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Oct 20, 1977 - His bundle electrocardiography is a useful technique for localising the site of atrioventricular block and, in some instances, can show atrioventri ...
British Heart Journal, 1978, 40, 911-917

Assessment of atrioventricular conduction in aortic valve disease' HOWARD S. FRIEDMAN, QAMAR ZAMAN, JACOB I. HAFT, AND SOFIA MELENDEZ From the Veterans Administration Hospital, Bronx, N. Y., and the Department of Medicine, Mount Sinai School of Medicine (CUNY), New York, New York, USA

To determine the frequency of atrioventricular conduction disturbances in aortic valve disease, 26 consecutive patients (age 54 ± 2 years) with symptomatic aortic valve disease were studied by His bundle electrocardiography at the time of cardiac catheterisation and were compared with a group of patients who underwent cardiac catheterisation and were found to have coronary artery or mitral valve disease but no aortic valve disease. Patients with aortic valve disease had significantly longer PR, AH, and HV intervals than cardiac patients not having this abnormality. Patients with aortic stenosis had prolonged HV, 52 i 6 vs 42 2 ms (P - 0.06), whereas patients with chronic aortic regurgitation had prolonged PR, 245 i 27 vs 163 5 ms (P < 0.001), and prolonged AH, 178 + 30 vs 102 ± ms (P < 0.001). Patients with combined lesions had significant prolongation of PR, AH, and HV intervals. Three patients with acute aortic regurgitation caused by endocarditis had normal atrioventricular conduction. Though the presence of valvular calcification did not significantly alter the pattern of atrioventricular conduction in these patients, those with calcified aortic valves had longer HV (P < 0.005) than the control group. In addition, ventricular dysfunction or coronary artery disease did not affect the pattern of atrioventricular conduction in these patients. Thus, atrioventricular conduction disturbances are common in symptomatic aortic valve disease. With aortic stenosis the site of delay occurs more frequently below the His deflection, whereas in aortic regurgitation it is more frequent above the His deflection. SUMMARY

Occurrence of heart block in calcific aortic valvular bundle studies done on patients with atrioventridisease has been recognised since the earliest cular block (Bharati et al., 1974; Rosen et al., 1975) clinical-pathological studies of patients with Adams- there has been no His bundle study of patients with Stokes disease (Stokes, 1846; Yater and Cornell, aortic valve disease per se. Accordingly, it is the 1935; Warshawsky and Abramson, 1947; Harris et purpose of this study to show the His bundle electroal., 1969). The proximity of the aortic valve and its cardiographic findings in patients with aortic valve supporting structures to the atrioventricular con- disease. The results of this study, which are reported duction system could explain this association (Lev, here, show that atrioventricular conduction abnor1964). His bundle electrocardiography is a useful malities are common in symptomatic aortic valve technique for localising the site of atrioventricular disease. block and, in some instances, can show atrioventricular conduction abnormalities even before they are Method apparent on the surface electrocardiogram (Damato et al., 1969). Though patients with calcific aortic The study group consisted of 26 patients undergoing valve disease have been included in previous His diagnostic cardiac catheterisation for symptomatic aortic valve disease. The control group was obtained 'Presented in part at the Eastern Section of the American from 25 consecutive patients undergoing diagnostic Federation for Clinical Research in January 1977, Clinical cardiac catheterisation and found to have significant Research 614A, 1976, and presented at the Scientific Session organic heart disease but no evidence of aortic valve of the American College of Cardiology in March 1977 disease. Aetiological diagnoses of both groups are (American Journal of Cardiology, 39, 314, 1977). shown in Tables 1 and 2. Patients having given informed consent were studied at the time of diagReceived for publication 20 October 1977 911

JIacob I. Haft, and Sofia Melendez electrode catheter was introduced percutaneously into the right femoral vein and passed across the

Howard S. Friedman, Qamar Zaman,

912

Table 1 Diagnosis in patients studied Control (N = 25)

Aortic valve disease (N = 26)

tricuspid valve. It

Coronary artery disease (23) Rheumatic mitral stenosis (1) Congenital atrial septal defect and mitral prolapse (1)

Rheumatic (8) Congenital bicuspid (6) Endocarditis (4) Syphilis (1) Calcific aortic sclerosis (5) Unknown (2)

characteristic His deflection

nostic cardiac catheterisation before any contrast studies. All patients were postabsorptive. None had received cardiac antiarrhythmic medication for at least one week before cardiac catheterisation, except for three patients with acute infective endocarditis, who were studied at the time of emergency cardiac catheterisation.

His bundle electrograms were recorded using a modification of the standard technique (Scherlag et al., 1969). Electrocardiograms from standard leads with filters set at a frequency response of 1 to 200 Hz and His bundle electrograms with filters set at a frequency response of 40 to 500 Hz were recorded simultaneously on a multichannel, oscilloscbpic photographic recorder (Electronics for Medicine DR-12) at a paper speed of 100 mm/s. A bipolar Table 2

gradually withdrawn until a was

observed at a time

when A and V were both prominent. The interval between the A and V was carefully explored to identify any split His deflections. Deflections occurring 31 ms or less before the V were assumed to represent the right bundle-branch deflection. The AH interval was measured from the onset of the first high frequency component of the A to the onset of the H deflection. HV interval was measured from the onset of the H deflection to the onset of ventricular

depolarisation on a standard electrocardiographic lead or the ventricular electrogram, whichever occurred earlier. PR interval was measured from the onset of the P wave to the onset of the R wave on the standard limb lead that had the longest duration. The intervals obtained represented the average of 10 cycles. Patients with sinus bradycardia had atrial pacing performed and corrected sinus recovery times were measured, using the methods of Narula and co-workers (1972). Haemodynamaic measurements were made using standard methods. Mean systolic gradient across the

Clincal and haemodynamic data Age (y)

Diagnosis

Gradient Cal (mmHg)

AR

CI

EF

Cor

1

57

Bicuspid

67

Yes

+

3-8

89

2 3

65 55 57 69 59 60 38 53 51 30 47 68 37 56

Tricuspid calcific Tricuspid calcific

44 67 52 20 80 55 ± 9 None None None None None None None

Yes Yes Yes Yes Yes

+ + + None None

-

39 51

LAD Rt LAD Patent ND ND ND

None

None None None None None None None Yes

3+ 2+ 3+ 3+ 4+ 4+ 3+

Endocarditis

None

None 3+

Rheumatic

59 35 80 65 55 35 60 66

Yes Yes Yes Yes Yes Yes Yes Yes

None None None

None 4+ None 3 + None 4 +

Case no.

(A) Aortic stenosis (n

-

6)

4 5 6

Mean ± SE

(B) Aortic regurgitation, chronic (n = 9)

Mean SE (C) Aortic stenosis and

7 8 9 10 11 12 13 14

15

18

60 49 48 62 60

19 20

56 57

21 22 23

57 65

regurgitation (n = 8) 16 17

Mean ± SE (D) Aortic regurgitation, acute (n = 3) Mean + SE

was

Rheumatic Tricuspid calcific

2

Rheumatic Unknown Rheumatic

Bicuspid Unknown Syphilis

Rheumatic Rheumatic

3+

4

62

58+2 24 25 26

Bicuspid

Bicuspid Rheumatic Bicuspid Rheumatic Tricuspid calcific Bicuspid Tricuspid calcific

55 Endocarditis 43 Endocarditis 47 Endocarditis 48± 4

56±5

3+ 3+ 3+ 3+ 3+ 3+ 3+ 3+

(lIminperm') (%)

2-9 3-2 3-0 3-2 1-5 30 3-2 30 30 2-5 2-8 2-2

-

0-2

2-3 2-6 0-2 30 40 2-5 2-9 3-6 3-5 ND 2-2 3-3 0-2 3-4 40 2-1 39±6

67 53 60

9

ND Patent ND ND ND ND ND LAD CX Patent

-

60 63 55 43 39 -

46 -

51 64 73 68 -

65 59 -

4

Patent Patent Patent ND Patent Patent ND Patent

42 62 4 ND 56 ND ND 40 48 + 8

Abbreviations: EF, Ejection fraction; ND, not done; CX, circumflex coronary artery stenosis; Rt, right coronary artery stenosis; Cal, valvular calcification; Cor, coronary arteriography; LAD, left anterior descending artery stenosis; AR, aortic regurgitation; CI, cardiac index.

913

AV conduction in AVD Table 3 Electrophvsiological data - --.-

-

Case no. Electrocardiogram (A) Aortic stenosis (n = 6)

1 2 3 4 5 6

LAE, NAST-T NAT LVH, LAE, NAST-T LVH, IVCD, LAE, NAST-T LVH, NAST-T LVH, NAST-T

7 8

LBBB, LAE LVH, AbnLAD

Mean ± SE (B) Aortic regurgitation, chronic (n = 9)

Mean ± SE (C) Aortic stenosis and regurgitation (n = 8)

Mean ± SE (D) Aortic regurgitation, acute (n = 3)

9 10 11 12 13 14 15

LVH, LAE LVH, NAST-T LVH, AbnLAD, NAST-T LBBB, LAE LVH, NAST-T LVH, NAST-T LVH, LAE, NAST-T

16 17 18 19 20 21 22 23

LVH, IVCD, LAE, NAST-T

LVH, LAE LAE, NAST-T LVH, LAE LVH, LAE, SSS, NAST-T LVH, LAE, SSS, NAST-T LVH, LAE, NAST-T LVH, LAE, NAST-T

24 25 26

LAE, AbnLAD, NAT Normal LAE, NAST-T, AbnLAD

Mean + SE

HR/min

PR (ms)

AH (ms)

85 65 90 90 90 84 84 5 85 80 86 63 65 70 71 88 77 78 85 77 ± 3 90 70 68 80 60 56 72 71 71 ± 4 55 43 47 48 ± 4

180 160 190 200 160 165 176 7 440 280 270 330 240 180 200 285 200 200 210 248 ±27 220 230 220 210 240 161 200 200 211 9 140 180 190 170 15

100 95 120 120 80 110 104 390 220 220 270 190 130 100 200 124 110 140 178 133 170 150 140 138 104 120 144 137 60 90 95 81

HV (ms) ----

47 40 42 70 70 45 6 52 50 50 50 50 50 35 45 55 43 81 40 30 48 51 49 70 55 79 36 55 35 7 53 45 50 50 11 48

6

4

5

2

Abbreviations: NAST-T, nonspecific abnormality of ST segment and T waves; LBBB, left bundle-branch block pattern; AbnLAD, abnormal left axis deviation; NAT, non-specific abnormality of T wave; LVH, left ventricular hypertrophy; SSS, sick sinus syndrome; LAE, left atrial enlargement; IVCD, intraventricular conduction defect.

Table 4 Summary of haemodynamic and electrophysiological data in control and aortic valve disease patients Control (n = 25) Age(y) CI (1/min per m2) EF (%) HR/min PR (ms) AH (ms) HV (ms)

Aortic valve disease (n = 26)

54 ±2 52 ±2 3-1 ± 0 1 2-8 ± 0 1 56 ± 3 57 ± 5 81 ± 2 76 ± 4 211 ± 11 163 ± 5 137 ± 12 102 ± 5 42 ± 2 50 ± 3

P value NS NS

NS NS