Third degree AV block surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Raviteja Guddeti, M.B.B.S. [4] Soroush Seifirad, M.D.[5] Qasim Khurshid, M.B.B.S [5]
Overview
Cardiac pacemakers are effective treatments for a variety of cardiac conduction abnormalities and can reestablish adequate circulation by generating appropriate heart rate and cardiac response. Two main factors guide the majority of decisions regarding permanent pacemaker insertion. First is the association of symptoms with arrhythmia, and second is the potential for progression of the rhythm disturbance. Symptoms related to atrioventricular block are determining factor of placing permanent pacemaker, regardless of the level of atrioventricular block. Permanent pacemaker is warranted if the site of atrioventricular block is Infranodal, regardless of the presence or absence of symptoms. Temporary transvenous pacing is used to provide hemodynamic support or back-up pacing to prevent asystole. If atrioventricular block seems to be irreversible, it is better to proceed directly with permanent pacemaker implantation.
Surgery
- A permanent pacemaker insertion is a minimally invasive procedure.
- The procedure is typically performed in a cardiac catheterization lab or an operating room.
- Transvenous access to the heart chambers under local anesthesia is the preferred technique, most commonly via the subclavian vein, the cephalic vein, or the internal jugular vein or the femoral vein.
- The pacing generator is most commonly placed subcutaneously in the pre-pectoral region.
- Placement of pacemaker leads, surgically via thoracotomy, is rarely used these days.
- Factors associated implantation of permanent pacemaker that should be noticed include:
- Symptoms related to bradycardia ( major determinant)
- Site of atrioventricular block including infranodal atrioventricular block and risk of progression to complete heart block due to unstable ventricular scape rhythm
- Side effects of high burden of right ventricular pacing
- Concomitant systemic disease as a potential risk of atrioventricular block or ventricular arrhythmia
Recommendation for implantation of temporary pacing for bradycardia associated atrioventricular block
| Recommendations for temporary pacing for bradycardia associated atrioventricular block |
| Medical therapy (Class IIa, Level of Evidence B): |
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❑ In patients with symptomatic bradycardia associated second or third degree atrioventricular block, refractory to medications, temporary transvenous pacing is recommended to increase heart rate and improve symptoms |
Comment
- Temporary transvenous pacing is used to provide hemodynamic support or back-up pacing to prevent asystole.
- If atrioventricular block seems to be irreversible, it is better to proceed directly with permanent pacemaker implantation.
- When transvenous pacing wires left in place for a longer duration (>48 hours), the likelihood of complications increases.[2]
- Transcutaneous pacing is used as a short-term bridge to temporary or permanent transvenous pacing or the resolution of bradycardia.
- There is no survival benefit to hospital discharge when transcutaneous pacing is used in the prehospital phase of bradyasystolic cardiac arrest. [3]
- Due to high capture thresholds and patient discomfort, transcutaneous pacing is poorly tolerated for prolonged use.
Recommendation for placement of permanent pacing
| Recommendations for permanent pacing for chronic management of Bradycardia Attributable to Atrioventricular Block |
| (Class I, Level of Evidence B): |
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❑Permanent pacing is recommended in patients with acquired second degree mobitz type2 atrioventricular block, high grade atrioventricular block, third degree atrioventricular block, regardless of symptoms that are not related to reversible causes |
| ( Class I, Level of Evidence C) : |
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❑ Permanent pacing is recommended in patients with permanent atrial fibrillation and symptomatic bradycardia |
| (Class IIa, Level of Evidence B) |
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❑ In patients with cardiac sarcoidosis and amyloidosis and evidence of mobitz type 2 atrioventricular block, high grade atrioventricular block, third degree atrioventricular block , permanent pacing with additional defibrillator capacity is reasonable if life expectancy>1 year |
| (Class IIa, Level of Evidence C) |
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❑ In patients with symptomatic first degree atrioventricular block or motitz tyoe 1 atrioventricular block, permanent pacing is recommended |
| (Class IIb, Level of Evidence C) |
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❑ Permanent pacing with additional defibrillator capacity is recommended in patients with neuromuscular disease including myotonic dystrophy type1 with PR interval >240ms , QRS duration >120 ms, fascicular block if life expectancy>1 year |
| The above table adopted from 2018 AHA/ACC/HRS Guideline[1] |
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Notes
- Symptoms related to atrioventricular block are determining factor of placing permanent pacemaker, regardless of the level of atrioventricular block.
- Permanent pacemaker is warranted if the site of atrioventricular block is Infranodal, regardless of the presence or absence of symptoms.[4]
- Varied degree of atrioventricular block from first degree atrioventricular block to complete atrioventricular block may develope over the time in neuromuscular disorders such as muscular dystrophies or Kearns-Sayre syndrome.[5]
- Intermittent second-degree or third-degree atrioventricular block on 24-hour ambulatory electrocardiographic monitoring or atrioventricular block on resting ECG was found in 20% of patients with myotonic dystrophy type 1.
- In the presence of atrial fibrillation and slow regular ventricular response and wide QRS and pauses >3 seconds, infranodal atrioventricular block may be suspected. [6]
- Atrioventricular block may develop by using betablocker for MI or heartfailure and amiodarone and sotalol for atrial fibrillation patients.
- The benefit of using these medications should be balanced over the side effects of right ventricular pacing.[7]
- Atrioventricular block in the setting of cardiac sarcoidosis may resolve by using corticosteroids for 30 days.[8]
- Evidence of prolonged HV interval (>55 ms) despite a narrow QRS was found in AL cardiac amyloidosis.
- Mutations in the lamin A/C gene can present with atrioventricular block, atrial arrhythmias, and ventricular arrhythmia.[9]
- Risk of atrioventricular block and sudden cardiac death may increase in the setting of lamin A/C mutation.
- In one study, the risk of ventricular arrhythmias increased in the presence of first-degree atrioventricular block in lamin A/C mutation.[10]
- Pseudo-pacemaker syndrome may develop in the setting of severe first-degree atrioventricular block with very long PR interval , atrial contraction during the closed atrioventricular valves leading to an increase in wedge pressure and a decrease in cardiac output.[11]
Management of bradycardia or pauses attributable to chronic atrioventricular block algorithm
| Atrioventricular block | |||||||||||||||||||||||||||||||
Complete heart block (aquired)
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| Permanent pacing (class1) | |||||||||||||||||||||||||||||||
| Consider risk for ventricular arrhythmia (class1) | |||||||||||||||||||||||||||||||
Cardiac resynchronization therapy
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NO
| Yes
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Yes
| N0
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Yes
| NO
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| LVEF>50% | |||||||||||||||||||||||||||||||
Yes
| NO
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NO
| Yes
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| His bundle pacing (class2b) | |||||||||||||||||||||||||||||||
| The above algorithm adopted from 2018 AHA/ACC/HRS Guideline[1] |
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Methods of implantation permanent pacing
- Common side effects of right ventricular pacing include ventricular dysfunction or heart failure symptoms.
- Lower baseline LVEF and a higher percentage of RV pacing may predict RV pacing cardiomyopathy.[12]
- Risk of RV pacing-induced cardiomyopathy increases when RV pacing exceeds 40% or perhaps as low as 20%.
- CRT-P reduced left ventricular end-systolic volume and improved LVEF in comparison with RV pacing in patients with relatively preserved LVEF and LVEF<35%.[13]
- His bundle pacing was associated with a significant decrease in heart failure hospitalizations when ventricular pacing >20% compared with RV pacing.[14][15]
- Among patients with AF who undergo atrioventricular node ablation to control rapid ventricular rates, implantation of physiologic pacing (CRT or His bundle) was associated with improvement in 6-minute walk distances and quality of life compared with RV pacing.[16]
- In patients with permanent AF when rhythm control is not planned , pacing and sensing of atrium is not recommended.[17]
| Recommendations for permanent pacing techniques and methods for bradycardia associated atrioventricular block |
| (Class I, Level of Evidence A): |
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❑ In patients with sinus node dysfunction or atrioventricular block, dual chamber permanent pacing is preferred over single chamber ventricular pacing |
| (Class I, Level of Evidence B): |
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❑ In the presence of pacemaker syndrome in single chamber pace maker, revising single chamber pace maker to dual chamber pacemaker is recommended |
| (Class IIa, Level of Evidence B): |
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❑Cardiac resynchronization therapy or His bundle pacing over right ventricular pacing is recommended in patients with LVEF between 36% -50 % who need more than 40% ventricular pacing |
| (Class IIb, Level of Evidence B): |
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❑ In patients with atrioventricular block at the level of atrioventricular node, His bundle pacing may be considered for maintaining physiologic activation of ventricle |
| (Class III, Level of Evidence C): |
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❑ For patients with permanent or persistent AF when the strategy of rhythm control is not planned, atrial lead should not be implanted |
References
- ↑ 1.0 1.1 1.2 1.3 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.
- ↑ Murphy JJ (May 1996). "Current practice and complications of temporary transvenous cardiac pacing". BMJ. 312 (7039): 1134. doi:10.1136/bmj.312.7039.1134. PMC 2350635. PMID 8620131.
- ↑ Morrison LJ, Long J, Vermeulen M, Schwartz B, Sawadsky B, Frank J, Cameron B, Burgess R, Shield J, Bagley P, Mausz V, Brewer JE, Dorian P (March 2008). "A randomized controlled feasibility trial comparing safety and effectiveness of prehospital pacing versus conventional treatment: 'PrePACE'". Resuscitation. 76 (3): 341–9. doi:10.1016/j.resuscitation.2007.08.008. PMC 7126680 Check
|pmc=value (help). PMID 17933452. - ↑ Shaw DB, Kekwick CA, Veale D, Gowers J, Whistance T (June 1985). "Survival in second degree atrioventricular block". Br Heart J. 53 (6): 587–93. doi:10.1136/hrt.53.6.587. PMC 481819. PMID 4005079.
- ↑ Facenda-Lorenzo M, Hernández-Afonso J, Rodríguez-Esteban M, de León-Hernández JC, Grillo-Pérez JJ (March 2013). "Cardiac manifestations in myotonic dystrophy type 1 patients followed using a standard protocol in a specialized unit". Rev Esp Cardiol (Engl Ed). 66 (3): 193–7. doi:10.1016/j.rec.2012.08.011. PMID 24775453.
- ↑ Dhingra RC, Denes P, Wu D, Chuquimia R, Rosen KM (April 1974). "The significance of second degree atrioventricular block and bundle branch block. Observations regarding site and type of block". Circulation. 49 (4): 638–46. doi:10.1161/01.cir.49.4.638. PMID 4817704.
- ↑ Dargie HJ (September 2000). "Design and methodology of the CAPRICORN trial - a randomised double blind placebo controlled study of the impact of carvedilol on morbidity and mortality in patients with left ventricular dysfunction after myocardial infarction". Eur J Heart Fail. 2 (3): 325–32. doi:10.1016/s1388-9842(00)00098-2. PMID 10938495.
- ↑ Zhou Y, Lower EE, Li HP, Costea A, Attari M, Baughman RP (January 2017). "Cardiac Sarcoidosis: The Impact of Age and Implanted Devices on Survival". Chest. 151 (1): 139–148. doi:10.1016/j.chest.2016.08.1457. PMID 27614001.
- ↑ van Rijsingen IA, Nannenberg EA, Arbustini E, Elliott PM, Mogensen J, Hermans-van Ast JF, van der Kooi AJ, van Tintelen JP, van den Berg MP, Grasso M, Serio A, Jenkins S, Rowland C, Richard P, Wilde AA, Perrot A, Pankuweit S, Zwinderman AH, Charron P, Christiaans I, Pinto YM (April 2013). "Gender-specific differences in major cardiac events and mortality in lamin A/C mutation carriers". Eur J Heart Fail. 15 (4): 376–84. doi:10.1093/eurjhf/hfs191. PMID 23183350.
- ↑ Hasselberg NE, Edvardsen T, Petri H, Berge KE, Leren TP, Bundgaard H, Haugaa KH (April 2014). "Risk prediction of ventricular arrhythmias and myocardial function in Lamin A/C mutation positive subjects". Europace. 16 (4): 563–71. doi:10.1093/europace/eut291. PMID 24058181.
- ↑ Lader JM, Park D, Aizer A, Holmes D, Chinitz LA, Barbhaiya CR (March 2018). "Slow pathway modification for treatment of pseudo-pacemaker syndrome due to first-degree atrioventricular block with dual atrioventricular nodal physiology". HeartRhythm Case Rep. 4 (3): 98–101. doi:10.1016/j.hrcr.2017.10.003. PMC 5919070. PMID 29707483.
- ↑ Dretzke J, Toff WD, Lip GY, Raftery J, Fry-Smith A, Taylor R (2004). "Dual chamber versus single chamber ventricular pacemakers for sick sinus syndrome and atrioventricular block". Cochrane Database Syst Rev (2): CD003710. doi:10.1002/14651858.CD003710.pub2. PMC 8095057 Check
|pmc=value (help). PMID 15106214. - ↑ Brignole M, Botto G, Mont L, Iacopino S, De Marchi G, Oddone D, Luzi M, Tolosana JM, Navazio A, Menozzi C (October 2011). "Cardiac resynchronization therapy in patients undergoing atrioventricular junction ablation for permanent atrial fibrillation: a randomized trial". Eur Heart J. 32 (19): 2420–9. doi:10.1093/eurheartj/ehr162. PMID 21606084.
- ↑ Lustgarten DL, Crespo EM, Arkhipova-Jenkins I, Lobel R, Winget J, Koehler J, Liberman E, Sheldon T (July 2015). "His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: A crossover design comparison". Heart Rhythm. 12 (7): 1548–57. doi:10.1016/j.hrthm.2015.03.048. PMID 25828601.
- ↑ Kronborg MB, Mortensen PT, Poulsen SH, Gerdes JC, Jensen HK, Nielsen JC (August 2014). "His or para-His pacing preserves left ventricular function in atrioventricular block: a double-blind, randomized, crossover study". Europace. 16 (8): 1189–96. doi:10.1093/europace/euu011. PMID 24509688.
- ↑ Vijayaraman P, Subzposh FA, Naperkowski A (December 2017). "Atrioventricular node ablation and His bundle pacing". Europace. 19 (suppl_4): iv10–iv16. doi:10.1093/europace/eux263. PMID 29220422.
- ↑ Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, Kutalek SP, Sharma A (December 2002). "Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial". JAMA. 288 (24): 3115–23. doi:10.1001/jama.288.24.3115. PMID 12495391.