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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 Jun 2024Advances in leadless pacemaker technology have enabled accelerometer-based atrioventricular (AV) synchronous pacing by sensing atrial mechanical contraction.
BACKGROUND
Advances in leadless pacemaker technology have enabled accelerometer-based atrioventricular (AV) synchronous pacing by sensing atrial mechanical contraction.
OBJECTIVES
To report performance of the Micra AV leadless pacemaker from the worldwide Micra AV post-approval registry (PAR) through 12-months.
METHODS
The Micra AV PAR is a prospective single-arm observational registry designed to assess safety and effectiveness of Micra AV in a real-world setting. For the present interim analysis, major complications and system revisions through 12-months were summarized and compared to a historical cohort of 2,667 transvenous dual-chamber pacing patients.
RESULTS
The device was successfully implanted in 796 of 801 patients (99.4%) at 97 centers in 19 countries. Micra AV patients were older (74.1 vs. 71.1 years, P<0.0001) with a higher incidence of renal disease (22.3% vs. 9.8%, P<0.0001) compared to transvenous dual-chamber patients. Through 12-months, the major complication rate was 3.7% in Micra AV patients compared to 8.8% in transvenous dual-chamber patients (hazard ratio [HR]: 0.42, 95% confidence interval [CI]: 0.28-0.61; P<0.001). The system revision rate was 1.5% in Micra AV patients compared to 5.5% for transvenous dual-chamber patients (HR: 0.25, 95% CI: 0.13-0.47; P<0.001); this reduction was largely driven by the absence of lead dislodgements requiring revision. Median AV synchrony index was 79.4% (IQR:65.2%-86.4%) among patients paced >90%.
CONCLUSIONS
The Micra AV leadless pacemaker was implanted with a high rate of success in patients with multiple co-morbidities, with a significantly lower rate of complications and system revisions through 12-months compared to a historical cohort of patients with transvenous dual-chamber pacemakers.
PubMed: 38878939
DOI: 10.1016/j.hrthm.2024.06.008 -
Neurology Jul 2024Generalized convulsive seizures (GCSs) are the main risk factor of sudden unexpected death in epilepsy (SUDEP), which is likely due to peri-ictal cardiorespiratory... (Observational Study)
Observational Study
BACKGROUND AND OBJECTIVES
Generalized convulsive seizures (GCSs) are the main risk factor of sudden unexpected death in epilepsy (SUDEP), which is likely due to peri-ictal cardiorespiratory dysfunction. The incidence of GCS-induced cardiac arrhythmias, their relationship to seizure severity markers, and their role in SUDEP physiopathology are unknown. The aim of this study was to analyze the incidence of seizure-induced cardiac arrhythmias, their association with electroclinical features and seizure severity biomarkers, as well as their specific occurrences in SUDEP cases.
METHODS
This is an observational, prospective, multicenter study of patients with epilepsy aged 18 years and older with recorded GCS during inpatient video-EEG monitoring for epilepsy evaluation. Exclusion criteria were status epilepticus and an obscured video recording. We analyzed semiologic and cardiorespiratory features through video-EEG (VEEG), electrocardiogram, thoracoabdominal bands, and pulse oximetry. We investigated the presence of bradycardia, asystole, supraventricular tachyarrhythmias (SVTs), premature atrial beats, premature ventricular beats, nonsustained ventricular tachycardia (NSVT), atrial fibrillation (Afib), ventricular fibrillation (VF), atrioventricular block (AVB), exaggerated sinus arrhythmia (ESA), and exaggerated sinus arrhythmia with bradycardia (ESAWB). A board-certified cardiac electrophysiologist diagnosed and classified the arrhythmia types. Bradycardia, asystole, SVT, NSVT, Afib, VF, AVB, and ESAWB were classified as arrhythmias of interest because these were of SUDEP pathophysiology value. The main outcome was the occurrence of seizure-induced arrhythmias of interest during inpatient VEEG monitoring. Moreover, yearly follow-up was conducted to identify SUDEP cases. Binary logistic generalized estimating equations were used to determine clinical-demographic and peri-ictal variables that were predictive of the presence of seizure-induced arrhythmias of interest. The -score test for 2 population proportions was used to test whether the proportion of seizures and patients with postconvulsive ESAWB or bradycardia differed between SUDEP cases and survivors.
RESULTS
This study includes data from 249 patients (mean age 37.2 ± 23.5 years, 55% female) who had 455 seizures. The most common arrhythmia was ESA, with an incidence of 137 of 382 seizures (35.9%) (106/224 patients [47.3%]). There were 50 of 352 seizure-induced arrhythmias of interest (14.2%) in 41 of 204 patients (20.1%). ESAWB was the commonest in 22 of 394 seizures (5.6%) (18/225 patients [8%]), followed by SVT in 18 of 397 seizures (4.5%) (17/228 patients [7.5%]). During follow-up (48.36 ± 31.34 months), 8 SUDEPs occurred. Seizure-induced bradycardia (3.8% vs 12.5%, = -16.66, < 0.01) and ESAWB (6.6% vs 25%; = -3.03, < 0.01) were over-represented in patients who later died of SUDEP. There was no association between arrhythmias of interest and seizure severity biomarkers ( > 0.05).
DISCUSSION
Markers of seizure severity are not related to seizure-induced arrhythmias of interest, suggesting that other factors such as occult cardiac abnormalities may be relevant for their occurrence. Seizure-induced ESAWB and bradycardia were more frequent in SUDEP cases, although this observation was based on a very limited number of SUDEP patients. Further case-control studies are needed to evaluate the yield of arrhythmias of interest along with respiratory changes as potential SUDEP biomarkers.
Topics: Humans; Female; Male; Adult; Arrhythmias, Cardiac; Incidence; Middle Aged; Prospective Studies; Electroencephalography; Sudden Unexpected Death in Epilepsy; Seizures; Epilepsy, Generalized; Aged; Young Adult; Electrocardiography; Adolescent
PubMed: 38870452
DOI: 10.1212/WNL.0000000000209501 -
European Heart Journal. Case Reports Jun 2024Acute myocarditis (AM) is an inflammatory heart disease that may occur as a consequence of autoimmune disorders. Although the correlation between myocarditis and...
Acute lymphocytic myocarditis characterized by cardiogenic shock and conduction system abnormalities in patients with Hashimoto's thyroiditis: a case report and review of literature.
BACKGROUND
Acute myocarditis (AM) is an inflammatory heart disease that may occur as a consequence of autoimmune disorders. Although the correlation between myocarditis and hyperthyroidism has been reported in the literature, the association with hypothyroidism is less frequent.
CASE SUMMARY
We describe a characteristic case of lymphocytic acute myocarditis deteriorated into cardiogenic shock due to Hashimoto's thyroiditis treated with vasopressor and inotropic drugs in combination with corticosteroid. On admission, electrocardiography revealed a sinus tachycardia with 1st degree atrioventricular (AV) block, right bundle branch block (RBBB), and left anterior fascicular block. Laboratory tests demonstrated a severe hypothyroidism and high-titre serum of antibodies against thyroglobulin. She presented a favourable clinical course, restoring haemodynamic stability. A resolution of hypothyroidism and a progressive reduction of the value of antibodies against thyroglobulin occurred. On Day 35, the patient was discharged showing on electrocardiogram the occurrence of left posterior fascicular block, disappearance of 1st degree AV block and partial improvement of RBBB along with the normalization of the left ventricular contractility abnormalities on echocardiography.
DISCUSSION
Autoimmune features, mostly Hashimoto's thyroiditis, are associated in lymphocytic acute myocarditis to a worse prognosis and an increased risk of recurrence. More studies are needed to elucidate the underlying mechanism.
PubMed: 38868158
DOI: 10.1093/ehjcr/ytae268 -
JA Clinical Reports Jun 2024Although several complications of transcranial motor-evoked potentials (Tc-MEPs) have been reported, reports of arrhythmias during Tc-MEP are very rare.
BACKGROUND
Although several complications of transcranial motor-evoked potentials (Tc-MEPs) have been reported, reports of arrhythmias during Tc-MEP are very rare.
CASE PRESENTATION
A 71-year-old woman underwent transforaminal lumbar interbody fusion under general anesthesia, with intraoperative Tc-MEP monitoring. Preoperative electrocardiography showed an incomplete right bundle branch block but no cardiovascular events in her life. After induction of anesthesia, Tc-MEP was recorded prior to the surgery. During the Tc-MEP monitoring, electrocardiography and arterial blood pressure showed a second-degree atrioventricular block, but it improved rapidly at the end of the stimulation, and the patient was hemodynamically stable. Tc-MEP was recorded seven times during surgery; the incidence of P waves without QRS complexes was significantly higher than before stimulation. The surgery was uneventful, and she was discharged eight days postoperatively without complications.
CONCLUSIONS
Our case suggests that electrical stimulation for Tc-MEP can cause arrhythmia. Electrocardiography and blood pressure must be closely monitored during Tc-MEP monitoring.
PubMed: 38862743
DOI: 10.1186/s40981-024-00722-3 -
Infection Jun 2024Most data regarding infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) comes from TAVI registries, rather than IE dedicated cohorts. The...
PURPOSE
Most data regarding infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) comes from TAVI registries, rather than IE dedicated cohorts. The objective of our study was to compare the clinical and microbiological profile, imaging features and outcomes of patients with IE after SAVR with a biological prosthetic valve (IE-SAVR) and IE after TAVI (IE-TAVI) from 6 centres with an Endocarditis Team (ET) and broad experience in IE.
METHODS
Retrospective analysis of prospectively collected data. From the time of first TAVI implantation in each centre to March 2021, all consecutive patients admitted for IE-SAVR or IE-TAVI were prospectively enrolled. Follow-up was monitored during admission and at 12 months after discharge.
RESULTS
169 patients with IE-SAVR and 41 with IE-TAVI were analysed. Early episodes were more frequent among IE-TAVI. Clinical course during hospitalization was similar in both groups, except for a higher incidence of atrioventricular block in IE-SAVR. The most frequently causative microorganisms were S. epidermidis, Enterococcus spp. and S. aureus in both groups. Periannular complications were more frequent in IE-SAVR. Cardiac surgery was performed in 53.6% of IE-SAVR and 7.3% of IE-TAVI (p=0.001), despite up to 54.8% of IE-TAVI patients had an indication. No differences were observed about death during hospitalization (32.7% vs 35.0%), and at 1-year follow-up (41.8% vs 37.5%), regardless of whether the patient underwent surgery or not.
CONCLUSION
Patients with IE-TAVI had a higher incidence of early prosthetic valve IE. Compared to IE-SAVR, IE-TAVI patients underwent cardiac surgery much less frequently, despite having surgical indications. However, in-hospital and 1-year mortality rate was similar between both groups.
PubMed: 38856806
DOI: 10.1007/s15010-024-02302-0 -
Journal of Medical Case Reports Jun 2024Bradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia syndrome is a potentially life-threatening clinical condition characterized by...
BACKGROUND
Bradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia syndrome is a potentially life-threatening clinical condition characterized by bradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia. It constitutes a vicious circle in which the accumulation of pharmacologically active compounds and hyperkalemia lead to hemodynamic instability and heart failure.
CASE PRESENTATION
A 66-year-old Caucasian female patient was admitted to the emergency department presenting with fatigue and bradycardia. Upon examination, the patient was found to be anuric and hypotensive. Laboratory investigations revealed metabolic acidosis and hyperkalemia. Clinical evaluation suggested signs of digoxin toxicity, with serum digoxin concentrations persistently elevated over several days. Despite the implementation of antikalemic measures, the patient's condition remained refractory, necessitating renal dialysis and administration of digoxin immune fab.
CONCLUSION
Bradycardia, renal failure, atrioventricular (AV) node blocking, shock, and hyperkalemia syndrome is a life-threatening condition that requires prompt management. It is important to also consider potential coexisting clinical manifestations indicative of intoxication from other pharmacological agents. Specifically, symptoms associated with the accumulation of drugs eliminated via the kidneys, such as digoxin. These manifestations may warrant targeted therapeutic measures.
Topics: Humans; Female; Aged; Digoxin; Hyperkalemia; Bradycardia; Renal Dialysis; Renal Insufficiency; Anti-Arrhythmia Agents; Syndrome; Acidosis; Shock; Atrioventricular Block; Immunoglobulin Fab Fragments
PubMed: 38851740
DOI: 10.1186/s13256-024-04600-5 -
Cell Research Jun 2024Physiologically, the atria contract first, followed by the ventricles, which is the prerequisite for normal blood circulation. The above phenomenon of atrioventricular...
Physiologically, the atria contract first, followed by the ventricles, which is the prerequisite for normal blood circulation. The above phenomenon of atrioventricular sequential contraction results from the characteristically slow conduction of electrical excitation of the atrioventricular node (AVN) between the atria and the ventricles. However, it is not clear what controls the conduction of electrical excitation within AVNs. Here, we find that AVN pacemaker cells (AVNPCs) possess an intact intrinsic GABAergic system, which plays a key role in electrical conduction from the atria to the ventricles. First, along with the discovery of abundant GABA-containing vesicles under the surface membranes of AVNPCs, key elements of the GABAergic system, including GABA metabolic enzymes, GABA receptors, and GABA transporters, were identified in AVNPCs. Second, GABA synchronously elicited GABA-gated currents in AVNPCs, which significantly weakened the excitability of AVNPCs. Third, the key molecular elements of the GABAergic system markedly modulated the conductivity of electrical excitation in the AVN. Fourth, GABA receptor deficiency in AVNPCs accelerated atrioventricular conduction, which impaired the AVN's protective potential against rapid ventricular frequency responses, increased susceptibility to lethal ventricular arrhythmias, and decreased the cardiac contractile function. Finally, interventions targeting the GABAergic system effectively prevented the occurrence and development of atrioventricular block. In summary, the endogenous GABAergic system in AVNPCs determines the slow conduction of electrical excitation within AVNs, thereby ensuring sequential atrioventricular contraction. The endogenous GABAergic system shows promise as a novel intervention target for cardiac arrhythmias.
PubMed: 38849501
DOI: 10.1038/s41422-024-00980-x -
Heart Rhythm Jun 2024Conduction disturbances play an important role in the occurrence and development of heart failure (HF). Studies suggest autoantibodies may attack conduction system....
BACKGROUND
Conduction disturbances play an important role in the occurrence and development of heart failure (HF). Studies suggest autoantibodies may attack conduction system. However, it is unclear whether autoantibodies are associated with conduction disturbances in patients with HF.
OBJECTIVE
Assess whether anti-SSA, anti-Ro/Sjögren's syndrome-related antigen A antibodies known for congenital atrioventricular block, is associated with conduction disturbances in patients with HF METHODS: This retrospective observational study used data from patients with HF who admitted to Beijing Anzhen Hospital between January 2018 and June 2022. We included patients who had anti-SSA tested and had electrocardiogram (ECG) examination during hospitalization. Conduction disturbances, including atrioventricular block (AVB), bundle branch block (BBB), and intraventricular conduction delay were confirmed by a cardiologist blinded to the anti-SSA status. Univariate and multivariable logistic regression analyses were performed to assess the association between anti-SSA and conduction disturbances.
RESULTS
766 patients were included in this study, 70(9.1%) of whom were anti-SSA positive. Subjects who were anti-SSA positive showed a higher prevalence of AVB (20% vs 10.6%) and BBB (27.3 % vs 10.9 %), including both left bundle branch block (LBBB) and right bundle branch block (RBBB) (all P<0.05). After adjusting for known risk factors, anti-SSA were independently associated with AVB (OR 2.42 (1.18-5.43), P = 0.03) and BBB (OR 3.15(1.68-5.89), P<0.001).
CONCLUSION
Anti-SSA is independently associated with AVB and BBB in patients with HF. We need to study the role of autoantibodies in the development of conduction abnormalities in patient with HF to generate possible targeted treatments.
PubMed: 38848863
DOI: 10.1016/j.hrthm.2024.05.060 -
Kardiologia Polska Jun 2024
From pneumonia to two cardiac surgeries: Aortic valve endocarditis complicated by aortic root abscess, atrioventricular block and postoperative left ventricular pseudoaneurysm.
PubMed: 38845434
DOI: 10.33963/v.phj.100773