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Third-degree block [keywords]
- Prognostic implications of atrio-ventricular block in patients undergoing primary coronary angioplasty in the stent era. [Journal Article]
- Acute Card Care 2014 Mar; 16(1):1-8.
Abstract Introduction: Conduction disorders in patients with ST-segment elevation myocardial infarction (STEMI) are associated with high mortality. Previous studies have analyzed the implications of AVB in acute coronary syndrome treated with fibrinolysis. However, the implications of AVB in patients with STEMI treated with primary angioplasty have not been sufficiently studied. Material and methods: 913 patients with STEMI treated with primary angioplasty. All clinical, electrocardiographic and angiographic variables were collected.
Results:AVB was documented in 115 patients (12.6%). On admission, AVB was present in 70 (7.7%), and persistent at hospital discharge in 36 (3.9 %). Within these, first-degree AVB was present in 29 (3.2%), second-degree in 27 (3%) and third-degree in 73 (8%). AVB was more frequent in women, elderly, hypertensive, diabetic, with worse functional class (Killip class > 2) and with higher incidence at inferior infarctions (P < 0.05). AVB in general and, more specifically, third-degree AVB was associated with a higher mortality (20.5% versus 5.7%; P < 0.001), re-infarction (8.2% versus 3.6%; P = 0.06) and a greater incidence of cardiogenic shock (33.3% versus 14%; P < 0.001). Interestingly, these events were more common in patients who had persistent AVB at hospital discharge than in those with transitory AVB or present at admission AVB. In the multivariate analysis, persistent AVB at hospital discharge proved to be an independent predictor of cardiovascular events (death and recurrent infarction), not the rest of AVB.
Conclusions:AVB in patients who underwent primary angioplasty is associated with a worse prognosis while is in-hospital. This risk is particularly high in patients who had persistent AVB at hospital discharge.
- [Interatrial block as anatomical-electrical substrate for supraventricular arrhythmias: Bayeś syndrome.] [JOURNAL ARTICLE]
- Arch Cardiol Mex 2014 Feb 12.
In this article we aimed to establish that interatrial block exists as an anatomical-electrical entity, which should be considered a true block. Interatrial block presents with different degrees as other blocks in the conduction system. It shows a correlation with the left atrium size, however, it can be seen in patients with normal atrial size too. Interatrial block is strongly associated with atrial arrhythmias and it could be considered a predictor of cardioembolic stroke. Interatrial block is an expression of atrial electrical remodeling and dysfunction. IAB can be transient and in certain clinical circumstances, may be reversible. The contribution of endocardial mapping has increased our knowledge of the anatomy and pathophysiology of interatrial block. Magnetocardiography could be a possible non-invasive procedure to further investigate this entity. The interatrial block classification should include first, second and third degree or alternatively, in order to simplify the terminology: partial or advanced. The P wave morphology should always be taking into consideration when diagnosing this condition. Finally, without the initial description of interatrial block made by Dr. Bayés de Luna, it would be impossible to understand interatrial block as an anatomical and electrical substrate for atrial arrhythmias. It is our opinion that this represents a major contribution to the knowledge of electrocardiography and electrophysiology, and makes commendable that this arrhythmic syndrome should be called «Bayés' syndrome»
- Automated functıonal ımagıng ın atrıoventrıcular delay tıme optımızatıon ın patıents wıth dual chamber pacemakers. [JOURNAL ARTICLE]
- Kardiol Pol 2014 Feb 14.
Optimization of atrioventricular (AV) delay time has positive effects on left ventricular functions in patients with DDD pacemaker. However, the method used for optimization is still debated. In our study, we aimed to evaluate the effect of different AV delay times on variation of left ventricular systolic performance by using automated functional imaging (AFI) in patients with DDD pacemaker and preserved left ventricular systolic function.The study population consisted of 40 patients with DDD pacemaker implanted for third degree AV block and preserved left ventricular systolic function (19 men; mean age 64,3 ± 10,9 years). During each pacing period, blood samples were taken for measurement of brain natriuretic peptide (BNP) levels, telemetric and echocardiographic evaluations were performed to all patients. Also peak systolic global longitudinal strain (PSGLS) was calculated by using AFI method.No significant differences except for left ventricular outflow tract-velocity time integral (LVOT-VTI) were observed in pulse wave Doppler parameters with different AV delay times. PSGLS were better at 150 and 200 ms AV delay times when compared to 100 ms (p<0,001 for 100-150 ms and 100-200 ms). Similarly LVOT-VTI values were significantly higher at 150 and 200 ms AV delay times when compared to 100 ms (for 100-150 ms p=0,017 and for 100-200 ms p=0,013). Also there was a significant reduction in BNP levels at 150 ms and 200 ms compared with 100 ms AV delay time (for 100-150 ms p=0,001, and for 100-200 ms p<0,001).In patients with implanted DDD pacemaker and preserved left ventricular systolic function, increasing AV delay time has beneficial effects on left ventricular systolic performance in acute phase, as shown by AFI method in our study.
- Complete atrioventricular septal defect: comparison of modified single-patch technique with two-patch technique in infants. [Journal Article]
- J Card Surg 2014 Mar; 29(2):251-5.
The purpose of this study was to compare the modified single-patch technique with the two-patch technique for infants with complete atrioventricular septal defects (AVSDs).Between December 2001 and October 2011, 98 infants underwent complete AVSD primary repair. Forty-six patients had a modified single-patch technique; 59 patients had a two-patch technique. Eighty-seven patients had follow-up by echocardiography to measure the degree of valve regurgitation.There were two deaths (one in modified single-patch group and one in two-patch group). Cross-clamp times and cardiopulmonary bypass times were shorter in the modified single-patch group (70.56 ± 21.05 vs. 83.76 ± 22.74 minutes, p = 0.004; 95.02 ± 19.73 vs. 109.9 ± 34.07, p = 0.011). There was no patient with third-degree atrioventricular (AV) block in the modified single-patch group, while two patients in the two-patch group required a pacemaker (3.85%, p = NS). During follow-up, one death occurred in the single-patch group and three deaths in the two-patch group. At last follow-up, ten patients had more than moderate left AV valve regurgitation (four in single-patch group vs. six in two-patch group, p = 0.886) and eight patients required reoperation (three in single-patch group vs. five in two-patch group, p = 0.841). One patient in the single-patch group required reoperation for a residual ventricular septal defect and none in the two-patch group.Modified single-patch repair in infants with complete AVSD is a safe and reproducible technique. The results are as good as the two-patch technique. Among long-term survivors, most have very good clinical and functional results and minimal or no regurgitation of either AV valve. doi: 10.1111/jocs.12295 (J Card Surg 2014;29:251-255).
- Reevaluation of the indications for permanent pacemaker implantation after transcatheter aortic valve implantation. [Journal Article]
- J Invasive Cardiol 2014 Feb; 26(2):94-9.
Conduction abnormalities (CA) requiring permanent pacemaker (PPM) are a well-known complication after transcatheter aortic valve implantation (TAVI). This study aimed to determine the incidence of TAVI-related PPM and reevaluate the indications for PPM after the periprocedural period.A total of 258 consecutive patients underwent TAVI with the Medtronic CoreValve (MCV), whereas 24 patients were excluded from the study. TAVI-related PPM was defined as PPM implantation ≤30 days after the procedure and due to atrioventricular block (AVB). Third-degree AVB, second-degree type-II, or advanced second-degree AVB were considered as absolute indications for PPM. The incidence of TAVI-related PPM implantation was 27.4%. Forty-six patients (19.7%) had an absolute indication for PPM, but CA had resolved in 50% beyond the periprocedural period. Electrocardiographic analysis of the patients who did not have a TAVI-related PPM implantation showed that the PR and QRS intervals increased following TAVI, reaching a peak on days 4-6 and 7-9, respectively, before decreasing to near baseline levels.Although the incidence of periprocedural PPM implantation following TAVI was high, most CAs following TAVI tend to resolve after the periprocedural period. This suggests that delaying the decision for PPM implantation after TAVI may reduce the PPM rate.
- Yellow oleander poisoning in eastern province: An analysis of admission and outcome. [Journal Article]
- Indian J Med Sci 2013 Jul; 67(7-8):178-83.
Introduction: Cardiac toxicity after self-poisoning from ingestion of yellow oleander seeds is common in Eastern Sri Lanka.
Objective:To determine the clinical manifestations, cardiac arrhythmias, electrolytes abnormalities and outcome of management using currently available treatment, Poisoning Unit, Tertiary Care Hospital in Eastern Sri Lanka. Materials and
Methods:We studied 65 patients [Mean age : 23(±0.43)yrs], (Male: Female=27:38) with yellow oleander poisoning (YOP) admitted to a Poisoning Unit, Tertiary Care Hospital in Eastern Sri Lanka from January to December 2011.
Results:Most patients are symptomatic who presented with classical symptoms of vomiting, abdominal pain and diarrhea. Cardiac dysrhythmias such as bradycardia or an irregular pulse are the most common findings on examination. Most symptomatic patients had conduction defects affecting the sinus node, the atrioventricular (AV) node, or both. Patients showing cardiac arrhythmias that required transfer for specialised management had significantly higher serum potassium concentrations. Almost all patients were treated with multiple activated charcoal even late presentation. Patients with brad arrhythmias were treated with intravenous boluses of atropine and intravenous infusions of isoprenaline. Temporary cardiac pacing was done for those not responding to drug therapy. There were two deaths (3.07%), both had third-degree heart block. They died even definitive treatment could be instituted. Of the remaining 63 patients, 54 (83.1%) patients required treatment, and 29 were treated with only atropine and/or isoprenaline while one required cardiac pacing in addition. 12 (18.4%) patients had arrhythmias that were considered life threatening (second-degree heart block type II, third-degree heart block and nodal bradycardia). They had good recovery even though they had developed cardiac toxicity.
Conclusions:YOP are common among young females. The cardiac toxicity develops within 24hrs of ingestion of YO seeds. The risk of toxicity has negative correlation with number of seeds. Most patients have nonspecific symptoms. AV conduction defects are common. Multiple activated charcoals alone were safe and adequate in most cases even late presentation.
- [In Process Citation]. [English Abstract, Journal Article]
- Ther Umsch 2014 Feb 1; 71(2):105-10.
Bradyarrhythmias are caused by a disturbed impulse formation in the sinus node and/or a disturbed impulse conduction and can be subclassified clinically as sinus node dysfunction, atrioventricular (AV) block, or functional bradycardia. Persistent bradycardia can be diagnosed by standard ECG. For diagnosis of intermittent bradycardia, often long-term ECG monitoring and/or additional testing is necessary. Symptomatic bradycardias are the standard indication for cardiac pacing after exclusion of reversible causes. Since sinus node dysfunction is associated with a good prognosis, pacing in this condition is only indicated in the presence of bradycardia-related symptoms. For prognostic reasons, pacemaker implantation is indicated in third degree AV block and second degree AV block Mobitz Type II, even if asymptomatic. Cardiac pacing for recurrent unpredictable neurocardiogenic syncope due to a cardioinhibitory reflex should be considered in certain circumstances. The implantation of cardiac pacemakers has been performed for more than half of a century. Due to the enormous technological progress, pacemaker implantations can nowadays be performed under local anesthesia in an outpatient setting. However, complications of pacemaker therapy are still not uncommon.
- Cesarean section in third degree heart block with severe hypertension. [Journal Article]
- J Obstet Gynaecol India 2013 Mar; 63(1):66-7.
- Transcatheter aortic valve implantation through carotid artery access under local anaesthesia. [JOURNAL ARTICLE]
- Eur J Cardiothorac Surg 2014 Jan 14.
Trans-femoral and transapical are the most commonly used accesses for transcatheter aortic valve implantation (TAVI). However, when these approaches are unsuitable, alternative accesses are needed. We report a series of 19 patients undergoing TAVI through common carotid artery (CCA) access under local anaesthesia in order to assess its feasibility and safety.From November 2008 to September 2013, 361 patients underwent TAVI at our institution. Nineteen of them (14 men) with mean age 82.2 ± 6.2 years, EuroSCORE 25.2 ± 15.7, Society of Thoracic Surgeons score 11.9 ± 5.1 and with severe peripheral arteriopathy were unsuitable for usual approaches and underwent TAVI through CCA access under local anaesthesia. Preoperative computed tomography assessed suitable carotid artery anatomy. Common carotid cross-clamping test allowed verifying patient's neurological status stability. An 18-Fr or 20-Fr sheath inserted into the CCA down into the ascending aorta was used for the delivery catheter. Valve implantation procedures were as usual. After sheath removal, the CCA was surgically purged and repaired. Feasibility and safety end points (VARC-2) were collected up to 30 days.Transcarotid insertion of the delivery sheath was successful in all cases (8 right, 11 left) and accurate deployment of the device was achieved in 18 patients (4 Edwards SAPIEN XT(®) and 14 Medtronic CoreValve(®)). There was 1 intraoperative death by annulus rupture during preimplant balloon valvuloplasty, and 1 in-hospital death due to multisystem organ failure. There was no myocardial infarction, stroke or major bleeding. Third-degree atrioventricular block requiring pacemaker implantation occurred in 3 patients. No vascular access-site, access-related or other TAVI-related complication occurred. Echocardiography revealed good prosthesis functioning with none, mild and moderate paravalvular leak in, respectively, 8, 9 and 1 patients. Patient ambulation was immediate after TAVI and hospital stay was 4.6 ± 2.3 days.TAVI through the CCA approach under local anaesthesia is feasible and safe. It allows continuous clinical neurological status monitoring with low risk of stroke, bleeding events, vascular access-site and access-related complications and immediate patient ambulation. It appears to be a valuable alternative access for patients who cannot undergo trans-femoral TAVI.
- Analysis of the atrial repolarization wave in dogs with third-degree atrioventricular block. [Journal Article]
- Am J Vet Res 2014 Jan; 75(1):54-8.
To characterize the electrocardiographic features of the atrial repolarization (Ta) wave in dogs with third-degree atrioventricular (AV) block.ECGs of 36 dogs with third-degree AV block and no identifiable structural heart diseases.Standard 12-lead ECGs were acquired with a digital system, and measurements were manually edited.A Ta wave was detectable in all dogs for at least 1 ECG lead. The Ta wave had negative polarity in leads I, II, III, and aVF and positive polarity in leads aVL and aVR, with a mean electrical axis of -114.26°. Mean duration and mean amplitude of the Ta wave in lead II were 140.2 milliseconds and -0.09 mV, respectively, with the ratio for the Ta-to-P wave duration of 2.3 and the ratio of Ta-to-P wave amplitude of -0.35. Significant correlations were found between the Ta wave duration and duration of the P-Ta interval, Ta wave amplitude and the ECG lead, Ta wave duration and body weight, and duration of the P-Ta interval and atrial rate. Measurements of the Ta wave were repeatable.Measurements of the Ta wave in dogs with third-degree AV block were repeatable. The values for the Ta wave reported here can be used as reference values for dogs with AV conduction disturbances and an echocardiographically normal atrial size. Further studies are needed to validate these results in dogs with structural heart diseases.