P309Aortic valve implantation-induced bundle branch block as a framework towards a more uniform electrocardiographic definition of left bundle branch block

INTRODUCTION

The electrocardiographic (ECG) pattern of true left bundle branch block (LBBB) has not been fully clarified and various definitions of LBBB exist. New-onset LBBB after transcatheter (TAVR) or surgical (SAVR) aortic valve replacement implies a proximal pathogenesis of LBBB and thus may provide a reference to characterize and define true LBBB.

PURPOSE

This study compares ECG characteristics in aortic valve implantation-induced LBBB (AVI-LBBB) to a non-procedural-induced LBBB control group (co-LBBB) in order to set a more homogenous definition for true LBBB.

METHODS

The study enrolled all patients with new-onset TAVR- and SAVR-induced LBBB between 2013 and 2019. AVI-LBBB was defined as new-onset persistent LBBB occurring within 24h after TAVR or SAVR. Patients were matched for age, sex, ischemic heart disease and left ventricular systolic function to randomly selected co-LBBB patients in a 1:2 ratio. For inclusion in both groups, a non-strict LBBB definition was used (QRSD ≥120ms, QS or rS in lead V1, absence of Q wave in leads V5-6). ECG characteristics were digitally analysed by the MUSE algorithm and confirmed by two experts. All ECG recordings were classified according to 4 different LBBB definitions: MADIT, European Society of Cardiology (ESC), Strauss and American Heart Association (AHA).

RESULTS

59 patients with AVI-LBBB (34 TAVR, 25 SAVR, median age 82 years, 42% male) were compared to 118 matched co-LBBB patients.

All patients with AVI-LBBB presented with QRS notching/slurring in the lateral leads, whereas this was present in only 85% of the co-LBBB group (p = 0.001). QRS duration (148ms vs 145ms, p = 0.074) and R wave peak time (58ms vs 62ms, p = 0.065) were not significantly different among both groups. AVI-LBBB was characterized by a more rightward QRS axis (-15° vs -30°, p = 0.013). When comparing AVI-LBBB to LBBB controls with QRS notching/slurring, a comparable QRS axis was observed.

Almost all AVI-LBBB patients met the MADIT (98%), ESC (100%) and Strauss (95%) definition. Only 18% of patients met the AHA definition, because of the low combined presence of QRS notching/slurring in all 4 lateral leads (54%) and because only 27% of patients had an R wave peak time >60ms in both leads V5-6.

In the co-LBBB group, adherence to the different definitions was significantly lower compared to the AVI-LBBB group: MADIT 86% (p = 0.007), ESC 85% (p = 0.001), Strauss 68% (p < 0.001) and AHA 7% (p = 0.035). Lower presence of lateral notching/slurring and more patients with smaller QRS duration (QRS duration ≥130ms, 86% vs 98%, p = 0.007) in the co-LBBB group explain these results.

CONCLUSIONS

Discordance exists between various definitions in scoring AVI-LBBB. Our data show that presence of QRS notching/slurring in the lateral leads is a crucial feature of proximal LBBB, rather than QRS duration and R wave peak time. The AVI-LBBB population provides a framework towards a more uniform definition and criteria for assessing true, proximal LBBB.

6119Correction of transcatheter aortic valve replacement induced left bundle branch block by His bundle pacing

Background

Left bundle branch block (LBBB) occurs frequently after transcatheter aortic valve replacement (TAVR) and is associated with increased risk of permanent pacemaker implantation, heart failure hospitalization and sudden cardiac death. This pilot study explored the feasibility of TAVR-induced LBBB correction with His bundle pacing (HBP).

Methods

Patients with TAVR -induced LBBB and postoperative need for permanent pacemaker implant were planned for electrophysiology study and HBP. Patients with persistent high degree AV-block were excluded. HBP was performed using the Select Secure pacing lead, delivered through a fixed curve or a deflectable sheath. Successful HBP was defined as correction of LBBB by selective or non-selective HBP with LBBB correction thresholds less than 3.5V at 1.0ms at implant.

Results

The study enrolled 6 patients (mean age 85±2.5 years, 50% male). Mean QRS duration was 152±10ms, PR-interval 212±12ms AH-interval 166±16ms and HV-interval 62±12ms. Successful HBP was achieved in 5/6 (83%) patients. Mean QRS duration decreased from 153±11ms to 88±14ms (p=0.002). At implantation, mean threshold for LBBB correction was 1.6±1.0V (unipolar) and 2.2±1.3V (bipolar) at 1.0ms. Periprocedural, two complete AV-blocks occurred, both spontaneously resolved by the end of the procedure. Thresholds remained stable at 1 month follow up: 1.8±1.0V (unipolar) and 2.3±1.5V (bipolar) at 1.0ms.

Figure 1

Conclusion

Permanent His bundle pacing can safely correct TAVR-induced LBBB in the majority of patients. Further studies are needed to assess potential benefits of His bundle pacing over conventional right ventricular pacing in this population.

P576The first handheld device for autonomic self-detection of symptomatic acute coronary artery occlusion: feasibility, performance and implications for time-efficient self-triage of outpatients with CAD

Background

Time delay between onset of symptoms and seeking medical attention is a major determinant of mortality and morbidity in patients with acute coronary artery occlusion (ACAO). Response time might be reduced by reliable self-detection of ACAO. Currently no self-applicable device can accurately detect ACAO. We have recently shown that an automatic algorithm based upon a three lead system (RELF method) accurately detects ACAO.

Purpose

In this multicenter observational study we tested the operational feasibility, sensitivity and specificity of our RELF method, built into a mobile handheld device, for detection of ACAO.

Methods

Patients with planned elective percutaneous coronary intervention (PCI), who were able to use a smartphone, were asked to perform random ambulatory self-recordings for at least one week. A similar self-recording was made before angioplasty and at 60 s of balloon occlusion.

Results

The operational feasibility of ambulatory self-recordings in enrolled patients with CAD was 59/64 (92.1%, 95% CI: 83.0–96.6). Of all self-recordings 91.1% (n=4567) were automatically classified as successful within one minute. The mean false positive rate during daily life conditions was 4.19% (95% CI: 3.29–5.10). Amongst 65 balloon occlusions, 63 index-tests at 60 s of occlusion were available. The sensitivity for the target conditions “ACAO”, “ACAO with ECG changes” and “ACAO with ECG changes and ST segment elevation myocardial infarction (STEMI) criteria” was respectively 55/63 (0.87; 95% CI: 0.77–0.93), 54/57 (0.95; 95% CI: 0.86–0.98) and 35/35 (1.00). The figure depicts all (n=3936) ST difference vector (STDVn) measurements obtained during ambulatory postural changes, exercise and coronary artery occlusion with and without ECG changes and/or STEMI criteria. Receiver Operator Curve (ROC) for ACAO at different cut-off values of the magnitude of STDVn was 0.973 (95% CI: 0.956–0.990).

Boxplots of all STDVn test recordings

Conclusions

Self-recording with our RELF device is feasible for the majority of patients with CAD. The sensitivity and specificity for automatic detection of the earliest phase of acute coronary artery occlusion support the concept of our RELF device for patient empowerment to reduce delay and increase survival without overloading emergency services. This is the first clinical study that confirms the proof-of-concept of self-detection of acute coronary artery occlusion in outpatients with CAD.

Acknowledgement/Funding

Ghent University, Industrial Research Fund (IOF reference: F2015/IOF-advanced/084).

[Common fungal infections of the foot]

Among the dermatological diseases affecting the foot, fungal infections are frequent in a daily practice. Treatments now available allow us to control most of them. However, multiple different clinical manifestations and the variety of fungal agents may lead to inappropriate diagnosis and treatments. The paper will consider cutaneous and nail manifestations of common fungal foot infections, their differential diagnosis and their local and systemic treatments.

Nail destruction in pemphigus vulgaris

Involvement of the nails in pemphigus vulgaris (PV) is rare and is usually seen when the disease is severe. The most common clinical manifestations are chronic paronychia and onychomadesis. Finger nails are more frequently involved than toe nails. We report a case of severe and persistent PV in which an exacerbation was preceded by an erosive and destructive lesion of the right hallux nail unit. A nail bed biopsy was performed to rule out a subungual tumour. The image of suprabasal acantholysis yielded the diagnosis of PV. This localisation and clinical manifestation of PV have only been reported once.

Fibrinogen and C-reactive protein on admission as markers of final infarct size after primary angioplasty for acute myocardial infarction

BACKGROUND

In acute myocardial infarction (AMI) treated conservatively or with thrombolysis, marked increases of C-reactive protein (CRP) and fibrinogen have been observed. No data are however available concerning a possible relation between CRP and fibrinogen levels on admission and markers of infarct size after obtaining thrombolysis in myocardial infarction (TIMI) flow III by primary angioplasty.

METHODS

We studied 34 patients with a first AMI (29 men, mean age 54+/-11 years) who were treated with primary angioplasty (TIMI flow III in all patients, no concomitant treatment with glycoprotein IIb-IIIa antagonists) within 6 h of onset of pain. CRP and fibrinogen levels on admission were determined and related to the following markers of infarct size: peak creatine kinase MB (CKMB) levels, radionuclide left ventricular ejection fraction (LVEF) at discharge and thallium-201 single-photon emission computed tomography (SPECT) infarct size at 1 month.

RESULTS

Median CRP levels were 0.4 mg/dl (range 0.09-3 mg/dl), median fibrinogen levels 412 mg/dl (range 198-679 mg/dl), mean CKMB was 178+/-151 U/l, mean LVEF 52+/-8% and mean thallium-201 infarct size 7+/-6%. Although CRP levels were related to fibrinogen levels on admission (r=0.56, P=0.002), only fibrinogen levels were related to markers of infarct size (r=0.58, P=0.001 for CKMB, r=-0.44, P=0.01 for LVEF and r=0.64, P=0.001 for thallium-201 infarct size). No relation was found between CRP or fibrinogen levels on admission and the extent of coronary artery disease or the myocardial area at risk. In multiple regression analysis, the relation between fibrinogen and markers of infarct size was independent of CRP levels and the duration of pain on admission.

CONCLUSIONS

These findings indicate a relation between fibrinogen levels on admission and myocardial infarct size in patients treated with primary angioplasty for AMI. This relation seems to be independent of CRP levels and the duration of pain on admission. If confirmed in larger patient populations, fibrinogen levels on admission could have an important value for risk stratification and more aggressive reduction of infarct size in patients who are treated with primary angioplasty.

An unusual case of squamous cell carcinoma of the nose

A 49-year-old man presented with a tumoral lesion of the tip of the nose which had been manifest for 2 months. Within a few weeks, the tumour increased in size and became infiltrated. The biopsy showed a squamous cell carcinoma. Treatment consisted of a radical surgical excision.

Reverse redistribution on thallium-201 single-photon emission tomography after primary angioplasty: a one-year follow-up study

The prognostic significance of reverse redistribution (RR) on thallium-201 single-photon emission tomography (SPET) images after acute myocardial infarction (AMI) has not been studied in detail. Moreover, RR data in patients treated with primary angioplasty are lacking. Fifty consecutive patients (including 40 men with a mean age of 54+/-11 years) with a first AMI were treated with primary angioplasty and followed up for 13+/-5 months for the following end-points: death, reinfarction and recurrent angina requiring revascularisation. Admission and peak creatine kinase myocardial enzyme (CKMB) and ejection fraction (EF) at discharge were studied as markers of myocardial damage. Thallium-201 stress-redistribution SPET studies at 1 month were analysed using a 13-segment, 4-point scoring system. Segments showing a worsening of perfusion by at least 1 point on redistribution studies were defined as showing RR. RR was present in 13 (26%) patients (group 1) and absent in 37 (74%) (group 2). Both groups were comparable for age, sex, peak CKMB release, EF and Q-wave myocardial infarctions. TIMI flow 3 was obtained in 92% in group 1 and 95% in group 2 (P = 0.95). On admission, CKMB was significantly lower in group 1 (18+/-14 vs 44+/-41 U/l, P = 0.03). Also, segments showing reversible perfusion were significantly more frequent in group 2 (1/169 vs 57/481, P = 0. 01). During follow-up, no death occurred and the combined documented endpoint of reinfarction and recurrent angina requiring angioplasty or coronary artery bypass grafting was significantly more frequently reached in group 2 (0/13 vs 10/37, P = 0.046). In conclusion, RR is common (26%) after primary angioplasty for a first AMI and is associated with lesser myocardial damage on admission. Patients with RR rarely have reversible segments on 201Tl SPET and tend to have a favourable outcome after 1 year of follow-up.

The Selvester 32-point QRS score for evaluation of myocardial infarct size after primary coronary angioplasty

In patients treated successfully with primary angioplasty for a first myocardial infarction, the Selvester 32-point score correlates well with infarct size measured with quantitative thallium-201 perfusion imaging. Therefore, it is a useful parameter for infarct sizing, particularly in patients with anterior infarction or reduced ejection fraction at discharge.

[Local treatment of leg ulcers]

Local treatments of leg ulcers require necrotic tissues destruction and preventing and reducing surinfection with local antiseptics. Local and general antibiotherapy are proposed in defined circumstances. Choice of local dressings are dependent on necrosis, degree of exustion, global cost and compliance of the patient.

[Clinical aspects of leg ulcers]

Clinical aspects of leg ulcers are reviewed. Among the most important factors to be kept in mind are: localisation, features of the ulcers and surrounding skin, clinical history and general physical examination. Leg ulcers are most frequently caused by vascular diseases.

Embolic stroke after unanticoagulated cardioversion despite prior exclusion of atrial thrombi by transoesophageal echocardiography

Recent studies in patients with atrial fibrillation, not on anticoagulation, suggest that if transoesophageal echocardiography (TEE) excludes the presence of thrombi, early cardioversion can be performed safely without the need for anticoagulation before the procedure. Immediately after successful cardioversion, however, left atrium or left atrial appendage stunning may be present, potentially carrying a risk for de novo thrombus formation. Furthermore, the presence of spontaneous contrast is considered as a contraindication for unanticoagulated cardioversion since it has been associated with postcardioversion thromboembolism. We present a case in which stroke developed in relation to unanticoagulated cardioversion regardless of careful prior evaluation with TEE.

Acute hemorrhage from a pyelocaliceal diverticulum of a native kidney in a renal transplant patient

A 28-year-old renal transplant patient developed a shock due to an acute bleeding from his right native kidney. An urgent nephrectomy was performed. Macroscopic and histological examination revealed a pyelocaliceal diverticulum as the cause of the hemorrhage. This rare event must be taken into account in every case of an unexplained acute renal bleeding.

Florid cutaneous papillomatosis, malignant acanthosis nigricans, and pulmonary squamous cell carcinoma

A 72-year-old man had florid cutaneous papillomatosis (FCP), which is an obligatory paraneoplastic syndrome always associated with an internal malignancy. The cancer, which is usually intraabdominal and most often gastric in origin, evolves parallel to the FCP. This patient is the first case of FCP occurring in association with a lung malignancy. An association of FCP with other signs of internal cancer is common, with malignant acanthosis nigricans usually appearing many times with the sign of Leser-Trélat. FCP, malignant acanthosis nigricans, and the sign of Leser-Trélat are part of a continuum, developing by a common or similar pathogenic pathway due to an underlying malignancy producing a factor possibly similar to human epidermal growth factor.

Plasma and erythrocyte lipids in two families with heterozygous hypobetalipoproteinemia

Erythrocyte morphology, kinematic viscosity, and membrane lipid composition have not been well documented in heterozygous hypobetalipoproteinemia (HBL). In our study of nine subjects with HBL from two kindreds, three presented with schistocytes (3-6%) while two of them also showed acanthocytosis (25-35%) on their peripheral blood films. The other affected family members had a normal RBC morphology despite a decreased kinematic viscosity of RBC suspension at 37 degrees C (log eta = 0.20 +/- 0.02 vs. log eta = 0.26 +/- 0.02) in all nine subjects; erythrocyte osmotic fragility however was normal. Although some subjects showed acanthocytosis total cholesterol (0.63 +/- 0.05 mol x 10(-6)/mg membrane protein) and sphingomyelin/lecithin ratio (0.905 +/- 0.042) of RBC membranes were normal while plasma from the subject with schistocytosis had a significantly decreased sphingomyelin/lecithin ratio in plasma (17.2 +/- 2.4 vs. 29.1 +/- 3.3) suggesting that sphingomyelin and lecithin are not freely exchangeable between plasma and the outer surface of RBC membranes.

Creatine determinations as an early marker for the diagnosis of acute myocardial infarction

In the acute phase of acute myocardial infarction (3-8 h after onset of symptoms) an early transient increase in the creatine concentration of serum, saliva, and especially of urine can be observed. Due to the renal threshold, urine values give a much better discrimination between infarction patients and controls than do serum determination. In some patients secondary peaks of serum and urine creatine concentrations can be seen about 24-36 h after hospital admission. Intramuscular injections of 5.0 mL of a saline solution and muscular trauma interfere with the test, but with angina pectoris interference is absent or limited. Creatine leakage from myocardium is insufficient to explain the observed creatinuria in infarctions, and intact extra-cardiac tissues are believed to be involved in creatine release.