Complete Heart Block After Aortic Valve Repair and Septal Myectomy in a Patient With Rheumatic Heart Disease

Figures

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  Figure 1. Preoperative EKG showing normal sinus rhythm There is no evidence of conduction disease, heart block, or significant ischemic changes on the EKG.

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  Figure 2. Intraoperative TEE demonstrating significant septal bulge and transvalvular systolic gradient across the AV A: Septal bulge (red arrow) with reduced systolic LVOT diameter (red bracket) at 0.81 cm (normal >2 cm); B: Continuous wave Doppler across AV during systole. Subvalvular LVOT gradient at 84 mmHg (normal <30 mmHg) consistent with LVOT obstruction in the setting of septal HOCM. The interventricular septum diameter was 2 cm (not measured on the image). TEE: Transesophageal echocardiogram, LVOT: Left ventricular outflow tract, AV: Aortic valve, HOCM: Hypertrophic obstructive cardiomyopathy

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  Figure 3. Leads 2 and 3 on POD 2 telemetry demonstrating CHB developing into asystole (red brackets) and cardiac arrest POD: Postoperative day, CHB: Complete heart block

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  Figure 4. Hematoxylin and eosin stain of the myocardial septum after surgery The histopathological examination revealed focal scarring with neutrophilic infiltration (Aschoff bodies indicated by the red arrows), consistent with the history of rheumatic heart disease, with no overt evidence of hypertrophic cardiomyopathy. Light pink areas indicate fibrosis, dark pink regions suggest cardiomyocytes, and the blue specks mark the nuclei.