Digoxin, a cardiac glycoside, functions by inhibiting the sodium potassium ATPase pump. It\'s crucial to note that digoxin has a very narrow therapeutic range. Its serum level vary due to changes in body weight, age, renal function, hepatic impairment and concomitant drug therapy. Chronic toxicity can lead to different types of arrrythmia,which span from heart blocks to ventricular tachycardia. This report present a case of an elderly male, where Digoxin toxicity resulted in syncope and mild traumatic brain injury. Initially upon patient\'s presentation ECG indicated myocardial infarction, subsequently bradycardia and complete heart block. The patient had a known history of chronic kidney disease and was prescribed 0.25mg of digoxin regularly without dose adjustment, which might have resulted in reduced digoxin elimination, leading to toxicity. Thus this case demonstrates a classic presentation of digoxin toxicity. Multiple risk factor such as old age, impaired renal function with continued digoxin treatment without dose adjustment was likely the cause of toxicity.

UNASSIGNED: Permanent pacemaker implantation (PPI) in neonates is challenging with respect to indications, device selection, implantation technique, and long-term outcomes. Complex anatomy, the need for long-term pacing with high rates, and a problematic postoperative period are the major problems.
UNASSIGNED: We prospectively followed up 22 newborns who underwent PPI below 28 days of life at our institute.
UNASSIGNED: The median age at implantation was 2 days (interquartile range 1-9 days), and 9% were born preterm. The average heart rate before implantation was 46.4 ± 7.2 bpm. Maternal lupus antibodies were positive in 8 (36.4%) neonates, whereas 11 (50.0%) had associated congenital heart disease. Nineteen neonates underwent single chamber (VVI) and three underwent dual chamber (DDD) pacemaker implantation. Over a median follow-up of 46 months (range 2-123 months), the average ventricular pacing percentage was 87.5 ± 24.9%, with a stable pacing threshold. Seven children underwent pulse generator replacement due to battery depletion at a median age of 47 months. Pacing-induced ventricular dysfunction was seen in five children at a median age of 23.6 months, and two underwent upgradation to cardiac resynchronization therapy. Overall mortality was 13.6%, all due to tissue hypoperfusion and lactic acidosis in the postimplantation period.
UNASSIGNED: PPI in neonates has a favorable outcome with excellent lead survival. Overall mortality is 13.6%, which is predominantly in the postimplantation period and related to myocardial dysfunction.

BACKGROUND: Modern cardiovascular implantable electronic devices (CIEDs) have mechanisms that prevent damage from external electric shocks, and malfunction following accidental electrocution is rare. However, the effects of lightning injuries in patients with CIEDs are uncertain.
METHODS: A 74-year-old man with a dual-chamber pacemaker due to complete heart block was struck by a lightning while farming. He had no serious injury at the time and sought medical evaluation 1 month later, when he presented with asymptomatic bradycardia. Device interrogation suggested major battery and lead damage, requiring extraction and subsequent placement of a new pacing system.
CONCLUSIONS: While a previous report depicted pacing threshold elevation without extensive device impairment, our patient presented with major damage to the whole pacing system. The factors contributing to these divergent outcomes are unclear. Differences in injury mechanism, pacemaker model, and the pattern of electric current dispersion within the device may each play a part in this discrepancy.

A 50-year-old woman presented with complete heart block on electrocardiogram. Echocardiogram revealed an intracardiac mass with extensive cardiac involvement. The patient was diagnosed with mantle cell lymphoma, confirmed via lymph node biopsy. Pacemaker implantation and chemotherapy were initiated, with subsequent improvement noted. This showcases an unusual manifestation of intracardiac metastasis with conduction system infiltration.

UNASSIGNED: Redo aortic valve replacement in twin pregnancy presents significant challenges because of the elevated risks for both maternal and fetal health. Mortality rates range from 12 % to 21 % in specialised centres, with previous cardiac surgeries further elevating the risk. Pregnancy complicates cardiac surgery, with fetal mortality rates as high as 16-33 %.
METHODS: A 31-year-old woman, 15 weeks pregnant with twins and with a history of mechanical aortic valve replacement, presented with worsening breathlessness and grade III dyspnoea. Echocardiography revealed severe valve obstruction, necessitating redo-aortic valve replacement and posterior aortic root enlargement. Despite intraoperative challenges, including ventricular fibrillation and postoperative heart block, she underwent successful surgery and pacemaker implantation, with both mother and fetuses remaining stable.
CONCLUSIONS: Optimal timing of surgery is crucial, considering fetal developmental vulnerability in the first trimester and maternal cardiac workload in the third trimester. Second-trimester risks are comparable to non-pregnant patients. A limited understanding of fetal-placental perfusion during bypass necessitates cautious management strategies, with emerging techniques like pulsatile perfusion showing promise. Anaesthesia selection prioritises fetal safety while monitoring fetal distress during surgery remains challenging. To achieve successful outcomes for both mother and babies in a twin pregnancy undergoing a redo aortic valve replacement, careful timing, appropriate surgical techniques, and meticulous perioperative care are essential.
CONCLUSIONS: A multidisciplinary approach is crucial for managing twin pregnancy following redo aortic valve surgery. Careful planning, close monitoring, and specialised surgical and anaesthetic techniques are key to minimising risks to both mother and fetus.

暂无摘要。

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital malformation. We present a case of an elderly patient with ALCAPA presenting with complete heart block and non-ST-elevation myocardial infarction years after diagnosis and surgical correction. An 81-year-old female with a history of ALCAPA presented to the emergency department with chest pain and progressive mental deterioration. She was bradycardic and hypotensive. An electrocardiogram revealed a complete heart block. Troponin was 4.04 ng/mL. She received atropine and underwent transcutaneous pacing. Left heart catheterization revealed complete occlusion of the mid-left circumflex artery, which was intervened with balloon angioplasty and chronic total occlusion of the right coronary artery. She was supported with temporary transvenous pacing, did not require further pacing support, and was discharged home. Previous records unearthed that in 1988 she had presented with syncope and was diagnosed with ALCAPA, filling from right-to-left collaterals with large and ectatic coronaries. At the time, she underwent surgical correction with excision of the left coronary from the pulmonary artery and reimplantation in the left coronary cusp along the posterior aorta. She had remained asymptomatic after her surgery until this presentation. ALCAPA is extremely rare in adults. Insufficient collaterals to the left ventricle cause inadequate blood supply, leading to ischemia in adults, predisposing them to arrhythmias and risk of sudden death. Adults with ALCAPA remain at increased risk of adverse cardiac events later in life, requiring long-term monitoring.

Bradyarrhythmias, characterized by heart rates of <60 bpm due to conduction issues, carry risks of sudden cardiac death and falls. Pacemaker implantation is a standard treatment, but the interplay between bradyarrhythmias, coronary artery disease (CAD), and patient attributes requires further exploration. This study was a retrospective hospital record-based study that analyzed data from 699 patients who underwent pacemaker implantation for symptomatic bradyarrhythmias between February 2019 and February 2022. Clinical parameters, coronary angiography (CAG) findings, ejection fraction, and indications for pacemaker implantation were documented. The relationship between CAD severity, specific bradyarrhythmias, and ejection fraction was explored. Statistical analysis included chi-squared tests and t tests. The mean age of the study population (n = 699) was 66.75 years (male:female ratio, 70:30), with 77.2% having type 2 diabetes and 61.6% being hypertensive. The majority of patients had minor or non-obstructive CAD (61.8%), followed by normal CAG findings (25.75%) and obstructive CAD (12.45%). Complete heart block (CHB) was the primary indication for pacemaker implantation (55.2%), followed by sick sinus syndrome (22.3%). The results did not show any association between ejection fraction and CAG findings. Patients who presented with CHB had a higher incidence of obstructive CAD, indicating greater severity. This study sheds light on the intricate interplay between severe bradyarrhythmias, CAD, and patient characteristics. Our analysis revealed no statistical significance between obstructive CAD and the need for a permanent pacemaker. This makes us question our practice of maintaining a low threshold for coronary angiography during pacemaker implantation. The observed low yield and anticoagulation protocol reassure us of the choice to delay this diagnostic intervention. These insights can guide tailored management strategies, enhancing clinical care approaches for patients with severe bradyarrhythmias necessitating pacemaker implantation.

BACKGROUND: Pacemaker-mediated tachycardia is a known arrhythmia in patients with dual chamber pacemakers and defibrillators and intact ventriculoatrial (VA) conduction. We report a case of pacemaker-mediated reentrant arrhythmia (PMRA) in a patient with an atrioventricular (AV) synchronous leadless pacemaker.
RESULTS: A 91-year-old female presented with 2:1 AV conduction and received an AV synchronous leadless pacemaker. She had atrial mechanical sense-ventricular paced beats between heart rates of 80-100 bpm more than 80% of the time. She was found to have a new cardiomyopathy and was referred for placement of biventricular pacemaker. At the time of device implantation, her electrocardiogram showed ventricular pacing with a short RP interval and superiorly directed P waves. Changes in the ventricular pacing rate resulted in changes in the atrial rate. Following device placement, her heart rate decreased to the lower rate limit of her pacemaker. The atrial mechanical sense impulse most likely was generated by a retrograde conducted P wave resulting in near incessant PMRA.
CONCLUSIONS: PMRA may occur in patients who receive an AV synchronous leadless pacemaker with intact VA conduction and sinoatrial node dysfunction. Due to the lower rates of PMRA, this arrhythmia may be underrecognized. Interventions for and implications of PMRA need further investigation.

OBJECTIVE: To compare early and late outcomes of septal myectomy in patients with obstructive hypertrophic cardiomyopathy who presented with residual or recurrent left ventricular outflow tract (LVOT) obstruction after previous septal-reduction therapy (SRT).
METHODS: From January 1989 to March 2022, 145 patients underwent reintervention by septal myectomy for residual LVOT obstruction after previous SRT; 72 patients had previous alcohol septal ablation (ASA) and 73 had previous surgical septal myectomy. Baseline patient characteristics, echocardiographic parameters, and surgical outcomes were compared between these 2 groups.
RESULTS: Patients who had previous ASA were more likely to be male (50.0% vs 30.1%; P = .015), be older (median age 57.5 years vs 48.3 years; P < .001), and have a greater body mass index (32.7 kg/m2 vs 30.0 kg/m2; P = .011). After repeat SRT by septal myectomy, there was no significant difference in the incidence of postoperative complete heart block, necessitating permanent pacemaker, between the 2 groups (8.3% vs 2.7%; P = .151). One (0.7%) patient died within 30 days of surgery. Over a median follow-up of 7.5 years (interquartile range, 3.0-13.8), there were 20 deaths. Kaplan-Meier 5-, 10-, and 15-year survival rates were 100%, 91%, and 76% for the previous septal myectomy group, and 93%, 81%, and 64% for the previous ASA group (P = .207).
CONCLUSIONS: Septal myectomy for residual or recurrent LVOT obstruction in patients who had previous ASA is safe, with an acceptably low rate of postoperative complete heart block. Surgical outcomes and late survival rates in patients with complete heart block ASA were satisfactory and comparable with patients who underwent repeat myectomy.