The impact of complete atrioventricular block on in-hospital and long-term mortality in patients treated with primary percutaneous coronary intervention

Objective: To analyze the incidence and the prognostic impact of complete AV block on in-hospital and 6-year mortality in STEMI patients treated with pPCI. Method: Study included 3044 consecutive STEMI patients. Results: Complete AV block was registered only at admission in 144 (4.73%) patients; 125 (86.8%) patients with complete AV block had inferior infarction. Temporary pacemaker was implanted in 72 (50%) patients with complete AV block. No patient underwent permanent pacemaker implantation. In-hospital mortality was significantly higher in patients with complete AV block than in patients without complete AV block: 17.9%vs3.6%, respectively, p<0.001. In patients with heart block and inferior infarction inhospital mortality was 13%, whereas in patients with heart block and anterior infarction inhospital mortality was 53%. When we analyzed patients who were discharged alive from the hospital, we also found significantly higher long-term (6-year) mortality rate in those with complete AV block vs patients without AV block: 7.8%v 3.4% respectively, p<0.001. Complete AV block was an independent predictor for in-hospital and 6-year mortality: inhospital mortality OR 2.94 95%CI 1.23-5.22; six year mortality HR 1.61, 95%CI 1.10- 2.37. When subanalysis was performed, in patients with inferior STEMI, complete AV block was an independent predictor of in-hospital and 6-year mortality, while in patients with anterior STEMI, complete AV block was an independent predictor of in-hospital mortality. Conclusion: In analyzed STEMI patients complete AV block was transitory and was registered only at hospital admission. Although transitory, complete AV block remained a strong independent predictor of in-hospital and long-term mortality.

Takotsubo syndrome presenting with syncope and third-degree atrioventricular block requiring permanent pacemaker implantation

Takotsubo syndrome (TS) is an acute but transient heart failure syndrome and it is very uncommon for TS to present as syncope with complete atrioventricular (AV)block.In this report,we aimed to present a case of TS complicated by third-degree AV block presented to the emergency department with syncope and requiring permanent pacemaker implantation.A 53-year-old female admitted to our emergency department with complaints of syncopal episodes and chest pain.Due to ongoing chest pain,electrocardiography (ECG) findings and segmentary wall motion abnormality on the transthoracic echocardiography (TTE),she was immediately transferred to cardiac catheterization laboratory.Coronary angiogram revealed normal coronary arteries and left ventriculography demonstrated apical ballooning and hypokinesis of the apex.As the diagnosis of TS was established,patient was transferred to coronary intensive care unit(CICU).Initial ECG at CICU demonstrated complete AV block with a heart rate of 35 beats/min.On third day of hospitalization,repeat TTE showed improved left ventricular functions with an ejection fraction of 50%.During the follow-up period in CICU,complete AV block persisted and the rhythm did not return to normal sinus rhythm after 6 days of monitorization.An electrophysiologic study demonstrated supra-hisian atrioventricular block and atrioventricular dissociation.On seventh day of hospitalization,TTE demonstrated recovered ventricular functions with an ejection fraction of 65% and a dual pacemaker was then implanted.Her third month follow-up was uneventful and TTE showed normal left ventricular functions but pacemaker interrogation revealed 99% of ventricular pacing.This case report demonstrated that,the decision to implant a permanent pacemaker on such patients should be considered on a case-by-case basis,and electrophysiologic study could be valuable on this decision.

A rare and reversible cause of third-degree atrioventricular block: a case report

Background Cardiac involvement of Lyme disease (LD) typically results in atrioventricular (AV) conduction disturbance, mainly third-degree AV block. Case summary A 54-year-old patient presented to our emergency department due to recurrent syncope. Third-degree AV block with a ventricular escape rhythm (33 b.p.m.) was identified as the underlying rhythm. Transthoracic echocardiography (TTE) was normal. To rule out common reversible causes of complete AV block, a screening test for Lyme borreliosis was carried out. Elevated levels for borrelia IgG/IgM were found and confirmed by western blot analysis. Lyme carditis (LC) was postulated as the most likely cause of the third-degree AV block given the young age of the patient. Initiation of antibiotic therapy with ceftriaxone resulted in a gradual normalization of the AV conduction with stable first-degree AV block on Day 6 of therapy. The patient was changed on oral antibiotics (doxycycline) and discharged without a pacemaker. After 3 months, the AV conduction recovered to normal. Discussion Lyme carditis should always be considered, particularly in younger patients with new-onset AV block and without evidence of structural heart disease. Atrioventricular block recovers in the majority of cases after appropriate antibiotic treatment.

Complete heart block associated with Remdesivir in COVID-19: a case report

Background Since the pandemic began in 2020, Remdesivir has been widely used for the treatment of coronavirus disease-2019 (COVID-19). Here, we describe a case of a patient with COVID-19 who developed transient complete atrioventricular (AV) block and bradycardia after initiating treatment with Remdesivir. Case summary A 72-year-old male with a history of atrial fibrillation and lung cancer was hospitalized for COVID-19. Electrocardiogram (ECG) on admission demonstrated atrial fibrillation and right bundle branch block. He was started on a course of Dexamethasone and Remdesivir. Within 24 h of starting Remdesivir, he was noted to be in atrial fibrillation with ventricular rates between 30 and 40 b.p.m. On Day 5 of Remdesivir therapy, ECG demonstrated complete AV block. Having completed the Remdesivir regimen, during the next 48 h, he was closely monitored, and the AV block resolved spontaneously. As he remained asymptomatic and had an adequate chronotropic response with activity, pacemaker implantation was not recommended. Discussion Despite the widespread use of Remdesivir, there is little known information about its cardiac toxicity. Daily ECGs and close cardiac surveillance of patients who develop severe bradycardia or AV block are essential. Discontinuation of the medication usually results in the resolution of these cardiac disturbances.

Conduction disturbances after TAVR: rates of pacemaker implantation, burden of ventricular pacing and prognostic significance

Funding Acknowledgements Type of funding sources: None. BACKGROUND The occurrence of conduction disturbances remains frequent after TAVR. However, the effect of PM on mortality is controversial and many patients may recover spontaneous AV conduction during follow-up. PURPOSE To evaluate the incidence of PM implantation after TAVR, PM dependency and burden of ventricular pacing during follow-up and their influence on mortality. METHODS AND RESULTS We performed a retrospective analysis of all consecutive 293 patients who underwent TAVR from 2015 to 2019 at our hospital, regional hub for this procedure. Patients were classified into 3 groups: patients without PM (no-PM), patients with a PM implanted prior to TAVR (pre-PM) and patients requiring a PM following TAVR (post-PM) and their clinical and procedural characteristics are listed in Table 1. The rate of PM implantation after TAVR was 20,8%, at a median of 3.6 days after the procedure. The most common indication was complete AV block. A VVIR pacemaker was implanted in 28 patients, a DDD/DDDR PM in 27 patients and 2 patients received a CRT device. Among post-PPM patients, only 16% were PM-dependent at 2-month and 1-year follow-up. All of them received a PM for complete AV block (AVB). At 1-year follow-up, RV pacing burden was 60% among AVB patients and 23% in patients with a PM implanted for other reasons. PM implantation after TAVR was not associated with a mortality difference at 30-day, 1-year and long-term follow-up. Pre-PPM patients showed a higher mortality rate at long-term follow-up although not statistically significant. CONCLUSIONS Our data suggest that a single chamber device should be preferred in patients implanted for reasons other than complete AVB; in patients with AVB, the use of dual chamber device with an algorithm to minimize RV pacing should be the most suitable choice. Overall (293)No PPM (216)Pre-PPM (19)Post-PPM (57)p-valueAge, median(IQR)82(80-86)82(80-86)82(79-87)82(80-86)0,53Female, n(%)160(55)129(59)6(32)25(44)0,40NYHA III-IV, n(%)191(65)147(68)15(79)29(51)0,06Logistic Euroscore, mean (IQR)7,53(3,5-8,3)7(3,5-8)9,83(3,6-12)6(3,5-7,4)0,51Right bundle-branch block, n(%)21(7)13(6)na8(14)0,04AVA, mean ± SD0,69 ± 0,190,7 ± 0,190,7 ± 0,160,66 ± 0,180,23Self-expandable valve, n(%)181(62)123(57)12(63)46(81)0,001Balloon-expandable valve, n(%)102(35)86(40)7(37)8(14)0,0003Implant depth, mean ± SD6,87 ± 2,96,32 ± 2,65,71 ± 39,12 ± 30,0001Abstract Figure. Kaplan-Meier survival curve

Complete atrio-ventricular block with coronary artery spasm due to direct laryngoscopy in a pediatric patient with laryngeal papillomatosis: a case report

Background Coronary artery spasm has rarely been reported in pediatric patients. Previous studies have reported comorbidities and risk factors for coronary artery spasms. We present the case of a complete atrio-ventricular (AV) block that occurred in the absence of other risk factors immediately after direct laryngoscopy. Case presentation A 2-year-old girl developed severe coronary artery spasm after direct laryngoscopy for elective laryngeal papillomatosis resection. Immediately after the initiation of laryngoscopy, complete AV block and ST elevation on lead II of the electrocardiogram were observed. These findings indicated that the complete AV block was caused by a right coronary artery spasm. Conclusion Coronary artery spasm resulting in lethal arrhythmia rarely occurs in healthy pediatric patients. To the best of our knowledge, this is the first pediatric case of a severe coronary artery spasm resulting in a complete AV block due to direct laryngoscopy in a healthy patient.

Permanent Pacemaker Implantation in a Patient with Takotsubo Cardiomyopathy and Complete Atrioventricular Block

This case report presents a patient with Takotsubo cardiomyopathy (TCM) and complete atrioventricular (AV) block who was treated with permanent pacemaker implantation. A 78-year-old woman with a history of hypertension presented with a 6-month history of palpitations. On initial evaluation, her heart rate was 40 beats/minute. Electrocardiography revealed a complete AV block and T-wave inversion in these leads: I, II, aVL, aVF, and V3–6. Echocardiography showed akinesis from the midventricle to the apex and hyperkinesis on the basal segments. The patient was diagnosed with TCM and complete AV block. Because improvement of TCM may subsequently improve the AV node dysfunction associated with TCM, the patient was admitted for treatment of heart failure without pacemaker implantation. The left ventricular (LV) abnormal wall motion improved gradually; however, the AV block persisted intermittently. On hospital day 14, a pause of 5–6 seconds without LV contraction was observed, and permanent pacemaker implantation was performed. On day 92, echocardiography revealed normal LV wall motion. However, electrocardiography revealed that the pacemaker rhythm with atrial sensing and ventricular pacing remained. Although specific degree of damage that may result from AV block associated with TCM is unknown, some of these patients require pacemaker implantation, despite improvement of abnormality in LV wall motion.

The impact of complete atrioventricular block on in-hospital and long-term mortality in patients with ST-elevation myocardial infarction

Funding Acknowledgements Type of funding sources: None. Background/aim: Complete atrioventricular (AV) block is associated with worse in-hospital outcome in patients with ST-elevation myocardial infarction (STEMI), while whether it has an impact on long-term outcome is uncertain. The majority of previous studies that analyzed this issue are performed before introduction primary percutaneous coronary intervention (pPCI). The aim of this study was to analyse the incidence and the prognostic impact of complete AV block at admission on in-hospital and 6-year mortality in STEMI patients treated with pPCI. Method we analyzed 2863 consecutive STEMI patients without cardiogenic shock at admission. Clinical, laboratory and echocardiographic characteristics and prognosis were compared between patients with and without complete AV block at admission. Results Complete AV block at admission was registered in 134 (4.6%) patients; 117 (87.3%) patients with complete AV block had inferior infarction. In comparison without complete AV block, patients with complete AV block were older; they were more likely to have heart failure, lower blood pressure and lower creatinine clearance at admission, multi-vessel disease on initial coronary angiogram and lower pre-discharge left ventricular ejection fraction (EF). Temporary pacemaker was implanted in 68 (50%) patients with complete AV block. No patient underwent permanent pacemaker implantation. In-hospital mortality was significantly higher in patients with complete AV block than in patients without complete AV block: 17.9% vs 3.6%, respectively, p &lt; 0.001. In patients with heart block and inferior infarction in-hospital mortality was 13%, whereas in patients with heart block and anterior infarction in-hospital mortality was 53%. When we analyze patients who were discharged alive from the hospital, we also find significantly higher long-term (6-year) mortality rate in those with complete AV block at admission vs patients without AV block: 7.8% vs 3.4% respectively, p &lt; 0.001 (Figure 1). The causes of death in patients with complete AV block during long-term follow up were cardiovascular, e.g. sudden death, reinfarction or worsening of heart failure. In Cox regression model complete AV block was an independent predictor for in-hospital and 6-year mortality: in-hospital mortality HR 2.54 85%CI 1.93-5.22, p = 0.011; six year mortality HR 1.61, 95CI 1,09-2.37, p = 0.017. Other independent predictors for both short- and long-term mortality were age, heart failure at admission, lower creatinine clearance at admission, EF and post-procedural flow TIMI &lt;3 thorugh infarct-related artery. Conclusion Complete AV block at admission is an independent predictor for in-hospital and long-term mortality in STEMI patients treated with primary PCI. Abstract Figure 1

Single-Chamber Cardiac Pacemaker Implantation in a Donkey with Complete AV Block: A Long-Term Follow-Up

A five-month-old African jenny was presented with a history of exercise intolerance and syncopal episodes. Severe bradycardic arrhythmia due to a high-grade second-degree atrioventricular (AV) block with progression to complete AV block was diagnosed. The jenny underwent a transvenous single-chamber pacemaker implantation. The implantation procedure was performed in a lateral recumbency and the ventricular lead was inserted through the jugular vein. Positioning of the lead was guided by echocardiography. The pacemaker was programmed to VVI mode with a minimal ventricular rate of 40 pulses per minute, a pulse amplitude of 2.4 V, a pulse width of 0.5 ms and sensing amplitude of 2.5 mV. Short-term complications associated with the procedure included lead dislodgement and pacemaker pocket infection. The long-term outcome was satisfactory; the jenny showed improvement in heart function and quality of life after pacemaker implantation. The pulse generator replacement was performed twice (at nine-year intervals) and the intervention was always associated with a local inflammatory reaction around the pacing device. Cardiac examination 18 years after pacemaker implantation revealed no morphological changes in the heart; the electrode lead was still in the correct position and successful pacing and sensing of the ventricle were obtained. Regular follow-up checks are important to evaluate pacemaker function.