Reverse complete heart block using transcutaneous pacing and repeated plasmapheresis in a neonate with lupus: a case report

BACKGROUND

It has been reported that the complete heart block (CHB) in neonatal lupus (NL) cannot be reversed. This study reported a case of NL-CHB that was reversed by transcutaneous pacing and repeated plasmapheresis.

CASE PRESENTATION

A 35+ 6-week male preterm baby was transferred to the neonatal intensive care unit of the Army Medical Center in May 2020 for slight cyanosis around the lips and nose. Two days after birth, a sudden decrease in heart rate was observed during electrocardiogram (EGG) monitoring. Physical examination revealed a bluish-purple discoloration around the lips and an irregular heartbeat. EGG showed the presence of isolated P (142 bpm) and QRS (78 bpm) waves, ventricular escape beats, and a diagnosis of NL-CHB. To reverse the condition, transcutaneous pacing and five sessions of plasmapheresis were performed. At a 1.5-year follow-up, the baby exhibited well-developed cardiac structure and normal neurodevelopment.

CONCLUSIONS

Transcutaneous pacing and repeated plasmapheresis might be possible to reverse CHB in NL.

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

Unusual course of congenital complete heart block in an adult: A case report

BACKGROUND

Congenital complete heart block (CCHB) with normal cardiac structure and negativity for anti-Ro/La antibody is rare. Additionally, CCHB is much less frequently diagnosed in adults, and its natural history in adults is less well known.

CASE SUMMARY

A 23-year-old woman was admitted to our hospital for frequent syncopal episodes. She had bradycardia at the age of 1 year but had never had impaired exercise capacity or a syncopal episode before admission. The possible diagnosis of acquired complete atrioventricular block was carefully ruled out, and then the diagnosis of CCHB was made. According to existing guidelines, permanent pacemaker implantation was recommended, but the patient declined. With regular follow-up for 28 years, the patient had an unusually good outcome without any invasive intervention or medicine. She had an uneventful pregnancy and led a normally active life without any symptoms of low cardiac output or syncopal recurrence.

CONCLUSION

This case implies that CCHB in adulthood may have good clinical outcomes and does not always require permanent pacemaker implantation.

Left ventricular systolic motion pattern differs among patients with left bundle branch block patterns

The study aimed to investigate left ventricular (LV) motion pattern in patients with LBBB patterns including patients with pacemaker rhythm (PM), type B Wolff-Parkinson-White syndrome (B-WPW), premature ventricular complexes originating from the right ventricular outflow tract (RVOT-PVC), and complete left bundle branch block (CLBBB). Two-dimensional speckle tracking was used to evaluate peak value and time to peak value of the LV twist, LV apex rotation, and LV base rotation in patients with PM, B-WPW, RVOT-PVC, and CLBBB with normal LV ejection fraction, and in age-matched control subjects. The LV motion patterns were altered in all patients compared to the control groups. Patients with PM and CLBBB had a similar LV motion pattern with a reduced peak value of LV apex rotation and LV twist. Patients with B-WPW demonstrated the opposite trend in the reduction of LV rotation peak value, which was more dominant in the basal layer. The most impairment in the LV twist/rotation peak value was identified in patients with RVOT-PVC. Compared to the control group, the apical-basal rotation delay was prolonged in patients with CLBBB, followed by those with B-WPW, PM, and RVOT-PVC. The LV motion patterns were different among patients with different patterns of LBBB. CLBBB and PM demonstrated a reduction in LV twist/rotation that was pronounced in the apical layer, B-WPW showed a reduction in the basal layer, and RVOT-PVC in both layers. CLBBB had the most pronounced LV apical-basal rotation dyssynchrony.

Optimization of Left Ventricle Pace Maker Location Using Echo-Based Fluid-Structure Interaction Models

Introduction

Cardiac pacing has been an effective treatment in the management of patients with bradyarrhythmia and tachyarrhythmia. Different pacemaker location has different responses, and pacemaker effectiveness to each individual can also be different. A novel image-based ventricle animal modeling approach was proposed to optimize ventricular pacemaker site for better cardiac outcome.

Method

One health female adult pig (weight 42.5 kg) was used to make a pacing animal model with different ventricle pacing locations. Ventricle surface electric signal, blood pressure and echo image were acquired 15 min after the pacemaker was implanted. Echo-based left ventricle fluid-structure interaction models were constructed to perform ventricle function analysis and investigate impact of pacemaker location on cardiac outcome. With the measured electric signal map from the pig associated with the actual pacemaker site, electric potential conduction of myocardium was modeled by material stiffening and softening in our model, with stiffening simulating contraction and softening simulating relaxation. Ventricle model without pacemaker (NP model) and three ventricle models with the following pacemaker locations were simulated: right ventricular apex (RVA model), posterior interventricular septum (PIVS model) and right ventricular outflow tract (RVOT model). Since higher peak flow velocity, flow shear stress (FSS), ventricle stress and strain are linked to better cardiac function, those data were collected for model comparisons.

Results

At the peak of filling, velocity magnitude, FSS, stress and strain for RVOT and PIVS models were 13%, 45%, 18%, 13% and 5%, 30%, 10%, 5% higher than NP model, respectively. At the peak of ejection, velocity magnitude, FSS, stress and strain for RVOT and PIVS models were 50%, 44%, 54%, 59% and 23%, 36%, 39%, 53% higher than NP model, respectively. RVA model had lower velocity, FSS, stress and strain than NP model. RVOT model had higher peak flow velocity and stress/strain than PIVS model. It indicated RVOT pacemaker site may be the best location.

Conclusion

This preliminary study indicated that RVOT model had the best performance among the four models compared. This modeling approach could be used as “virtual surgery” to try various pacemaker locations and avoid risky and dangerous surgical experiments on real patients.

Congenital heart block: Pace earlier (Childhood) than later (Adulthood)

Congenital complete heart block (CCHB) occurs in 2-5% of pregnancies with positive anti-Ro/SSA and/or anti-La/SSB antibodies, and has a recurrence rate of 12-25% in a subsequent pregnancy. After trans-placental passage, these autoantibodies attack and destroy the atrioventricular (AV) node in susceptible fetuses with the highest-risk period observed between 16 and 28 weeks' gestational age. Many mothers are asymptomatic carriers, while <1/3 have a preexisting diagnosis of a rheumatic disease. The mortality of CCHB is predominant in utero and in the first months of life, reaching 15-30%. The diagnosis of CCHB can be confirmed by fetal echocardiography before birth and by electrocardiography after birth. Whether early in-utero detection and treatment might prevent or reverse this condition remains controversial. In addition to autoantibody-associated CCHB, there is also an isolated (absent structural heart disease) nonimmune early- or late-onset heart block detected later in childhood that may be associated with specific genetic markers or other pathogenic mechanisms. In isolated immune or non-immune CCHB, cardiac pacemakers are implanted in symptomatic patients, however, data on the natural history of CCHB in the adult life indicate that all patients, even if asymptomatic, should receive a pacemaker when first diagnosed. However, important issues have emerged in these patients wherein life-long conventional right ventricular apical pacing may produce left ventricular dysfunction (pacing-induced cardiomyopathy) necessitating a priori alternate site pacing or subsequent upgrading to biventricular pacing. All these issues are herein reviewed and two algorithms are proposed for diagnosis and management of CCHB in the fetus and in the older individual.

Predicting postpartum cardiac events in pregnant women with complete atrioventricular block

BACKGROUND

Women with complete atrioventricular block (CAVB) can tolerate hemodynamic changes during pregnancy; however, the incidence of cardiac events in women with CAVB may increase after delivery. The aim of this study was to investigate predictive factors for postpartum cardiac events in pregnant women with CAVB.

METHODS AND RESULTS

Pregnant women with CAVB who received perinatal management at a tertiary cardiac center from 1981 to 2015 were retrospectively reviewed. Univariate and multivariate logistic analyses of postpartum cardiac events were performed. Postpartum cardiac event was defined as cardiopulmonary arrest, cardiac failure, or the need for permanent pacemaker implantation (p-PMI) within 3 months after delivery. A total of 63 pregnancies in 36 women with CAVB were included in this study; 25 had undergone p-PMI before pregnancy. Regardless of p-PMI status, women with CAVB had no further increases in heart rate during the second and third trimesters. No heart failure was found during pregnancy and delivery. Postpartum cardiac events occurred in 9 pregnancies (14.3%) in 8 women with CAVB; 3 had cardiac failure and p-PMI, 3 had cardiac failure, 2 required p-PMI, and 1 had cardiopulmonary arrest. Multivariate analysis showed that perinatal ventricular pause (odds ratio 11.60, 95% confidence interval 1.90-82.18, p<0.01) and family history of CAVB (odds ratio 10.59, 95% confidence interval 1.36-90.56, p=0.03) were associated with postpartum cardiac events.

CONCLUSIONS

All cardiac events occurred during the postpartum period among women with CAVB, and ventricular pause during the perinatal period and a family history of CAVB were predictors of postpartum cardiac events. Close follow-up should be considered during the postpartum period for women with high-risk CAVB.

Echocardiographic assessment of ventricular contraction and synchrony in children with isolated complete atrioventricular block and epicardial pacing: Implications of interventricular mechanical delay

AIMS

To assess the correlations between interventricular mechanical delay (IVMD) and cardiac function in children with isolated complete atrioventricular block and epicardial pacing.

METHODS AND RESULTS

We enrolled 13 children (six boys) with an epicardial dual-chamber pacemaker due to isolated complete or advanced atrioventricular block. The patients were 9.8 (range, 6.8-15.3) years old, and none had symptomatic heart failure at the follow-up visit. Ventricular pacing sites, which remained the same for 7.2 (1.6-12.3) years, were the left ventricle (LV) in two patients, right ventricle (RV) in four patients, and both ventricles in seven patients. IVMD was ≤40 ms in six patients (short IVMD group) and >40 ms in seven patients (long IVMD group). Compared with the long IVMD group, the short IVMD group was associated with better LV longitudinal strain (-20% [-24% to -18%] vs -16% [-20% to -13%], P < .05). The short IVMD group had superior LV mechanical synchrony than the long IVMD group (septal to lateral delay of the time to peak longitudinal strain 15 [-16-78] ms vs 78 [13-93] ms, P < .05; standard deviation of the time to peak radial strain 13 [9-34] ms vs 35 [18-64] ms, P < .05).

CONCLUSION

In children with epicardial pacing at LV, RV, or both ventricles, a left-sided contraction delay was associated with poorer LV contraction and impaired LV synchrony. IVMD will help to stratify patients during follow-up.

Dilated cardiomyopathy

Dilated cardiomyopathy is defined by the presence of left ventricular dilatation and contractile dysfunction. Genetic mutations involving genes that encode cytoskeletal, sarcomere, and nuclear envelope proteins, among others, account for up to 35% of cases. Acquired causes include myocarditis and exposure to alcohol, drugs and toxins, and metabolic and endocrine disturbances. The most common presenting symptoms relate to congestive heart failure, but can also include circulatory collapse, arrhythmias, and thromboembolic events. Secondary neurohormonal changes contribute to reverse remodelling and ongoing myocyte damage. The prognosis is worst for individuals with the lowest ejection fractions or severe diastolic dysfunction. Treatment of chronic heart failure comprises medications that improve survival and reduce hospital admission-namely, angiotensin converting enzyme inhibitors and β blockers. Other interventions include enrolment in a multidisciplinary heart failure service, and device therapy for arrhythmia management and sudden death prevention. Patients who are refractory to medical therapy might benefit from mechanical circulatory support and heart transplantation. Treatment of preclinical disease and the potential role of stem-cell therapy are being investigated.