Utility of new FDG-PET/CT guidelines for diagnosing cardiac sarcoidosis in patients with implanted cardiac pacemakers for atrioventricular block.

Diagnosing cardiac sarcoidosis (CS), especially in isolated cases, is challenging, particularly due to the limitations of endomyocardial biopsy, leading to potential undiagnosed cases in pacemaker-implanted patients. This study aims to provide real world findings to support new guideline for CS using 18F-fluoro-deoxyglucose positron-emission tomography computed tomography (FDG-PET/CT) which give a definite diagnosis of isolated CS (iCS) without histological findings. We examined consecutive patients with cardiac pacemakers for atrioventricular block (AV-b) attending our outpatient pacemaker clinic. The patients underwent periodical follow-up echocardiography and were divided into two groups according to echocardiographic findings: those with suspected CS and those without suspected CS. Patients suspected of having nonischemic cardiomyopathy underwent FDG-PET/CT for CS diagnosis. We investigated the utility of the new guideline for CS using FDG-PET/CT. Among the 272 patients enrolled, 97 patients were implanted with cardiac pacemakers for AV-b. Twenty-two patients were suspected of having CS during a median observation period of 5.4 years after pacemaker implantation. Of these, one did not consent, and nine of 21 cases (43%) were diagnosed with definite CS according to the new guidelines. Five of these nine patients were diagnosed with iCS using FDG-PET/CT. The number of patients diagnosed with definite CS using the new guidelines tended to be approximately 2.3 times that of the conventional criteria (p = 0.074). Three of the nine patients underwent steroid treatment. The composite outcome, comprising all-cause death, heart failure hospitalization, and a substantial reduction in left ventricular ejection fraction, were significantly lower in patients receiving steroid treatment compared to those without steroid treatment (p = 0.048). The utilization of FDG-PET/CT in accordance with the new guidelines facilitates the diagnosis of CS, including iCS, resulting in approximately 2.3 times as many diagnoses of CS compared to the conventional criteria. This guideline has the potential to support the early identification of iCS and may contribute to enhancing patient clinical outcomes.

Cardiac Hydatid Cyst: An Uncommon Cause of Complete Atrioventricular Block. / Cisto Hidático Cardíaco: Uma Causa Incomum de Bloqueio Atrioventricular Total.

Hydatidosis is a zoonosis caused by Echinococcus granulosus, leading to the formation of cysts on involved organs. Cardiac involvement is rare and can cause a wide range of complications secondary to rupture, embolization, or compression. Its diagnosis is challenging, and is generally confirmed through data related to clinical manifestations, environmental exposure, and laboratory and imaging exams. Surgical removal is necessary in most cases, in which an association with antiparasite therapy is recommended. The present article describes a case of a cardiac hydatid cyst associated with a complete atrioventricular block (AVB) in a young adult patient, with the need for a pacemaker implant, an atypical presentation, and scarce reports in the literature.

A hidatidose é uma zoonose causada pelo Echinococcus granulosus, levando à formação de cistos nos órgãos acometidos. O envolvimento cardíaco é raro e pode causar diversas complicações secundárias à ruptura, embolização ou compressão. Seu diagnóstico é desafiador, sendo confirmado por meio de dados relacionados a manifestações clínicas, exposição ambiental, exames laboratoriais e de imagem. A ressecção cirúrgica é necessária na maioria dos casos, sendo indicada a associação com terapia antiparasitária. No presente artigo, descreve-se um caso de cisto hidático cardíaco associado a bloqueio atrioventricular total em paciente jovem, com necessidade de implante de marcapasso, uma apresentação atípica e pouco relatada na literatura.

The ECG in sarcoidosis - a marker of cardiac involvement? Current evidence and clinical implications.

Sarcoidosis is a multisystem granulomatous disease of unknown etiology characterized by noncaseating granulomas. Cardiac involvement is often limiting patients' prognosis. Cardiac sarcoidosis can manifest with variant cardiac arrhythmias, of which atrioventricular (AV)-block-related bradycardia and ventricular tachycardias are the most common. Although cardiac sarcoidosis remains a histopathological diagnosis, the significance of imaging modalities, especially cardiac magnetic resonance imaging is increasing rapidly but mainly remains reserved for patients with a high suspicion due to a previous arrhythmia or unknown cardiomyopathy. Thus, there is a need for screening in daily clinical practice so that possible characteristic electrocardiographic (ECG) findings may guide the way to detect the disease. We therefore evaluated the ECG as a potential tool for screening of cardiac sarcoidosis and present different electrophysiological manifestations of cardiac sarcoidosis based on a literature review. The ECG is a valuable tool for screening of cardiac involvement in patients with sarcoidosis. Several parameters have been shown to be associated with cardiac involvement in sarcoidosis such as higher-degree AV-block, QRS complex fragmentation and widening, as well as certain T wave abnormalities that may indicate cardiac involvement, of which the latter two are most promising and specific. However, prospective studies examining a large number of trials are desirable.

Incidence of atrioventricular block with vasodilator stress SPECT: A meta-analysis.

BACKGROUND: Adenosine or regadenoson are often used with pharmacologic stress testing. Adenosine may trigger atrioventricular block (AVB). Despite its higher selectivity, regadenoson has also been associated with AVB. We studied the incidence of de novo AVB with these agents. METHODS: A comprehensive search of SCOPUS was performed from inception to March 2016. Studies of at least 10 patients, using adenosine and/or regadenoson with SPECT-MPI, reporting rates of AVB were selected for further review. RESULTS: Thirty four studies were pooled including 22,957 patients. Adenosine was used in 21 studies and regadenoson in 15. Both were administered in two studies. The estimated incidence of overall and high-grade AVB was 3.81% (95% CI 1.99%-6.19%) and 1.93% (95% CI 0.77%-3.59%), respectively. The incidence of AVB (8.58%; 95% CI 5.55%-12.21% vs 0.30%; 95% CI 0.04%-0.82%, respectively, P < .001) and high-grade AVB (5.21%; 95% CI 2.81%-8.30% vs 0.05%; 95% CI < .001%-0.19% respectively, P < .001) were higher with adenosine compared to regadenoson. CONCLUSION: AVB is seen in about 4% of patients undergoing vasodilator stress test. Both overall and high-grade AVB are more frequent with adenosine compared to regadenoson.

Eighty-two-year-old man with a systolic murmur.

CLINICAL INTRODUCTION: An 82-year-old man with a history of coronary artery bypass surgery, hypertension and small bowel gastrointestinal stromal tumour underwent cardiac risk evaluation prior to surgical resection of his tumour. He was asymptomatic from a cardiovascular perspective, but his activity level was less than four metabolic equivalents. Physical examination was notable for a 2/6 systolic murmur at the apex. ECG showed sinus rhythm. A transthoracic echocardiogram was performed (figure 1 and online supplementary video 1).DC1SP110.1136/heartjnl-2018-313413.supp1Supplementary file 1 heartjnl;104/22/1887/F1F1F1Figure 1Transthoracic echocardiography. (A) Mitral valve continuous wave Doppler and (B) tricuspid valve continuous wave Doppler. QUESTION: The findings in figure 1 are most likely due to which of the following?Atrioventricular conduction block.Acute severe aortic regurgitation.Patent ductus arteriosus.Atrial flutter.Severe mitral stenosis.

Complete atrioventricular block as an initial manifestation of recurred oral cavity cancer: a case report.

BACKGROUND: Intracardiac invasion of head and neck cancer is extremely rare. Here, we report a case of recurred oral cavity cancer presenting with complete atrioventricular (AV) block caused by cardiac metastasis. CASE PRESENTATION: A 70-year-old male presented with dizziness for 2 days. He had a history of oral cavity cancer a year ago, and the tumor was treated by surgical excision after induction chemotherapy and concurrent chemoradiation therapy. Electrocardiography showed complete AV block with ventricular escape rate of 43 beats per minute. Cardiac imaging revealed about 4.0 × 2.0 cm-sized mass invading interventricular septum and AV nodes and protruding into the right ventricle. Magenetic resonance imaging of head and neck demonstrated recurred mass in oral cavity and maxillary sinus. Fluorodeoxyglucose-positron emission tomography showed hypermetabolic lesion in both oral cavity and the heart around interventricular septum and atrioventricular node indicating recurred oral cavity cancer with cardiac metastasis. Permament pacemaker of DDD type was implanted for the symptomatic complete AV block, and palliative chemotherapy was initiated. CONCLUSION: The present case demonstrated that oral cavity cancer can metastasize to the heart, and complete AV block may be an initial manifestation of the recurrence of extracardiac cancer with intracardiac invasion.

Atrioventricular conduction disturbance during pulmonary vein isolation using the second-generation cryoballoon - Vagal impact of cryoballoon ablation.

BACKGROUND: Vagal reactions of the sinus node during pulmonary vein isolation (PVI) have been reported, however, data on intra-procedural atrioventricular conduction disturbances have been sparse. The present study aimed to investigate the clinical characteristics of atrioventricular conduction block (AVB) during PVI using second-generation cryoballoons. METHODS: A total of 2252 PVs among 568 consecutive atrial fibrillation patients undergoing PVI with 28-mm cryoballoons were analyzed. In 44 patients, left superior PVs (LSPVs) were initially targeted (initial-LSPV-group). In the remaining 524 patients, LSPVs were targeted following right superior PVs (RSPVs) (initial-RSPV-group). RESULTS: Marked sinus arrests/bradycardia occurred in 14 patients only in the initial-LSPV-group, and the incidence was significantly higher in the initial-LSPV than initial-RSPV-group (14/44 vs. 0/524, p < 0.001). Intra-procedural AVB with 3.6 [1.9-8.2] second maximal RR intervals appeared in 12 patients during freezing (n = 1) or after balloon deflation following freezing (n = 11). The targeted PVs were the LSPV, left common PV, right inferior PV, and RSPV in 8, 1, 2, and 1 patients, respectively. The incidence was similar between the initial-LSPV and initial-RSPV-groups (1/44 vs. 11/524, p = 0.938). Four patients exhibited complete AVB with more than a 6 s maximal RR interval. Three patients experienced AVB during atrial fibrillation. AVB was observed a median of 23.0 [15.0-70.0] seconds after balloon deflation and 76.0 [60.0-125.0] seconds after freezing termination. AVB persisted for 56.0 [36.0-110.0] seconds, and all recovered spontaneously with or without requiring back-up pacing. CONCLUSIONS: A marked transient AV conduction disturbance could occur after balloon deflation, especially during LSPV ablation, regardless of the order of targeted PVs.

Exercise-induced Atrioventricular Block with Coronary Artery Stenosis that Appeared Five Years after Bypass Surgery.

A 68-year-old man with a history of coronary artery bypass surgery was referred to our hospital because of pre-syncope on effort. During a treadmill exercise electrocardiogram test, the patient developed advanced atrioventricular block associated with dizziness. Coronary angiography revealed significant stenosis of the right coronary artery, which had not existed at the time of the bypass surgery. We implanted drug-eluting stents in the stenotic lesion, and an exercise test showed resolution of the atrioventricular block. Exercise-induced atrioventricular block is rare, and it is necessary to distinguish it from ischemic heart disease, especially in patients with a history of coronary artery disease.

Efectos de la estimulación endocárdica prolongada sobre la sincronía mecánica ventricular izquierda. Ensayo piloto aplicando análisis de fase por tomografía computada por emisión de fotón único gatillada. Estimulación prolongada y disincronía mecánica / Effects of prolonged endocardial stimulation on left ventricular mechanical synchrony. A pilot study applying gated-SPECT phase analysis. Endocardial stimulation and dyssynchrony

Resumen: Objetivo: Evaluar la disincronía mecánica ventricular izquierda (DMVI) asociada a la estimulación endocárdica prolongada del ventrículo derecho mediante el ensayo piloto de una nueva técnica de imagen en Uruguay. Métodos: Se estudiaron 12 pacientes con marcapasos implantados al menos hace un año utilizando SPECT gatillada con 99mTc-MIBI y análisis de fase en reposo. Se registraron variables clínicas, duración del QRS, tasa, modo y sitio de estimulación ventricular, presencia y extensión de infarto e isquemia, volúmenes cavitarios y FEVI en reposo. Utilizando V-Sync de Emory Cardiac Toolbox se obtuvieron desviación estándar y ancho de banda de fase en reposo (grados), comparando los individuos con FEVI ≥ y < 50% con una población control. Resultados: Los pacientes de la serie con estimulación endocárdica prolongada en el ventrículo derecho exhibieron marcada DMVI. Los pacientes con FEVI moderada/severamente disminuida (con diámetros cavitarios mayores, estimulación septal, infarto extenso o isquemia significativa) exhibieron mayor disincronía que aquellos con FEVI conservada/levemente disminuida (ancho de banda = 144.33o vs. 77.41o, p < 0.05; desviación estándar = 46.67o vs. 26.81o, p < 0.05). Conclusiones: En la cardiopatía isquémica la elevada tasa de estimulación endocárdica crónica se asocia con marcada DMVI, aun cuando la función sistólica esté conservada. El análisis de fase podría ser una herramienta válida para evaluar la disincronía asociada al infarto en pacientes con marcapasos, y aportar a la indicación oportuna del pasaje (upgrading) al modo de estimulación biventricular.

Abstract: Objetive: To evaluate left ventricular mechanical dyssynchrony (LVMD) associated with prolonged right ventricular pacing through an innovative imaging technique as a pilot study in Uruguay. Methods: A 99mTc-MIBI gated-SPECT and phase analysis was performed in 12 patients with pace-makers implanted at least one year before scintigraphy, due to advanced atrioventricular block. Clinical data, QRS duration, rate, mode and site of pacing in right ventricle, chamber diameters, presence and extension of myocardial scar and ischaemia, as well as LVEF at rest, were recorded. Using V-Sync of Emory Cardiac Toolbox, a standard deviation (PSD) and band-width (PBW) from rest phase histogram was obtained and these indexes were compared with controls in the subgroups of patients with LVEF ≥ 50% and < 50%. Results: Patients with prolonged RV endocardial pacing exhibited marked LVMD. More severe dyssynchrony was found in patients with impaired LVEF than in patients with preserved LVEF (PSD: 46.67o vs. 26.81o, P < .05; PBW: 144.33o vs. 77.41o, P < .05). Higher left ventricle diameters, extensive infarct, or significant ischaemia were found in patients with impaired LVEF. Conclusions: Chronic right ventricular pacing was invariably associated with LVMD, even when systolic function was preserved. Phase analysis could be a potentially useful technique to evaluate LMVD associated with myocardial scar in patients with pacemakers, and to decide promptly the upgrading to biventricular pacing.

Electrocardiographic, echocardiographic, and left atrial strain imaging features of a dog with atrial flutter and third-degree atrioventricular block.

A 14-year-old American Staffordshire terrier was presented for episodes of exercise-induced syncope. At admission, atrial flutter coupled to third-degree atrioventricular block was diagnosed electrocardiographically. On the second day of hospitalization, surface electrocardiogram revealed spontaneous conversion to sinus rhythm with persistence of atrioventricular block. Complete transthoracic echocardiograms were performed after each electrocardiographic examination. The combined use of conventional echocardiography with tissue Doppler imaging-based modalities allowed to investigate the atrial electromechanical correlation and function during typical atrial flutter and after its resolution.

Detecting Cardiac Sarcoidosis with a Right Atrial Mass Using Transthoracic Echocardiography.

An asymptomatic 40-year-old woman with a first-degree atrioventricular block presented a right atrial mass in transthoracic echocardiograms. Transesophageal echocardiograms showed abnormally thickened tissue on the interatrial septum, which extended around the aortic annulus. Multimodality examinations demonstrated lesions in the heart, lungs, liver, and spleen, suggesting sarcoidosis. She was diagnosed with cardiac sarcoidosis after we detected granulomas in a lung specimen. A right atrial mass shrunk following steroid therapy. We should therefore consider the possibility of cardiac sarcoidosis when we see wall thickening and a mass echo in the atrium. These signs may point to an early-phase lesion of cardiac sarcoidosis.

TEMPORARY PACE MAKERS IMPLANTATION: DO WE NEED FLUOROSCOPY?

BACKGROUND: Temporary pace maker (TPM implantation is done mostly in emergency with assistance of fluoroscopy. Fluoroscopy has various constrains which may delay the procedure at different occasion. We are going to share our experience in TPM implantation without fluoroscopy from internal jugular vein. METHODS: The case series study was conducted in Hayatabad Medical complex Peshawar from January 2011 to November 2011. Internal jugular vein was cannulated with 6 French sheaths in the supra-clavicular region with modified Seldinger technique. TPM wire connected to the TPM device and advanced in the sheath to the right ventricle. Position was confirmed from captured beat on monitor. There was no need of repositioning and lead remains stable. RESULTS: Total 122 TPM leads were implanted in the study period. All patients were implanted from internal jugular vein. There were 71 male and 51 female patients. Among these patients 55 were in hemodynamically unstable state. The average time of implantation was less than 10 minutes. There was failure in one case. So the overall success rate was 99.180%. CONCLUSION: TPM implantation from the internal jugular vein even without fluoroscopy is safe, less time consuming and convenient.