Complete Heart Block

Complete Heart Block

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  COMPLETE HEART BLOCK Dr.Nagula Praveen Perspectiveof Chronic heart block in Eastern India, Manotosh Panja
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  PERSPECTIVE • Chronic AVblock significant problem • Increased economic burden as increased use of PPI needed. • Geographical variation in prevalence – 42% population (Eastern India) • Symptomatic AV block – 5th to 6th decade, middle class smokers, sedentary life style. North zone 15% Central zone 15% West zone 10% South zone 18%
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  Clinical correlations 1.Coronary arterydisease • 15/100 cases (pathology) are due to ischemia – Davies et al. • Sidden and simons – no more than 20% cases due to IHD. • Panja et al – 20% cases IHD • Histopathologically – atherosclerotic changes of the coronary artery thrombosis of intraluminal vessels. • MI – Ischemia CHB • Nodal artery – main bundle destruction (Fulconer and Dean) • Fibrosis and calcification of the ventricular septum that involves the branching part of the AV bundle and LBBB – genesis of conduction defect.
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  Demographic profile Mustard oilconsumption 89.3% Rapseed oil consumption 23.5% Other oils 11.7% Smoker 67% Sedentary habit 90.6% Bengalee 97.3% Panja et al.
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  coronary angiography profilein CHB – Panja et al. • Age 35-65 years (40 years) • Males -35,Females -15 • 3 pts < 30% obstruction, 6 pts - >70% significant obstruction • AV nodal artery visualized in 46 cases (92%) • Septal perforators identified in all. • 18% cases due to ischemia • LAD,RCA,LCX artery involved frequently. • 41 patients had normal CAG.
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  2.Diabetes mellitus • 4/50 •Proliferative changes of diabetic microangiopathy, intramural coronary vessels, myocardial fibrosis, AV nodal, proximal bundle of His • Increased fascicular block • Small vessel changes – lead to CHB • Deposition of PAS(periodic acid schiff) +ve – endothelial proliferation, basement membrane thickening • Small vessels – CHB, large vessel – CAD.
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  3.Hypertension • Coronary arteriosclerosisor sclerosis of the left side of cardiac skeleton (increased in hypertension) 4.Cardiomyopathy • Idiopathic • Secondary • 15% DCMP • 3% HCM • Sarcoidosis – important cause of CHB • Chagas disease • AV block rarely associated with rheumatoid arthritis,common in ankylosing spondylitis.
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  5.valvular heart disease •Calcific aortic stenosis • Mitral valve disease (uncommon) • MAC+ • AV – main HIS bundle 6.congenital heart disease • Isolated abnormality • CCTGA • Atrial musculature – AV bundle(absent) – HIS bundle • Fetal myocarditis • Idiopathic hemorrhage and necrosis within the conducting tissue • Degeneration and fibrosis related in some instance to transplacental passage of Anti Ro/Anti SSA
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  Saxena et al •44 cases of congenital CHB (AIIMS, Delhi) • 31 – asymptomatic (group I),13 - syncope, near syncope, convulsions (group II) • Ventricular rate ( 56.7 ± 13.2 beats/min vs 46.5 ± 6.0 beats/min) • Wide QRS (2/31 vs 2/13) • Pauses > 3 sec – infrequent in both • EP study – suprahisian block on ECG • Corrected junctional recovery time – no significance • HR<50/min (during waking hours) • Wide QRS escape rhythm • Pause > 3 seconds PPM
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  • 7. Degenerativedisease • Lev and lenegre • Impaired function of conduction system • Degenerative, fibrous changes • From outside - Lev’s disease • Primary degeneration – Lenegre disease • 46/100 cases – Davies et al • 8/15 cases – Panja et al
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  Erucic acid –The culprit of mustard oil • 1-10% of total fatty acids • Increased concentration in mustard oil • Sen et al – Human hearts, Bengalees • Erucic acid was found in normal atheroscleortic heart muscle • Increased esterified cholesterol (↑DOHA) • Increased phosphatidyl choline • Increased sphingomyelin • Decreased phosphatidyl ethanolamine • Decreased cardiolipin • Decreased linoleic acid ( damaged by erucic acid) – inhibits oxidation of long chain fatty acids – increased TG synthesis, increased cholesterol eructitate • Lipidosis- acute effect of the mustard oil feedings • increased collagen synthesis - long term effect
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  Panja et al HistopathologyPrimary HTN/OHD Diabetes Myocardial fibrosis 8 0 1 AV nodal with HIS bundle fibrosis 5 1 2 Small vessel change 0 0 3 Atherosclerotic changes 0 4 0
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  Causes of chronicAV block – Davies et al 100 cases Idiopathic bilateral branch fibrosis 46% Ischaemic coronary artery disease Destruction of both bundle branches 14% Destruction of AV node 01% Cardiomyopathy 13% Calcific valve disease 8% Myocarditis 4% Connective tissue disorder 3% Amyloidosis 3% Transfusion siderosis only AV node affected 2% Congenital heart block only main bundle affected 3% Gumma of IVS 3%
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  Postmortem study –15 patients Age range 30 -90 years idiopathic 8 IHD 3 Diabetes 4 Hypertension 4 Connective tissue disease 1
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