Third-Degree Atrioventricular Block And Asystole After Lung Resection: A Rare Complication.

Surgical resection remains the optimal therapeutic option for early-stage operable NSCLC. Despite significant advances in recent years related to anesthetic and surgical techniques, cardiopulmonary complications remain major causes for postoperative morbimortality. In this paper we present a case of a patient who developed complete AV block followed by asystole after lung resection surgery. The patient underwent surgery via right VATS and the procedure was uneventful.  On the first post-operative day patient developed a third-degree atrioventricular block followed by 6 seconds asystole. Pharmacological treatment was instituted and implementation of a permanent pacemaker occurred on the third post-operative day, without complications. The remaining postoperative course was uneventful and the patient was discharged home on the sixth post-operative day. It is the objective of the authors to report and highlight this rare and potencial fatal complication of lung resection.

Reversible complete atrioventricular block caused by aortic bicuspid valve calcification with severe aortic stenosis: a case report.

Background: The aetiology of secondary complete atrioventricular blocks includes ischaemia, cardiac sarcoidosis, electrolyte imbalance, drug use, rheumatic fever, and infections such as Lyme disease and endocarditis. Diagnosis is important since some of these causes are reversible. Although several studies have reported on aortic valve calcification causing complete atrioventricular blocks, no study has described improvement of complete atrioventricular blocks by removal of the calcification. Case summary: A 42-year-old man with syncope had a Mobitz type II atrioventricular block, an alternating bundle branch block, and severe aortic stenosis. We identified a 10 s paroxysmal complete atrioventricular block with pre-syncope and performed pacemaker implantation. Electrocardiography-gated computed tomography confirmed that the calcification had reached the muscular septum. 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed significant FDG uptake with high CT value of calcification in basal interventricular septum. The calcification in the septum was removed carefully, and aortic valve replacement was performed. The atrioventricular conduction capacity improved post-surgery. During the 1-year follow-up, the patient reported dramatic improvement in exercise capacity. We also noted an improvement of <0.1% in the right ventricular pacing burden. Discussion: Complete atrioventricular blocks occur in patients with aortic stenosis accompanied by severe calcification of the aortic valve, which are visualized comprehensively by echocardiography. Electrocardiography-gated computed tomography and FDG-PET enabled detailed evaluation of the extent of calcification and pre- and post-operative tissue inflammation. Hence, we suspected that the calcification in the septum was causing complete atrioventricular block. Moreover, clinicians should recognize that aortic valve calcification with aortic stenosis can cause complete atrioventricular blocks.

Impact of New-Onset Right Bundle-Branch Block After Transcatheter Aortic Valve Replacement on Permanent Pacemaker Implantation.

BACKGROUND: A delayed and recurrent complete atrioventricular block (CAVB) is a life-threatening complication of transcatheter aortic valve replacement (TAVR). Post-TAVR evaluation may be important in predicting delayed and recurrent CAVB requiring permanent pacemaker implantation (PPI). The impact of new-onset right bundle-branch block (RBBB) after TAVR on PPI remains unknown. METHODS AND RESULTS: In total, 407 patients with aortic stenosis who underwent TAVR were included in this analysis. Intraprocedural CAVB was defined as CAVB that occurred during TAVR. A 12-lead ECG was evaluated at baseline, immediately after TAVR, on postoperative days 1 and 5, and according to the need to identify new-onset bundle-branch block (BBB) and CAVB after TAVR. Forty patients (9.8%) required PPI, 17 patients (4.2%) had persistent intraprocedural CAVB, and 23 (5.7%) had delayed or recurrent CAVB after TAVR. The rates of no new-onset BBB, new-onset left BBB, and new-onset RBBB were 65.1%, 26.8%, and 4.7%, respectively. Compared with patients without new-onset BBB and those with new-onset left BBB, the rate of PPI was higher in patients with new-onset RBBB (3.4% versus 5.6% versus 44.4%, P<0.0001). On post-TAVR evaluation in patients without persistent intraprocedural CAVB, the multivariate logistic regression analysis showed that new-onset RBBB was a statistically significant predictor of PPI compared with no new-onset BBB (odds ratio [OR], 18.0 [95% CI, 5.94-54.4]) in addition to the use of a self-expanding valve (OR, 2.97 [95% CI, 1.09-8.10]). CONCLUSIONS: Patients with new-onset RBBB after TAVR are at high risk for PPI.

Prevalence of neonatal lupus in a small group of antibody-carrying mothers and frequency of complete atrioventricular block / Prevalencia de lupus neonatal en un pequeño grupo de madres portadoras de anticuerpos y frecuencia de bloqueo auriculoventricular completo

Abstract Background: Neonatal lupus (NL) is extremely rare and is caused by the transplacental passage of maternal IgG autoantibodies against Ro, La, and/or RNP proteins into the fetal circulation, which can cause congenital complete atrioventricular block (CCAB), permanent skin lesions, and liver involvement. Objective: To know the prevalence of NL in patients with CCAB and the clinical course in long-term follow-up. Methods: From January 1992 to December 2017, patients with CCAB were included. The presence of anti-SSA/Ro and anti-SSB/La antinuclear antibodies in maternal serum confirmed NL. Results: Eight patients were included with a follow-up of 10 ± 6 years; NL was concluded in 62.5%; two were male. One of them was diagnosed in utero, two at birth, and a pacemaker was implanted in them, one at 12 years of age and another at 15. The other two cases were diagnosed at 18 and 26 years of age, and permanent pacemakers were implanted 8 and 5 years later, respectively. In one case, a definitive pacemaker was not implanted in a newborn with only 1 year of follow-up. At delivery, 60% of the mothers were free of rheumatic disease, and altogether, they all had 19 children; none of them presented NL manifestations. Conclusions: CCAB is rare and frequently associated with a maternal autoimmune disease, practically all of them will require a definitive pacemaker at some point in their lives.

Resumen Antecedentes: El lupus neonatal (LN) es extremadamente raro y es ocasionado por el paso transplacentario de auto-anticuerpos maternos IgG contra las proteínas Ro, La y/o RNP a la circulación fetal que puede ocasionar bloqueo aurículo-ventricular completo congénito (BAVCC) permanente, lesiones dérmicas y afectación hepática. Objetivo: Conocer la prevalencia de LN en paciente con BAVCC y la evolución clínica en un seguimiento a largo plazo. Métodos: De enero de 1992 a diciembre 2017 se incluyeron paciente con BAVCC. La presencia de anticuerpos antinucleares anti-SSA/Ro y anti-SSB/La en suero materno confirmó LN. Resultados: Ocho pacientes fueron incluidos con seguimiento de 10 ± 6 años, el 62.5 % con LN; dos fueron del sexo masculino. Uno diagnosticado in útero, dos al nacimiento, en ellos se implantó marcapaso; uno a los 12 años de edad y otro a los 15. Los otros dos casos fueron diagnosticados a los 18 y 26 años, se implantó marcapaso definitivo en ellos 8 y 5 años después respectivamente. En un caso no se implantó marcapaso definitivo; un recién nacido con solo un año de seguimiento. Al dar a luz, el 60 % de las madres estaban libres de enfermedad reumática y en conjunto todas tuvieron 19 hijos, ninguno de ellos presentó manifestaciones de LN. Conclusiones: El BAVCC es raro y frecuentemente está asociado a una enfermedad autoinmune materna, prácticamente todos requerirán de marcapaso definitivo en alguna época de su vida.

Bailout Deep Septal LV Pacing to Treat Inadvertent Complete AV Block During Complex Ablation Procedure.

We present a case of persistent complete atrioventricular block that occurred during the diagnostic portion of a premature ventricular contractions' radiofrequency ablation in a complex heart failure patient. The case was managed by bailout deep left ventricular septal pacing after bipolar radiofrequency elimination of premature ventricular contractions.

Prevalence of neonatal lupus in a small group of antibody-carrying mothers and frequency of complete atrioventricular block.

BACKGROUND: Neonatal lupus (NL) is extremely rare and is caused by the transplacental passage of maternal IgG autoantibodies against Ro, La, and/or RNP proteins into the fetal circulation, which can cause congenital complete atrioventricular block (CCAB), permanent skin lesions, and liver involvement. OBJECTIVE: To know the prevalence of NL in patients with CCAB and the clinical course in long-term follow-up. METHODS: From January 1992 to December 2017, patients with CCAB were included. The presence of anti-SSA/Ro and anti-SSB/La antinuclear antibodies in maternal serum confirmed NL. RESULTS: Eight patients were included with a follow-up of 10 ± 6 years; NL was concluded in 62.5%; two were male. One of them was diagnosed in utero, two at birth, and a pacemaker was implanted in them, one at 12 years of age and another at 15. The other two cases were diagnosed at 18 and 26 years of age, and permanent pacemakers were implanted 8 and 5 years later, respectively. In one case, a definitive pacemaker was not implanted in a newborn with only 1 year of follow-up. At delivery, 60% of the mothers were free of rheumatic disease, and altogether, they all had 19 children; none of them presented NL manifestations. CONCLUSIONS: CCAB is rare and frequently associated with a maternal autoimmune disease, practically all of them will require a definitive pacemaker at some point in their lives.

ANTECEDENTES: El lupus neonatal (LN) es extremadamente raro y es ocasionado por el paso transplacentario de auto-anticuerpos maternos IgG contra las proteínas Ro, La y/o RNP a la circulación fetal que puede ocasionar bloqueo aurículo-ventricular completo congénito (BAVCC) permanente, lesiones dérmicas y afectación hepática. OBJETIVO: Conocer la prevalencia de LN en paciente con BAVCC y la evolución clínica en un seguimiento a largo plazo. MÉTODOS: De enero de 1992 a diciembre 2017 se incluyeron paciente con BAVCC. La presencia de anticuerpos antinucleares anti-SSA/Ro y anti-SSB/La en suero materno confirmó LN. RESULTADOS: Ocho pacientes fueron incluidos con seguimiento de 10 ± 6 años, el 62.5 % con LN; dos fueron del sexo masculino. Uno diagnosticado in útero, dos al nacimiento, en ellos se implantó marcapaso; uno a los 12 años de edad y otro a los 15. Los otros dos casos fueron diagnosticados a los 18 y 26 años, se implantó marcapaso definitivo en ellos 8 y 5 años después respectivamente. En un caso no se implantó marcapaso definitivo; un recién nacido con solo un año de seguimiento. Al dar a luz, el 60 % de las madres estaban libres de enfermedad reumática y en conjunto todas tuvieron 19 hijos, ninguno de ellos presentó manifestaciones de LN. CONCLUSIONES: El BAVCC es raro y frecuentemente está asociado a una enfermedad autoinmune materna, prácticamente todos requerirán de marcapaso definitivo en alguna época de su vida.

Relationship between systemic immune inflammation index and development of complete atrioventricular block in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: The systemic immune-inflammation index (SII), based on white blood cell, neutrophil, and platelet counts, is a proposed marker of systemic inflammation and immune activation. This study aimed to explore the relationship between SII and complete atrioventricular block (CAVB) development in STEMI patients undergoing primary PCI. METHODS: We retrospectively analyzed data from 883 patients who underwent primary PCI for STEMI between January 2009 and December 2017. Patients were categorized into two groups based on CAVB development. SII levels were calculated from blood samples taken on admission. RESULTS: Of the included patients, 48 (5.03%) developed CAVB. SII was higher in patients with CAVB compared to those without CAVB (1370 [1050-1779]x109/L vs. 771 [427-1462] x109/L, p < 0.001). Multivariate analysis showed a significant positive correlation between SII and the risk of CAVB development (OR:1.0003, 95%CI:1.0001-1.0005, P = 0.044). The cut-off value for the SII in the estimation of CAVB was 1117.7 × 109/L (area under the ROC curve [AUC]: 0.714, 95% CI = 0.657-0.770 with a sensitivity of 70.8% and specificity of 65.6%, p < 0.001). CONCLUSION: This study showed a significant link between high SII levels and CAVB development in STEMI patients undergoing PCI. Our findings suggest that SII may be a valuable, routinely available, and inexpensive marker for identifying patients at increased risk of CAVB.

Recurrent cardiac arrest and complete atrioventricular block due to idiopathic coronary vasospasm: A case report.

Recurrent complete atrioventricular block induced by coronary spasm is rare. We present a case of a 47-year-old woman who suffered from two episodes of out-of-hospital cardiac arrest within one year due to complete atrioventricular block caused by coronary vasospasm. No implantable cardioverter defibrillator was implanted after her first episode. As for the second episode, permanent brain injury was left behind despite successful cardiopulmonary resuscitation. She underwent a challenging rehabilitation process and an implantable cardioverter defibrillator was implanted before discharge. We captured the dynamic changes of the electrocardiogram during the episode with high temporal resolution. This case illustrates the importance of recognizing coronary spasm as a potential cause of complete atrioventricular block and highlights the need for implantable cardioverter defibrillator in such patients to improve survival and quality of life.

Diagnostic Dilemma of Syncope: Esophageal Hiatal Hernia and High-risk Bundle-branch Block.

We herein report a complicated case of recurrent syncope accompanying bundle branch block and hiatal hernia of the esophagus. An 83-year-old woman presented with syncope. Echocardiography visualized the left atrium compressed by an esophageal hiatal hernia, which had potential to decrease the cardiac output. Although she underwent esophageal repair surgery, two months after the surgery, she presented to the emergency department again with complaints of syncope. At the return visit, her face was pale and her pulse rate was 30 beats per minute. Electrocardiography showed complete atrioventricular block. On reviewing the patient's previous electrocardiography findings, we found a record of trifascicular block. This case illustrates the importance of predicting atrioventricular blocks in patients with high-risk bundle-branch blocks. Keeping in mind high-risk bundle-branch blocks will help clinicians avoid anchoring bias due to a striking image masquerading as the true diagnosis.

Ratio of left ventricular outflow tract area to aortic annulus area and complete atrioventricular block after transcatheter aortic valve replacement for aortic stenosis.

BACKGROUND: Mechanical compression of cardiac conduction system by transcatheter heart valves leads to complete atrioventricular block (CAVB) after transcatheter aortic valve replacement (TAVR). Bulging of ventricular septum in the left ventricular outflow tract (LVOT) may be associated with greater compression of conduction system, leading to irreversible CAVB. OBJECTIVE: This study aimed to investigate the association of ventricular septal bulging with TAVR-related CAVB and permanent pacemaker implantation (PPI). METHODS: Among 294 consecutive patients with severe aortic stenosis who underwent TAVR between July 2017 and February 2023, 271 were included in the analysis. As a quantitative evaluation of bulging of the ventricular septum, the ratio of LVOT area to aortic annulus area (L/A ratio) was measured at the systolic phase of computed tomography images. RESULTS: TAVR-related CAVB occurred in 64 patients (23.6%). Twenty-eight patients (10.3%) required PPI. The optimal thresholds of L/A ratio for predicting TAVR-related CAVB and PPI were 1.0181 and 0.985, respectively. Patients with less than the cut-off values had higher rate of TAVR-related CAVB and PPI than those above (28.3% vs 13.1%, p = 0.0063; 14.7% vs 4.4%, p = 0.0077, respectively). A multivariate analysis showed that L/A ratio < 1.0181 was an independent predictor of TAVR-related CAVB (odds ratio [OR] 2.65, p = 0.011), in addition to prior right bundle branch block (OR 3.76, p = 0.0005), use of a self-expanding valve (OR 1.99, p = 0.030), and short membranous septum length (OR 0.96, p = 0.037). Only L/A ratio < 0.985 was independently associated with PPI (OR 3.70, p = 0.011). CONCLUSION: Low L/A ratio is a predictor of TAVR-related CAVB and PPI.

Unusual atrial pacing induced by type II far-field p-wave sensing in a patient with complete atrioventricular block.

An 88-year-old Japanese woman underwent DDD pacemaker (MicroPort KORA 250 DR, V lead: VEGA R52) implantation for complete atrioventricular block. A 12-lead electrocardiogram for a routine examination showed atrial pacing within the intrinsic P wave, followed by inhibition of ventricular pacing. Pacemaker interrogation revealed no abnormalities in the basic parameters; however, ventricular pacing was inhibited by far-field sensing of intrinsic atrial waves before atrial events; type II far-field P-wave sensing. As a result, unusual atrial pacing occurred due to the pause suppression algorithm, which is the one of the functions that prevent atrial fibrillation development.

Endocardial pacing compared to epicardial left ventricle pacing and right ventricle pacing: A single-center long-term experience in a pediatric population.

BACKGROUND AND AIMS: Pediatric pacing is usually performed as epicardial pacing in small children in need of pacemaker therapy. Epicardial pacing compared with transvenous pacing for pediatric complete atrioventricular block (CAVB) has different strengths and weaknesses. The epicardial left ventricular wall position of the lead has been considered superior, in terms of contraction pattern, compared to a transvenous right ventricular stimulation. We aimed to compare QRS duration and cardiac function before and after the switch from epicardial to transvenous pacing in a pediatric population. METHODS: Pediatric patients with congenital or acquired CAVB, who underwent a switch from epicardial-to transvenous pacing at our center from 2005 to 2021, were identified through the national ICD- and Pacemaker Registry. Data regarding clinical status, ECG, and echocardiography before and after the switch and at last follow-up were collected. RESULTS: We included 15 children. The median age at the switch was 6.7 (4.4-11.7) years with a median weight of 21 (15-39) Kg. The median QRS duration with the transvenous systems was 136 (128-152) ms vs. a QRS duration during epicardial stimulation of 150 (144-170) ms with a median difference in QRS duration of 14 (6-20) ms. Children with a post-surgical AV block had a broader QRS duration, both with epicardial and endocardial stimulation. Before the switch, there was one patient with impaired left ventricular function (LVF) but with normal left ventricular end-diastolic diameters. After the switch, one patient developed symptomatic LV dysfunction with the recovery of LVF at the last follow-up after being implanted with a cardiac resynchronization therapy device. CONCLUSIONS: Our report of pediatric patients after switching from epicardial to transvenous pacing shows how transvenous pacing is not inferior to epicardial pacing in terms of QRS duration and no significant deterioration of cardiac function was detectable.

Disruption of the endothelial glycocalyx layer is associated with idiopathic complete atrioventricular block in the elderly population: An observational pilot study.

Idiopathic atrioventricular block (iCAVB) is the most common reason for the need for a permanent pacemaker in the elderly population. The fibrotic process that occurs in the conduction system of the heart with aging is the main pathogenesis in the development of iCAVB. However, the processes that trigger the development of iCAVB in the elderly population have not been fully elucidated. In this study, we aimed to reveal the possible relationship between the endothelial glycocalyx (EG) layer and idiopathic complete atrioventricular block. A group of 68 consecutive patients who developed iCAVB and a group of 68 healthy subjects matched for age, sex, and cardiovascular risk factors were included in the study. The groups were compared for clinical, laboratory, and levels of Syndecan-1 (SDC1), an EG layer marker. In the study, SDC1 levels were found to be significantly higher in the iCAVB group compared to the control group (23.7 ± 7.5 vs 16.7 ± 5.2; p = 0.009). In multivariable regression analysis, SDC1 was determined as an independent potential predictor for iCAVB (OR: 1.200; 95% CI: 1.119-1.287; p < 0.001). In the receiver operating characteristic curve analysis, SDC1 predicted iCAVB with 74% sensitivity and 72% specificity at the best cut-off value of 18.5 ng/mL (area under the curve: 0.777; confidence interval: 0.698-0.856; p < 0.001). Disruption of the endothelial glycolic layer may be one of the main triggering factors for the process leading to iCAVB.

Efficacy and Safety of Isoprenaline during Unstable Third-Degree Atrioventricular Block.

Unstable and symptomatic complete atrioventricular block represents a potentially fatal condition that requires prompt therapy while waiting for definitive pacemaker implantation. Although transcutaneous pacing is included in acute management, it could be a difficult approach due to its painfulness and the occasional failure of mechanical capture. Drug therapy is a feasible choice, and current guidelines encompass the use of atropine, dopamine, or epinephrine. Isoprenaline has never been investigated in this setting, and no specific indication of its use has been provided despite its potentially more favorable pharmacological profile. The study population included a consecutive series of patients who presented to the emergency department because of unstable third-degree atrioventricular block and were treated with either isoprenaline or dopamine infusion while waiting for definitive pacemaker implantation. Asymptomatic patients or those with reversible causes of complete atrioventricular block were excluded. The clinical response to the drug was deemed poor if, despite achieving a full drug dose, patients remained symptomatic and/or with hemodynamic instability, ventricular rate and rhythm did not improve or worsened, including if ventricular arrhythmias or asystolic pauses and/or irrepressible nausea/vomiting occurred. Isoprenaline infusion has proved to be safe and tolerated with no arrhythmia induction or hypotensive issues. Isoprenaline has also proven to be more satisfactory in achieving an effective clinical response in 84% of patients rather than dopamine (31%, p < 0.001), reducing the need for temporary artificial pacing. Our data point out the efficacy and safety of isoprenaline infusion and its greater tolerability over dopamine in the acute management of unstable third-degree AV block while waiting for definitive pacemaker implantation.

Epicardial pacing lead implantation for congenital complete atrioventricular block immediately after birth: a case report.

BACKGROUND: The incidence of congenital complete atrioventricular block is estimated to be 1 per 20,000 deliveries. In the fetal period, the fetal mortality rate is high, but the treatment strategy has not yet been established. In severe cases, early postnatal pacing therapy is necessary. CASE PRESENTATION: A 0-day-old Japanese baby girl was diagnosed with fetal congenital complete atrioventricular block during a prenatal physical examination. A joint conference was held preoperatively among multidisciplinary departments, and a cesarean section was performed at 37 weeks pregnancy, immediately followed by scheduled internal ventricular pacing lead implantation in an adjacent room. Percutaneous pacing was ineffective. The epicardial pacing lead was sutured at 17.5 minutes after birth, and perioperative management was successful with a heart rate and pulse rate of 150 beats per minute. CONCLUSION: The infant with a congenital complete atrioventricular block was rescued by an uneventful epicardial lead implantation.

Case report: Recovery of long-term delayed complete atrioventricular block after minimally invasive transthoracic closure of ventricular septal defect.

Introduction: Long-term delayed complete atrioventricular block (CAVB) is a serious complication of ventricular septal defect (VSD) closure treatment. Thus, cardiac surgeons have made significant efforts to explore its causes and reduce its incidence. In recent years, minimally invasive transthoracic closure (MITC) of VSD has been used widely and successfully in China as it is easy to repeat, ensures individualized closure, and can be debugged repeatedly. Theoretically, the possibility of the recurrence of CAVB is lower than that with transcatheter closure. Although the incidence of CAVB after MITC of VSD is inevitable, long-term delayed CAVB has rarely been reported. Case description: Herein, we report a case of delayed CAVB that occurred 2 years and 5 months after performing MITC of a perimembranous VSD. The cardiac rhythm recovered after the occluder was removed surgically. Conclusion: The findings of our case report emphasize that since delayed CAVB may occur in the long term after MITC of VSD, the safety of MITC of VSD should be reassessed, the indications for MITC should be strictly followed, and long-term follow-up, including lifelong follow-up, is recommended for patients postoperatively. In addition, the occluder should be removed surgically in patients with CAVB as it may restore normal heart rhythm.

Multiple complications of a well-known disease: a case report of acquired Gerbode defect after bicuspid aortic valve endocarditis.

Background: Infective endocarditis is a rare but serious disease with high morbidity and mortality due to its potential life-threatening complications. Gerbode defect is an anomalous connection between the left ventricle and the right atrium that can be either congenital or acquired, with previous rare reports following abscess formation in infective endocarditis. Case summary: A 27-year-old woman presented in hospital with Janeway lesions, stroke, splenic and hepatic abscesses, and transient complete auriculoventricular block. Bicuspid aortic valve infective endocarditis to methicillin-sensitive Staphylococcus aureus and acquired Gerbode defect were diagnosed. After intravenous antibiotics and aortic valve replacement, the patient was discharged without sequelae. Discussion: Bicuspid aortic valve patients have a higher risk of infective endocarditis than the general population. Infective endocarditis may present with multiple complications, including systemic embolization and local perivalvular lesions. Acquired Gerbode defect is a rare complication of infective endocarditis where transoesophageal echocardiography plays an important role for small shunt detection before surgical intervention.