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JACC. Clinical Electrophysiology Aug 2023
Topics: Humans; Atrioventricular Block
PubMed: 37354190
DOI: 10.1016/j.jacep.2023.04.005 -
Journal of the American Heart... Jun 2024Advanced atrioventricular block (AVB), that is, higher than second-degree Mobitz-1, is an abnormal finding in athletes. Despite intensive investigation, in several cases...
BACKGROUND
Advanced atrioventricular block (AVB), that is, higher than second-degree Mobitz-1, is an abnormal finding in athletes. Despite intensive investigation, in several cases the pathogenesis remains unknown, but frequently pacemaker implantation is still indicated. Increasing evidence points to circulating anti-Ro/Sjögren syndrome-related antigen A (SSA) antibodies cross-reacting with L-type calcium channel and inhibiting the related current as an epidemiologically relevant and potentially reversible cause of isolated AVB in adults. The aim of the study was to determine the prevalence of anti-Ro/SSA-associated advanced AVBs in a large sample of young athletes.
METHODS AND RESULTS
A total of 2536 consecutive athletes aged <40 years without a history of cardiac diseases/interventions were enrolled in a cross-sectional study. Resting and exercise electrocardiography was performed, and those presenting any AVB were further evaluated by 24-hour Holter ECG. Athletes with second-degree AVBs and their mothers underwent anti-Ro/SSA testing. Moreover, purified immunoglobulin G from subjects with anti-Ro/SSA-positive and anti-Ro/SSA-negative advanced AVB were tested on L-type calcium current and L-type-calcium channel expression using tSA201 cells. The global prevalence of advanced AVB in the overall sample was ≈0.1%, but the risk considerably increased (2%) when intensely trained postpubertal male subjects were selectively considered. While none of the athletes with advanced AVB showed heart abnormalities, in 100% of cases anti-Ro/SSA antibodies were detected. Ex vivo experiments showed that immunoglobulin G from anti-Ro/SSA-positive but not -negative subjects with advanced AVB acutely inhibit L-type calcium current and chronically downregulate L-type-calcium channel expression.
CONCLUSIONS
Our study provides evidence that advanced AVB occurs in young athletes, in most cases associated with anti-Ro/SSA antibodies blocking L-type calcium channels. These findings may open new avenues for immunomodulating therapies to reduce the risk of life-threatening events in athletes, avoiding or delaying pacemaker implantation.
Topics: Humans; Male; Female; Adult; Cross-Sectional Studies; Atrioventricular Block; Prevalence; Young Adult; Calcium Channels, L-Type; Antibodies, Antinuclear; Athletes; Adolescent; Electrocardiography, Ambulatory; Ribonucleoproteins
PubMed: 38879447
DOI: 10.1161/JAHA.124.034893 -
Heart Rhythm May 2023New-onset left bundle branch block (LBBB) is one of the most frequent complications after transcatheter aortic valve implantation (TAVI) and is associated with delayed...
BACKGROUND
New-onset left bundle branch block (LBBB) is one of the most frequent complications after transcatheter aortic valve implantation (TAVI) and is associated with delayed high degree atrioventricular (AV) block.
OBJECTIVES
The objectives of this study were to determine the incidence of AV block in such a population and to assess the performance and safety of a risk stratification algorithm on the basis of electrophysiology study (EPS) followed by implantation of a pacemaker or implantable loop recorder (ILR).
METHODS
This was a prospective open-label study with 12-month follow-up. From June 8, 2015, to November 8, 2018, 183 TAVI recipients (mean age 82.3 ± 5.9 years) were included at 10 centers. New-onset LBBB after TAVI persisting for >24 hours was assessed by electrophysiology study during initial hospitalization. High-risk patients (His-ventricle interval ≥70 ms) were implanted with a dual-chamber pacemaker recording AV conduction disturbance episodes. Patients at lower risk were implanted with an ILR with automatic remote monitoring.
RESULTS
A high-grade AV conduction disorder was identified in 56 patients (30.6%) at 12 months. Four subjects were symptomatic, all in the ILR group. No complications were associated with the stratification procedure. Patients with His-ventricle interval ≥70 ms displayed more high-grade AV conduction disorders (53.2% [25 of 47] vs 22.8% [31 of 136]; P < .001). In a multivariate analysis, His-ventricle interval ≥70 ms was independently associated with the occurrence of a high-grade conduction disorder (subdistribution hazard ratio 2.4; 95% confidence interval 1.2-4.8; P = .010).
CONCLUSION
New-onset LBBB after TAVI was associated with high rates of high-grade AV conduction disturbances. The stratification algorithm provided safe and valuable aid to management decisions and reliable guidance on pacemaker implantation.
Topics: Humans; Aged; Aged, 80 and over; Transcatheter Aortic Valve Replacement; Bundle-Branch Block; Incidence; Prospective Studies; Electrocardiography; Cardiac Conduction System Disease; Atrioventricular Block; Pacemaker, Artificial; Aortic Valve Stenosis; Treatment Outcome
PubMed: 36646235
DOI: 10.1016/j.hrthm.2023.01.013 -
QJM : Monthly Journal of the... Aug 2022
Topics: Atrioventricular Block; Cardiomyopathies; Humans; Myocarditis; Sarcoidosis
PubMed: 35512412
DOI: 10.1093/qjmed/hcac116 -
Journal of Cardiovascular... Aug 2023The efficacy and safety of leadless cardiac pacemakers (LPMs) as an alternative to conventional transvenous cardiac pacing have been largely reported. The first...
INTRODUCTION
The efficacy and safety of leadless cardiac pacemakers (LPMs) as an alternative to conventional transvenous cardiac pacing have been largely reported. The first generation of the Micra transcatheter pacing system (VR; Medtronic) was able to provide single-chamber VVI(R) pacing mode only, with a potential risk of pacemaker syndrome in sinus rhythm patients. A second-generation system (AV) now provides atrioventricular synchrony through atrial mechanical (Am) sensing capability (VDD mode).
OBJECTIVE
We sought to compare VR and AV systems in sinus rhythm patients with chronic ventricular pacing (Vp) for complete atrioventricular block.
METHODS
All consecutive patients implanted with an LPM in our department for complete atrioventricular block were retrospectively screened. Patients with atrial fibrillation, sinus dysfunction, or Vp burden <20% at 1 month postimplantation were excluded. Patients were systematically followed with a visit at 1 month, and then at least once a year.
RESULTS
A total of 93 patients-45 VR (2015-2020) and 48 AV (2020-2021)-were included. VR and AV patients had similar baseline characteristics, except for VR patients being older (80 ± 8 vs. 77 ± 9 years, p = 0.049). The mean Vp burden was 77% in the VR and 82% in the AV group (p = 0.38). In AV patients, the median AV synchronous beats rate was 78%, with 65% having a >66% rate. An E/A ratio <1.2 as measured on echocardiography was the only independent predictor of accurate atrial mechanical tracking (p = 0.01). One-year survival rate was similar in both groups. Five patients in the VR and 0 in the AV group eventually developed pacemaker syndrome within 1 year post-implantation (p = 0.02).
CONCLUSION
In sinus rhythm patients with chronic Vp for complete atrioventricular block implanted with an LPM, the atrial mechanical sensing algorithm allowed significant atrioventricular synchrony in most patients and was associated with no occurrence of-otherwise rare-pacemaker syndrome.
Topics: Humans; Atrioventricular Block; Atrial Fibrillation; Retrospective Studies; Pacemaker, Artificial; Heart Atria; Postoperative Complications; Cardiac Pacing, Artificial
PubMed: 37354448
DOI: 10.1111/jce.15981 -
Journal of the American Heart... Jun 2022
Topics: Atrioventricular Block; Cardiovascular System; Electrocardiography; Heart; Humans; Magnetic Resonance Imaging
PubMed: 35658512
DOI: 10.1161/JAHA.122.026199 -
Heart Rhythm Sep 2023
Topics: Humans; Atrioventricular Block
PubMed: 37648362
DOI: 10.1016/j.hrthm.2022.11.014 -
Lupus Nov 2019Conduction abnormalities are uncommon in adult patients with lupus. We present a young woman with recurrent syncope caused by third-degree atrio-ventricular block as the... (Review)
Review
Conduction abnormalities are uncommon in adult patients with lupus. We present a young woman with recurrent syncope caused by third-degree atrio-ventricular block as the initial manifestation of lupus and review 31 additional cases of systemic lupus erythematosus patients that have been described previously with complete heart block. Heart blocks occurred almost exclusively in females. The median age was 37 years. In 24 cases heart blocks were diagnosed in patients with established lupus. In only five patients, including the patient presented here, heart blocks were diagnosed before the lupus diagnosis. Syncope was the most common presenting symptom of heart block. Electrocardiographic findings prior to heart block episodes were reported in 17 cases: eight had normal findings, but nine had already variant forms of atrioventricular or intraventricular conduction defects. Anti-nuclear antibody tests were reported in 25 cases and were all positive. Anti-DNA antibodies were also common and were positive in 16 of 19 cases (84%). Anti-La and anti-Ro antibodies were less common (13% and 35%, respectively). Three patients died, all prior to 1975. Heart block resolved in 10 cases. Follow-up was reported in four of these cases and heart block recurred in three of them. A permanent pacemaker was the eventual treatment in 22 cases. The etiology of lupus-associated complete heart block is not clear. It is probably variable, possibly related to effects of autoantibodies reacting with the conduction system, myocardial disease and adverse effects of antimalarials. Insertion of a permanent pacemaker seems to be the preferable method of treatment.
Topics: Adult; Antibodies, Antinuclear; Atrioventricular Block; Female; Humans; Lupus Erythematosus, Systemic; Pacemaker, Artificial; Recurrence; Syncope; Young Adult
PubMed: 31615326
DOI: 10.1177/0961203319881198 -
Journal of the American Heart... May 2021Background The temporal incidence of high-grade atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR) is uncertain. As a result,...
Background The temporal incidence of high-grade atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR) is uncertain. As a result, periprocedural monitoring and pacing strategies remain controversial. This study aimed to describe the temporal incidence of initial episode of HAVB stratified by pre- and post-TAVR conduction and identify predictors of delayed events. Methods and Results Consecutive patients undergoing TAVR at a single center between February 2012 and June 2019 were retrospectively assessed for HAVB within 30 days. Patients with prior aortic valve replacement, permanent pacemaker (PPM), or conversion to surgical replacement were excluded. Multivariable logistic regression was performed to assess predictors of delayed HAVB (initial event >24 hours post-TAVR). A total of 953 patients were included in this study. HAVB occurred in 153 (16.1%). After exclusion of those with prophylactic PPM placed post-TAVR, the incidence of delayed HAVB was 33/882 (3.7%). Variables independently associated with delayed HAVB included baseline first-degree atrioventricular block or right bundle-branch block, self-expanding valve, and new left bundle-branch block. Forty patients had intraprocedural transient HAVB, including 16 who developed HAVB recurrence and 6 who had PPM implantation without recurrence. PPM was placed for HAVB in 130 (13.6%) (self-expanding valve, 23.7% versus balloon-expandable valve, 11.9%; <0.001). Eight (0.8%) patients died by 30 days, including 1 unexplained without PPM present. Conclusions Delayed HAVB occurs with higher frequency in patients with baseline first-degree atrioventricular block or right bundle-branch block, new left bundle-branch block, and self-expanding valve. These findings provide insight into optimal monitoring and pacing strategies based on periprocedural ECG findings.
Topics: Aged, 80 and over; Aortic Valve Stenosis; Atrioventricular Block; Electrocardiography; Female; Follow-Up Studies; Heart Conduction System; Heart Rate; Humans; Incidence; Male; Minnesota; Postoperative Complications; Retrospective Studies; Risk Factors; Risk Management; Transcatheter Aortic Valve Replacement
PubMed: 33960210
DOI: 10.1161/JAHA.120.020033 -
Annals of Emergency Medicine Apr 2021
Topics: Aged; Atrioventricular Block; Diagnosis, Differential; Humans; Male; Point-of-Care Testing; Syncope; Ultrasonography
PubMed: 33766283
DOI: 10.1016/j.annemergmed.2020.10.011