Complete Heart Block

complete heart block is an important condition to be considered in cardiology, particularly Indian perspective

1. COMPLETE HEART BLOCK Dr.Nagula Praveen Perspective of Chronic heart block in Eastern India, Manotosh Panja

2. PERSPECTIVE Chronic AV block significant problem Increased economic burden as increased use of PPI needed. Geographical variation in prevalence – 42% population (Eastern India) Symptomatic AV block – 5 th to 6 th decade, middle class smokers, sedentary life style. North zone 15% Central zone 15% West zone 10% South zone 18%

3. Clinical correlations 1.Coronary artery disease 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.

4. Demographic profile Mustard oil consumption 89.3% Rapseed oil consumption 23.5% Other oils 11.7% Smoker 67% Sedentary habit 90.6% Bengalee 97.3% Panja et al.

5. coronary angiography profile in 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.

6. 2.Diabetes mellitus 4/50 P roliferative 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.

7. 3.Hypertension Coronary arteriosclerosis or 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.

8. 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

9. 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

10. 7. Degenerative disease 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

11. 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

12. Panja et al Histopathology Primary HTN/OHD Diabetes Myocardial fibrosis 8 1 AV nodal with HIS bundle fibrosis 5 1 2 Small vessel change 3 Atherosclerotic changes 4

13. Causes of chronic AV 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%

14. 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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