Non-ischemic Painful Intermittent Left Bundle Branch Block With Infra-Hisian Block Treated Successfully With Biventricular Pacemaker: A Case Report and Literature Review.

Non-ischemic painful left bundle branch block (LBBB) is defined as chest pain that occurs simultaneously with the appearance of left bundle branch block and resolves with the disappearance of the left bundle branch block in patients without evidence of myocardial ischemia. The underlying mechanism of this rare clinical occurrence has not been fully understood, but it has been proposed that it results from ventricular dyssynchrony. In this case report, we present a 65-year-old male with non-ischemic chest pain who was found to have intermittent left bundle branch block (ILBBB) with infra-Hisian conduction delay, treated successfully with a biventricular pacemaker. After excluding the presence of angiographic coronary artery disease, an electrophysiology study was conducted to direct the management and investigate other causes of chest pain. The present study highlights the importance of obtaining electrophysiology studies in patients with painful left bundle branch block with no angiographic evidence of coronary artery disease to diagnose this uncommon syndrome.

Limitation of standard ECG criteria to localize an outflow tract PVC.

Multiple ECG algorithms exist to localize outflow tract PVCs. They can be invaluable in pre-procedure planning and patient counseling. We describe a case where the published algorithm for PVC localization did not predict the site of origin and successful ablation site. This case highlights the strengths and limitations of established ECG PVC localization algorithms.

Bradyarrhythmias in patients with COVID-19: Marker of poor prognosis?

BACKGROUND: Despite descriptions of various cardiovascular manifestations in patients with coronavirus disease 2019 (COVID-19), there is a paucity of reports of new onset bradyarrhythmias, and the clinical implications of these events are unknown. METHODS: Seven patients presented with or developed severe bradyarrhythmias requiring pacing support during the course of their COVID-19 illness over a 6-week period of peak COVID-19 incidence. A retrospective review of their presentations and clinical course was performed. RESULTS: Symptomatic high-degree heart block was present on initial presentation in three of seven patients (43%), and four patients developed sinus arrest or paroxysmal high-degree atrioventricular block. No patients in this series demonstrated left ventricular systolic dysfunction or acute cardiac injury, whereas all patients had elevated inflammatory markers. In some patients, bradyarrhythmias occurred prior to the onset of respiratory symptoms. Death from complications of COVID-19 infection occurred in 57% (4/7) patients during the initial hospitalization and in 71% (5/7) patients within 3 months of presentation. CONCLUSIONS: Despite management of bradycardia with temporary (3/7) or permanent leadless pacemakers (4/7), there was a high rate of short-term morbidity and death due to complications of COVID-19. The association between new-onset bradyarrhythmias and poor outcomes may influence management strategies for acutely ill patients with COVID-19.

Survival of a Patient with an Esophagopericardial Fistula After Catheter Ablation for Atrial Fibrillation: A Case Report and Literature Review.

Esophageal injury leading to esophagopericardial fistula (EPF) or atrioesophageal fistula is a very rare and dreaded complication of catheter ablation for atrial fibrillation that carries a high mortality rate. We present a case of EPF following radiofrequency catheter ablation for atrial fibrillation and an extensive review of the literature regarding catheter ablation-related esophageal injury.

Left Atrial Appendage Occlusion in the Management of Stroke in Patients With Atrial Fibrillation.

Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.