COVID-19 presenting as complete heart block:A case report

Rationale:COVID-19 has a wide range of clinical presentations requiring a high index of suspicion for diagnosing patients presenting with extrapulmonary manifestations.Among them,patients with cardiovascular involvement have a high mortality.Patient’s concerns:A 50-year-old male patient with COVID-19 infection presented with multiple syncopal episodes,myalgia,and mild respiratory symptoms.Diagnosis:Mild COVID-19 infection with complete heart block.Interventions:Temporary pacing followed by permanent pacemaker insertion 10 days after the onset.Outcomes:The patient was managed as per COVID-19 protocol in an isolation ward,and his condition improved but remained pacemaker dependent until a repeat RT-PCR for COVID-19 tested negative,after which he was shifted back to the cardiac care unit for permanent pacemaker insertion.The patient was discharged after inflammatory markers were normal and clinical condition was completely stable.Lessons:COVID-19 has a wide range of clinical presentations,and extrapulmonary manifestations,especially,cardiovascular involvement can not be ignored.

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

BACKGROUND Congenital complete heart block(CCHB)with normal cardiac structure and negativity for anti-Ro/La antibody is rare.Additionally,CCHB is much less frequently diagnosed in adults,and its natural history in adults is less well known.CASE SUMMARY A 23-year-old woman was admitted to our hospital for frequent syncopal episodes.She had bradycardia at the age of 1 year but had never had impaired exercise capacity or a syncopal episode before admission.The possible diagnosis of acquired complete atrioventricular block was carefully ruled out,and then the diagnosis of CCHB was made.According to existing guidelines,permanent pacemaker implantation was recommended,but the patient declined.With regular follow-up for 28 years,the patient had an unusually good outcome without any invasive intervention or medicine.She had an uneventful pregnancy and led a normally active life without any symptoms of low cardiac output or syncopal recurrence.CONCLUSION This case implies that CCHB in adulthood may have good clinical outcomes and does not always require permanent pacemaker implantation.

Cope's sign and complete heart block secondary to acute cholecystitis: A case report

Rationale: Cope's sign is reflex bradycardia seen in the patient presenting with symptoms of acute cholecystitis. This bradycardia may be due to vagally mediated cardio-biliary reflex. Many of these reflexes due to acute cholecystitis have similar clinical features (some electrocardiographic changes like bradycardia, complete heart block, and asystole) mimicking that of acute coronary syndrome. Patient's concern: A 60-year old male presented with symptoms of acute cholecystitis and referred to the emergency department with complete heart block and abdominal pain with hypotension requiring an emergency temporary pacemaker. Diagnosis: Cope's sign and complete heart block. Intervention: Emergency temporary cardiac pacemaker insertion. Outcomes: The patient was discharged after three days with regular follow-up and advice for laparoscopic cholecystectomy. Lessons: Complete heart block or any symptomatic bradycardia associated with abdominal pain should be under consideration of cholecystitis that may be associated with either presence or absence of gall stones due to cardio biliary reflex.

Acquired Complete Heart Block with Long QT Interval and Recurrent Polymorphic Ventricular Tachycardia: A Case Report

We are reporting a case of acquired complete heart block and long QT interval (a dispersion of repolarization that leads to polymorphic ventricular tachycardia) that has presented with loss of conscious and proved to be due to torsade de pointes. The patient responded well to cardiac pacing and beta blocker therapy. The association of complete acquired heart block and long QT interval is quite rare.

Unruptured Right Sinus of Valsalva Aneurysm Dissecting into Interventricular Septum Causing Complete Heart Block: Can Early Surgical Correction Revert Rhythm Disturbances?

A sinus of Valsalva aneurysm (SOVA) is abnormal dilatation of the either aortic sinuses, area of the aortic root between the aortic valve annulus and the sinotubular junction. Their clinical presentation may range from being asymptomatic as an incidental finding on cardiac imaging to symptomatic presentations related to the compression of adjoining structures or intracardiac shunting caused by rupture of the SOVA mostly into the right side of the heart. The compression leads to findings of tricuspid valve regurgitation, right ventricular outflow tract (RVOT) obstruction and rarely complete heart block (CHB). Dissection or erosion into interventricular septum is one of the rarest complications of SOVA. The symptomatic presentation is almost always a surgical emergency. Here we present a case report of a patient with unruptured sinus of valsalva originating from right sinus dissecting into interventricular septum causing complete heart bock. In this case after surgical correction the complete heart block reverted to sinus rhythm.

Do Patients with Asymptomatic Congenital Complete Heart Block Require a Pacemaker for Non-Cardiac Surgery?

The appropriate preparation of the patient with asymptomatic congenital complete heart block (CCHB) and a narrow QRS complex for elective non-cardiac surgery is controversial. Prophylactic temporary pacemaker insertion is associated with well-defined risks, and less invasive techniques exist to treat transient, hemodynamically significant intraoperative brady-arrhythmias. The present case report details the performance of general anesthesia for arthroscopic knee surgery in an adult patient with this condition without a pacemaker. Documentation of preoperative chronotropic competence with isoproterenol may be of value in deciding whether to proceed without temporary pacing capability in this setting.

Autoimmune-associated Congenital Heart Block： A New Insight in Fetal Life

Objective： Congenital heart block （CHB） is a rare but life-threatening disorder. More than half of CHB cases are associated with maternal autoimmune, which are termed as autoimmune-associated CHB. This review summarized the recent research findings in understanding autoimmune-associated CHB, discussed the current diagnostic approaches and management strategies, and summarized the problems and future directions for this disorder. Data Sources： We retrieved the articles published in English from the PubMed database up to January 2017, using the keywords including＂Autoimmune-associated＂, ＂Autoimmune-mediated＂, and ＂Congenital heart block＂. Study Selection： Articles about autoimmune-associated CHB were obtained and reviewed. Results： Observational studies consistently reported that transplacental maternal antibodies might recognize fetal or neonatal antigens in various tissues and result in immunological damages, but the molecular mechanisms underlying CHB pathogenesis still need illuminated. Multiple factors were involved in the process of atrioventricular block development and progression. While several susceptibility genes had been successfully defined, how these genes and their protein interact and impact each other remains to be explored. With currently available diagnostic tools, fetal ultrasound cardiography, and fetal magnetocardiography, most of CHB could be successfully diagnosed and comprehensively evaluated prenatally. The efficacy of current approaches for preventing the progression and recurrence of CHB and other autoimmune-mediated damages was still controversial. Conclusions： This review highlighted the relationships between autoimmune injuries and CHB and strengthened the importance of perinatal management and therapy for autoimmune-associated CHB.

Cardiac resynchronization therapy for heart failure induced by left bundle branch block after transcatheter closure of ventricular septal defect

有先天的心疾病的一个 54 岁的女病人让一个坚持的完全的左捆分支由 Amplatzer 室的氏族的缺点 occluder 在闭合以后堵住三个月。九个月以后，病人受不了胸悲痛，心跳，并且在每日的活动，和她的 6-min 散步距离出汗显著地减少了(155 &#x000a0； m ) 。她显示出的 echocardiography 与 37% 的左室的喷射部分增加了左室的结束心脏舒张的直径。她一个星期在收到的心脏的再同步治疗以后显著地减少的症状。她没在每日的活动有症状，并且她的回响显示出 46% 和 53% 的左室的喷射部分。而且，左室的结束心脏舒张的直径减少了在心脏的再同步治疗以后的 6 和 10 个月，和 6-min 散步距离显著地增加了。在有室的氏族的缺点 Amplatzer occluder 的 transcatheter 闭合能在左室的收缩功能导致左室的增大和重要减少以后，这个盒子表明了那坚持的完全的左捆分支块九个月。心脏的再同步治疗减少了左室的结束心脏舒张的直径和增加的左室的喷射部分，从而改进病人的心工作。

Different Effects of Right and Left Stellate Ganglion Block on Systolic Blood Pressure and Heart Rate

Purpose: Whether or not right and left stellate ganglion blocks (SGB) affect blood pressure (BP) and heart rate (HR) differently has been controversial. The aim of this study was to analyze BP and HR changes after large numbers of right or left SGBs. Methods: A total of 16,404 right SGBs and 13,766 left SGBs were performed with 6 ml of 1% mepivacaine using the anterior paratracheal approach at C6. Changes in systolic BP and HR 30 min after SGBs were compared to the baseline values. Results: Systolic BP decreased by 25 to 49 mmHg in 10.93% and more than 50 mmHg in 0.67% of 16,404 right SGBs. Those percentages were significantly higher than corresponding percentages;8.43% and 0.49% of 13,766 left SGBs (P < 0.0001 and P < 0.05, respectively). On the other hand, systolic BP increased by 25-49 mmHg in 5.74% and more than 50 mmHg in 0.52% of left SGBs, and in 4.15% and 0.18% of right SGBs (P < 0.0001and P < 0.0001 between left and right SGBs, respectively). Right SGB caused marked reduction in HR (greater than 30 beats/min), more than left SGB (4.22% versus 2.70%, P Conclusions: Both right and left SGBs could produce clinically significant hypertension and hypotension, and also severe bradycardia. However, right SGB produces a higher incidence of significant reductions in systolic BP and HR, compared to left SGB. On the other hand, left SGB produces a significant increase in systolic BP compared to right SGB. Those differences likely stem from the hemispheric asymmetry in autonomic cardiovascular control.

An index for evaluating distance of a healthy heart from Sino-Atrial blocking arrhythmia

In this paper, an index for evaluating Distance of a healthy heart from Sino-Atrial Blocking Arrhythmia (SABA) is presented. After definition of the main pacemakers' model of heart, Sino-Atrial (SA) and Atrio-Ventricular nodes (AV), the boundary of synchronization, which demonstrates the boundary of blocking arrhythmia, is obtained using perturbation method. In order to estimate of healthy heart characteristics, a parameter estimator is introduced. The distance from SABA is calculated using Lagrange method and Kohn-Tucker conditions. In addition, the maximum admissible decrease in the coupling intensity and the maximum admissible increase in the discrepancy between the natural frequencies of two pacemakers are determined in order to maintain the synchronization between the two pacemakers.

超声引导下RISS平面阻滞对胸腹部手术患者血清Cor、SP、PGE2、IL-6的影响

目的 探究超声引导下菱形肌-肋间肌-低位前锯肌(RISS)平面阻滞对胸腹部手术患者血清Cor、SP、PGE2、IL-6的影响。方法 选取2021年1月至2022年7月入住秦皇岛市第一医院接受胸腹部手术的患者126例,按照随机掷硬币法分为观察组和对照组,各63例,两组进行常规麻醉诱导,气管插管后观察组行超声引导下RISS平面阻滞,对照组不行神经阻滞。比较两组术后疼痛视觉模拟(VAS)评分及镇静Ramsay评分、手术麻醉药物用量、围术期血流动力学指标(收缩压、舒张压、心率)及炎症应激指标[皮质醇(Cor)、P物质(SP)、前列腺素E2(PGE2)、白细胞介素-6(IL-6)]水平、不良反应发生情况。结果 手术结束后2 h、12 h、24 h,观察组VAS评分和Ramsay评分均显著低于对照组,差异均有统计学意义(P<0.05);术中及术后24 h,观察组舒芬太尼使用量显著低于对照组,差异有统计学意义(P<0.05);插管后两组收缩压、舒张压和心率均低于插管前,差异有统计学意义(P<0.05),插管后10 min和停药后10 min,观察组收缩压、舒张压心率显著低于对照组,差异有统计学意义(P<0.05);术后两组外周血中Cor、SP、PGE2、IL-6水平均低于术前,差异有统计学意义(P<0.05);术后12 h、24 h,观察组Cor、SP、PGE2、IL-6水平均低于对照组,差异有统计学意义(P<0.05);观察组麻醉不良反应总发生率低于对照组,差异有统计学意义(P<0.05)。结论 超声引导下RISS平面阻滞具有良好镇痛镇静效果,能减轻胸腹部手术患者应激及炎症反应,安全性较高,值得临床应用推广。

胎儿超声心动图诊断自身抗体相关的先天性心脏传导阻滞的研究进展

自身抗体相关的先天性心脏传导阻滞与母体抗干燥综合征抗原A、抗干燥综合征抗原B抗体阳性均相关,该病病情进展迅速,严重的房室传导阻滞患儿死亡率较高,大多患儿需植入永久起搏器,早期准确诊断对改善患儿预后具有重要的临床意义。本文就自身抗体对心脏的影响、自身抗体相关的先天性心脏传导阻滞发病特点和胎儿超声心动图诊断的研究进展进行综述。

改良腰椎竖脊肌平面阻滞对剖宫产产妇术后镇痛及血流动力学、应激反应影响

目的探讨改良腰椎竖脊肌平面阻滞对剖宫产产妇术后镇痛及血流动力学、应激反应影响。方法选取2019年3月—2022年1月行剖宫产产妇100例,采用随机数字表法随机将其分为研究组和对照组2组各50例。研究组术后采用改良腰椎竖脊肌平面阻滞,对照组术后采用腹横肌平面阻滞。比较2组一般指标,手术前后血流动力学、应激反应指标和镇痛效果,以及术后3 d内不良反应发生情况。结果研究组术中镇痛泵按压次数、舒芬太尼用量和镇痛补救率少于或低于对照组(P<0.05)。术后6、12、24 h,对照组心率和平均动脉压(MAP)与术前比较明显升高,研究组心率和MAP与术前比较无明显变化且明显低于对照组(P<0.05);术后12、24、48 h,研究组和对照组去甲肾上腺素和皮质醇明显高于术前,且研究组低于对照组(P<0.05)。术后6、12、24、48 h,2组视觉模拟评分法评分低于术前,且研究组低于对照组(P<0.05)。术后3 d内,研究组不良反应发生率低于对照组(P<0.05)。结论与腹横肌平面阻滞比较,剖宫产产妇术后采用改良腰椎竖脊肌平面阻滞可促使血流动力学稳定,减少应激反应,且镇痛效果好,具有较高安全性。

高胸段硬膜外交感神经阻滞对慢性心力衰竭大鼠冠状动脉微循环的影响

目的评估高胸段硬膜外交感神经阻滞(HTSB)治疗对慢性心力衰竭(CHF)大鼠冠状动脉微循环的影响。方法2023年6~9月在宁德师范学院将30只雄性Wistar大鼠根据随机数字表法随机分为对照组、CHF组和HTSB组每组10只。通过皮下注射异丙肾上腺素(ISO)来建立CHF大鼠模型。通过硬膜外导管注射0.2%罗哌卡因进行HTSB治疗。测定冠状动脉血流速度储备(CFVR)、射血分数(EF)、缩短分数(FS)、舒张末期左心室内径(LVDd)和收缩末左心室内径(LVDs)。采用相应试剂盒检测血清一氧化氮(NO)、肌酸激酶(CK)、丙二醛(MDA)、超氧化物歧化酶(SOD)、N末端B型利钠肽原(NT-proBNP)、肿瘤坏死因子-α(TNF‐α)、白介素-6(IL-6)水平。蛋白免疫印迹分析相关蛋白表达。结果与对照组相比,CHF组大鼠CFVR、EF和FS显著降低[(3.27±0.61)比(2.51±0.65),(78.35±0.25)%比(53.58±6.75)%,(38.22±4.69)%比(24.37±3.18)%,P<0.05];与CHF组相比,HTSB组大鼠CFVR、LVDd和显著升高(P<0.05)。与对照组相比,CHF组大鼠血清CK、cTnI、NT-proBNP、TNF-α、IL-6和MDA水平均显著升高,而NO、SOD水平显著降低(P<0.05);与CHF组相比,HTSB组大鼠血清CK、cTnI、NT-proBNP、TNF-α、IL-6和MDA水平均显著降低,而NO、SOD水平显著升高(P<0.05)。与对照组相比,HTSB组大鼠心肌组织诱导型一氧化氮合酶(iNOS)、细胞间黏附分子-1(ICAM-1)和P-选择素(P-Selectin)表达均显著升高,而内皮型一氧化氮合酶(eNOS)表达显著降低(P<0.05);与CHF组相比,HTSB组大鼠iNOS、ICAM-1和P-Selectin表达均显著降低,而eNOS表达显著升高(P<0.05)。结论HSTB治疗能够改善CHF大鼠冠状动脉微循环功能障碍,这可能是通过抑制炎症反应和氧化应激进而减轻内皮功能障碍来实现。

左束支区域起搏应用于合并左束支阻滞心力衰竭患者的研究进展

生理性起搏如希氏束起搏和左束支区域起搏能明显改善心脏电机械收缩同步性,而左束支区域起搏相较于希氏束起搏植入成功率高,起搏阈值低而稳定,且并发症发生率较低。左束支区域起搏用于合并左束支阻滞的慢性心力衰竭患者的可行性、安全性和有效性已得到初步证实,逐渐成为研究的热点。现就左束支区域起搏在合并左束支阻滞的心力衰竭患者中的相关研究及进展做一综述。

胸横肌平面阻滞对体外循环下心脏瓣膜置换术的应用研究

目的观察胸横肌平面阻滞(TTP)对体外循环(CPB)下心脏瓣膜置换术的应用效果。方法本研究为前瞻性研究,选择的研究对象为2021年6月~2023年9月期间至郑州市第七人民医院接受CPB心脏瓣膜置换术治疗的98例患者,以计算机随机分组法将其分为常规组(49例)和TTP组(49例),常规组实施常规全身麻醉,TTP组采用TTP辅助麻醉,比较两组患者围手术期基础体征,术前术后应激指标变化情况,术后6h、12h等时间点下静息或咳嗽时的疼痛情况,及术后并发症发生情况。结果TTP组切皮时(T1)的心率(HR)、平均动脉压(MAP)均低于常规组;锯胸骨时(T2)的HR、MAP、血管紧张素Ⅱ(AngⅡ)、β-内啡肽(β-EP),术后6h、12h静息时的视觉模拟疼痛量表(VAS)评分、咳嗽时的VAS评分均低于常规组,差异均具有统计学意义(P<0.05)。试验组的术后并发症发生率略高于常规组,差异无统计学意义(P>0.05)。结论TTP联合全身麻醉能稳定CBP下心脏瓣膜置换术患者的基础体征,并减轻应激损伤,对缓解患者术后疼痛并降低并发症发生风险均有积极意义。

右美托咪定联合超声引导下臂丛神经阻滞对上肢骨折手术患者睡眠质量的影响

目的分析右美托咪定联合超声引导下臂丛神经阻滞对上肢骨折手术患者睡眠质量的影响。方法便利选取于2020年1月—2023年5月江苏大学附属武进医院收治的103例上肢骨折患者作为研究对象,利用随机数表法将患者分为观察组和对照组。其中观察组52例,对照组51例。对照组给予超声引导下臂丛神经阻滞麻醉方案,观察组在对照组基础上联合右美托咪定麻醉方案。比较两组患者麻醉即刻(T_(0))、麻醉5 min(T_(1))、术中30 min(T_(2))、术毕即刻(T_(3))平均动脉压及心率,采用匹兹堡睡眠质量指数评价两组患者术后1 d睡眠质量。结果观察组T_(0)、T_(3)各时间点动脉压波动均小于对照组,差异有统计学意义(P均<0.05);观察组T_(0)、T_(3)各时间点心率波动均小于对照组,差异有统计学意义(P均<0.05);观察组术后1 d睡眠质量为(7.63±2.58)分,高于对照组的(11.28±2.37)分,差异有统计学意义(t=7.473,P<0.05)。结论右美托咪定联合超声引导下的臂丛神经阻滞有助于提升上肢骨折手术患者睡眠质量,并且能够维持患者血流动力学指标的稳定,对上肢骨折手术患者的治疗过程产生积极的影响。

Pediatric Post-Operative Atrio-Ventricular Block Meets the Affordable Care Act: A New Strategy for Management

Introduction: Post-operative (post-op) complete atrio-ventricular heart block (CAVB) occurs after 1% - 4% of pediatric cardiac operations. Current practice dictates implantation of permanent pacemaker (PPM) when post-op CAVB persists >9 days. We propose that earlier PPM implantation may be the most cost-effective methodology since patient costs increase with extended length of stay (LOS). Methods: Data on the probabilities of persistent post-op CAVB were extracted from published reports. No individual patient data were utilized during this study. This was utilized to create a decision-making model and a total cost analysis on post-op day 0 - 10 to determine the most cost-efficient day to implant a PPM. Cost variables included estimates of daily cardiac ICU care, cost of PPM implantation, LOS, cost related to possible superficial or deep infection based on published prevalence rates (2.3% and 4.9%, respectively) and need for explant due to deep infection or recovery of native conduction. The model assumes 5-day minimum LOS and 1 day increase in LOS with PPM implantation. Cost data were obtained from relevant billing codes and manufacturer list prices for PPM and leads. A secondary analysis evaluated probability of unnecessary PPMs implanted and excess costs. Results: Post-op day (POD) 4 is the lowest total cost of PPM implantation for post-op CAVB, even when accounting for possible risk of either superficial or deep infection. A one-way sensitivity analysis accounting for variability of cardiac ICU care costs between centers ranging from $3000 - $9000 per day consistently replicates POD 4 as the most cost-effective day for PPM implantation. Implant on POD 4 results in a 26% chance of unnecessary implantation. Conclusions: The most cost-efficient day for PPM implantation for post-op CAVB is post-op day 4, which results in a minimum total cost savings of $17,422 per patient. Added costs due to risk of superficial or deep infection are marginal due to low prevalence of post-operative infection in this population.

Scalp block for brain abscess drainage in a patient with uncorrected tetralogy of Fallot

We report a case of an 11-year-old boy with diagnosed but uncorrected tetralogy of Fallot presented to us for brain abscess drainage. The child was managed successfully with scalp block with sedation.

肋间神经阻滞联合喉罩全身麻醉在小儿先天性心脏病介入封堵术中的应用效果

目的探讨肋间神经阻滞(ICNB)联合喉罩全身麻醉在小儿先天性心脏病介入封堵术中的应用效果与安全性。方法选择2022年1月至2022年10月河南省儿童医院收治的112例先天性心脏病患儿为研究对象,所有患儿行介入封堵术,根据麻醉方法将患儿分为观察组和对照组。观察组患儿给予ICNB联合喉罩全身麻醉,对照组患儿给予气管插管全身麻醉。记录2组患儿的麻醉时间、手术时间、瑞芬太尼用量、麻醉后复苏室(PACU)停留时间、拔出喉罩或气管导管时间、不良反应及麻醉诱导前(T_(0))、插入喉罩或气管导管后即刻(T_(1))、切皮时(T_(2))、置入封堵器即刻(T_(3))、气管导管或喉罩去除即刻(T_(4))、苏醒即刻(T_(5))的心率(HR)和平均动脉压(MAP)。术后1、4、8、12、24 h,采用Wong-baker脸谱或FLACC评分法评估患儿的疼痛程度。结果T_(0)、T_(5)时,2组患儿的MAP、HR比较差异无统计学意义(P>0.05);T_(1)、T_(2)、T_(3)、T_(4)时,观察组患儿的MAP、HR均显著低于对照组(P<0.05);术后1~24 h,2组患儿疼痛评分均呈升高趋势(P<0.05);术后1、4 h时,2组患儿的疼痛评分比较差异无统计学意义(P>0.05);术后8、16、24 h时,观察组患儿的疼痛评分均显著低于对照组(P<0.05)。2组患儿的手术时间、麻醉时间比较差异无统计学意义(P>0.05);观察组患儿瑞芬太尼用量显著少于对照组,PACU停留时间、拔出喉罩或气管导管时间显著短于对照组(P<0.05)。观察组患儿苏醒期躁动、咽喉痛、呛咳、恶心呕吐的发生率显著低于对照组(χ^(2)=4.940、4.264、10.500,P<0.05)。结论ICNB联合喉罩全身麻醉用于先天性心脏病介入封堵术可维持患儿血流动力学稳定,且镇痛效果好、并发症少。