Lino Rossi

Right Bundle Branch Block, Right Precordial ST-Segment Elevation, and Sudden Death in Young People

Background —Patients with the ECG pattern of right bundle branch block and right precordial ST-segment elevation may experience sudden death in the setting of either arrhythmogenic right ventricular cardiomyopathy (ARVC) or a functional electrical disorder such as Brugada syndrome. Methods and Results —Among a series of 273 young (≤35 years) victims of cardiovascular sudden death who were prospectively studied from 1979 to 1998 in the Veneto Region of Italy, 12-lead ECG was available in 96 cases. Thirteen (14%; 12 males and 1 female aged 24±8 years) had right precordial ST-segment elevation, either isolated (9 cases) or associated with right bundle branch block (4 cases). At autopsy, all patients had ARVC (92%) except one, who had no evidence of structural heart disease. Compared with the 19 young sudden death victims with ARVC and no ST-segment abnormalities from the same series, those with AVRC and right precordial ST-segment elevation included fewer competitive athletes (17% versus 58%;P =0.03), more often died suddenly at rest or during sleep (83% versus 26%;P =0.003), and showed serial ECG changes over time (83% versus 0;P =0.015), polymorphic ventricular tachycardia (33% versus 0;P =0.016), and predominant fatty replacement of the right ventricular anterior wall (58% versus 21%;P =0.05), Conclusions —Right precordial ST-segment elevation was found in 14% of young sudden death victims with available ECG. It mostly reflected underlying ARVC with predominant right ventricular anterior wall involvement and characterized a subgroup of patients who share with Brugada patients the propensity to die from non–exercise-related cardiac arrest and to exhibit dynamic ECG changes and polymorphic ventricular tachycardia.

The atrioventricular conduction system in dissecting aneurysm of the aorta

Abstract In dissecting aneurysm of the ascending aorta the hemorrhage may spread into the interatrial septum and into the area of the specialized atrioventricular junctional tissue. A clinicopathologic investigation has been performed in 48 cases with classical complete dissecting aneurysm in order to evaluate whether such hemorrhage may lead to conduction disturbances. Among 42 cases with aortic dissection originating in the ascending aorta, eight hearts (19 per cent) presented with hemorrhagic infiltration of the atrial septum, extended to the coronary sinus. Histologic examination of the atrioventricular conduction tissues was performed in six of these hearts and in five without such gross evidence (“controls”). In the former the hemorrhage had spread between the transitional cell zone of the atrioventricular junctional area, but never actually penetrated the compact node. In none of the “controls” was there any histological evidence for hemorrhage. The correlation between the histologic data and the available electrocardiographic findings disclosed that atrioventricular conduction disturbances, including atrioventricular dissociation, were present only in cases with hemorrhage of the atrial septum. It is suggested that: (a) hematoma of the interatrial septum is not at all infrequent in cases with dissection of the ascending aorta, (b) this complication leads to atrioventricular conduction disturbances, (c) the hemorrhage preserves a large part of the atrioventricular junctional tissues, thus explaining the occurrence of the atrioventricular dissociation with junctional rhythm and eventual restoration of the normal conduction.

Histologic Findings in the Conduction System After Cardiac Transplantation and Correlation With Electrocardiographic Findings

The study of the sinus node and the specialized atrioventricular junction by serial sections in cardiac transplantation revealed that acute rejection involving the conduction system was equally severe as the working myocardium, with the exception of the His bundle. During acute rejection, the sudden appearance of a first-degree atrioventricular block may suggest severe involvement of the conduction system with impending cardiac arrest.

The Permanent Form of Junctional Reciprocating Tachycardia

In 1967, Coumel et al. [1] described a fascinating tachycardia with a normal QRS occurring predominantly in infants and children. Due to the incessant nature of this tachycardia the arrhythmia was named “permanent junctional reciprocating tachycardia” (PJRT). Although the clinical characteristics and electrocardiographic findings of PJRT have been confirmed following the original reports of the French authors, controversy has persisted for many years concerning the pathophysiologic substrate of this arrhythmia [2–9]. Recent data strongly suggest that PJRT represents a “variant” form of the preexcitation syndromes [10–17].

Involvement of the cardiac conducting system in panarteritis nodosa

Histopathological observations on the conduction system of the heart were carried out in three cases of panarteritis nodosa. This specialized tissue was involved in each case secondary to ischemia and/or periarterial extension of the inflammatory process affecting the nutrient arteries of the conducting system. The high risk of disturbances in impulse formation and conduction in patients with panarteritis is emphasized as well as the need for appropriate clinical investigation (protracted cardiac monitoring and control by catheter recording and stimulation) in order to secure early detection and prevention of life-threatening arrhythmias.