Second degree AV block surgery: Difference between revisions
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* [[Permanent pacing]] may not be effective when the [[symptoms]] of [[dizziness]], [[presyncope]], [[syncope]] are not related to [[atrioventricular block]] in [[patients]] with [[second-degree Mobitz type I]] ([[Wenckebach]]) or 2:1 [[atrioventricular block]]. | * [[Permanent pacing]] may not be effective when the [[symptoms]] of [[dizziness]], [[presyncope]], [[syncope]] are not related to [[atrioventricular block]] in [[patients]] with [[second-degree Mobitz type I]] ([[Wenckebach]]) or 2:1 [[atrioventricular block]]. | ||
* Progression of [[atrioventricular block]] at the [[nodal level]] to higher degree [[atrioventricular block]] is unlikely. | * Progression of [[atrioventricular block]] at the [[nodal level]] to higher degree [[atrioventricular block]] is unlikely. | ||
* First- and [[second-degree Mobitz type I]] ([[Wenckebach]]) [[atrioventricular blocks]] or 2:1 [[atrioventricular block]] are benign if the level of block is at the [[atrioventricular node]]. | |||
* Second-degree [[Mobitz type I]] ([[Wenckebach]]) [[atrioventricular block]] is [[intranodal]],implantation of [[pacemaker]] may be considered even in the absence of [[symptoms]]. | |||
* Narrow [[QRS]] complex with then the level of the [[atrioventricular node]] block, intranodal during an [[EPS]] | |||
First- and second-degree Mobitz type I (Wenckebach) atrioventricular blocks (or 2:1 atrioventricular block, if the level of block is at the atrioventricular node) are typically benign in that they do not progress suddenly to complete heart block.S6.4.1-1,S6.4.1-3 Treatment of these conduction disorders with a pacemaker are typically reserved for significant symptoms that affect QOL. Occasionally second-degree Mobitz type I (Wenckebach) atrioventricular block is in fact infranodal, and in those instances a pacemaker may be considered even in the absence of symptoms.S6.4.1-1 Although a narrow QRS complex suggests that the block is at the level of the atrioventricular node, there are instances where it has been determined to be infranodal during an EPS. Symptoms may be difficult to correlate but ambulatory electrocardiographic monitoring or a treadmill exercise test may be useful. Improvement in atrioventricular conduction suggests that the site of block is at the atrioventricular node, whereas worsening atrioventricular conduction suggests infranodal block. If the symptoms do not clearly correspond to the episodes of atrioventricular block, the risks associated with the pacemaker in the absence of clear benefit make the overall risk-benefit ratio unfavorable.S6.4.1-11 Similarly, in patients with long-standing persistent or permanent AF with a low heart rate and appropriate chronotropic response, in the absence of symptoms, pacing for rate support is unlikely to be beneficial. Although PPM implantation is a relatively low-risk cardiac procedure, procedural complications and death directly related to implant can occur, and implanted leads have long-term management implications | |||
===Mobitz I=== | ===Mobitz I=== |
Revision as of 05:50, 4 July 2021
Second degree AV block Microchapters |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Salih, M.D., Cafer Zorkun, M.D., Ph.D. [2]; Raviteja Guddeti, M.B.B.S. [3]
Overview
If no reversible causes are present, definitive treatment of Mobitz type II second degree AV block involves permanent pacemaker placement in most patients. Dual-chamber pacing to maintain AV synchrony is preferred (rather than single chamber right ventricular pacing) in most patients due to the favorable hemodynamic benefits of AV synchrony. Unlike asymptomatic patients with Mobitz type I second degree AV block who do not require any specific therapy, patients with Mobitz type II second degree AV block have a high likelihood of progressing to symptomatic Mobitz type II second degree AV block or complete heart block and should be considered candidates for pacemaker insertion on initial presentation.
Surgery
Management of bradycardia attributable to atrioventricular block
AV block | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Mobitz type1 block | Mobitz type2 block, evidence of infranodal block | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Symtoms | Permanent pacing (class1) | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Permanent pacing (class1) | Neuromascular disease associated with progressive conduction disorder | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Permanent pacing (class1) | Observation | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Permanent pacing (class3), Harm | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Risk of ventricular arrhythmia, heart failure symptoms(LVEF<35%) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Medical therapy | Infrequent pacing? Other comorbidities? | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Single chamber ventricular pacing (class1) | Permanent atrial fibrillation | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Single chamber ventricular pacing | Dual chamber ventricular pacing | ||||||||||||||||||||||||||||||||||||||||||||||||||||
LVEF>50% | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO, Predicted pacing>40% | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Right ventricular pacing (class2a) | Pacing for maintaining physiologic function of left ventricle (class2a) | ||||||||||||||||||||||||||||||||||||||||||||||||||||
His bundle pacing (class2b) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
The above algorithm adopted from 2018 AHA/ACC/HRS Guideline[1] |
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Recommendations for management of bradycardia associated atrioventricular block |
(Class III (Harm), Level of Evidence C): |
❑ Permanent pacing is not recommended in patients with first degree atrioventricular block or mobitz type 1 second degree atrioventricular block (wenchebach), or 2:1 atrioventricular block when the level of block is in atrioventricular node or symptoms are not related to atrioventricular block |
Notes
- Common factors associated with implantation of permanent pacemaker include:
- Symptoms related to atrioventricular bradycardia
- Infranodal atrioventricular block progressing to complete AV block with unstable ventricular scape rhythm
- Side effects of right ventricular pacing
- Permanent pacing may not be effective when the symptoms of dizziness, presyncope, syncope are not related to atrioventricular block in patients with second-degree Mobitz type I (Wenckebach) or 2:1 atrioventricular block.
- Progression of atrioventricular block at the nodal level to higher degree atrioventricular block is unlikely.
- First- and second-degree Mobitz type I (Wenckebach) atrioventricular blocks or 2:1 atrioventricular block are benign if the level of block is at the atrioventricular node.
- Second-degree Mobitz type I (Wenckebach) atrioventricular block is intranodal,implantation of pacemaker may be considered even in the absence of symptoms.
- Narrow QRS complex with then the level of the atrioventricular node block, intranodal during an EPS
First- and second-degree Mobitz type I (Wenckebach) atrioventricular blocks (or 2:1 atrioventricular block, if the level of block is at the atrioventricular node) are typically benign in that they do not progress suddenly to complete heart block.S6.4.1-1,S6.4.1-3 Treatment of these conduction disorders with a pacemaker are typically reserved for significant symptoms that affect QOL. Occasionally second-degree Mobitz type I (Wenckebach) atrioventricular block is in fact infranodal, and in those instances a pacemaker may be considered even in the absence of symptoms.S6.4.1-1 Although a narrow QRS complex suggests that the block is at the level of the atrioventricular node, there are instances where it has been determined to be infranodal during an EPS. Symptoms may be difficult to correlate but ambulatory electrocardiographic monitoring or a treadmill exercise test may be useful. Improvement in atrioventricular conduction suggests that the site of block is at the atrioventricular node, whereas worsening atrioventricular conduction suggests infranodal block. If the symptoms do not clearly correspond to the episodes of atrioventricular block, the risks associated with the pacemaker in the absence of clear benefit make the overall risk-benefit ratio unfavorable.S6.4.1-11 Similarly, in patients with long-standing persistent or permanent AF with a low heart rate and appropriate chronotropic response, in the absence of symptoms, pacing for rate support is unlikely to be beneficial. Although PPM implantation is a relatively low-risk cardiac procedure, procedural complications and death directly related to implant can occur, and implanted leads have long-term management implications
Mobitz I
Indications for implantation of a pacemaker include[2][3][4]:
- Symptomatic bradycardia
- Heart failure
- Asystole for more than 3 sec
- Pseudopacemaker syndrome: Rarely second degree type I AV block can present with symptoms similar to pacemaker syndrome. In such cases placement of a pacemaker is warranted.
Dual chamber DDD pacing mode is usually employed in patients with Mobitz I and symptomatic bradycardia. This mode maintains the normal physiologic synchrony between the atria and the ventricles unlike the single chamber VVI mode.
Mobitz II
- Type II Mobitz (symptomatic or asymptomatic) is by itself an indication for insertion of a pacemaker. Other indications include[5][6]:
- Myotonic dystrophy
- Kearns-Sayre syndrome
- Erb's dystrophy
- Peroneal muscular atrophy. These neuromuscular disorders have a high potential for unpredictable rapid progression to complete heart block.
- Implantation of permanent pacemakers in both asymptomatic and symptomatic patients is usually done. Asymptomatic Mobitz II are prone to be converted to symptomatic or third degree heart block. Thus, they should be considered for a pacemaker even if asymptomatic.
- A dual chamber DDD pacemaker is preferred over a single chambered VVI pacemakers as it maintains physiologic AV synchrony.
- A dual-chamber artificial pacemaker is a type of device that typically listens for a pulse from the SA node and sends a pulse to the AV node at an appropriate interval, essentially completing the connection between the two nodes. Pacemakers in this role are usually programmed to enforce a minimum heart rate and to record instances of atrial flutter and atrial fibrillation.
References
- ↑ Kusumoto, Fred M.; Schoenfeld, Mark H.; Barrett, Coletta; Edgerton, James R.; Ellenbogen, Kenneth A.; Gold, Michael R.; Goldschlager, Nora F.; Hamilton, Robert M.; Joglar, José A.; Kim, Robert J.; Lee, Richard; Marine, Joseph E.; McLeod, Christopher J.; Oken, Keith R.; Patton, Kristen K.; Pellegrini, Cara N.; Selzman, Kimberly A.; Thompson, Annemarie; Varosy, Paul D. (2019). "2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". Circulation. 140 (8). doi:10.1161/CIR.0000000000000628. ISSN 0009-7322.
- ↑ Shigematsu-Locatelli M, Kawano T, Nishigaki A, Yamanaka D, Aoyama B, Tateiwa H, Kitaoka N, Yokoyama M (2017). "General anesthesia in a patient with asymptomatic second-degree two-to-one atrioventricular block". JA Clin Rep. 3 (1): 27. doi:10.1186/s40981-017-0099-0. PMC 5804611. PMID 29457071.
- ↑ Dhingra RC, Palileo E, Strasberg B, Swiryn S, Bauernfeind RA, Wyndham CR, Rosen KM (December 1981). "Significance of the HV interval in 517 patients with chronic bifascicular block". Circulation. 64 (6): 1265–71. doi:10.1161/01.cir.64.6.1265. PMID 7296798.
- ↑ Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, Cleland J, Deharo JC, Delgado V, Elliott PM, Gorenek B, Israel CW, Leclercq C, Linde C, Mont L, Padeletti L, Sutton R, Vardas PE, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Kirchhof P, Blomstrom-Lundqvist C, Badano LP, Aliyev F, Bänsch D, Baumgartner H, Bsata W, Buser P, Charron P, Daubert JC, Dobreanu D, Faerestrand S, Hasdai D, Hoes AW, Le Heuzey JY, Mavrakis H, McDonagh T, Merino JL, Nawar MM, Nielsen JC, Pieske B, Poposka L, Ruschitzka F, Tendera M, Van Gelder IC, Wilson CM (August 2013). "2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA)". Eur. Heart J. 34 (29): 2281–329. doi:10.1093/eurheartj/eht150. PMID 23801822.
- ↑ Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD (August 2019). "2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". J. Am. Coll. Cardiol. 74 (7): e51–e156. doi:10.1016/j.jacc.2018.10.044. PMID 30412709.
- ↑ Strasberg B, Amat-Y-Leon F, Dhingra RC, Palileo E, Swiryn S, Bauernfeind R, Wyndham C, Rosen KM (May 1981). "Natural history of chronic second-degree atrioventricular nodal block". Circulation. 63 (5): 1043–9. doi:10.1161/01.cir.63.5.1043. PMID 7471363.