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Third-degree block [keywords]
- A 9-year-old boy with severe diphtherial infection and cardiac complications. [Journal Article]
- BMJ Case Rep 2014.
The incidence of diphtheria has decreased since the introduction of an effective vaccine. However, in countries with low vaccination rates it has now become a re-emerging disease. Complications from diphtheria commonly include upper airway obstruction and cardiac complications. We present a 9-year-old boy who was diagnosed with diphtheria. He presented with fever, tonsilar plaques, respiratory failure and an incomplete vaccination history. He was endotracheal intubated and received diphtheria antitoxin and penicillin on the first day of hospitalisation. He developed progressive arrhythmias and fulminant myocarditis despite early identification and treatment with equine antitoxin and antibiotics. After a temporary transvenous pacemaker insertion due to third-degree atrioventricular block and hypotension for 1 week, he developed myocardial perforation from the pacemaker tip resulting in pericardial effusion. The treatment included emergency pericardiocentesis and pacemaker removal. His electrocardiogram showed a junctional rhythm with occasional premature ventricular complexes. He then developed ventricular tachycardia and cardiac arrest and finally died.
- Notes from the field: update on lyme carditis, groups at high risk, and frequency of associated sudden cardiac death - United States. [Journal Article]
- MMWR Morb Mortal Wkly Rep 2014 Oct 31; 63(43):982-3.
On December 13, 2013, MMWR published a report describing three cases of sudden cardiac death associated with Lyme carditis. State public health departments and CDC conducted a follow-up investigation to determine 1) whether carditis was disproportionately common among certain demographic groups of patients diagnosed with Lyme disease, 2) the frequency of death among patients diagnosed with Lyme disease and Lyme carditis, and 3) whether any additional deaths potentially attributable to Lyme carditis could be identified. Lyme disease cases are reported to CDC through the Nationally Notifiable Disease Surveillance System; reporting of clinical features, including Lyme carditis, is optional. For surveillance purposes, Lyme carditis is defined as acute second-degree or third-degree atrioventricular conduction block accompanying a diagnosis of Lyme disease. During 2001-2010, a total of 256,373 Lyme disease case reports were submitted to CDC, of which 174,385 (68%) included clinical information. Among these, 1,876 (1.1%) were identified as cases of Lyme carditis. Median age of patients with Lyme carditis was 43 years (range = 1-99 years); 1,209 (65%) of the patients were male, which is disproportionately larger than the male proportion among patients with other clinical manifestations (p<0.001). Of cases with this information available, 69% were diagnosed during the months of June-August, and 42% patients had an accompanying erythema migrans, a characteristic rash. Relative to patients aged 55-59 years, carditis was more common among men aged 20-39 years, women aged 25-29 years, and persons aged ≥75 years.
- Influence of Second- and Third-Degree Heart Block on 30-Day Outcome Following Acute Myocardial Infarction in the Drug-Eluting Stent Era. [JOURNAL ARTICLE]
- Am J Cardiol 2014 Sep 16.
This study was conducted to investigate the prognostic value of heart block among patients with acute myocardial infarction (AMI) treated with drug-eluting stents. A total of 13,862 patients with AMI, registered in the nation-wide AMI database from January 2005 to June 2013, were analyzed. Second- (Mobitz type I or II) and third-degree atrioventricular block were considered as heart block in this study. Thirty-day major adverse cardiac events (MACE) including all causes of death, recurrent myocardial infarction, and revascularization were evaluated. Percutaneous coronary intervention with implantation of drug-eluting stent was performed in 89.8% of the patients. Heart block occurred in 378 patients (2.7%). Thirty-day MACE occurred in 1,144 patients (8.2%). Patients with heart block showed worse clinical parameters at initial admission, and the presence of heart block was associated with 30-day MACE in univariate analyses. However, the prognostic impact of heart block was not significant after adjustment of potential confounders (p = 0.489). Among patients with heart block, patients with a culprit in the left anterior descending (LAD) coronary artery had worse clinical outcomes than those of patients with a culprit in the left circumflex or right coronary artery. LAD culprit was a significant risk factor for 30-day MACE even after controlling for confounders (odds ratio 5.28, 95% confidence interval 1.22 to 22.81, p = 0.026). In conclusion, despite differences in clinical parameters at the initial admission, heart block was not an independent risk factor for 30-day MACE in adjusted analyses. However, a LAD culprit was an independent risk factor for 30-day MACE among patients with heart block.
- [Cardiac arrest due to torsades de pointes ventricular tachycardia in a patient with Lyme carditis.] [JOURNAL ARTICLE]
- Ugeskr Laeger 2014 Aug 25; 176(35)
A 45-year-old female presented with third degree atrioventricular block and was diagnosed with Lyme carditis. Despite appropriate antibiotic treatment and continuous ventricular pacing, she suffered sudden cardiac arrest due to torsades de pointes ventricular tachycardia. Although rare, severe and potentially fatal ventricular tachyarrhythmias can occur in patients with Lyme borreliosis.
- [Acute atrio-ventricular block in sickle cell anemia.] [JOURNAL ARTICLE]
- Ann Cardiol Angeiol (Paris) 2014 Sep 4.
Even though sickle cell disease has a high prevalence amongst the black race and despite its well known potential of micro infarction, there have been only a few reports regarding the acute myocardial damage during vaso-occlusive crisis. The risk of atrio ventricular block during these crises has never been described in a large survey.Ten patients (six men and four women, mean age 39 years old) were hospitalized for an acute atrio ventricular block. The patients were all African or Caribbean natives. Three patients were found with a heterozygous phenotype for hemoglobin S (sickle trait) and seven were found with a homozygous phenotype. The most common symptoms were asthenia (10 cases), shortness of breath (8 cases) and acute coronary syndrome (1 case) (syncope was not reported). Four patients had a second degree atrio ventricular block and six patients had third degree block. The treatment involved bed rest, intravenous hydration, and pain relief with opiates. All the cases of atrio ventricular block were only transitory and none of the patients underwent a pacemaker implantation.This report is the largest survey regarding transitory acute atrio ventricular block in patients with sickle cell disease. A local ischemic event affecting the AV node and Hiss bundle area can explain the conduction abnormalities. Sickle cell disease must be ruled out in black patients with an AV block.
- Expanding the indication for sutureless aortic valve replacement to patients with mitral disease. [Journal Article, Research Support, Non-U.S. Gov't]
- J Thorac Cardiovasc Surg 2014 Oct; 148(4):1354-9.
To review our experience with sutureless aortic valve replacement (AVR) in the setting of concomitant mitral valve (MV) surgery and discuss the technical considerations.Between January 2012 and March 2013, 10 patients underwent sutureless AVR with the Perceval prosthesis in the setting of concomitant mitral disease. Five patients underwent MV repair, 4 underwent MV replacement, and 1 had a previously implanted mechanical mitral prosthesis.The median age was 79 years and 7 patients (70%) were male. Median logistic EuroSCORE II was 6.2%. All valves were successfully implanted with no 30-day mortality. There was no residual aortic paravalvular leak. Two patients had from third-degree atrioventricular block requiring permanent pacemaker implantation. At a mean follow-up of 8±4 months (range, 2-16 months), the overall survival was 80% with 2 non-valve-related deaths and the mean transaortic gradient and aortic valve area had improved to 11.1±4.6 mm Hg and 1.5±0.3 cm2, respectively. There was no evidence of mitral dysfunction in any patient.In our experience, sutureless AVR in the setting of concomitant mitral surgery is a feasible and reproducible procedure. Elderly patients undergoing multiple valve surgery present a higher operative risk, therefore extending the indication for sutureless AVR to patients with concomitant mitral disease could greatly benefit this specific population.
- Assessment of Cardiac Sarcoidosis with Advanced Imaging Modalities. [REVIEW]
- Biomed Res Int 2014.:897956.
Sarcoidosis is a chronic systemic disease of unknown etiology that is characterized by the presence of noncaseating epithelioid granulomas, usually in multiple organs. Several studies have shown that sarcoidosis might be the result of an exaggerated granulomatous reaction after exposure to unidentified antigens in genetically susceptible individuals. Cardiac involvement may occur and lead to an adverse outcome: the heart mechanics will be affected and that causes ventricular failure, and the cardiac electrical system will be disrupted and lead to third degree atrioventricular block, malignant ventricular tachycardia, and sudden cardiac death. Thus, early diagnosis and treatment of this potentially devastating disease is critically important. However, sensitive and accurate imaging modalities have not been established. Recent studies have demonstrated the promising potential of cardiac magnetic resonance imaging (MRI) and (18)F-fluoro-2-deoxyglucose positron emission tomography ((18)F-FDG PET) in the diagnosis and assessment of cardiac sarcoidosis (CS). In this review, we discuss the epidemiology, etiology, histological findings, and clinical features of sarcoidosis. We also introduce advanced imaging including (18)F-FDG PET and cardiac MRI as more reliable diagnostic modalities for CS.
- Chloroquine cardiomyopathy: beyond ocular adverse effects. [Journal Article]
- BMJ Case Rep 2014.
A 36-year-old woman who had received long-term treatment with chloroquine for systemic lupus erythematosus developed a third degree atrioventricular block and required a permanent pacemaker. Notably, left ventricular thickening and mild systolic dysfunction were noticed on echocardiography as well as on cardiac MRI. As there was no clear explanation for myocardial findings, the patient underwent an endomyocardial biopsy that demonstrated vacuolar degeneration of myocytes on light microscopy and curvilinear bodies on electron microscopy, both findings consistent with chloroquine toxicity. The drug was withheld and treatment with candesartan and carvedilol was prescribed. At 2-year follow-up, the patient remained asymptomatic and left ventricular systolic function had improved. Physicians who prescribe antimalarial drugs for rheumatic diseases should be aware of the potentially life-threatening effects of chloroquine on the heart.
- Oliguric acute kidney injury as a main symptom of bradycardia and arteriosclerosis resolved by pacemaker implantation: a case report. [JOURNAL ARTICLE]
- J Med Case Rep 2014 Sep 1; 8(1):289.
Cardiovascular comorbidities regularly determine renal function. We report a case of acute kidney injury (Acute Kidney Injury Network stage 3) due to an intermittent third-degree atrioventricular block, which had not been diagnosed before.A 76-year-old Caucasian man with liver cirrhosis due to non-alcoholic fatty liver disease, and type-2 diabetes was cognitively impaired and had reduced vigilance presumably caused by hepatic encephalopathy and/or Alzheimer dementia. Within 2 years, two hospitalizations occurred for syncope attributed to orthostatic failure and hypovolemia. During the last hospitalization, oliguric acute kidney injury occurred. Sonography ruled out a post-renal cause. His renal resistive index was 1.0; his heart rate was below 50 beats per minute. After cessation of beta-blocker therapy, Holter electrocardiogram showed a new intermittent third-degree atrioventricular block with pauses for less than 3 seconds. Pacemaker insertion resolved his acute kidney injury, despite resumption of beta-blocker therapy. During four months of follow-up, syncope has not occurred, and vigilance was stable. However, his renal resistive index of 1.0 remained.Here, typical neurologic symptoms of bradycardia were misclassified. Diagnostic work-up of oliguric acute kidney injury revealed intermittent third-degree heart block. The pathomechanism of acute kidney injury relates to relevant bradycardia and increased vascular stiffness attenuating arterial diastolic renal blood flow.
- Clinical outcome as a function of the PR-interval-there is virtue in moderation: data from the Duke Databank for cardiovascular disease. [JOURNAL ARTICLE]
- Europace 2014 Aug 27.
Recently, a U-shaped association between PR-interval and the risk of developing atrial fibrillation was described, with higher risk in patients with long and short PR-intervals. Little is known regarding the association of PR-interval duration and mortality. The objective of the current study was to explore the relationship between PR-interval and major cardiovascular outcomes in patients with known coronary heart disease.Patients in sinus rhythm, undergoing coronary angiography at Duke University Medical Center between 1989 and 2010, who had significant stenosis in at least one native coronary artery, were included. Patients with arrhythmia, second- or third-degree AV-block, QRS > 120 ms were excluded. A total of 9,637 patients were included (median age 63, IQR 55-71 years, 67% men). After adjustment for relevant covariates, the risk of a CV event increased with a decreasing PR-interval (10 ms decrements) for PR-interval values <162 ms (all-cause mortality; HR 1.057, 95% CI 1.019-1.096, P = 0.0030, composite of death or stroke; HR 1.047, 95% CI 1.011-1.085, P = 0.0095 and composite of cardiovascular death or cardiovascular rehospitalization; HR 1.032, 95% CI 1.002-1.063, P = 0.0387). No statistically significant changes in the risk associated with PR-interval for values >162 ms were seen for any of the studied endpoints.In patients with coronary heart disease, a prolongation of the PR-interval was not independently associated with poor outcomes, but a PR-interval shorter than normal was associated with increased all-cause mortality and other major cardiovascular events.