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STUDY OBJECTIVES: Monitoring electrocardiogram is an integral component of pediatric polysomnography (PSG). There are limited data regarding arrhythmia and conduction disturbances in the pediatric population undergoing a PSG. In this work we present abnormal electrocardiogram findings during PSG in our sleep center. METHODS: A retrospective chart review from children who underwent PSG read by a single sleep medicine physician in the last year was carried out. Findings in children without cardiac disease and with first or second degree atrioventricular block were compared to those from children with premature ventricular contractions. RESULTS: A total of 1,235 PSGs were included. Twenty-four children (9 girls and 15 boys) aged 2–17 years (median 9 years) were identified with arrhythmias or conduction disturbances (1.9%). Nineteen out of 24 of these children (79.2%) had obstructive apnea-hypopnea index > 1 event/h; this frequency was not significantly different from that found in the whole group of 1,235 children. No statistically significant difference was found between children with atrioventricular block or premature ventricular contractions. Seven out of 9 children with atrioventricular block and 7 out of 10 with premature ventricular contractions had obstructive apnea-hypopnea index > 1 event/h, while 8 children with atrioventricular block out of 9 and 4 out of 10 with premature ventricular contractions were males (Fisher’s exact test P = .04). None of the children were found to have a structural or conduction abnormality when referred to cardiology. CONCLUSIONS: Our study supports that electrocardiogram abnormalities are rare in PSGs of children and not associated with cardiac disease or sleep disorders but appear more commonly in males. CITATION: Amin A, Mogavero MP, Ferri R, DelRosso LM. Incidental electrocardiogram abnormalities in children undergoing polysomnography. J Clin Sleep Med. 2021;17(12):2393–2398.

Mortality due to cardiovascular disease in pregnancy is a growing problem in developed countries, being nowadays the leading cause of maternal death. Within this group, the most common cause of death are congenital or acquired heart diseases, representing a challenge in the management of these patients, since the pregnancy-related physiological alterations can impair their basal condition and treatment. We present the case of a 34-year-old patient, without any relevant pathological antecedents, who developed a second-degree atrioventricular block, Mobitz type I, following the administration of methylergometrine during cesarean section due to failure to progress in labour. We emphasize the importance of considering the side effects of commonly used drugs in pregnant patients, despite rare possibility of some adverse reactions.

Amitraz is a drug which is used against the external parasites of domestic animals such as lice, fleas, tick species, and scabies agents. There are no indications for use in humans. In this case report, we presented the findings related to intoxication due to the intake of amitraz via dermal and inhalation route. We tried to explain the possible complications and treatment options. Oral ingestion intoxication cases due to the amitraz use have been reported in humans. In addition, several animal experiments have been conducted, but there exists very few publications in the literature related to the amitraz intake via dermal or inhalation routein humans. Here we present a case of a second-degree AV block in an adolescent with an acute dermal and inhalational amitraz intoxication.

We describe an adolescent withStreptococcus pneumoniaemeningitis and symptomatic high-grade, second-degree atrioventricular block requiring permanent pacemaker placement. It is difficult to ascertain if these two diagnoses were independent or had a causal relationship though ongoing symptoms were not present prior to the infection. Because of this uncertainty, awareness that rhythm disturbances can be cardiac in origin but also secondary to other aetiologies, such as infection, is warranted.

Background: Bruton tyrosine kinase (BTK) inhibitors are effective treatments for B-cell malignancies, but an increased incidence of cardiovascular (CV) toxicities has been observed with ibrutinib. Acalabrutinib (acala) is a next-generation, potent, highly selective, covalent BTK inhibitor approved for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma and mantle cell lymphoma. The objective of this analysis was to characterize CV adverse events (AEs) in patients (pts) with CLL who received acala monotherapy. Methods: Data from pts with CLL in 4 studies (ACE-CL-001 [NCT02029443]; ACE-CL-007 [ELEVATE-TN, NCT02475681]; ACE-CL-309 [ASCEND, NCT02970318]; 15-H-0016 [NCT02337829]) were pooled. Cutoff dates ranged from December 2018 to February 2019. Pts who received ≥1 dose of acala monotherapy were included. For pts who crossed over from control arms to acala, only AEs recorded after crossover were included. Acala was given orally at total daily doses of 100 mg to 400 mg, later switched to 100 mg twice daily, and continued until disease progression (PD) or toxicity. Cardiac AEs and hypertension (htn) were examined. Results: 762 pts were included (treatment-naïve: n=352 [46%]; relapsed/refractory: n=410 [54%]; median age: 67 years [range: 32-89]; Eastern Cooperative Oncology Group performance status ≤1: 93%; median acala exposure: 24.9 mo [range: 0-58.5]; median follow-up: 25.9 mo [range: 0-58.5]). A total of 199 cardiac AEs of any grade (irrespective of treatment relationship) were reported in 129 pts (17%). Cardiac AEs led to treatment discontinuation in 7 pts (0.9%). The most frequent cardiac AEs reported in ≥2% of pts were atrial fibrillation (afib: n=34; 4%; afib/flutter: n=38; 5%), palpitations (n=23; 3%), and tachycardia (n=17; 2%). The median time to afib/flutter onset was 521 days (range: 8-1280). Overall, 91% (117/129) of pts with vs 79% (503/633) without cardiac AEs had ≥1 CV risk factor before acala initiation. The most prevalent CV risk factors (≥20%) among the 129 pts with cardiac AEs were htn (n=86; 67%), hyperlipidemia (n=38; 29%), and arrhythmias (n=29; 22% [afib: n=16; 12%]). Htn AEs were reported in 9% (67/762) of pts, among whom 46 (69%) had pre-existing htn and 18 (27%) had htn risk factors. The median time to htn onset was 197 days (range: 2-1345). Thirty-seven pts (4%) had 51 grade ≥3 cardiac AEs (grade 3: n=37; grade 4: n=12; grade 5: n=2). Grade ≥3 cardiac AEs of interest included afib (n=10; 1.3%), complete atrioventricular (AV) block (n=2; 0.3%), acute coronary syndrome (n=1; 0.1%), atrial flutter (n=1; 0.1%), second degree AV block (n=1; 0.1%), and ventricular fibrillation (n=1; 0.1%). Two patients experienced grade 5 AEs (cardiac failure congestive [n=1], acute myocardial infarction [n=1]). Among the 37 pts with grade ≥3 AEs, 18 (49%) were continuing acala at data cutoff; 6 (16%) had discontinued due to the grade ≥3 cardiac AEs, 4 (11%) to other AEs, 5 (14%) to PD, 3 (8%) to death, and 1 (3%) to other reasons. Among the 51 grade ≥3 cardiac AEs, 16 (31%) led to dose delay and 36 (71%) were managed with concomitant medications. Most events (43/51 [84%]) resolved (dose delay: n=15; drug withdrawal: n=4; no dose change: n=24). Cardiac AEs occurring in the first 6 mo on acala were assessed based on a predominance of AEs (afib) during this time period with ibrutinib (Brown JR, et al, Haematologica. 2017;102:1796). Overall, 48% of pts with any-grade cardiac AEs experienced them in the first 6 mo on acala. Thirteen grade ≥3 cardiac AEs (25% of total) were observed in 9 pts in the first 6 mo (Table); all but 1 AE (grade 4 cardiac tamponade resulting in hospitalization) were managed with concomitant medications. Two of the 13 AEs resulted in treatment discontinuation (Table). Conclusions: At a median exposure of 24.9 mo, cardiac AEs occurred infrequently in pts with CLL treated with acala monotherapy; only 0.9% discontinued treatment due to cardiac AEs. Among grade ≥3 cardiac AEs, 25% were reported during the first 6 mo on treatment. Most pts with cardiac AEs had pre-existing risk factors that may have contributed to their development. The incidence of afib with acala (4%) was comparable to that of the general CLL population (6.1%; Shanafelt TD, et al. Leuk Lymphoma. 2017;58:1630). These data suggest a low risk of cardiac AEs with acala treatment in pts with CLL. The safety of acala vs ibrutinib in pts with high-risk CLL will be investigated in the phase 3, randomized ACE-CL-006 trial (NCT02477696). Disclosures Brown: Janssen, Teva: Speakers Bureau; Abbvie, Acerta, AstraZeneca, Beigene, Invectys, Juno/Celgene, Kite, Morphosys, Novartis, Octapharma, Pharmacyclics, Sunesis, TG Therapeutics, Verastem: Consultancy; Gilead, Loxo, Sun, Verastem: Research Funding. Byrd:Acerta Pharma: Research Funding; Syndax: Research Funding; Leukemia and Lymphoma Society: Other; Trillium: Research Funding; Kartos Therapeutics: Research Funding; Vincera: Research Funding; Novartis: Research Funding; Janssen: Consultancy; Pharmacyclics LLC, an AbbVie Company, Gilead, TG Therapeutics, BeiGene: Research Funding; Pharmacyclics LLC, an AbbVie Company, Gilead, TG Therapeutics, Novartis, Janssen: Speakers Bureau; Pharmacyclics LLC, an AbbVie Company, Janssen, Novartis, Gilead, TG Therapeutics: Other. Ghia:Adaptive, Dynamo: Consultancy, Honoraria; Novartis: Research Funding; Acerta/AstraZeneca: Consultancy, Honoraria; ArQule: Consultancy, Honoraria; Gilead: Consultancy, Honoraria, Research Funding; BeiGene: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company), Research Funding; Celgene/Juno: Consultancy, Honoraria; Lilly: Consultancy, Honoraria; MEI: Consultancy, Honoraria; Sunesis: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company), Research Funding. Sharman:TG Therapeutics: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Pharmacyclics: Consultancy, Research Funding; AstraZeneca: Consultancy, Research Funding; Genentech: Consultancy, Research Funding; Acerta: Consultancy, Research Funding; Roche: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Bristol Meyers Squibb: Consultancy, Research Funding; BeiGene: Research Funding. Hillmen:F. Hoffmann-La Roche: Honoraria, Research Funding; Astra Zeneca: Honoraria; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company), Research Funding, Speakers Bureau; AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company), Research Funding, Speakers Bureau; Pharmacyclics: Research Funding; Gilead: Research Funding. Stephens:MingSight: Research Funding; Acerta: Research Funding; Karyopharm: Consultancy, Research Funding; Gilead: Research Funding; Arqule: Research Funding; Pharmacyclics: Consultancy; Verastem: Research Funding; Beigene: Consultancy; Juno: Research Funding; Innate: Consultancy; Janssen: Consultancy. Sun:VERASTEM, GENMAB: Research Funding. Jurczak:Janssen, MeiPharma, Merck, Pharmacyclics, Roche, Tekeda, TG Therapeutics: Research Funding; Maria Sklodowska-Curie National Research Institute of Oncology: Consultancy, Current Employment; Jagiellonian University: Ended employment in the past 24 months, Research Funding. Patel:AstraZeneca: Current Employment, Current equity holder in publicly-traded company. Baek:Acerta Pharma: Current Employment. Lezhava:Astra Zeneca: Current Employment; Melinta Therapeutics Inc: Ended employment in the past 24 months. Kuptsova-Clarkson:AstraZeneca: Current Employment. Moslehi:AstraZeneca, Janssen, BMS, Boston Biomedical, Immunocure, Myovant, Boston Biomedical, Deciphera: Consultancy. Furman:Acerta: Consultancy; Abbvie: Consultancy; Verastem: Consultancy; Sunesis: Consultancy; Pharmacyclics: Consultancy; Oncotarget: Consultancy; Loxo Oncology: Consultancy; Janssen: Consultancy, Speakers Bureau; Incyte: Consultancy; TG Therapeutics: Consultancy, Research Funding; AstraZeneca: Consultancy, Research Funding; Beigene: Consultancy; Genentech: Consultancy.

Arrhythmias can complicate the course of patients with ST-elevation myocardial infarction. These arrhythmias can include both tachyarrhythmias and bradyarrhythmias. Tachyarrhythmias range from Ventricular premature complexes to life-threatening ventricular tachycardia/ fibrillation. Bradyarrhythmias range from sinus bradycardia to complete heart block. These arrhythmias have the ability to provoke hemodynamic consequences and increase mortality. Tachyarrhythmias are more common with Anterior wall myocardial infarction and bradyarrhythmias are more common with Inferior wall myocardial infarction. We report a case of Mobitz Type 1 (Wenkebach) second-degree atrioventricular block in a patient with Anterior wall myocardial infarction. Angiography showed a significant lesion in Left anterior descending artery, after the first septal and diagonal branch. After the successful percutaneous coronary intervention, this second degree AV block reverted to first degree AV block. To the best of our knowledge, there is no case report describing this association separately.

Background Takotsubo cardiomyopathy is characterized by transient left systolic dysfunction that can mimic acute myocardial infarction. Atrioventricular (AV) block associated with Takotsubo is rare, but a few cases have been reported in recent years. Methods We present the case of a 77-year-old woman presenting with second-degree AV and Takotsubo syndrome. Results The diagnosis of Takotsubo syndrome was based on echocardiogram changes and the absence of coronary artery obstruction on coronary angiography. Conclusions We describe a patient with a diagnosis of Takotsubo syndrome and AV conduction defect. These conditions rarely occur simultaneous, but when they do, a dilemma arises regarding pacemaker implantation. LEARNING POINTS Takotsubo syndrome is a rare disorder that can mimic acute myocardial infarction.Takotsubo syndrome normally resolves by itself, but the associated arrhythmias may need treatment and pacemaker implantation.The timing of pacemaker implantation has to be evaluated on a case-by-case basis.

Funding Acknowledgements Type of funding sources: None. Background Syncope is a common reason for emergency department attendance. This entity may be associated with significant morbidity and mortality and its differential diagnosis is not straightforward. Arrhythmic causes include tachycardia and bradycardia; the later may require pacemaker implantation. Many hospitals lack a dedicated syncope unit to approach these patients. So, patients’ triage may fall into medical or surgical (trauma) areas. Purpose To describe the population of patients that required permanent pacemaker implantation in the year of 2019, particularly those who had a previous visit to the emergency department with syncope or presyncope. Methods Single-center descriptive analysis of patients that implanted a permanent pacemaker in 2019 (inclusion criteria). Additional information was collected in patients with emergency department visits in the 365 days that preceded the device implantation. Results In 2019, a total of 398 patients were admitted for pacemaker implantation in 2019, 55% male (n = 218), 45% female (n = 180), with mean age of 79 years. Regarding indications for pacing, 41% (n= 156) had complete atrioventricular (AV) block, 26% (n = 105) had a second degree AV block, 16% (n = 64) had sinus node dysfunction, 13.5% (n = 53) had atrial fibrillation with slow ventricular conduction, and 3.5% (n = 14) had other indications. Twenty-two percent (n = 88) of patients had a previous visit to the emergency department (other than the ones that triggered the pacemaker implantation) with complaints of syncope (60%) or presyncope (40%). Of these, 73% (n = 64) were referred to a medical area and 27% (n = 24) were referred to a surgical area; 40 patients presented with traumatic lesions (68% cranioencephalic trauma and 32% other traumas). Of the 88 patients, only 67% (n = 59) performed an ECG and only 23% (n = 20) were referred for observation by a cardiologist in the emergency department. Comparing medical and surgical triage, we observe that patients referred to the surgical area were less likely to perform an ECG and to be observed by a cardiologist (with statistical significance). Conclusions Our work describes a common problem in hospitals without dedicated syncope evaluation units. As all the patients ended up implanting a pacemaker, it is interesting to observe that 22%of these had a "warning" visit to the emergency and 33% of the last did not get and ECG. Also, trauma-oriented approaches result in a lower likelihood of performing a complete evaluation of the cause of the syncopal event. This analysis highlights the need for a comprehensive and multidisciplinary approach of patients presenting with syncope and presyncope to promote early identification and treatment of arrhythmic causes, reducing patient morbidity and healthcare costs.

Funding Acknowledgements Type of funding sources: None. BACKGROUND The incidence of atrial fibrillation (AF) following stroke has been studied with implantable loop recorders. However, these devices do not record short lasting AF episodes ( PURPOSE To evaluate the incidence, type and clinical relevance of arrhythmias detected by one-month continuous ECG monitoring in patients after cryptogenic stroke. MATERIAL AND METHODS Consecutive patients (p) with stroke and no previous AF or other cardioembolic or atheroembolic causes were prospectively enrolled in the study. An external wearable 2-lead ECG monitoring system (NUUBO) was used for 30 days (d) in all of them after the acute phase of the stroke. In the absence of documented AF, a parafibrillatory status was defined as >3000 atrial ectopic beats/d or >2 "micro AF" episodes (fibrillatory burst 14 s. RESULTS 130 p. were included in the study (age 73 ± 12, 57% males, 19% previous stroke, 7% ischemic cardiopathy, CHA2DSVA2Sc pre-stroke 3.1 ± 1.7). 3 were withdrawn from the study due to inadequate use (recording time 30 s was detected in a total of 27 (21.4%) p, average AF duration was 52 hours (range 30 s-22 d). AF >30s was detected in 2 (17%) p with repeated monitoring. All these patients were placed on anticoagulation. Sustained paroxysmal supraventricular tachycardia (SVT) was documented in 4 (4.4%) p without AF. All episodes of AF and SVT were asymptomatic. Mobitz I second degree AV block in 4 (3.2%) p. 3 (2.4%) p had a pacemaker implanted: 2 for severe sinus dysfunction and 1 for AV block. High-density ventricular ectopy (>3000/d) was present in 7 (6%) p and ≥1 episode of non-sustained ventricular tachycardia was detected in 26 (21%) p. A parafibrillatory status was identified in 27 (21%) p with no AF >30 s. At 1-year follow up 4/22 (18%) of patients with parafibrillatory status and 3/59 (5%) without parafibrillatory status suffered a new stroke (p = 0.08). CONCLUSIONS AF and other potentially relevant arrhythmias are frequent after stroke and easily detectable with one-month non-invasive continuous ECG monitoring. Patients with a parafibrillatory status could benefit from longer monitoring time to detect AF.

Background Since late 2019, the outbreak of COVID-19 has rapidly spread worldwide. As it is a newly emerged disease, many of its manifestations and complications are unknown to us. Cardiac involvement and arrhythmias are another aspect of the disease about which very little is known. Case summary A 71-year-old male patient presented at the Emergency Department complaining of fever, a dry cough, and dyspneoa. He was admitted due to these symptoms suggestive of COVID-19, and a chest CT and PCR test confirmed the diagnosis. During admission, cardiac involvement was detected, i.e. second-degree atrioventricular block with intermittent left bundle branch block (LBBB) which progressed to fixed LBBB and eventually developed into atrial fibrillation/flutter with bradycardia. Both cardiac troponin and echocardiographic findings for detecting myocarditis were negative. We waited 14 days for resolution of atrioventricular block before permanent pacemaker implantation, but the condition still did not improve after the waiting period. Discussion COVID-19 is mainly a respiratory infection but cardiac involvement is not uncommon in the course of the disease. Arrhythmia, during this infection, seems to be caused by an inflammatory response in the myocardium, electrolyte disturbances, and hypoxia; the course of the disease in our case study shows that the virus can preferentially and irreversibly involve the cardiac conduction system.

Sickle cell disease (SCD) affects approximately 100,000 Americans, and it occurs in one out of every 365 African American births. Cardiac complications are a common feature of SCD and are an essential cause of the morbidity and mortality associated with SCD. However, there is insufficient literature on SCD and atrioventricular (AV) blocks. We present a case of a young African American male with transient second-degree Mobitz type 1 block during an acute episode of sickle cell crisis.

Lacosamide enhances slow inactivation of voltage-gated sodium channels and can lead to dose-dependent PR interval prolongation. Previously, lacosamide has been associated with second-degree atrioventricular (AV) heart block in the context of multiple medical comorbidities and/or in the elderly with multimorbidity on other dromotropic agents. We report a case of second-degree AV block occurring in a healthy, athletic young adult. The patient had baseline bradycardia with no known cardiac comorbidities. He was exquisitely sensitive to lacosamide with EKG and telemetry changes developing on the order of hours after receiving intravenous lacosamide. Lacosamide was subsequently stopped, the second-degree AV block was no longer present and EKG returned to baseline. We hypothesize that his sensitivity to lacosamide-induced AV block was possibly secondary to his baseline bradycardia with early repolarization changes. The case underscores the importance of surveillance cardiac monitoring. While medical comorbidities and an older age may portend a greater risk of PR prolongation, routine EKGs should be considered in all patients receiving lacosamide., Highlights • This is a case of second-degree AV block with lacosamide in a healthy, young adult. • PR prolongation can be seen with lacosamide irrespective of medical comorbidities. • Surveillance cardiac monitoring should be considered in patients taking lacosamide.

Pembrolizumab is a monoclonal antibody directed towards programmed cell death protein 1 (PD-1) and is an antineoplastic drug which has a growing variety of oncologic uses. Pembrolizumab is commonly associated with immune-related adverse events (IRAEs) but is infrequently noted to cause cardiotoxicities such as myocarditis, arrhythmias, and heart failure. The following case report illustrates the clinical course of a 67-year-old female patient with stage IV non-small-cell lung cancer who developed Mobitz type 2 second-degree atrioventricular block three weeks after receiving her first infusion of pembrolizumab. Within a few hours of presentation, she progressed to symptomatic complete heart block requiring emergent placement of a temporary transvenous pacemaker. The article further discusses proposed mechanisms to explain IRAEs and management of IRAEs. We conclude by recommending a higher degree of caution and awareness among all physicians when treating patients on immunotherapy and a multidisciplinary approach when considering resumption of immune checkpoint inhibitor therapy.

Bradyarrhythmias may be due to disorders of impulse origination in the sinus node and disorders of atrioventricular conduction. These abnormalities can be asymptomatic or result in symptoms such as fatigue, lightheadedness, syncope, exertional dyspnea, or chest discomfort. In almost all cases, diagnosis can be made by obtaining a surface 12-lead electrocardiogram. If asymptomatic, bradyarrhythmias often do not require treatment except for second-degree atrioventricular block Mobitz type II, high-grade atrioventricular block, and complete heart block. If symptomatic, the importance of establishing a temporal symptom correlation with the bradycardia cannot be over-emphasized. Hemodynamically unstable patients may require treatment with medications such as atropine, dopamine, or temporary transcutaneous or transvenous cardiac pacing if available. In the long term, a permanent pacemaker is often indicated in symptomatic patients except if the etiology is considered to be reversible such as medication induced.

Objectives To analyze the timing of appearance of conduction abnormalities (CAs) after transcatheter aortic valve implantation (TAVI), to identify predictors of delayed CAs requiring pacemaker (PM) implantation and to provide guidance regarding the duration of telemetry monitoring. Background How long patients remain at risk of development of CAs requiring PM implantation after TAVI and for how long they should be monitored remains unclear but is crucial when considering early discharge. Methods Development of CAs was studied in 701 consecutive patients treated with Edwards Sapien 3 valves and monitored with telemetry for 7 days in a single center. After excluding valve-in-valve procedures and patients with previous PM, 606 patients remained for analysis. Predictors of CAs requiring PM and the time of onset of CAs were analyzed. Results Of 606 patients 76 (12.5%) required a PM after TAVI. CAs requiring PM implantation occurred after 48 h in 22.4% (17 patients) and in 10.5% (8 patients) even after 5 days. Of the patients who developed high grade CAs requiring PM after 48 h, 47.1% had no CAs prior to TAVI, and 23.5% had neither pre-existing CAs nor new-developed CAs within the first 48 h after TAVI. Conclusion After TAVI using a new-generation balloon-expandable valve, delayed development of CAs requiring PM implantation is not uncommon, even after 5 days. More importantly, 23.5% of patients eventually requiring a delayed PM implantation had still no CAs at 48 h after TAVI in this study. These results question the safety of early discharge and support ECG monitoring for a longer time period. The most optimal way to monitor these patients is yet to be determined.

Normal Holter reference intervals have not been established for dogs1 year of age. This lack of Holter reference intervals inhibits the ability to screen puppies for early indicators of heart disease, especially in breeds that have inherited cardiac arrhythmias (e.g. German Shepherd Dogs) or a high incidence of arrhythmic heart disease (e.g. Boxer dogs). The objective of this project was to establish Holter minimum, average, and maximum heart rates and incidence of arrhythmias in clinically healthy dogs1 year of age and to compare these results to previously reported Holter data for their adult counterparts. Forty-four client-owned clinically healthy puppies between 12 and 51 weeks of age were prospectively studied. Age was determined by date of birth and corroborated by dental examination. Puppies were deemed healthy based on history and physical examination. Puppies with heart murmurs underwent echocardiographic examination. Dogs with physiologic heart murmurs were included. Twenty-four hour ECG recordings were obtained using a digital Holter system. The median (interquartile range) Holter minimum, average, and maximum heart rates were 51 bpm (43-60 bpm), 99 bpm (85-113 bpm), and 274 bpm (257-291 bpm), respectively. The median for ventricular and supraventricular arrhythmias was 0. Ventricular and supraventricular premature complexes were identified in 4/44 (9%) and 6/44 (13%) puppies, respectively. Second degree atrioventricular block was identified in 2/44 puppies (5%). Overall, minimum, average, and maximum Holter heart rates of puppies are higher than adult dogs. The incidence of ventricular and supraventricular premature complexes in puppies is similar to adult dogs.

Background: Atypical antipsychotics, unlike traditional antipsychotics, are considered to have limited cardiovascular side effects, but recent evidence drew attention to potential cardiac rhythm disturbances during aripiprazole therapy. Prolonged QT-interval and increased heart rate were described during treatment with therapeutic doses of aripiprazole, and some reports have even shown relevant arrhythmias, such as ventricular trigeminy and supraventricular tachycardia, in patients treated with this drug. Case Report: Here, we report a case of a young female who attempted suicide with aripiprazole overdose presenting with a concomitant 2:1 second degree atrioventricular block. Little is known on the cardiac toxicity of atypical antipsychotics in overdose: reporting this case description, far from establishing direct causality. Results and Conclusion: We would promote further efforts to define the possible effects of the drug on the cardiac conduction system, for a safer management of patients in clinical practice.

Introduction Monitoring electrocardiogram (EKG) is an integral component of pediatric polysomnography (PSG). There is limited data regarding arrhythmia and conduction disturbances in the pediatric population undergoing a PSG. In this work we will present abnormal EKG findings during PSG in our sleep center. Methods A retrospective chart review from children at Seattle Children’s Hospital who underwent PSG read by a single Sleep Medicine physician (LD) in the last year was carried out. Data included age, sex, type of EKG abnormality, sleep diagnosis from PSG. Data from children with 1st or 2nd degree atrioventricular block (AVB) were compared to those from children with premature ventricular contractions (PVC). Results A total of 1,235 PSG were included. Twenty-four children (9 girls and 15 boys) aged 2–17 years (median 9 years) were identified with arrhythmias or conduction disturbances (1.9%). Nineteen out of 24 of these children (79.2%) had oAHI >1/hour; this frequency was not significantly different from that found in the whole group of 1,235 children (Chi-square test p=0.16). When comparing PSG parameters from children with AVB with those with PVC, we found no statistically significant difference. Seven out of nine children with AVB and seven out of ten with PVC had oAHI >1/hour (Fisher exact test p=0.56) while eight children with AVB out of nine and four out of ten with PVC were males, and this difference was the only statistically significant difference found (Fisher exact test p=0.04). None of the children were found to have a structural or conduction abnormality when referred to cardiology. Conclusion Our study found ECG abnormalities in 1.9 % of children undergoing PSG. None of the children were found to have abnormal findings after cardiology referral. Our study supports that EKG abnormalities are rare in PSGs of children and not associated with cardiac disease or sleep disorders, but appear more commonly in males. Support (if any)

Two dogs, victims of motor vehicle accidents, were hospitalised at our Veterinary Teaching Hospital with multiple injuries. Electrocardiographic abnormalities were observed in both dogs: case 1 showed ventricular arrhythmias, while case 2 manifested second degree atrioventricular block. Increased cardiac troponin-I serum levels and echocardiographic alterations compatible with left atrial wall lesions and thrombosis were detected. Based on these symptoms, the dogs were diagnosed with traumatic blunt cardiac injury. Both patients had left atrial thrombus formation, but only case 1 underwent antiplatelet therapy and experienced thromboembolic spread. Blunt cardiac injury and related consequences should be considered in traumatised patients. ECG together with cardiac troponin-I measurement and echocardiography could help clinicians to diagnose and monitor the condition.

Syncope most frequent etiopathogenic mechanism in children is Vasovagal, which is produced by decreased cerebral blood flow, and stimulation of the mechanoreceptors of the left ventricle in the context of relative central hypovolemia that causes vigorous ventricular contraction and exaggerated reflex vagal response with hypotension, bradycardia and syncope. Objetive Analyze cardiac structure and function in pediatric patients with clinical syncope. 408 cases of patients who have consulted the Pediatric Cardiology service of the Hospital de Nens de Barcelona, from March 2013 to March 2018, with syncope, between 5 to 18 years old. To establish the discard of cardiopathy or associated vascular pathology, studies were carried out such as: electrocardiography, transthoracic echocardiography, Rhythm Holter and Ergometry with moving tape (stress test). 203 masculine, 205 female patients; single test average age: 11.2 years, 95% Confidence Index (CI): 10.8 - 11.2. Heart rates (HR) showed progressive decrease, with greater fall between 0 - 7 years, both average and minimum; mean HR: 85.34 (95% CI: 84.2 - 86.494); and mean minimum HR: 49.1 (95% CI: 48.2 - 49.9). In the Pearson Correlation Analysis, negative results were evidenced for mean and minimum HR, for age: maximum HR: -0.291’; average HR: -0.586’ and minimum HR: -0.452’; and sex: maximum HR: 0.022; average HR: 0.129’ and minimum: 0.0184’. In Rhythm Holter: 79.7% of patients (n=325) had normal results; 6.1% (n=25): second-degree atrioventricular block type 1; 5.4% (n=22) supraventricular extrasystoles; 4.4% (n=18) ventricular extrasystoles; 2.5% (n=10) first degree atrioventricular block; 0.5% (n=2) sinus bradycardia; 0.5% (n=2) second degree atrioventricular block type 2; 0.4% (n=2) Wolf Parkinson’s White syndrome. All patients had normal anatomical and functional cardiac evaluations, except 1 patient (0.2%): severe systolic and diastolic dysfunction FE: 49%, second-degree auto-ventricular block type 2 II grade 2, and highly impaired ergometry: HR under maximum: 50%, syncope with any movement. Ergometry: 406 patients obtained normal results, maximum heart rates - 87.7% average of 100% calculated per patient (95% CI 87.2 - 88.3). Mets obtained - single test average: 13.7 IC (13.4 - 14.0). 2 patients with less than 80% maximum heart rate, due to dyspnea due to physical exertion, presented normal echocardiography and altered rhythm Holter with diagnoses of second degree atrioventricular block type II. Conclusions Most of the patients analyzed with rhythm Holter, echocardiography and ergometry, did not present diagnoses related to syncopal symptoms. Only 1 patient with syncope (0.2%): severe diastolic and systolic dysfunction, second-degree atrioventricular block type 2 II grade 2, and highly altered ergometry.

Atrioventricular block (AVB) is a type of heart block in which the conduction between the atria and ventricles of the heart is impaired. The purpose of the present paper is to report the occurrence of second-degree AVB in a diarrheic calf-camel. A 7-day-old female calf-camel (Camelus dromedarius) weighting approximately 50 kg was referred to the veterinary hospital with a 5-day history of diarrhea, prostration, tremors, sternal recumbency, and muscular weakness. Clinical examination revealed increases in rectal temperature (RT 39.9 °C), heart rate (HR 124 beats min−1), and respiratory rate (RR 49 breaths min−1) with hyperemic mucous membranes. Incidentally, in precise cardiac auscultation, the clinicians found out irregularities in the rhythm and recognized the random absence of S1 and S2 heart sounds. Moreover, no palpable pulse and jugular pulsation (JP) could be detected during the cardiac irregularities. Other clinical examinations showed no sign of cardiovascular insufficiency such as edema and jugular distension (JD) and no murmur was auscultated. Before the treatment, serum levels of magnesium were significantly lower than the reference values, while the concentration of potassium was significantly higher than the reference value (P 0.05). Based on the cardiovascular examination (observation, palpation, and auscultation), heart block was suspected. ECG recording confirmed the presence of sinus arrhythmia (SA) and heart block including first-degree and Mobitz type 1 (Wenkebach) second-degree. Finally, since the AVB was resolved after correction of serum electrolyte imbalance, it can be suggested that electrolyte disturbance was the main cause of Mobitz I second-degree AVB in the above described diarrheic calf-camel.

Binge drinking adolescents often present to the emergency department with an alcohol intoxication. Known clinical signs of alcohol intoxications are impaired consciousness and vomiting, occasionally complicated by pulmonary aspiration. Emergency physicians are often not aware of the fact that excessive alcohol intake can also lead to atrioventricular (AV) conduction disturbances. We present a case of a second-degree AV block in an adolescent with an acute alcohol intoxication. The etiology of this condition is not well understood; possible explanations are reviewed in this manuscript.

We discuss the nursing intervention of nonstop minimally invasive tricuspid valve forming with simultaneous atrial flutter after secondary cardiac surgery. Patient is a 50-years-old male who undergoing repair of atrial septal defect by central thoracotomy with extracorporeal circulation as atrial septal defect in the 30 years ago require repair of atrial septal defect by central thoracotomy with extracorporeal circulation again as residual shunt after repair. In patient checking report of January 2019, it indicated that in the case of no obvious inducement patients appear palpitation, palpitation, is persistent. Base on admission dynamic electrocardiogram, it indicated: (1) Persistent atrial flutter (2) second degree atrioventricular block with junctional escape (3) severe tricuspid regurgitation. In result of operation, we successfully completed the operation, and the patient had no complications after the operation. The surgical procedure was to perform electrophysiological mapping of the right atrium, establish extracorporeal circulation, surgical bipolar radiofrequency ablation, and tricuspid valve formation. Base on result of this operation, effective implementation of prospective nursing interventions can reduce the risk of surgery. In addition, in operation process, as the operation involves a large number of instruments and equipment and surgical personnel, the position of equipment and the rationality of personnel station will influence the result of operation.

Spontaneous second-degree atrioventricular block induced by exercise (Ex2AVB) is rare, but it can cause profound exercise intolerance.We sought to determine the frequency of Ex2AVB in our exercise testing practice and to describe characteristics of patients with Ex2AVB. We hypothesized that the number of patients would be small, but they would require invasive treatment.We reviewed the Mayo Clinic Integrated Stress Center database for nonimaging tests performed from 2006 through 2010. All exercise tests coded as "second-degree atrioventricular block" were captured and reviewed. Tests were excluded if results showed evidence of second-degree atrioventricular block at rest.From 40,715 tests performed, definite Ex2AVB was found in only 19 patients (0.05%; 5 women and 14 men). Ex2AVB occurred as a Mobitz type II block in 4 patients and as a Mobitz type I block in 15. In 3 patients, Ex2AVB occurred only in recovery. Ex2AVB was intermittent in 11 patients and persistent in 8. Mean peak heart rate was higher with intermittent Ex2AVB than with persistent Ex2AVB (126 ± 39 vs 88 ± 28 bpm, P .01), as was mean functional aerobic capacity (87% ± 20% vs 59% ± 14%, P .01). Seven patients with persistent Ex2AVB received a permanent pacemaker; 1 underwent pacemaker adjustment.Ex2AVB is uncommon but can cause exercise intolerance that requires pacemaker implantation. Structural or ischemic heart disease and resting conduction abnormalities are common findings in patients with Ex2AVB. Intervention is seldom required for intermittent Ex2AVB.

Fetal atrioventricular (AV) block is a rare and potentially devastating condition. Most commonly fetal AV block is mediated by maternal lupus antibodies which cause irreversible damage to the AV node. For many fetuses, the only potential intervention is premature delivery and highly invasive pacemaker implantation. However, there exists a small subset of fetuses with non-immune mediated AV block who appear to have far better outcomes, with potential for spontaneous resolution and a return to sinus rhythm. Despite this, it is not clear that prenatal counseling takes this fact into account. We describe a series of three patients with non-immune fetal second-degree AV block with spontaneous resolution prior to delivery, underscoring the need for appropriate prenatal counseling in this scenario.

Key Clinical Message Because atrioventricular block can cause cardiovascular collapse, the rapid management of this condition is necessary. An 82-year-old man complained of discomfort after tooth extraction, and electrocardiography showed second- and third-degree atrioventricular blocks. Dentists should monitor patients who report discomfort using electrocardiography because of the possibility of life-threatening arrhythmia.

Objective: To investigate the genetic basis of a Chinese familial third degree atrioventricular block. MethOds: The clinical data of all family members were collected, including physical examination, electrocardiogram and echocardiography. Exome sequencing was performed for all patients. Results: This family contains 22 members of which 6 are patients. Cardiac symptoms appeared at forty years of age, starting with second degree atrioventricular block eventually developing into third degree atrioventricular block. These 6 patients received permanent pacemaker implantation. The genetic pedigree suggested that the autosomal disorder may not be completely dominant. Compared with normal subjects, 24 different genes were detected in patients with familial atrioventricular block. Conclusion: This family is unambiguously affected by familial atrioventricular block caused by incomplete dominant inheritance of euchromosome, and another genetic mutations that may contribute to it.

Although cardiac arrhythmias are occasionally associated with dental extractions and dental anesthesia, atrioventricular block is rarely seen during dental procedures. We report a rare case of type I second-degree atrioventricular block (Wenckebach phenomenon) occurring after bilateral extraction of impacted mandibular third molars under general anesthesia in a 16-year-old Japanese girl. Under consultation with a cardiovascular physician, we carefully monitored the patient's vital signs postoperatively, including blood pressure, oxygen saturation, and electrocardiogram, using a bedside monitor. Her postoperative course was uneventful. A 12-lead electrocardiogram the following day revealed no abnormality. In this case, we hypothesize that extubation of the nasotracheal tube or oral/pharyngeal suction might have triggered a vagal reflex that caused type I second-degree atrioventricular block. Our experience indicates that standard cardiovascular monitoring should be used for patients undergoing dental treatment under general anesthesia, even for young, healthy patients, to prevent and detect cardiovascular emergencies.

In a 45-year-old woman with syncope, an electrocardiogram revealed intermittent asymptomatic type I second degree atrioventricular block, right bundle branch block and left anterior fascicular block. An echocardiogram documented concentric left ventricular hypertrophy and right ventricular dilatation and hypokinesia. Because the patient did not have second degree atrioventricular block at the time of an electrophysiological study, the atrioventricular node, the left posterior fascicle, and the His bundle all remain potential sites for the type I second degree atrioventricular block on her initial electrocardiogram.

Doppler echocardiographic examinations are an important technique for evaluating the blood flow also in avian cardiology. The influence of anesthesia on the blood flow in the heart is in detail unknown for the most avian species. The present study investigated the influence of an isoflurane anesthesia on the systolic blood flow of the aorta and the pulmonary artery in the area of the heart valves examined by pulsed wave Doppler sonography in Racing Pigeons (Columba livia f. domestica, n = 43). Measurements were taken in conscious and anaesthetized birds in the left (aorta) and right (pulmonary artery) parasternal longitudinal horizontal heart view. The results demonstrated a significant decrease in heart rate and systolic peak flow velocities as well as prolonged ejection times during anesthesia. A positive correlation of systolic peak flow velocity and heart rate could be demonstrated, especially for the pulmonary artery in conscious pigeons. The aortic systolic peak flow velocity and heart rate showed a significantly negative correlation in anaesthetized pigeons. These correlations should be borne in mind in the echocardiographic examination, especially of conscious birds. A higher incidence of second degree atrioventricular block (30.23%) was induced by anesthesia in the Racing Pigeons. These results of the present study indicate the necessity for establishing normal heart values in conscious and anaesthetized individuals.Keywords: Aorta, Birds, Blood flow velocity, Pulmonary artery, Sonography

Transcatheter closure of secondum atrial septal defect (ASD) is an alternative option to open heart surgery with good short and long-term outcomes. For this purpose, the Amplatzer septal occluder (ASO) device is widely used. Arrhythmias are known complications of ASD device closure including atrial ectopy and heart block.We report a seven-year-old female patient who developed second degree atrioventricular block (AVB) within few hours after ASD device closure using ASO device. At the seventh post-procedure day; while under close observation; patient regained sinus rhythm which was maintained thereafter. A 3-day course of prednisolone was given.

Purpose To evaluate CT utility for detection of cardiac or lung abnormalities in the diagnosis of organic cardiac disease in subjects with second- or third-degree atrioventricular block (AVB) excepting Wenckebach type. Materials and methods A total of 50 consecutive patients (25 male; 64±15years) with de novo third- or second-degree AVB underwent both TTE and a combination of cardiac and chest 320 slice CT (Aquilion one, Toshiba Medical) and were retrospectively analyzed. The presence of focal left ventricular (LV) wall thinning and thickening was evaluated on both TTE and cardiac CT. We evaluated the presence of significant coronary artery stenosis, focal late enhancement (LE) in LV myocardium, significant-sized (>10mm) lymph nodes in hialus or mediastinum and/or typical lung nodules for sarcoidosis on CT. Results Abnormalities for 26%, 30%, and 36% of patients were demonstrated on TTE, cardiac CT, and a combination of cardiac and chest CT, respectively. 12% and 18% patients who did not exhibit cardiac abnormalities on TTE, revealed abnormalities on cardiac CT, or a combination of cardiac and chest CT, respectively. 36% patients had organic cardiac diseases. Sensitivities for detection of organic cardiac disease were significantly greater when cardiac and chest CT were combined than TTE alone ( P Conclusions Approximately one third of patients with third- or second-degree AVB had organic cardiac diseases. For detection of cardiac and chest abnormality and correct diagnosis of organic cardiac disease in patients with third- or second-degree AVB, TTE is not sufficient on its own. CT or a combination of TTE and CT are required.

Aims The aim of the study was to evaluate the procedural and 30-day results for the repositionable Lotus valve in patients undergoing transfemoral aortic valve implantation in a single-centre experience. Methods and results We prospectively enrolled 110 patients with severe symptomatic aortic stenosis (NCT02162069). All procedures were performed without general anaesthesia by the transfemoral approach. Patients were followed for 30 days. Patients received the 23 mm (n=20), 25 mm (n=43) or 27 mm (n=47) Lotus device. Mean oversizing in relation to annulus or left ventricular outflow tract (LVOT) did not differ among groups. There was no residual moderate or severe aortic regurgitation. The rate of mild aortic regurgitation was low at 9.1%. There was no valve embolisation, no need for a second valve and no conversion to surgery. The need for a new pacemaker implantation due to complete (third degree) or type II (Mobitz) second degree atrioventricular block was 24.1%, excluding patients with previously implanted devices. Within 30 days the rates of all-cause mortality and stroke were low. Conclusions In patients with severe aortic stenosis, transfemoral TAVI with the repositionable Lotus valve was associated with a high rate of device success, no moderate or severe residual aortic regurgitation, low rates of major vascular complications and mortality within 30 days.