Atrioventricular block surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2], Hardik Patel, M.D.

Overview

Pacemaker insertion is a surgical procedure performed under local anesthesia in an electrophysiologic laboratory. Temporary transcutaneous or transvenous pacemaker insertion is the treatment of choice for all AV blocks.

Surgery

Complications

Complications of a pacemaker include:

Lifestyle Modifications

  • Avoid contact sports.
  • Restricted weight lifting for the first 4 to 6 weeks.
  • Avoid electromagnetic fields from powerful electric lines which may interfere with the functioning of the pacemaker and slow it down.

Follow-up

  • Follow-up with a cardiologist is indicated to look for development of complications of pacemaker insertion and also in case of unexplained syncope suggesting progression of the heart block.

2012 ACC/AHA/HRS Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities (DO NOT EDIT)[1][2]

Acquired Atrioventricular Block in Adults (DO NOT EDIT)[2]

Class I
"1. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with bradycardia with symptoms (including heart failure) or ventricular arrhythmias presumed to be due to AV block. (Level of Evidence: C)[3][4][5][6]"
2. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with arrhythmias and other medical conditions that require drug therapy that results in symptomatic bradycardia. (Level of Evidence: C)[3][4][5][6]"
"3. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level in awake, symptom-free patients in sinus rhythm, with documented periods of asystole greater than or equal to 3.0 seconds[7]) or any escape rate less than 40 bpm, or with an escape rhythm that is below the AV node. (Level of Evidence: C)[8][9]"
"4. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level in awake, symptom-free patients with atrial fibrillation and bradycardia with 1 or more pauses of at least 5 seconds or longer. (Level of Evidence: C)"
"5. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level after catheter ablation of the AV junction. (Level of Evidence: C)[10][11]"
"6. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with postoperative AV block that is not expected to resolve after cardiac surgery. (Level of Evidence: C)[6][12][13][14]"

"7. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with neuromuscular diseases with AV block, such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy, with or without symptoms. (Level of Evidence: B)[15][16][17][18][19][20][21]"

"8. Permanent pacemaker implantation is indicated for second-degree AV block with associated symptomatic bradycardia regardless of type or site of block. (Level of Evidence: B)[22]"
"9. Permanent pacemaker implantation is indicated for asymptomatic persistent third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster if cardiomegaly or left ventricular (LV) dysfunction is present or if the site of block is below the AV node. (Level of Evidence: B)[5][23]"
"10. Permanent pacemaker implantation is indicated for second- or third-degree AV block during exercise in the absence of myocardial ischemia. (Level of Evidence: C)[24]"
Class III (No Benefit)
"1. Permanent pacemaker implantation is not indicated for asymptomatic first-degree AV block. (Level of Evidence: B)[25]"
2. Permanent pacemaker implantation is not indicated for asymptomatic type I second-degree AV block at the supra-His (AV node) level or that which is not known to be intra- or infra-Hisian. (Level of Evidence: C)[22]"
3. Permanent pacemaker implantation is not indicated for AV block that is expected to resolve and is unlikely to recur[26] (e.g., drug toxicity, Lyme disease, or transient increases in vagal tone, or during hypoxia in sleep apnea syndrome in the absence of symptoms). (Level of Evidence: B)[27][26]"
Class IIa
"1. Permanent pacemaker implantation is reasonable for persistent third-degree AV block with an escape rate greater than 40 bpm in asymptomatic adult patients without cardiomegaly. (Level of Evidence: C)[3][4][5][6][28]"
2. Permanent pacemaker implantation is reasonable for asymptomatic second-degree AV block at intra- or infra- His levels found at electrophysiological study. (Level of Evidence: B)[5][22][23]"
3. Permanent pacemaker implantation is reasonable for first- or second-degree AV block with symptoms similar to those of pacemaker syndrome or hemodynamic compromise. (Level of Evidence: B)[29][30]"
4. Permanent pacemaker implantation is reasonable for asymptomatic type II second-degree AV block with a narrow QRS. When type II second-degree AV block occurs with a wide QRS, including isolated right bundle-branch block, pacing becomes a Class I recommendation. (Level of Evidence: B)[5][6][29][31]"
Class IIb
"1. Permanent pacemaker implantation may be considered for neuromuscular diseases such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy with any degree of AV block (including first-degree AV block), with or without symptoms, because there may be unpredictable progression of AV conduction disease. (Level of Evidence: B)[15][16][17][18][19][20][21]"
2. Permanent pacemaker implantation may be considered for AV block in the setting of drug use and/or drug toxicity when the block is expected to recur even after the drug is withdrawn. (Level of Evidence: B)[32][27]"

Sources

  • The ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities [2]

References

  1. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NA, Ferguson TB, Hammill SC, Karasik PE, Link MS, Marine JE, Schoenfeld MH, Shanker AJ, Silka MJ, Stevenson LW, Stevenson WG, Varosy PD (2013). "2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". J. Am. Coll. Cardiol. 61 (3): e6–75. doi:10.1016/j.jacc.2012.11.007. PMID 23265327.
  2. 2.0 2.1 2.2 Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207
  3. 3.0 3.1 3.2 Dreifus LS, Michelson EL, Kaplinsky E (1983). "Bradyarrhythmias: clinical significance and management". J Am Coll Cardiol. 1 (1): 327–38. PMID 6826942.
  4. 4.0 4.1 4.2 FRIEDBERG CK, DONOSO E, STEIN WG (1964). "NONSURGICAL ACQUIRED HEART BLOCK". Ann N Y Acad Sci. 111: 835–47. PMID 14206803.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 "Recommendations for pacemaker prescription for symptomatic bradycardia. Report of a working party of the British Pacing and Electrophysiology Group". Br Heart J. 66 (2): 185–91. 1991. PMC 1024617. PMID 1883673.
  6. 6.0 6.1 6.2 6.3 6.4 Kastor JA (1975). "Atrioventricular block (first of two parts)". N Engl J Med. 292 (9): 462–5. doi:10.1056/NEJM197502272920906. PMID 1089890.
  7. Ector H, Rolies L, De Geest H (1983). "Dynamic electrocardiography and ventricular pauses of 3 seconds and more: etiology and therapeutic implications". Pacing Clin Electrophysiol. 6 (3 Pt 1): 548–51. PMID 6191291.
  8. Kay R, Estioko M, Wiener I (1982). "Primary sick sinus syndrome as an indication for chronic pacemaker therapy in young adults: incidence, clinical features, and long-term evaluation". Am Heart J. 103 (3): 338–42. PMID 6461235.
  9. Shaw DB, Holman RR, Gowers JI (1980). "Survival in sinoatrial disorder (sick-sinus syndrome)". Br Med J. 280 (6208): 139–41. PMC 1600350. PMID 7357290.
  10. Gallagher JJ, Svenson RH, Kasell JH, German LD, Bardy GH, Broughton A; et al. (1982). "Catheter technique for closed-chest ablation of the atrioventricular conduction system". N Engl J Med. 306 (4): 194–200. doi:10.1056/NEJM198201283060402. PMID 7054682.
  11. Langberg JJ, Chin MC, Rosenqvist M, Cockrell J, Dullet N, Van Hare G; et al. (1989). "Catheter ablation of the atrioventricular junction with radiofrequency energy". Circulation. 80 (6): 1527–35. PMID 2598419.
  12. Glikson M, Dearani JA, Hyberger LK, Schaff HV, Hammill SC, Hayes DL (1997). "Indications, effectiveness, and long-term dependency in permanent pacing after cardiac surgery". Am J Cardiol. 80 (10): 1309–13. PMID 9388104.
  13. Kim MH, Deeb GM, Eagle KA, Bruckman D, Pelosi F, Oral H; et al. (2001). "Complete atrioventricular block after valvular heart surgery and the timing of pacemaker implantation". Am J Cardiol. 87 (5): 649–51, A10. PMID 11230857.
  14. Koplan BA, Stevenson WG, Epstein LM, Aranki SF, Maisel WH (2003). "Development and validation of a simple risk score to predict the need for permanent pacing after cardiac valve surgery". J Am Coll Cardiol. 41 (5): 795–801. PMID 12628725.
  15. 15.0 15.1 Perloff JK, Stevenson WG, Roberts NK, Cabeen W, Weiss J (1984). "Cardiac involvement in myotonic muscular dystrophy (Steinert's disease): a prospective study of 25 patients". Am J Cardiol. 54 (8): 1074–81. PMID 6496328.
  16. 16.0 16.1 Hiromasa S, Ikeda T, Kubota K, Hattori N, Nishimura M, Watanabe Y; et al. (1987). "Myotonic dystrophy: ambulatory electrocardiogram, electrophysiologic study, and echocardiographic evaluation". Am Heart J. 113 (6): 1482–8. PMID 3591615.
  17. 17.0 17.1 Stevenson WG, Perloff JK, Weiss JN, Anderson TL (1990). "Facioscapulohumeral muscular dystrophy: evidence for selective, genetic electrophysiologic cardiac involvement". J Am Coll Cardiol. 15 (2): 292–9. PMID 2299071.
  18. 18.0 18.1 JAMES TN, FISCH C (1963). "OBSERVATIONS ON THE CARDIOVASCULAR INVOLVEMENT IN FRIEDREICH'S ATAXIA". Am Heart J. 66: 164–75. PMID 14051182.
  19. 19.0 19.1 Roberts NK, Perloff JK, Kark RA (1979). "Cardiac conduction in the Kearns-Sayre syndrome (a neuromuscular disorder associated with progressive external ophthalmoplegia and pigmentary retinopathy). Report of 2 cases and review of 17 published cases". Am J Cardiol. 44 (7): 1396–400. PMID 506943.
  20. 20.0 20.1 Charles R, Holt S, Kay JM, Epstein EJ, Rees JR (1981). "Myocardial ultrastructure and the development of atrioventricular block in Kearns-Sayre syndrome". Circulation. 63 (1): 214–9. PMID 7438396.
  21. 21.0 21.1 JAMES TN (1962). "Observations on the cardiovascular involvement, including the cardiac conduction system, in progressive muscular dystrophy". Am Heart J. 63: 48–56. PMID 14451031.
  22. 22.0 22.1 22.2 Strasberg B, Amat-Y-Leon F, Dhingra RC, Palileo E, Swiryn S, Bauernfeind R; et al. (1981). "Natural history of chronic second-degree atrioventricular nodal block". Circulation. 63 (5): 1043–9. PMID 7471363.
  23. 23.0 23.1 Shaw DB, Kekwick CA, Veale D, Gowers J, Whistance T (1985). "Survival in second degree atrioventricular block". Br Heart J. 53 (6): 587–93. PMC 481819. PMID 4005079.
  24. Chokshi SK, Sarmiento J, Nazari J, Mattioni T, Zheutlin T, Kehoe R (1990). "Exercise-provoked distal atrioventricular block". Am J Cardiol. 66 (1): 114–6. PMID 2360528.
  25. Mymin D, Mathewson FA, Tate RB, Manfreda J (1986). "The natural history of primary first-degree atrioventricular heart block". N Engl J Med. 315 (19): 1183–7. doi:10.1056/NEJM198611063151902. PMID 3762641.
  26. 26.0 26.1 McAlister HF, Klementowicz PT, Andrews C, Fisher JD, Feld M, Furman S (1989). "Lyme carditis: an important cause of reversible heart block". Ann Intern Med. 110 (5): 339–45. PMID 2644885.
  27. 27.0 27.1 Shohat-Zabarski R, Iakobishvili Z, Kusniec J, Mazur A, Strasberg B (2004). "Paroxysmal atrioventricular block: clinical experience with 20 patients". Int J Cardiol. 97 (3): 399–405. doi:10.1016/j.ijcard.2003.10.023. PMID 15561325.
  28. GADBOYS HL, WISOFF G, LITWAK RS (1964). "SURGICAL TREATMENT OF COMPLETE HEART BLOCK. AN ANALYSIS OF 36 CASES". JAMA. 189: 97–102. PMID 14149997.
  29. 29.0 29.1 Barold SS (1996). "Indications for permanent cardiac pacing in first-degree AV block: class I, II, or III?". Pacing Clin Electrophysiol. 19 (5): 747–51. PMID 8734740.
  30. Kim YH, O'Nunain S, Trouton T, Sosa-Suarez G, Levine RA, Garan H; et al. (1993). "Pseudo-pacemaker syndrome following inadvertent fast pathway ablation for atrioventricular nodal reentrant tachycardia". J Cardiovasc Electrophysiol. 4 (2): 178–82. PMID 8269289.
  31. Zipes DP (1979). "Second-degree atrioventricular block". Circulation. 60 (3): 465–72. PMID 378457.
  32. Zeltser D, Justo D, Halkin A, Rosso R, Ish-Shalom M, Hochenberg M; et al. (2004). "Drug-induced atrioventricular block: prognosis after discontinuation of the culprit drug". J Am Coll Cardiol. 44 (1): 105–8. doi:10.1016/j.jacc.2004.03.057. PMID 15234417.

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