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Dr. Kavya Pingali Dr. O Adikesava Naidu, Dr. YV Subba Reddy, Dr. Ravi Srinivas

World Heart Congress May 22- 24, 2017 Osaka, Japan. Clinical and angiographic profile of patients with complete heart block. Dr. Kavya Pingali Dr. O Adikesava Naidu, Dr. YV Subba Reddy, Dr. Ravi Srinivas Osmania General Hospital, Hyderabad, India. Background.

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Dr. Kavya Pingali Dr. O Adikesava Naidu, Dr. YV Subba Reddy, Dr. Ravi Srinivas

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  1. World Heart Congress May 22- 24, 2017 Osaka, Japan Clinical and angiographic profile of patients with complete heart block Dr. KavyaPingali Dr. O AdikesavaNaidu, Dr. YV SubbaReddy, Dr. Ravi Srinivas Osmania General Hospital, Hyderabad, India

  2. Background • Complete heart block (CHB), also known as the complete atrioventricular (AV) block, is the interruption in the transmission of the impulse that is originated from SA node in the atria to the ventricles, either due to an anatomical or functional impairment in the AV conduction system • The global prevalence of CHB has been reported to be 0.04% • The common presenting symptoms have been hypotension, bradycardiaand hemodynamicinstability

  3. Background • Electrocardiographic examination assists the diagnosis of CHB, pertaining to various features like: • Atrial rate • Ventricular rate • Degree of variation of both atrial and ventricular rates • Presence or absence of changing block • Width of the QRS

  4. Background • Usually the damage in AV node or His bundle is not due to the abnormality in proper AV node, but more probably due to obstruction in arteries that supply blood to AV node • The obstruction is mainly due to prenodal atrial myocardial necrosis or large areas of infarction • Therefore the presence of CHB is usually allied with the occurrence of myocardial infarction (MI)

  5. Background • Moreover, CHB had been independently related with an escalated risk of in-hospital mortality for acute MI, and also with the occurrence of heart failure, cardiogenic shock, and atrial fibrillation • The determination of the actual cause of CHB and the underlying culprit artery would lead to improved prognosis of such patients • Therefore, the angiographic appraisal of CHB patients becomes crucial

  6. Objective • To study the clinical profile, risk factors, angiographic distribution and in-hospital outcomes of patients with complete heart block

  7. Methods • Prospective, single-centered study • 100 patients who came to the department of cardiology with symptoms of CHB were included • Routine blood investigations including serum electrolytes were done • Coronary angiogram was performed and lesions were assessed • Temporary pacemaker was implanted followed by permanent pacemakers in patients who required its implantation • Occurrence of any type of complications was noted down

  8. Results Baseline demographics and clinical presentation of patients

  9. Results • Mean heart rate - 40 bpm • Lowered mean blood pressure - 100/70 mmHg • Tachypnoea - 5% patients • Auscultation crepts - 5% patients • Elevated creatininelevels - 5% patients

  10. Results Baseline demographics and clinical presentation of patients

  11. Results • Type of block • AV block – 53 patients • Bifascicular block – 14 patients • LBBB – 23 patients • RBBB – 6 patients • Mobitz I – 3 patients • Mobitz II – 1 patients

  12. Results Echocardiography and coronary angiography findings

  13. Results • Temporary pacemakers – 35% • Permanent pacemakers – 5.9% • In-hospital outcomes • Cardiogenic shock – 10 patients • Death – 26 patients • The patients who died either had 80-90% stenosis in RCA, triple vessel disease, ostio-proximal LAD occlusion, or diphtheric myocarditis

  14. Discussion • The anatomic location of AV block is of prognostic importance, such that CHB patients with anterior wall acute MI have a poorer prognosis than those with inferior wall acute MI • In this study, inferior wall MI was mostly present in patients • Literature suggests that temporary pacing has not been associated with decrease in in-hospital death but indeed it increases two-fold risk of in-hospital death

  15. Discussion • However the prognosis of patients following pacemaker implantation for isolated CHB is excellent • The permanent pacemaker implantation has been found to be positively associated with in-hospital survival • Implantation of pacemaker lowers the death rate and also improves the quality of life of patients with CHB

  16. Discussion • The CHB has been associated with various in-hospital complications: • Re-infarction • Cardiac rupture • Cardiogenic shock • Congestive heart failure • Cardiac arrest • Sustained ventricular tachycardia • Atrial fibrillation/flutter • Stroke • Death

  17. Conclusion • Complete heart block was majorly associated with advanced age and inferior wall MI, virtually caused by dominant RCA occlusion • The in-hospital mortality was significantly higher in the patients with CHB

  18. References • Kamp A, Scott WA. Complete Atrioventricular Block Third-Degree Heart Block. Clinical Cardiac Electrophysiology in the Young: Springer; 2015. p. 221-9. • Epstein A, Dimarco J, Ellenbogen K, Estes N, Freedman R, Gettes L, et al. American College of Cardiology/American Heart Association Task Force on Practice; American Association for Thoracic Surgery; Society of Thoracic Surgeons. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary. Heart Rhythm. 2008;5(6):934-55. • UllahI, Ahmad F, Igbal M, Ahmad S, Wali M. Comparison of conduction abnormalities between anterior and inferior myocardial infarction. Rawal Med J. 2015;40:48-51.

  19. References • Cosby RS, Cafferky EA, Lau FY, Rohde RA. 13. Electrocardiographic and clinical features in the prognosis of complete heart block. The American Journal of Cardiology. 1965;15(1):128. • ZahidA, Akbar A, Abid A, Imran M. Frequency of complete heart block in acute inferior wall myocardial infarction and its relation with severe obstructive disease of the infarct related artery. J Cardiovasc Dis. 2012;10(4):114-7. • Jim M-H, Chan A, Tse H-F, Barold SS, Lau C-P. Clinical and angiographic findings of complete atrioventricular block in acute inferior myocardial infarction. Ann Acad Med Singapore. 2010;39(3):185-90.

  20. References • Spencer FA, Jabbour S, Lessard D, Yarzebski J, Ravid S, Zaleskas V, et al. Two-decade-long trends (1975-1997) in the incidence, hospitalization, and long-term death rates associated with complete heart block complicating acute myocardial infarction: a community-wide perspective. American heart journal. 2003;145(3):500-7. • Aplin M, Engstrøm T, Vejlstrup NG, Clemmensen P, Torp-Pedersen C, Køber L, et al. Prognostic importance of complete atrioventricular block complicating acute myocardial infarction. The American Journal of Cardiology. 2003;92(7):853-6. • Harpaz D, Behar S, Gottlieb S, Boyko V, Kishon Y, Eldar M, et al. Complete atrioventricular block complicating acute myocardial infarction in the thrombolytic era. Journal of the American College of Cardiology. 1999;34(6):1721-8.

  21. References • Nguyen HL, Lessard D, Spencer FA, Yarzebski J, Zevallos JC, Gore JM, et al. Thirty-year trends (1975-2005) in the magnitude and hospital death rates associated with complete heart block in patients with acute myocardial infarction: a population-based perspective. American heart journal. 2008;156(2):227-33. • Bassan R, Maia IG, Bozza A, Amino JGC, Santos M. Atrioventricular block in acute inferior wall myocardial infarction: harbinger of associated obstruction of the left anterior descending coronary artery. J Am Col Cardiol. 1986;8(4):773-8. • Goldberg RJ, Zevallos JC, Yarzebski J, Alpert JS, Gore JM, Chen Z, et al. Prognosis of acute myocardial infarction complicated by complete heart block (the Worcester Heart Attack Study). The American Journal of Cardiology. 1992;69(14):1135-41.

  22. References • Singh SM, FitzGerald G, Yan AT, Brieger D, Fox KA, López-Sendón J, et al. High-grade atrioventricular block in acute coronary syndromes: insights from the Global Registry of Acute Coronary Events. European heart journal. 2014:ehu357. • Scott M, Geddes J, Patterson G, Adgey A, Pantridge J. Management of complete heart block complicating acute myocardial infarction. The Lancet. 1967;290(7531):1382-5.

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