Second degree AV block surgery: Difference between revisions

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{{Second degree AV block}}
{{Second degree AV block}}
{{CMG}}; {{AE}} {{CZ}}
{{CMG}}; {{AE}} {{Sara.Zand}} [[User:Mohammed Salih|Mohammed Salih, M.D.]], {{CZ}}; {{RT}}


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==Overview==
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. So, [[patients]] should be continuously monitored with [[transcutaneous pacing]] pads in place in the event of [[clinical]] deterioration. While stable [[patients]] are being monitored, reversible causes of Mobitz type II second degree [[AV block]] such as [[myocardial ischemia]], increased [[vagal]] tone, [[hypothyroidism]], [[hyperkalemia]], and [[drugs]] that depress conduction, should be excluded in [[patients]] prior to implantation of a [[permanent pacemaker]]. If no reversible causes are present, definitive treatment of Mobitz type II second degree AV block involves [[permanent pacemaker]] placement in most [[patients]]. There is no benefit of implantation of [[permanent pacacemaker]] in [[patients]] with long-standing [[asymptomatic]] persistent or [[permanent]] [[atrial fibrillation]] with a [[low heart rate]] and appropriate [[chronotropic]] response.


==Surgery==
==Surgery==
===Mobitz I===
===Management of [[bradycardia]] attributable to [[atrioventricular block]]===
Indications for implantation of pacemaker include:
{{Family tree/start}}
* Symptomatic [[bradycardia]]
{{Family tree| | | | | A01 | | | |A01= [[AV block]]}}
* 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.
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | A02 | | | | A03 |A03= [[Mobitz type2 block]], evidence of [[infranodal block]]| A02= [[Mobitz type1 block]]}}
{{Family tree| | |!| | | | | |!| | | | | | | | | | | | | |}}
{{Family tree| |  A4 | | | |  A5 | |A4=[[Symtoms]]|A5=[[Permanent pacing ]] (class1)}}
{{Family tree| |,|^|-|.| | | | |:| |}}
{{Family tree| A6| |A7 | | |:| | | |A6=Yes|A7=NO}}
{{Family tree| |!| | |!| | | | |:| |}}
{{Family tree|A8 | | A9| | |:| | | |A8=[[Permanent pacing ]] (class1)|A9=[[Neuromascular disease]] associated with progressive conduction [[disorder]]}}
{{Family tree|:| | |,|^|-|.| | |:| |}}
{{Family tree|:| |B1 | |  B2 |:| | |B1=Yes |B2=NO}}
{{Family tree|:| |!| | | |!| | |:| | |}}
{{Family tree|:| |B3 | | B4|:| | | |B3=[[Permanent pacing]] (class1)|B4=Observation}}
{{Family tree|:| |:| | | |!| | |:| |}}
{{Family tree|:| |:| | | B5| |:| | |B5=[[Permanent pacing]] (class3), Harm}}
{{Family tree|`|-|^|-|-|-|^|-|-|'|}}
{{Family tree| | | | | | |!| | | |}}
{{Family tree| | | | | | | B6| | | |B6=Risk of [[ventricular arrhythmia]], [[heart failure symptoms]]([[LVEF]]<35%)}}
{{Family tree| | | | | | |,|^|-|.|}}
{{Family tree| | | | | |B7 | | B8| |B7=Yes|B8=NO}}
{{Family tree| | | | | |!| | | |!| |}}
{{Family tree| | | | | |B9 | |B10| | |B9=[[Medical therapy]] |B10=Infrequent pacing? Other [[comorbidities]]?}}
{{Family tree| | | | | | | | |,|^|-|-|-|-|.|}}
{{Family tree| | | | | | | | |C1 | |C2 |C1=Yes|C2=NO}}
{{Family tree| | | | | | | | |!| | | |!| | |}}
{{Family tree| | | | | | | | C3| | C4| | |C3=Single chamber [[ventricular]] [[pacing]] (class1)|C4= Permanent [[atrial fibrillation]]}}
{{Family tree| | | | | | | | | | |,|^|-|.| |}}
{{Family tree| | | | | | | | | | C5| | C6| | |C5=Yes|C6=NO}}
{{Family tree| | | | | | | | | | |!| | |!| | | |}}
{{Family tree| | | | | | | | | |C7 | | C8| |C7=Single chamber [[ventricular]] [[pacing]]|C8=Dual chamber [[ventricular]] [[pacing]]}}
{{Family tree| | | | | | | | | |`|-|^|-|'| | | | |}}
{{Family tree| | | | | | | | | | | |!| | | | | | |}}
{{Family tree| | | | | | | | | | | C9| | | | | | | | | | | | |C9=[[LVEF]]>50% |}}
{{Family tree| | | | | | | | | | |,|^|.| | | | | | | |}}
{{Family tree| | | | | | | | | C10 | | C11 | | | | | | | | | | |C10=Yes |C11=NO, Predicted pacing>40%| | }}
{{Family tree| | | | | | | | | |!| | | |!| | | | | | | }}
{{Family tree| | | | | | | | | C12 | |  C13| | | | | | | |C12=[[Right ventricular]] [[pacing]] (class2a)|C13=[[Pacing]] for maintaining [[physiologic]] function of [[left ventricle]] (class2a) }}
{{Family tree| | | | | | | | | | | | | |!| | | | | | | |}}
{{Family tree| | | | | | | | | | | | | |C14| | | | | | | C14=[[His bundle]] [[pacing]] (class2b)|}}
{{Family tree/end}}


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.
<br>
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2018 AHA/ACC/HRS Guideline<ref name="KusumotoSchoenfeld2019">{{cite journal|last1=Kusumoto|first1=Fred M.|last2=Schoenfeld|first2=Mark H.|last3=Barrett|first3=Coletta|last4=Edgerton|first4=James R.|last5=Ellenbogen|first5=Kenneth A.|last6=Gold|first6=Michael R.|last7=Goldschlager|first7=Nora F.|last8=Hamilton|first8=Robert M.|last9=Joglar|first9=José A.|last10=Kim|first10=Robert J.|last11=Lee|first11=Richard|last12=Marine|first12=Joseph E.|last13=McLeod|first13=Christopher J.|last14=Oken|first14=Keith R.|last15=Patton|first15=Kristen K.|last16=Pellegrini|first16=Cara N.|last17=Selzman|first17=Kimberly A.|last18=Thompson|first18=Annemarie|last19=Varosy|first19=Paul D.|title=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|journal=Circulation|volume=140|issue=8|year=2019|issn=0009-7322|doi=10.1161/CIR.0000000000000628}}</ref>
|-
|}


===Mobitz II===
 
* Type II Mobitz is by itself an indication for insertion of a pacemaker. Other indications include:
 
** [[Myotonic dystrophy]]
 
** [[Kearns-Sayre syndrome]]
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
** [[Erb's dystrophy]]
|-
** [[Peroneal muscular atrophy]]
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of bradycardia associated atrioventricular 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.
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''  ([[ACC AHA guidelines classification scheme|Class III (Harm), Level of Evidence C]]):'''
* 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]].
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Permanent pacing]] is not recommended in [[patients]] with [[First-degree atrioventricular block]] or [[mobitz]] type 1 second degree [[atrioventricular block]] ([[wenchebache]]), or 2:1 [[atrioventricular block]] when the level of block is in [[atrioventricular node]] or [[symptoms]] are not related to [[atrioventricular block]]<br>
❑[[Permanent pacing]] should not be implanted in [[asymptomatic]] [[patients]] with [[First- degree atrioventricular block]] or [[mobitz]] type 1 second degree [[atrioventricular block]] ([[wenchebache]]), 2:1 [[atrioventricular block]] or when the level of block is in [[atrioventricular node]]<br>
<br>
|}
 
===Notes===
::*Common factors associated with implantation of [[permanent pacemaker]] include:
:* [[Symptoms]] related to [[atrioventricular bradycardia]]
:* [[Infranodal atrioventricular block]] that may progress 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]].
*  When  [[atrioventricular block]] is above or at the [[nodal level]], progression 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]].<ref name="pmid17334913">{{cite journal |vauthors=Barold SS, Ilercil A, Leonelli F, Herweg B |title=First-degree atrioventricular block. Clinical manifestations, indications for pacing, pacemaker management & consequences during cardiac resynchronization |journal=J Interv Card Electrophysiol |volume=17 |issue=2 |pages=139–52 |date=November 2006 |pmid=17334913 |doi=10.1007/s10840-006-9065-x |url=}}</ref>
* In the presence of  second-degree [[Mobitz type I]] ([[Wenckebach]])  infranodal [[atrioventricular block]], implantation of  [[pacemaker]] is considered even in the absence of [[symptoms]].
* For finding the level of the [[atrioventricular node]] block whether nodal or intranodal in the narrow [[QRS]] complex, [[EPS]] is necessary.
*[[Ambulatory electrocardiographic monitoring]] or a [[treadmill exercise test]] may be useful to determine the correlation of [[symptoms]] and [[atrioventricular block]].
* Improvement in [[atrioventricular conduction]] with [[exercise]] suggests that the site of block is at the [[atrioventricular node]], but worsening [[atrioventricular]] conduction suggests [[infranodal block]].
* There is no benefit of implantation of [[permanent pacacemaker]] in [[patients]] with long-standing [[asymptomatic]] persistent or [[permanent AF]]  with a [[low heart rate]] and appropriate [[chronotropic]] response.


==References==
==References==

Latest revision as of 10:41, 21 July 2021

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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] Mohammed Salih, M.D., Cafer Zorkun, M.D., Ph.D. [3]; Raviteja Guddeti, M.B.B.S. [4]

Overview

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. So, patients should be continuously monitored with transcutaneous pacing pads in place in the event of clinical deterioration. While stable patients are being monitored, reversible causes of Mobitz type II second degree AV block such as myocardial ischemia, increased vagal tone, hypothyroidism, hyperkalemia, and drugs that depress conduction, should be excluded in patients prior to implantation of a permanent pacemaker. If no reversible causes are present, definitive treatment of Mobitz type II second degree AV block involves permanent pacemaker placement in most patients. There is no benefit of implantation of permanent pacacemaker in patients with long-standing asymptomatic persistent or permanent atrial fibrillation with a low heart rate and appropriate chronotropic response.

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]



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 (wenchebache), or 2:1 atrioventricular block when the level of block is in atrioventricular node or symptoms are not related to atrioventricular block
❑Permanent pacing should not be implanted in asymptomatic patients with First- degree atrioventricular block or mobitz type 1 second degree atrioventricular block (wenchebache), 2:1 atrioventricular block or when the level of block is in atrioventricular node

Notes

References

  1. ↑ 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.
  2. ↑ Barold SS, Ilercil A, Leonelli F, Herweg B (November 2006). "First-degree atrioventricular block. Clinical manifestations, indications for pacing, pacemaker management & consequences during cardiac resynchronization". J Interv Card Electrophysiol. 17 (2): 139–52. doi:10.1007/s10840-006-9065-x. PMID 17334913.


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