Trends in complete heart block after transcatheter aortic valve replacement: A population based analysis.

OBJECTIVES: To define the national rate of complete heart block (CHB) after transcatheter aortic valve replacement (TAVR) and its impact on procedural mortality, overall cost, and length of hospital stay. BACKGROUND: CHB leading to permanent pacemaker (PPM) implantation is one of the most common complications post TAVR. National data on the temporal trend of CHB post TAVR are lacking. METHODS: We queried the 2012-2014 National Inpatient Sample databases to identify all patients who underwent TAVR. Patients with preoperative pacemakers or implantable cardioverter-defibrillators were excluded. Association between CHB and outcomes, and overall trends in rate of CHB, PPM implantation, and inpatient mortality were examined. RESULTS: Of 35,500 TAVR procedures, 3,675 (10.4%) had CHB. Overall, occurrence of CHB significantly increased from 8.4% in 2012 to 11.8% in 2014 (adjusted OR per year: 1.23; 95% confidence interval [CI]: 1.17-1.29, P trend <0.001). During the same period, PPM implantation increased from 9.5 to 13.7% (adjusted OR per year: 1.22; 95% CI: 1.16-1.28, P trend <0.001). Patients with CHB had higher odds of in-hospital mortality when compared to patients without CHB (5.9% vs. 4.2%, adjusted OR: 1.32; 95% CI: 1.12-1.56; p = 0.001). Moreover, CHB was also associated with longer length of stay (LOS) and higher hospitalization cost. CONCLUSIONS: There was a significant increase in rates of CHB and PPM implantation over the study period. Development of CHB was associated with increased in-hospital mortality, LOS, and hospitalization cost.

Assessment of fluorinated steroids to avert progression and mortality in anti-SSA/Ro-associated cardiac injury limited to the fetal conduction system.

OBJECTIVES: Extension of disease beyond the atrioventricular (AV) node is associated with increased mortality in cardiac neonatal lupus (NL). Treatment of isolated heart block with fluorinated steroids to prevent disease progression has been considered but published data are limited and discordant regarding efficacy. This study evaluated whether fluorinated steroids given to manage isolated advanced block prevented development of disease beyond the AV node and conferred a survival benefit. METHODS: In this retrospective study of cases enrolled in the Research Registry for NL, inclusion was restricted to anti-SSA/Ro-exposed cases presenting with isolated advanced heart block in utero who either received fluorinated steroids within 1 week of detection (N=71) or no treatment (N=85). Outcomes evaluated were: development of endocardial fibroelastosis, dilated cardiomyopathy and/or hydrops fetalis; mortality and pacemaker implantation. RESULTS: In Cox proportional hazards regression analyses, fluorinated steroids did not significantly prevent development of disease beyond the AV node (adjusted HR=0.90; 95% CI 0.43 to 1.85; p=0.77), reduce mortality (HR=1.63; 95% CI 0.43 to 6.14; p=0.47) or forestall/prevent pacemaker implantation (HR=0.87; 95% CI 0.57 to 1.33; p=0.53). No risk factors for development of disease beyond the AV node were identified. CONCLUSIONS: These data do not provide evidence to support the use of fluorinated steroids to prevent disease progression or death in cases presenting with isolated heart block.

Postoperative heart block in children with common forms of congenital heart disease: results from the KID Database.

INTRODUCTION: Cardiac conduction system injury is a cause of postoperative cardiac morbidity following repair of congenital heart disease (CHD). The national occurrence of postoperative complete heart block (CHB) following surgical repair of CHD is unknown. We sought to describe the occurrence of and costs related to postoperative CHB following surgical repair of common forms of CHD using a large national database. METHODS AND RESULTS: Retrospective, observational analysis performed over a 10-year period (2000-2009) using the Kids' Inpatient Database (KID). Visits for patients ≤24 months of age were identified who underwent surgical repair of ventricular septal defects (VSD), atrioventricular canal defects (AVC), and tetralogy of Fallot (TOF). Patients were identified who were diagnosed with postoperative CHB, further identifying those requiring a new pacemaker placement during the same hospitalization. Costs associated with visits were calculated. There were 16,105 surgical visits: 7,146 VSD, 3,480 AVC, and 5,480 TOF. There was a decrease in postoperative mortality (P = 0.0001) with no significant change in postoperative CHB. Hospital stay and cost were higher with CHB and placement of a permanent pacemaker. Repair of AVC (OR 1.77; [1.32-2.38]) was associated with a higher rate of postoperative CHB. Length of hospital stay and total cost were significantly increased with the development of postoperative CHB and increased further with placement of a permanent pacemaker. CONCLUSION: There has been little change over time in the frequency of postoperative CHB in patients undergoing repair of VSD, AVC, and TOF. Postoperative CHB results in major added cost to the healthcare system.

External validation of the recalibrated thoracic revised cardiac risk index for predicting the risk of major cardiac complications after lung resection.

BACKGROUND: The recalibrated thoracic revised cardiac risk index (ThRCRI) has been recently proposed as a specific tool for cardiac risk stratification before lung resection. However, the ThRCRI has never been externally validated in a population other than the one from which it was derived. The objective of this study was to validate the ThRCRI in an external population of candidates having undergone major lung resections to assess its reliability for cardiac risk stratification across different samples. METHODS: We analyzed 2,621 patients undergoing lobectomy (2,431) or pneumonectomy (190) in a single center from 2000 to 2009. Patients were grouped into four classes of risk (A, B, C, and D) according to the recalibrated ThRCRI. The outcome variable measured was the occurrence of major cardiac complications (cardiac arrest, complete heart block, acute myocardial infarction, pulmonary edema, cardiac death during admission). Incidence of major cardiac events was assessed in the four risk class groupings to assess the discriminative ability of the index score. RESULTS: The incidence of major cardiac morbidity was 2.2% (59 cases). Patients were grouped into four risk classes according to their recalibrated ThRCRI. Incidence of major cardiac morbidity in risk classes A, B, C, and D were 0.9%, 4.2%, 8%, and 18%, respectively (p<0.0001). CONCLUSIONS: The recalibrated ThRCRI is a reliable instrument that can be used during preoperative workup to differentiate patients needing further cardiologic testing from those who can proceed without any further cardiac testing.

Prospective assessment of cardiovascular events in patients with partial and advanced interatrial conduction delay: a preliminary observation.

INTRODUCTION: Major adverse cardiovascular events (MACE) have been investigated with partial interatrial block (IAB; P wave > or = 110 ms) but not with advanced IAB. METHODS: Twenty-four advanced IAB and 34 partial IAB patients were followed for 24 months for MACE, change in renal function and death. RESULTS: Three patients with advanced IAB had myocardial infarction compared to none with partial IAB (p = 0.03). However, overall MACE was not significantly different between groups with an overall low event rate. There was also no difference between change in mean blood urea nitrogen levels and calculated glomerular filtration rates over time. CONCLUSION: In a preliminary 24-month period, when compared to patients with partial IAB, those with the uncommon, advanced form of IAB do not appear to be overly at increased risk for MACE. However, larger prospective studies are needed to confirm these results in order to appraise other cardiovascular risk factors.

Cost benefit analysis of single and dual chamber pacing for sick sinus syndrome and atrioventricular block. An economic sensitivity analysis of the literature.

The benefits of dual (DDD) over single chamber pacing (VVI) have been demonstrated in haemodynamics, exercise capacity, quality of life and reduced complications in atrioventricular block and sick sinus syndrome. The literature was reviewed to provide complication rates for dual and VVI pacing. Cost calculations were based on United Kingdom 1991 prices. Over a 10-year period, a computer model calculated the incidence and prevalence of atrial fibrillation, stroke, permanent disability, heart failure and mortality in six patient categories: sick sinus syndrome paced VVI, sick sinus syndrome upgraded to DDD, sick sinus syndrome paced DDD from outset, atrioventricular block paced VVI and those upgraded to DDD and atrioventricular block paced initially DDD. Calculations were based on intention to treat. The 10 year survival with DDD vs VVI pacing was 71% vs 57% in sick sinus syndrome and 61% vs 51%, respectively, in atrioventricular block. In both indications the prevalence of heart failure in the 10 year survivors was 60% lower with DDD pacing. In sick sinus syndrome patients paced VVI, 36% had severe disability while only 8% experienced this with DDD pacing. For atrioventricular block the figures were, respectively, 22% vs 3%. The difference in 10 year cumulative cost between VVI and DDD is 13 times the purchase price of a VVI pulse generator for sick sinus syndrome and 7 times for atrioventricular block. In the third year after implantation the cumulative costs of DDD were lower than for VVI for both indications. Dual chamber pacing for both indications, sick sinus syndrome and atrioventricular block, is both clinically and cost effective.

Prognosis in patients with diphtheric myocarditis and bradyarrhythmias: assessment of results of ventricular pacing.

OBJECTIVE: To determine the prognosis in patients with diphtherial myocarditis and bradyarrhythmias and to assess the results of ventricular pacing in those with third degree atrioventricular block. DESIGN: Case series. SETTING: Referral department of cardiology in a teaching hospital. PATIENTS: Twenty four out of 46 patients admitted with diphtherial myocarditis over 10 years had bradyarrhythmias. Six had sinus bradycardia, 15 atrioventricular or intraventricular conduction disturbances, and three atrioventricular dissociation. MAIN OUTCOME MEASURE: Death rate. RESULTS: Eleven patients died (46%): all seven patients with third degree atrioventricular block, the patient with bifascicular block, and three of the six patients with bundle branch block. Seven died of cardiogenic shock and four of ventricular fibrillation. All nine patients with sinus bradycardia or atrioventricular dissociation survived. CONCLUSION: Conduction system disturbances in patients with diphtherial myocarditis are markers of severe myocardial damage and a poor prognosis. In addition, ventricular pacing does not improve survival.