Discussion in our registry, consistently with previous literature, ventricular arrhythmias in BrS patients are rare and a negative EPS identifies with high accuracy those that are at low risk for this event. Conversely, a positive EPS may overestimate the risk of these patients resulting, according to current practice, in frequent implantations of ICD that will never be required for defibrillation. Although the patient-year observation period of the presented cohort is sizeable, our results should be furtherly validated on multi-center cohorts with even longer follow-up periods. Nonetheless, our results support the idea that risk stratification tools other than EPS are probably needed to properly identify the minority of BrS patients that will experience a ventricular arrhythmia throughout their life. In addition, we report a considerable number of supraventricular arrhythmias recorded by the implanted cardiac monitoring devices in our population. This is consistent with the knowledge of BrS patients being at increased risk of sinoatrial node dysfunction and atrial fibrillation and may elicit a more widespread and methodical screening for these events.

Sinus Bradycardia and Hypotension Following Reconstructive Hemi Mandibulectomy. Unusual Complication of Orofacial Reconstructive Surgery

Postoperative complications following pectoralis major myocutaneous flap in orofacial reconstruction are a well-known entity. Still, literature search didn’t reveal sinus bradycardia as one of those post-operative complications. One of our patients, a 63-year-old gentleman with squamous cell carcinoma in the right cheek, who underwent wide local excision with right side hemi-mandibulectomy and pectoralis major myocutaneous flap reconstruction, developed symptomatic sinus bradycardia and hypotension as a postoperative complication. Initially there was a struggle to find out the underlying cause but later, carotid sinus hypersensitivity was suspected as a probable cause. Ultimately, it was alleviated by a debulking surgery to reduce the pressure in the neck.

Implantable loop recorder as a strategy following cardiovascular implantable electronic device extraction without reimplantation.

Limited data exists for outcomes in patients undergoing cardiovascular implantable electronic device (CIED) transvenous lead extraction (TLE) without clear indications for device reimplantation. The implantable loop recorder (ILR) may be an effective strategy for continuous monitoring in select individuals. This retrospective analysis aims to investigate patients who have undergone ILR implant following TLE without CIED reimplantation. Clinical data from consecutive patients who have undergone TLE with ILR implant and without CIED reimplantation from October 2016 to May 2020 at a single center were collected. Among 380 patients undergoing TLE, 28 (7.7%) underwent ILR placement without CIED reimplantation. TLE indications were systemic infection (n=13, 46.4%), pain at the site (n=8, 28.6%), device/lead malfunction (n=4, 14.2%), and other. Devices extracted included: dual-chamber and single-chamber pacemaker (n=14, 50%; n=4, 14.2%), dual-chamber implantable cardiac defibrillator (n=10; 35.7%), and cardiac-resynchronization therapy with defibrillator (n=1, 3.5%). Reasons for no reimplantation included no longer meeting CIED criteria (n=14, 50%), patient preference (n=9, 32.1%), and no clear or inappropriate indication for initial CIED implantation (n=5, 18%). During an average of 12.3±13.1months of follow-up, there were no lethal arrhythmias, and four (13.3%) patients underwent permanent pacemaker reimplantation due to symptomatic sinus bradycardia and atrioventricular block with syncope as discovered on ILR. Three patients died due to unknown causes (n=1), noncardiac (n=1), and acute coronary syndrome (n=1). In patients undergoing TLE without reimplantation, an ILR may be an effective monitoring strategy in patients at low risk for cardiac arrhythmia.

Bradyarrhythmia After Remdesivir Administration in SARS-CoV-2: A Review of Literature and Meta-Analysis of Observational Studies in Epidemiology.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has required timely and informed decisions about treatment recommendations for clinical practice. One such drug used for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is remdesivir (RDV), and several cardiac side effects have been reported including bradyarrhythmia (e.g., transient sinus bradycardia, symptomatic sinus bradycardia, complete atrioventricular (AV) block). The current study aimed to explore the association between RDV treatment for SARS-CoV-2 infection and the risk of bradyarrhythmia by presenting a review and meta-analysis of available published studies.MethodsWe presented a review of published literature and meta-analysis of observational studies (MOOSE). A narrative summary of RDV and bradyarrhythmia in COVID-19 infection and pooled analysis of observational studies that meet inclusion criteria was included. Studies included were published between January 2020 and December 2021 (identified through PubMed and ScienceDirect) and examined the association between treatment with RDV in SARS-CoV-2 infection and the risk of bradyarrhythmia.ResultsThree studies (two retrospective cohort studies and one prospective cohort study) met inclusion criteria for pooled meta-analysis of bradyarrhythmia and RDV therapy in COVID-19 patients. Treatment with RDV was associated with increased risk of sinus bradycardia when compared to controls (odds ratio 3.27 (95% confidence interval 1.90 - 5.63)). In the pooled analysis, the incidence of bradycardia in those that received RDV was 34.07% vs. 18.13% among controls. Thirteen case reports, three case series, and three disproportionality analyses were identified in review of the literature.ConclusionData from real-world observational studies suggest that treating COVID-19 patients with RDV may predispose the development of bradyarrhythmia. The importance of this observation is of uncertain clinical significance as some observational studies have reported more favorable outcomes among patients who experience bradycardia after RDV therapy. The current study is limited by the small number of studies that could be meaningfully pooled and more well-designed cohort studies are needed to explore this association.

PO-623-06 LIMITED CARDIO-NEURAL ABLATION OF THE SUPERIOR VENA CAVA-AORTA AND RIGHT SUPERIOR GANGLIONATED PLEXI AS AN ADJUNCT TO PULMONARY VEIN ISOLATION FOR TACHY-BRADY SYNDROME

Use of negative chronotropic agents in atrial fibrillation (AF) can cause symptomatic sinus bradycardia (tachy-brady syndrome), often leading to pacemaker implantation. Limited cardioneural ablation (CNA) of ganglionated plexi (GPs) immediately following radiofrequency ablation (RFA) for AF can increase heart rate (HR) by modifying autonomic tone, which may help avoid device implantation. To explore limited CNA for sinus HR augmentation as an adjunct to RFA for AF in patients with tachy-brady syndrome and to determine if increases in sinus HR are sustained. We performed CNA of the right superior and superior vena cava (SVC)-aorta GPs in 11 patients following RFA for AF. All patients had resting sinus bradycardia (HR<60 bpm). Ten patients were male, age 62 ± 11 years (all data mean ± SD), paroxysmal AF in 5 cases, repeat AF procedure in 3 cases, posterior wall isolation / additional lines in 9 cases. All procedures were performed under general anesthesia with jet ventilation. GPs were identified by fractionated electrograms in typical anatomic locations with HR increase during ablation. Intra-procedural HR was obtained following AF ablation immediately before and after CNA. Ambulatory sinus HR was collected from 12 lead ECGs before ablation and at 2 week and 2 month post-procedure visits. Intra-procedural HR increased immediately following CNA from 48 ± 10 bpm to 78 ± 15 bpm, p<0.001, median increase 36 bpm. Compared to pre-procedure ambulatory HR (53 ± 7 bpm), post-procedure HR increased to 65 ± 9 bpm at 2 week and 73 ± 11 bpm at 2 month follow-up visits (p<0.05). One patient developed post-procedure bradycardia due to suspected sinus node artery injury requiring temporary dopamine infusion but no permanent pacing. In 2 cases, antiarrhythmic drugs were stopped during follow-up, but beta blockers were continued unchanged in all patients. Limited CNA of the SVC-aorta and right superior GPs as an adjunct to AF ablation resulted in an immediate HR increase that was sustained over 2 months of follow-up. This strategy may be useful in augmenting sinus rates in patients with tachy-brady syndrome.

Efficacy and safety of temporary permanent pacemaker: A single-center experience

Temporary cardiac pacing is commonly indicated for the treatment of symptomatic bradycardia and various types of reversible symptomatic heart block. Conventional transvenous temporary cardiac pacing therapy is widely used. This technique is associated with a number of limitations and complications, compared to permanent pacing system. The aim of our study was to identify the indications, complications and outcomes of transvenous semi-permanent pacing. A retrospective study was conducted in our cardiology department from 2017 to 2019. We investigated semi-permanent transvenous pacing system. Were included all patients presenting symptomatic heart block potentially reversible or in a context of severe infection, and patients hospitalized for alcohol septal ablation. A total of 18 patients were implanted, aged between 47 and 92 years. Seven were enrolled for STEMI with symptomatic atrioventricular block, 4 for alcohol septal ablation for hypertrophic cardiomyopathy, 1 for hyperkaliemia, 1 for myocarditis with atrioventricular block and 5 for symptomatic sinus bradycardia or atrioventricular block with infection circumstances. The venous access was sub clavicular in 17 patients (94%) and internal jugular in just 1 patient. After a median follow-up of 14.5 ± 9.63 months, the total duration of hospital stay was 13.5 ± 10.14 days. The duration of temporary pacing was 10 ± 6.27 days. A total of 12 patients (67%) were definitely implanted of dual chamber pacemaker (75%), cardio resynchronization therapy pacemaker (17%) or defibrillator (8%). One patient died with the semi-permanent pacing system in situ. No major or minor intra-operative or postoperative complication occurred. Temporary permanent pacemaker with bipolar active fixation leads and epicutaneous pulse generators provide a cost effectiveness option for prolonged temporary pacing as a bridge to permanent system implantation or recovery.

640 Cannabis abuse and syncope

Abstract Aims Cannabis (marijuana) is the most consumed drug worldwide, counting roughly 200 million users in 2019 (4% of the global population). Once illegal in most of the world countries, cannabis is now legal for medical and recreational use in several states. During the last 20 years, we have observed a growing decriminalization wave parallel with an increase number of consumers: it is therefore mandatory not only for the cardiologists but for every physician to be aware of marijuana potential cardiovascular adverse health effects. With this paper, we present a case report of cannabis induced 16 s implantable loop recorder (ILR) recorded asystole from hypervagotonia in a 24-year-old heavy marijuana consumer. We focus on the infrequently reported association between syncope and chronic marijuana use and we try to explain the underlying mechanisms against the background of the current literature. Methods and results A 24-year-old presented to the emergency department sent by her cardiologist because of a recent finding of a 16 s asystole on the ILR she implanted 7 months before for recurrent syncopes. She openly declared that she is a heavy marijuana user (at least 5 cannabis-cigarette per day, not mixed up with tobacco, for no less than 12 years). She had a history of at least two spontaneous atypical syncopal episodes and a multitude of pre-syncopal episodes. Before being hospitalized, she underwent several diagnostic tests excluding a neurological etiology and, upon outpatient regimen, she begun a cardiology evaluation which lead to the ILR implantation. While watching TV at late night, the second prodrome-less syncopal episode occurred and a 16-s asystole was found on the ILR. During hospitalization, the patient was closely monitored and we evaluated basic autonomic function tests, carotid sinus massage, echocardiography, exercise stress test, and 24 h telemetry. Following the results of the exams, we considered a heart conduction system anomaly unlikely. Finally, the patient underwent a toxicological and a psychiatric evaluation, where she strongly expressed not wanting to abandon cannabis abuse. After a collective discussion with the heart team, syncope unit, electrophysiologists, and toxicologist, we decided to implant a dual chamber pacemaker with a rate response algorithm due to the high risk of trauma of the syncopal episodes. Conclusions Cannabis cardiovascular effects are not well known; among these we find ischaemic episodes, tachyarrhythmias, symptomatic sinus bradycardia, sinus arrest, and ventricular asystole. In the light of the poor literature, we believe that cannabis may produce opposite adverse effects depending on the duration of the habit. Acute administration increases sympathetic tone and reduces parasympathetic tone; conversely, with chronic intake an opposite effect is observed: repetitive dosing decreases sympathetic activity and increases parasympathetic activity. Physicians should be aware of the effects that cannabis produces upon the cardiovascular system: this could avoid expensive, prolonged hospitalizations, and needless diagnostic tests.

Safety and Effectiveness of Pharmacologic Conversion of Atrial Fibrillation and Flutter: Results of Multicenter Trial. Part II: Assessment of Safety

Aim.We aimed to assess safety and effectiveness of class III antiarrhythmic drug Refralon for conversion of atrial fibrillation (AFib) and flutter (AFl) in post-registration trial and to compare data of primary center (National medical research center in cardiology) with data of other hospitals.Material and Methods. We performed retrospective cohort study in 727 patients (451 enrolled in primary center and 276 enrolled in other hospitals) admitted between June 24, 2014 and June 24, 2019. Refralon was administered for conversion of AFib and AFl in intense care units in escalating doses (10-30 micrograms/kg) intravenously.Results.Conversion of AFib and AFl into sinus rhythm was achieved in 53,6% after administration of 10 mcg/kg dose, in 73% after administration of 20 mcg/kg dose and in 91,6% after administration of Refralon in dose up to 30 mcg/kg. No mortality and no major adverse cardiac events registered in our study. Asystole &gt;3.0 sec observed in 5% (35 of 727) of patients): in 5% (24 of 451) of patients enrolled in primary center and in 4% (11 of 276) of patients enrolled in other hospitals; 95% confidence interval (CI) [-0.09; 0.113]. Asystole&gt; 5.0 s observed in 1.7% of patients who further required non-urgent implantation of a permanent pacemaker due to manifestations of sinus node dysfunction. Cardiac conduction disturbances (exclusively sinus bradycardia) were registered in 7% (53 of 727) patients: in 8% (37 of 451) of patients enrolled in primary center and in 6% (17 of 276) of patients enrolled in other hospitals; 95% CI: [-0.1; 0.15]. Only 0.14% of patients had symptomatic sinus bradycardia that resolved after atropine injection. Ventricular arrhythmias (exclusively Torsade de pointes tachycardia in excessive QT interval prolongation) were registered in 1.7% (12 of 727) patients: in 2% (9 of 451) of patients in primary center and in 1% (3 of 276) of patients of other hospitals; 95% CI: [-0.06; 0.08]. QTc interval prolongation to values &gt;500 ms documented in 19% (138 of 727) of patients: in 21% (95 of 451) of patients in primary center and in 16% (43 of 276) of patients in other hospitals; 95% CI: [-0.13; 0.24].Conclusion:In post-registration multicenter trial Refralon demonstrated good safety profile in conversion of AFib and AFl. Potential risk of TdP tachycardia mandates precautions with the use of the drug. In other hospitals Refralon did not demonstrate lower safety than in primary medical center.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

Symptomatic sinus bradycardia due to electrolyte imbalances in syndrome of inappropriate antidiuretic hormone (SIADH) related covid-19: a case report

BackgroundCoronavirus Disease-2019 (COVID-19) has been declared a global pandemic since March 11th, 2020. Despite emerging reports and literature covering a broad spectrum of COVID-19 clinical manifestations, facets of COVID-19 have not been fully elucidated. To the authors’ concern, sinus bradycardia as a manifestation of COVID-19-induced syndrome of inappropriate antidiuretic hormone (SIADH) has never been reported before.Case presentationIn this paper, we report a case of a 59-year-old male patient with confirmed COVID-19 initially presented with presyncope. Further investigations reveal sinus bradycardia related to COVID-19-induced SIADH. This case highlights the possibility of immuno-neuroendocrino-cardiovascular crosstalk resulting in an atypical manifestation of COVID-19: near syncope due to sinus bradycardia.ConclusionsAnother possible cause of sinus bradycardia in COVID-19 is electrolyte imbalance due to COVID-19-related SIADH.

Isolated Sinus Bradycardia as a Cardiac Manifestation of COVID -19

Novel coronavirus-19 disease (COVID-19) is associated with significant cardiovascular morbidity and mortality. These two-case report suggest that transient sinus bradycardia is a possible manifestation of COVID-19 and an important for close surveillance [1]. These cases were presented with isolated symptomatic primary sinus bradycardia which was transient and disappear by the recovery of the COVID-19 infection.

Atrial Autonomic Denervation for The Treatment of Longstanding Symptomatic Sinus Bradycardia: A Case Report

Atrial Autonomic Denervation for The Treatment of Longstanding Symptomatic Sinus Bradycardia: A Case Report

P1097Heart rate acceleration is a poor surrogate of complete parasympathetic denervation of sinus node during cardioneuroablation

Abstract Background Ablation of superior paraseptal ganglionic plexi is invariantly associated with the acceleration of sinus rhythm. This is considered a favourable sign during cardioneuroablation for the treatment of recurrent neurally-mediated cardioinhibitory syncope or symptomatic sinus bradycardia. Purpose In this retrospective study, we investigated whether the magnitude of sinus rhythm acceleration corresponds with directly assessed sinus nodal parasympathetic denervation. Methods The study included 48 patients (age: 39 ± 13 years, 58% males) who underwent cardioneuroablation in general anaesthesia. The procedural endpoint was non-responsiveness (i.e. loss of original cardioinhibitory response) of the sinus node to extracardiac high-frequency stimulation of the vagal nerve. The magnitude of sinus rhythm acceleration was compared between patients who reached or did not reach this endpoint. Results All patients had positive atropine test (baseline heart rate: 65 ± 14 bpm; post-atropine: 109 ± 22 bpm). Complete sinus nodal denervation as assessed by vagal nerve stimulation was achieved in 44/48 (92%) patients. Intraprocedurally, heart rate accelerated from 54 ± 11 to 85 ± 14 bpm (difference: 31 ± 10; median 29; interquartile range: 24–40; total range: 13–61 bpm). This change did not correlate with age and was not related to pre-procedural post-atropine sinus rhythm acceleration. There was no difference in heart rate acceleration between the patient with and without sinus nodal denervation (Figure). Conclusions Sinus rhythm acceleration is not reliable endpoint for cardioneuroablation. Guidance by extracardiac vagal nerve stimulation may help to tailor the procedures to increase the clinical success rate and, at the same time, to avoid patient overtreatment. Abstract Figure.