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Li-Hong Lu, Yu-Qing Song, Qi-Ming Wu, Zhao Wang, Yong-Fu Chen, Qian Dong, Xiao-Tao Han Department of Cardiology, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of ChinaCorrespondence: Qi-Ming WuDepartment of Cardiology, Beijing Ditan Hospital, Capital Medical University, No. 8 of Jingshun Street, Chaoyang District, Beijing, 100015, People’s Republic of ChinaTel +86 138 0100 9058Fax +86 10-84322988Email lulihong1954@163.comObjective: To improve our knowledge of cardiac manifestations caused by brucellosis through analyzing abnormal electrocardiograms of patients infected with brucella.Methods: A total of 108 cases were enrolled, and their electrocardiograms were analyzed and summarized retrospectively.Results: Among 108 cases, 77 (71.3%) had a normal electrocardiogram, and 31 (28.7%) had an abnormal electrocardiogram. There were 13 cases with nodal tachycardia (12%), 9 cases with sinus bradycardia (8%), 7 cases with sinus arrhythmia (6%), 8 cases with left ventricular high voltage (7%), 13 cases with abnormal ST segment and T wave (12%), 2 cases with abnormal Q wave (1.85%), 3 cases with complete right bundle branch block (2.78%), 3 cases with ventricular premature beat (2.78%), 1 case with left anterior fascicular block (0.9%), 1 case with first degree a-v block (0.9%), 1 case with QT internal prolongation (0.9%), 1 case with poor R wave progression (0.9%), and 1 case with short PR interval (0.9%).Conclusion: The cardiac manifestations of brucellosis were rare, but the mortality was high. Patients with abnormal electrocardiogram should have improved echocardiography in time. Early detection of the abnormal electrocardiogram could give a hint of cardiac damage to avoid the serious consequences.Keywords: brucella, brucellosis, ECG, manifestations, cardiac manifestations

In a patient with variant angina of the proximal left anterior descending coronary artery, myocardial ischemia changed the QRS-ST-T configurations without J-waves into those resembling “lambda” waves at maximal ST-segment elevation, and couplets or triplets of supraventricular extrasystole (SVE) changed the ischemia-induced “lambda” waves into QRS-ST-T configurations resembling a “tombstone” morphology or “monophasic QRS-ST complex.” At the resolution phase of coronary spasm, the QRS-ST-T configurations returned to those without J-waves and were changed by SVE into “lambda” waves. Interestingly, neither ischemia- nor SVE-induced “lambda” waves or SVE-induced “tombstone” morphology or “monophasic QRS-ST complex” were complicated by ventricular tachyarrhythmia.

BACKGROUND Intraventricular conduction disturbances are associated with an increased risk of adverse cardiovascular outcomes. However, data about factors associated with intraventricular conduction disturbances are sparse. We aimed to identify the clinical factors associated with intraventricular conduction disturbances in the general population. METHODS Cross-sectional study in a sample of 3704 participants (age range 45-86 years, 55.2% women). Intraventricular conduction disturbances were defined as QRS > 110 ms on electrocardiograms, and classified into right bundle branch block (RBBB), left bundle branch block (LBBB), left anterior fascicular block (LAFB) and non-specific intraventricular conduction disturbances (NIVCD). RESULTS The number of participants, the resulting prevalence (square brackets) and 95% CI (round brackets) of intraventricular conduction disturbances and subtypes (RBBB, LBBB, LAFB and NIVCD) were 187 [5.1% (4.4-5.8%)], 103 [2.9%, (2.3-3.4%)], 29 [0.8% (0.6-1.1%)], 31 (0.9% [0.6-1.2%]), and 47 [1.3% (0.9-1.7)], respectively. Multivariable logistic regression identified male sex [odds ratio and (95% CI): 2.55 (1.34-4.86)] and increasing age (p-value for trend

Aims The aims of this study are to evaluate the progressive involvement of the cardiac conduction system in the Kearn–Sayre syndrome (KSS) and to establish criteria for the prevention of episodes of syncope or sudden cardiac death. Methods and results This is a prospective monocentric study including KSS patients, with diagnosis based on clinical manifestations, muscle biopsy, and genetic tests, before the age of 18. All patients underwent cardiac screening examination with 12-lead electrocardiogram (ECG), 24-h Holter monitoring, and pacemaker (PM) interrogation twice a year. Fifteen patients (nine males, mean age 16.6 ± 3.9 years) with a sporadic KSS were recruited. All subjects manifested at least one of the intraventricular conduction defects (IVDs): 1 right bundle branch block (RBBB), 2 left anterior fascicular block (LAFB), 11 a bi-fascicular block (RBBB + LAFB), and 1 left posterior fascicular block. Most children with bi-fascicular block developed LAFB before the RBBB (P = 0.0049). In six patients, IVD degenerated into atrioventricular block (AVB). Endocavitary PM was implanted in 11 patients (6 with AVB and 5 with a bi-fascicular block), while an implantable cardioverter-defibrillator only in one patient with a non-sustained ventricular tachycardia. Four died at mean age of 14.7 ± 2.6 years, but none of them suddenly. Conclusion Even a ‘simple’ ECG can predict the arrhythmic risk and the occurrence of catastrophic events in young patients with KSS. Left anterior fascicular block precedes RBBB in determining the bi-fascicular block and this can predict an inexorable progression of the conduction defects even in a short time. Pacemaker implantation may be indicated in these patients since the first bi-fascicular block manifestation.

Background The right bundle branch block (RBBB) and the bifascicular blocks affect QRS duration in the right precordial leads, which are usually used for QT interval determination. Up to now, there is no clear recommendation how to determine QT interval in patients with RBBB or bifascicular block. Hypothesis The hypothesis of the present study was to evaluate the feasibility of a simple formula for RBBB and bifascicular block correction, thereby making it easier to determine the QTc interval. Methods In patients with intrinsic QRS duration

Aims This study aimed to develop and validate a simple method for predicting long‐term all‐cause mortality in ambulatory patients with chronic heart failure (CHF) residing in an area where Chagas disease is endemic, which will be important not only for patients living in Latin America but also to those living in developed non‐endemic countries. Methods and results A total of 677 patients with a wide spectrum of aetiologies for left ventricular systolic dysfunction and receiving optimized evidence‐based treatment for CHF were prospectively followed for approximately 11 years. We established a risk score using Cox proportional hazard regression models. After multivariable analysis, four variables were independently associated with mortality and included in the CALL Risk Score: Chagas cardiomyopathy aetiology alone [hazard ratio, 3.36; 95% confidence interval (CI), 2.61–4.33; P

Objective:To determine the prevalence of pacemaker and conduction disturbances in patients with atrial septal defects.Design:All patients with an atrial septal defect born before 1994 were identified in the Danish National Patient Registry, and 297 patients were analysed for atrioventricular block, bradycardia, right bundle branch block, left anterior fascicular block, left posterior fascicular block, pacemaker, and mortality. Our results were compared with pre-existing data from a healthy background population. Further, outcomes were compared between patients with open atrial septal defects and atrial septal defects closed by surgery or transcatheter.Results:Most frequent findings were incomplete right bundle branch block (40.1%), left anterior fascicular block (3.7%), atrioventricular block (3.7%), and pacemaker (3.7%). Average age at pacemaker implantation was 32 years. Patients with defects closed surgically or by transcatheter had an increased prevalence of atrioventricular block (p < 0.01), incomplete right bundle branch block (p < 0.01), and left anterior fascicular block (p = 0.02) when compared to patients with unclosed atrial septal defects. At age above 25 years, there was a considerably higher prevalence of atrioventricular block (9.4% versus 0.1%) and complete right bundle branch block (1.9% versus 0.4%) when compared to the background cohorts.Conclusions:Patients with atrial septal defects have a considerably higher prevalence of conduction abnormalities when compared to the background population. Patients with surgically or transcatheter closed atrial septal defects demonstrated a higher demand for pacemaker and a higher prevalence of atrioventricular block, incomplete right bundle branch block, and left anterior fascicular block when compared to patients with unclosed atrial septal defects.

Background Several electrocardiographic (ECG) indices have previously been proposed to diagnose left ventricular hypertrophy (LVH). Such indices utilize different criteria, including increased QRS voltage, prolonged QRS duration, left axis deviation, and LAFB and LBBB-like patterns in varying combinations. However, the inter-relationships of these different electrocardiographic indices of LVH with each otherare not fully understood. The purpose of this study is to estimate the relationships between the different LVH indices. Methods Electronic tracings of 12-lead ECGs recorded in 24,786 adult participants in the China Kadoorie Biobank recorded in 2014 were accessed to detect presence of LVH. ECG parameters of LVH, including individual and combinations of such parameters (voltage-only criteria such as Sokolov-Lyon, Cornell, Gubner as well as scores such as Romhilt-Estes point score) were estimated using customized computer software (Cardiolyse Oy, Finland) and compared proprietary LVH point score algorithms (Mortara, USA). Relationships between the different indices were assessed using a correlation matrix to explore associations between individual parameters and combined indices of such parameters. The matrices were used to construct heat maps and identify clustering of individual parameters. Results Overall, approximately 10% of the population had LVH assessed by Mortara algorithms. This graph shows that along with the free standing peaks, the rest are divided into two clusters of interconnected individual parameters. In the center of the largest cluster is the parameter, reflecting R-peak magnitude in aVL lead. In the center of another cluster was the left ventricular strain pattern, as described in Romhilt-Estes point score system. Overall, the Sokolov-Lyon index and LVH point score in Veritas algorithm had the strongest relationships with each other, but the Gubner and Cornell indices had relatively weak correlations with the other indices (Table 1). The mean correlation coefficient between five combined LVH indices was as follows: Veritas (Mortara) – 0.58, Sokolov-Lyon – 0.56, Romhilt-Estes – 0.45, Gubner – 0,32, Cornell – 0,3. Conclusions Parameters such as R-peak magnitude in aVL and left ventricular strain pattern were the most strongly related with each other. Aggregate indices, such as the Sokolov-Lyon index and LVH point score in Veritas algorithm were the most strongly related with all other indices, but the Gubner and Cornell indices were only weakly correlated. The results reinforce the utility of Sokolov-Lyon index and Mortara algorithms as the optimum measures of LVH. Funding Acknowledgement Type of funding sources: None.

Transcatheter aortic valve replacement (TAVR) is a revolutionized treatment for severe aortic valve stenosis. Although new and improved TAVR devices are constantly being developed, cardiac conduction abnormalities post-TAVR requiring permanent pacemaker implantation (PPMI) still occur frequently1. Previously, pre-existing right bundle branch block (RBBB) has been shown to be predictive of PPMI after TAVR compared with patients without RBBB2, while occurrence of new left bundle branch block (LBBB) was associated with a higher rate of PPMI3. However, less attention has been paid to the clinical values of new onset non-LBBB conduction disturbances such as RBBB, left anterior fascicular block (LAFB) or atrioventricular block (AVB). To our knowledge, this is the first report focus on the association of new-onset non-LBBB and PPMI after TAVR. The study was approved by the Ethics Committee of HwaMei Hospital, University of Chinese Academy of Sciences. This article is protected by copyright. All rights reserved.

Patient: Female, 55-year-old Final Diagnosis: Trazodone overdose Symptoms: Altered mental status • seizure • shock • arrhythmia Medication: — Clinical Procedure: — Specialty: Toxicology Objective: Rare disease Background: Trazodone is widely used in the treatment of depression, anxiety, and insomnia. It is thought to have a safe cardiac profile due to the relative lack of anticholinergic effects. Publications about cardiac toxicities of trazodone are scant. Case Report: A 55-year-old woman presented with acute disorder of consciousness secondary to an intentional trazodone overdose. She was found to have seizure activity without cerebral edema. The initial electrocardiogram was unremarkable, with a normal QTc interval. She eventually developed QTc prolongation that evolved into ventricular tachycardia, and then into a transient right bundle-branch block, left anterior fascicular block, and variable degrees of atrioventricular nodal blocks at 12–24 h after ingestion. She then developed generalized tonic-clonic seizures, cardiogenic shock, and respiratory arrest. She was intubated and treated with antiepileptics, norepinephrine, and dopamine infusion. QTc interval prolongation gradually resolved and the various forms of heart block did not recur after at 24–36 h. She did not require transcutaneous pacing, and was successfully extubated with intact neurological function. Conclusions: Fatal arrhythmias can occur in trazodone overdose. Close monitoring and supportive care are crucial for patient survival.

Мета роботи – вивчити показники біоелектричної активності міокарда у представників плавання на дистанції від 100 до 400 метрів різних спортивних кваліфікацій у підготовчому періоді тренувального процесу.Матеріали та методи. На початку підготовчого періоду обстежили 257 спортсменів віком від 11 до 29 років (середній вік – 15,40 ± 0,18 року), які займаються плаванням, мають кваліфікацію від III розряду до ЗМС, змагальна дистанція – 100–400 метрів. Біоелектричну активність міокарда вивчали на діагностичному автоматизованому комплексі «Кардіо+». Для диференційної діагностики спортсменам з правопередсердним ритмом, міграцією водія ритму (МВР) та змінами кінцевої частини шлуночкового комплексу (ЗКЧШК) виконали пробу з фізичним навантаженням на велоергометрі – субмаксимальний тест PWC170, а спортсменам із синдромом CLC і блокадою передньо-верхньої гілки лівої ніжки пучка Гіса (БПВГЛНПГ) – ехокардіографію на апараті My Lab Seven (Італія).Результати. Серед плавців рівня МС–ЗМС порівняно зі спортсменами кваліфікації КМС–1 розряд менше осіб із правопередсердним ритмом і СРРШ; порівняно з плавцями кваліфікації II–III розряд у них частіше діагностували брадикардію, підвищений вольтаж ЕКГ і ЗКЧШК, рідше – синдром CLC. У плавців кваліфікації КМС–1 розряд порівняно зі спортсменами II–III розряду частіше виявляють підвищений вольтаж ЕКГ, СРРШ, але серед них менше осіб із синдромом CLC та T-infantile.Висновки. Після фізичного навантаження, а саме субмаксимального тесту PWC170 у спортсменів із правопередсердним ритмом і МВР відбувалося відновлення синусового ритму, у спортсменів зі ЗКЧШК – нормалізація ЕКГ. У спортсменів із синдромом CLC і БПВГЛНПГ, за даними ехокардіографії, не встановлена дилатація та гіпертрофія серця, а наявність НБПНПГ і СРРШ варто розглядати як особливості ЕКГ., The purpose of the work. To study the indicators of bioelectric myocardial activity in swimmers for a distance from 100 to 400 meters of different sports qualifications in the preparatory period of the training process.Materials and methods. At the beginning of the preparatory period, 257 sportsmen aged from 11 to 29 years old (average age 15.4 ± 0.18 years) who were engaged in swimming and their competition distance was from 100 to 400 meters with qualification from category III to MMS were examined. The bioelectric activity of the myocardium was studied using diagnostic automated complex “Cardio+”. For differential diagnostics, sportsmen with right atrial ectopic rhythm, wandering pacemaker (WP) and changes in the end part of the ventricular complex were subjected to an exercise tolerance test on a bicycle ergometer using the method of submaximal exercise PWC170 test and sportsmen with CLC syndrome and left anterior fascicular block – to echocardiography using a device My Lab 7 (Italy).Results. The MS-MMS swimmers differ from the CMS-1 qualification swimmers by less number of individuals with right atrial ectopic rhythm and early repolarization syndrome (ERS); they are more likely to be diagnosed with bradycardia, high ECG voltage and changes in the end part of the ventricular complex, but CLC syndrome is less frequently, compared with the swimmers of II–III qualification category. Swimmers of CMS I qualification are more often diagnosed with high ECG voltage, ERS, but the number of persons with CLC syndrome and T-infantile is less among them in comparison with the sportsmen of II–III category.Conclusions. After physical activity in the form of a submaximal exercise PWC170 test, sportsmen with right atrial ectopic rhythm and WP demonstrated sinus rhythm restoration, and sportsmen with changes in the end part of the ECG ventricular complex showed ECG normalization. Echocardiography revealed neither heart dilatation no hypertrophy in the sportsmen with CLC syndrome and left anterior fascicular block, and the presence of incomplete right bundle branch block and ERS should be considered as the ECG features in this category of sportsmen., Цель работы – изучить показатели биоэлектрической активности миокарда у представителей плавания на дистанции от 100 до 400 метров различных спортивных квалификаций в подготовительном периоде тренировочного процесса.Материалы и методы. В начале подготовительного периода обследовали 257 спортсменов в возрасте от 11 до 29 лет (средний возраст – 15,40 ± 0,18 года), занимающихся плаванием, имеют квалификацию от III разряда до ЗМС, соревновательная дистанция – от 100 до 400 метров. Биоэлектрическую активность миокарда изучали на диагностическом автоматизированном комплексе «Кардио+». Для дифференциальной диагностики спортсменам с правопредсердным ритмом, миграцией водителя ритма (МВР) и изменениями конечной части желудочкового комплекса (ИКЧЖК) проводили пробу с физической нагрузкой на велоэргометре в виде субмаксимального теста PWC170, а спортсменам с синдромом CLC и блокадой передне-верхней ветви левой ножки пучка Гиса (БПВВЛНПГ) – эхокардиографию на аппарате My Lab Seven (Италия).Результаты. Среди пловцов уровня МС–ЗМС по сравнению с пловцами квалификации КМС–1 разряд меньше лиц с правопредсердным ритмом и СРРЖ; по сравнению с пловцами квалификации II–III разряд у них чаще диагностируют брадикардию, повышенный вольтаж ЭКГ и ИКЧЖК, реже – синдром CLC. У пловцов квалификации КМС–1 разряд по сравнению со спортсменами II–III разряда чаще устанавливают повышенный вольтаж ЭКГ, СРРЖ, однако среди них меньше лиц с синдромом CLC и T-infantile.Выводы. После физической нагрузки в виде субмаксимального теста PWC170 у спортсменов с правопредсердным ритмом и МВР происходило восстановление синусового ритма, у спортсменов с ИКЧЖК – нормализация ЭКГ. У спортсменов с синдромом CLC и БПВВЛНПГ по данным эхокардиографии не установлена дилатация и гипертрофия сердца, а наличие НБПНПГ и СРРЖ следует рассматривать как особенности ЭКГ.

Clinical data: Infant, 7 months, female, referred to our department at one month of age, suspecting of congenital heart disease for further investigation. Chest radiography: Demonstrates cardiomegaly and prominent pulmonary vascular markings. Electrocardiography: Shows right ventricular hypertrophy and left anterior fascicular block. Echocardiography: Evidenced common atrioventricular valve with two orifices and the left superior pulmonary vein draining on the brachiocephalic vein. Computed tomography angiography: This complementary imaging exam was performed to confirm the diagnosis. Diagnosis: The patient presented an association between AVSD and PAPVC, a rare combination. The clinical picture of heart failure was preponderant, characterized by need for diuretics and complementary exams findings, and early surgical treatment was indicated. Operation: The operation was performed through a median sternotomy with 123 minutes of cardiopulmonary bypass and 89 minutes of cross-clamping time. The patient had no postoperative complications, remaining 10 days hospitalized.

Traditional electrocardiographic (ECG) criteria for left ventricular hypertrophy (LVH), introduced in the pre-echocardiographic era of diagnosis, have a relatively low sensitivity (usually not exceeding 25–40%) in detecting LVH. A novel Peguero-Lo Presti ECG-LVH criterion was recently shown to exhibit a higher sensitivity than the traditional ECG-LVH criteria in hypertension. Our aim was to test the diagnostic ability of the novel Peguero-Lo Presti ECG-LVH criterion in severe aortic stenosis. We retrospectively analyzed 12-lead ECG tracings and echocardiographic records from the index hospitalization of 50 patients with isolated severe aortic stenosis (mean age: 77 ± 10 years, 30 women and 20 men). Exclusion criteria included QRS &gt, 120 ms, bundle branch blocks or left anterior fascicular block, a history of myocardial infarction, more than mild aortic or mitral regurgitation, and significant LV dysfunction by echocardiography. We compared the agreement of the novel Peguero-Lo Presti criterion and traditional ECG-LVH criteria with echocardiographic LVH (LV mass index &gt, 95 g/m2 in women and &gt, 115 g/m2 in men). Echocardiographic LVH was found in 32 out of 50 study patients. The sensitivity of the Peguero-Lo Presti criterion in detecting LVH was improved (55% vs. 9–34%) at lower specificity (72% vs. 78–100%) in comparison to 8 single traditional ECG-LVH criteria. Additionally, the positive predictive value (77% vs. 72%), positive likelihood ratio (2.0 vs. 1.5), and odds ratio (3.2 vs. 2.4) were higher for the Peguero-Lo Presti criterion versus the presence of any of these 8 traditional ECG-LVH criteria. Cohen’s Kappa, a measure of concordance between ECG and echocardiography with regard to LVH, was 0.24 for the Peguero-Lo Presti criterion, −0.01–0.13 for single traditional criteria, and 0.20 for any traditional criterion. However, by the receiver operating characteristics (ROC) curve analysis, the overall ability to discriminate between patients with and without LVH was insignificantly lower for the Peguero-Lo Presti versus Cornell voltage as a continuous variable (area under the ROC curve: 0.65 (95% CI, 0.48–0.81) vs. 0.71 (0.55–0.86), p = 0.5). In conclusion, our preliminary results suggest a slightly better, albeit still low, agreement of the novel Peguero-Lo Presti ECG criterion compared to the traditional ECG-LVH criteria with echocardiographic LVH in severe aortic stenosis.

Background: Facioscapulohumeral muscular dystrophy (FSHD) is one of the most common muscular dystrophies and predominantly affects facial and shoulder girdle muscles. Previous case reports and cohort studies identified minor cardiac abnormalities in FSHD patients, but their nature and frequency remain incompletely characterized.Methods: We reviewed cardiac, neurological and genetic findings of 104 patients with genetically confirmed FSHD.Results: The most common conduction abnormality was complete (7%) or incomplete (5%) right bundle branch block (RBBB). Bifascicular block, left anterior fascicular block, complete atrioventricular block, and 2:1 atrioventricular block each occurred in 1% of patients. Atrial fibrillation or flutter were seen in 5% of patients. Eight percent of patients had heart failure with reduced ejection fraction and 25% had valvular disease. The latter included aortic stenosis in 6% (severe in 4% and moderate in 2%) and moderate aortic regurgitation in 8%. Mitral valve prolapse (MVP) was present in 9% of patients without significant mitral regurgitation. There were no significant associations between structural or conduction abnormalities and age, degree of muscle weakness, or size of the 4q deletion.Conclusions: Both structural and conduction abnormalities can occur in FSHD. The most common abnormalities are benign (RBBB and MVP), but more significant cardiac involvement was also observed. The presence of cardiac abnormalities cannot be predicted from the severity of the neurological phenotype, nor from the genotype.

Funding Acknowledgements Type of funding sources: None. Introduction One of the most frequent intraprocedural complication of patients undergoing transcatheter aortic valve replacement (TAVR) is high degree atrioventricular block (HDAVB). The incidence varies from 5-20% depending on the type of valve, previous surgical valve replacement (SVR) and basal conduction disturbances. Purpose The purpose of this study was to evaluate the incidence of intraprocedural HDAVB in patients undergoing TAVR in native valves versus patients with previous SVR derived for valve-in-valve TAVR (VIV-TAVR). Methods Data was collected from all the patients undergoing TAVI in a single center from December 2007 to July 2019. The primary endpoint was to compare the incidence of HDAVB in patients undergoing TAVR versus patients undergoing VIV-TAVI. The secondary endpoint was to describe the differences in the baseline characteristics of patients that presented with HDAVB vs patients without HDAVB. Results A total of 661 patients were derived for TAVR and separated into 2 groups for analysis. 596 patients with native valves treated with TAVR and 65 patients with previous SVR treated with VIV-TAVI. The primary outcome was present in 87 patients (14,6%) in the TAVR group vs 1 patient (1,54%) in the VIV-TAVR group (p: 0,0033). Patients with HDAVB (n = 88) had a mean age of 83,1 ± 6,26 years. The baseline EKG showed a conduction disturbance in 47,6% of the cases (50% of right bundle branch block; 21,8% of first degree AVB; 15,09% of left bundle branch block and 35,85% of left anterior fascicular block). A new permanent pacemaker was implanted in 77 (87,5%) patients. Patients without HDAVB (n = 573) had a mean age of 82,5 ± 6,14 years. The baseline EKG showed a conduction disturbance in 28,91% of the cases (22,73% of Right bundle branch block; 25,68% of first degree AVB; 31,70% of left bundle branch block and 21,25% of left anterior fascicular block). A new permanent pacemaker was implanted in 59 (10,30%) patients. Conclusions There is a very low incidence of intraprocedural HDAVB in patients undergoing VIV-TAVR compared to the rest of TAVR procedures (1,54% vs 14,6% p:0,0033). Moreover, the only predictors that associated with the development of HDAVB where previous right bundle branch block and left anterior fasicular hemiblock. The development of intraprocedural HDAVB is associated with the need of a new permanent pacemaker. Table 1: Basal CharacteristicsNo HDAVBHDAVBp VALUEAge, yrs82,683,10,453Basal conduction disturbance28,91 %47,62 %

Background Fascicular heart blocks can progress to complete heart blocks, but this risk has not been evaluated in a large general population. Objective The purpose of this study was to investigate the association between various types of fascicular blocks diagnosed by electrocardiographic (ECG) readings and the risk of incident higher degree atrioventricular block (AVB), syncope, pacemaker implantation, and death. Methods We studied primary care patients referred for ECG recording between 2001 and 2015. Cox regression models were used to estimate hazard ratios (HRs) as well as absolute risks of cardiovascular outcomes. Results Of 358,958 primary care patients (median age 54 years; 55% women), 13,636 (3.8%) had any type of fascicular block. Patients were followed up to 15.9 years. We found increasing HRs of incident syncope, pacemaker implantation, and third-degree AVB with increasing complexity of fascicular block. Compared with no block, isolated left anterior fascicular block (LAFB) was associated with 0%–2% increased 10-year risk of developing third-degree AVB (HR 1.6; 95% confidence interval [CI] 1.25–2.05), whereas right bundle branch block combined with LAFB and first-degree AVB was associated with up to 23% increased 10-year risk (HR 11.0; 95% CI 7.7–15.7), depending on age and sex group. Except for left posterior fascicular block (HR 2.09; 95% CI 1.87–2.32), we did not find any relevant associations between fascicular block and death. Conclusion We found that higher degrees of fascicular blocks were associated with increasing risk of syncope, pacemaker implantation, and complete heart block, but the association with death was negligible.

Objectives The aim of this analysis was to evaluate the predictors associated with increased risk of permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR). Background While TAVR has evolved as the standard of care for patients with severe aortic stenosis, conduction abnormalities leading to the need for PPMI is one of the most common postprocedural complications. Methods A systematic literature search was performed to identify relevant trials from inception to May 2020. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints. Results Thirty-seven observational studies with 71 455 patients were identified. The incidence of PPMI following TAVR was 22%. Risk was greater in men and increased with age. Patients with diabetes mellitus, presence of right bundle branch block, baseline atrioventricular conduction block, and left anterior fascicular block were noted to be at higher risk. Other significant predictors include the presence of high calcium volume in the area below the left coronary cusp and noncoronary cusp, use of self-expandable valve over balloon-expandable valve, depth of implant, valve size/annulus size, predilatation balloon valvuloplasty, and postimplant balloon dilation. Conclusion Fourteen factors were found to be associated with increased risk of PPMI after TAVR, suggesting early identification of high-risk populations and targeting modifiable risk factors may aid in reducing the need for this post TAVR PPMI.

A 3-year-old female spayed indoor/outdoor Siamese cat was diagnosed with cytauxzoonosis and irregular heart rhythm was appreciated during a physical examination. On electrocardiogram, the cat had an average ventricular rate of 144 beats/min with Wenckebach type (Mobitz type I) atrioventricular block. The QRS complexes of sinus conducted beats had left anterior fascicular block morphology, they were followed by two subsequent beats presented with a prolonged P-R interval and QRS conducted with a left bundle branch block. The finding of alternating left anterior fascicular block and left bundle branch block along with atrioventricular block is consistent with trifascicular block. No structural heart changes were noted on echocardiography. Approximately 48 h after presentation to the emergency service, the cat acutely decompensated and spontaneously died.

In a patient with an old inferior myocardial infarct, the Q waves disappear when he develops left anterior fascicular block.

A 74-year-old female with a history of diabetes presented with chest pain and shortness of breath for two days. She was hypoxic to an oxygen saturation of 60% in the emergency department, requiring bilevel positive airway pressure (BiPAP) to maintain saturations. Chest X-ray demonstrated bilateral hazy opacities suspicious for viral pneumonia. Coronavirus disease 2019 (COVID-19) was confirmed. Right bundle branch block (RBBB) with left anterior fascicular block was noted on admission electrocardiogram (ECG). Cardiac enzymes and brain natriuretic peptide levels were within normal limits. After noting frequent pauses on telemetry, a repeat ECG was performed that demonstrated RBBB with left posterior fascicular block as well as second-degree atrioventricular block (Mobitz type II). Transcutaneous pacing pads were placed, and atropine was placed at the bedside. Cardiac enzymes remained negative. Interleukin-6 levels were elevated at 159 pg/mL. Hydroxychloroquine was deferred due to the patient's arrhythmia and prolonged QTc. Tocilizumab was deferred due to the patient's age. The patient's oxygen requirements and mental status continued to worsen. She continued to desaturate despite maximal BiPAP therapy and eventually died. Cardiac involvement in COVID-19, whether caused primarily by the virus, secondary to its clinical sequelae, or even due to its treatment, cannot be ignored. Further high-quality research is needed to clarify the cardiac pathophysiology. Thorough cardiac exams with electrocardiographic correlation should be performed on all patients with COVID-19. Clinicians should not hesitate to consult cardiovascular services in the event of abnormality.

Background Previous population studies have presented conflicting results regarding the prognostic impact of intraventricular conduction delays (IVCD). Methods We studied long‐term prognostic impact and the association with comorbidities of eight IVCDs in a random sample of 6,299 Finnish subjects (2,857 men and 3,442 women, mean age 52.8, SD 14.9 years) aged 30 or over who participated in the health examination including 12‐lead ECG. For left bundle branch block (LBBB) and non‐specific IVCD (NSIVCD), two different definitions were used. Results During 16.5 years’ follow‐up, 1,309 of the 6,299 subjects (20.8%) died and of these 655 (10.4%) were cardiovascular (CV) deaths. After controlling for known clinical risk factors, the hazard ratio for CV death, compared with individuals without IVCD, was 1.55 for the Minnesota definition of LBBB (95% confidence interval 1.04–2.31, p = .032) and 1.27 (95% confidence interval 0.80–2.02, p = .308) for the Strauss’ definition of LBBB. Subjects with NSIVCD were associated with twofold to threefold increase in CV mortality depending on the definition. While right bundle branch block, left anterior fascicular block and incomplete bundle branch blocks were associated with seemingly higher mortality, this was no longer the case after adjustment for age and sex. The presence of R‐R’ pattern was not associated with any adverse outcome. Conclusions In a population study with long‐term follow‐up, NSIVCD and Minnesota definition of LBBB were independently associated with CV mortality. Other IVCDs had no significant impact on prognosis. The prognostic impact of LBBB and NSIVCD was affected by the definition of the conduction disorder.

Background The study was performed to estimate the incidence and economic burden of electrocardiogram (ECG) precordial lead mispositioning, in an effort to highlight the need for quality improvement. Lead mispositioning may result in further cardiovascular testing to rule out significant cardiac disease, thus adding to the national healthcare financial burden. Methods All consecutive adult ECGs done during 2018, were reviewed. ECGs with acute anterior myocardial infarction (AMI), bundle branch blocks, left ventricular hypertrophy (LVH), left anterior fascicular block (LAFB), pre-excitation, left axis deviation, ventricular pacing and low voltage QRS were excluded. Septal infarcts identified automatically by the computerized software or identified manually using the criteria of QS composite in V2 were not excluded. Computer interpreted ECGs as "cannot rule-out anterior infarct" were also not excluded from this data. Reimbursement of various stress test types was used to estimate the cost burden of misdiagnosed ECGs. Results A total of 9424 adult ECGs were evaluated. Poor R-wave progression (PRWP) or reversed R-wave progression (RRWP) accounted for 497 (5.27%) and 102 (1.08%) ECGs, respectively. A total of 335 septal infarct interpretations constituted about 3.55% of all ECGs. ECGs categorized as "cannot rule-out AMI" due to PRWP constituted about 0.89%. Therefore, a total of 1018 ECGs (10.8%) could be possibly falsely labelled as some type of myocardial infarction. Conclusion Precordial ECG lead mispositioning can lead to significantly abnormal ECG patterns, leading to false diagnoses and further unnecessary cardiovascular testing. This not only increases risk and cost to the patient, but also adds to the national healthcare financial burden.

BACKGROUND: Myocarditis is a rare complication of idiopathic inflammatory myopathies (IIMs), which is usually underestimated because of limited applications of endomyocardial biopsy and cardiovascular magnetic resonance (CMR) in clinical routines. METHODS: From January 2014 to January 2019, 62 patients with initial untreated IIMs were enrolled, including 31 cases with myocarditis (case group) and 31 cases without cardiac involvement (control group). Myocarditis secondary to IIMs was defined based on definitions of IIMs. All medical data were retrieved from electrical medical records of PUMCH. The differences between two groups in symptoms, serum levels of cardiac troponin I (cTnI), creatine kinase-isozyme and N-terminal pro-brain natriuretic peptide (NT-proBNP) were analyzed. The comparisons of arrhythmia, left ventricular ejection fraction (LVEF) and restrictive diastolic dysfunction between two groups were conducted in the analysis of electrocardiogram and electrocardiogram. Besides, CMR data were analyzed to explore the characteristics of CMR in the identification of myocarditis. Meanwhile, 31 patients with myocarditis were divided into two subgroups based on the activity of anti-mitochondrial antibody M2 (AMA-M2), and the differences between two subgroups in the above tests were also analyzed. RESULTS: Compared with control group, patients with myocarditis exhibited shorter disease durations (defined as the period from onset symptoms of IIM to diagnosis of IIM), more symptoms associated with IIMs, more manifestations of heart failure, and higher frequency of positive AMA-M2 antibody (P

INTRODUCTION: Patients with Chagas disease (CD), caused by Trypanosoma cruzi, present a higher risk of developing other chronic diseases, which may contribute to CD severity. Since CD is underreported in the southern state of Paraná, Brazil, we aimed to characterize clinical and epidemiological aspects of individuals chronically infected with T. cruzi in Southern Brazil. METHODS: A community hospital-based study was performed, recording clinical/demographic characteristics of 237 patients with CD from Southern Brazil. To estimate the association between different forms of CD and sociodemographic and clinical variables, multiple logistic regression models were built using the Akaike information criterion. RESULTS: Mean age was 57.5 years and 59% were females. Most patients’ (60%) place of origin/birth was within Paraná and they were admitted to the CD outpatient clinic after presenting with cardiac/digestive symptoms (64%). The predominant form of CD was cardiac (53%), followed by indeterminate (36%), and digestive (11%). The main electrocardiographic changes were in the right bundle branch block (39%) and left anterior fascicular block (32%). The average number of comorbidities per patient was 3.9±2.3; systemic arterial hypertension was most common (64%), followed by dyslipidemia (34%) and diabetes (19%); overlapping comorbidities were counted separately. Male sex was associated with symptomatic cardiac CD (OR=2.92; 95%CI: 1.05-8.12; p=0.040). CONCLUSIONS: This study provided greater understanding of the distribution and clinical profile of CD patients in Southern Brazil, indicating a high prevalence of comorbidities among these patients who are a vulnerable group due to advanced age and substantial risk of morbidity.

Background: Ankylosing spondylitis (AS) is a chronic inflammatory condition associated with more cardiac manifestations than those in the normal population. In this study, we sought to determine the prevalence of cardiac involvement in patients suffering from AS without cardiovascular risk factors. Methods: The present case-control study, conducted in 2 university hospitals in Tehran from January 2016 to December 2017, recruited 67 patients with AS and 40 age- and sex-matched healthy controls. The diagnosis of AS was based on the classification criteria of the Assessment of SpondyloArthritis International Society. All the participants were examined using transthoracic echocardiography and a standard 12-lead ECG. Baseline characteristics, echocardiographic findings, and ECG features were compared between the AS and control groups using univariate analyses. Results: The median age was 33.5 (IQR25-75%: 20.5–59) years in the AS group and 35 (IQR25-75%: 26–59) years in the control group (P=0.301). The number of patients with left ventricular systolic and diastolic dysfunction was significantly higher in the patients with AS than in the controls (7.5% vs. 20.9%; P=0.067, and 22.9% vs. 5.0%; P=0.026, respectively). The number of individuals with a left-axis deviation and a left anterior fascicular block was significantly higher in the patients suffering from AS than in the control group. The number of patients with aortic valve involvement was comparable between the groups (P=0.332). Conclusion: The most common cardiac involvement in our patients with AS was left ventricular dysfunction, followed by rhythm disturbances and aortic valve insufficiency. These findings were independent of age, AS severity, and disease duration. Therefore, the implementation of cardiovascular screening can be recommended for patients with AS.

Background: Although sutureless and rapid deployment aortic valve replacement (SURD-AVR) has been associated with an increased rate of permanent pacemaker (PPM) implantation compared to conventional AVR (c-AVR), the predictors of new conduction abnormalities remain to be clarified. This study aimed to identify risk factors for conduction disorders in patients undergoing AVR surgery. Methods: Data from 243 patients receiving minimally invasive AVR were prospectively collected. SURD-AVR was performed in 103 (42.4%) patients and c-AVR in 140 (57.6%). The primary endpoint was the occurrence of new-onset conduction disorders, defined as first degree atrioventricular (AV) block, advanced AV block requiring PPM implantation, left anterior fascicular block (LAFB), left bundle branch block (LBBB) and right bundle branch block (RBBB). Results: The unadjusted comparison revealed that SURD-AVR was associated with a higher rate of advanced AV block requiring PPM when compared with c-AVR (10.5% vs. 2.1%, P=0.01). After adjusting for other measured covariates (OR: 1.6, P=0.58) and for the estimated propensity of SURD-AVR (OR: 5.1, P=0.1), no significant relationship between type of AVR and PPM implantation emerged. On multivariable analysis, preoperative first-degree AV block (OR: 6.9, P=0.04) and RBBB (OR: 6.9, P=0.03) were independent risk factors for PPM. Subgroup analysis of patients with normal preoperative conduction revealed similar incidence of PPM between SURD-AVR and c-AVR (1.3% vs. 1.9%, P=0.6). When compared with c-AVR, SURD-AVR was associated with a greater incidence of postoperative new onset LBBB (18.1% vs. 3.2%, P