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]


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.


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):

❑ 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


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):

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
permanent pacing with additional defibrillator capacity is needed in patients with neuromuscular disease associated conduction disorder such as myotonic dystrophy type1 or kearn sayre syndrome and presence of second degree atrioventricular block, third degree atioventricular block, HV interval of 70 ms or greater, regardless of symptoms if life expectancy>1 year

( Class I, Level of Evidence C) :

Permanent pacing is recommended in patients with permanent atrial fibrillation and symptomatic bradycardia
❑ In patients with symptomatic atrioventricular block associated with necessary medications which there is not alternative treatment, permanent pacing is needed

(Class IIa, Level of Evidence B)

❑ 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
❑ In patients with lamin A/C mutation such as limb girdle, emery driefuss muscular dystrophies with PR interval>240 ms and LBBB, permanent pacing with additional defibrillator capacity is reasonable if life expectancy >1 year

(Class IIa, Level of Evidence C)

❑ In patients with symptomatic first degree atrioventricular block or motitz tyoe 1 atrioventricular block, permanent pacing is recommended

(Class IIb, Level of Evidence C)

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]


Management of bradycardia or pauses attributable to chronic atrioventricular block algorithm

Atrioventricular block
Complete heart block (aquired)
Permanent pacing (class1)
Consider risk for ventricular arrhythmia (class1)
Cardiac resynchronization therapy
  • Is LVEF<35%?
  • Medical therapy
  • Permanent atrial fibrillation
  • Dual chamber pacing (class1)
  • Is predicted pacing <40%
  • Righr ventricular pacing (class2a)
    His bundle pacing (class2b)

    The above algorithm adopted from 2018 AHA/ACC/HRS Guideline[1]

    Methods of implantation permanent pacing

    Recommendations for permanent pacing techniques and methods for bradycardia associated atrioventricular block
    (Class I, Level of Evidence A):

    ❑ In patients with sinus node dysfunction or atrioventricular block, dual chamber permanent pacing is preferred over single chamber ventricular pacing
    Single chamber ventricular pacing is recommended in patients with No need for frequent pacing, significant comorbidities, NO clinical benefit of dual chamber pacing

    (Class I, Level of Evidence B):

    ❑ 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):

    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
    Right ventricular pacing is recommended over CRT or His bundle pacing in patients with LVEF between 36%-50% who require less than 40% ventricular pacing

    (Class IIb, Level of Evidence B):

    ❑ 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):

    ❑ For patients with permanent or persistent AF when the strategy of rhythm control is not planned, atrial lead should not be implanted



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