Second degree AV block surgery: Difference between revisions
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{{Second degree AV block}} | {{Second degree AV block}} | ||
{{CMG}}; {{AE}} [[User:Mohammed Salih|Mohammed Salih, M.D.]], {{CZ}}; {{RT}} | {{CMG}}; {{AE}} {{Sara.Zand}} [[User:Mohammed Salih|Mohammed Salih, M.D.]], {{CZ}}; {{RT}} | ||
==Overview== | ==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== | ||
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❑ [[Permanent pacing]] is not recommended in [[patients]] with | ❑ [[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 | ❑[[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> | <br> | ||
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===Notes=== | ===Notes=== | ||
::*Common factors associated with implantation of [[permanent pacemaker]] include: | ::*Common factors associated with implantation of [[permanent pacemaker]] include: | ||
:* [[Symptoms]] related to [[atrioventricular bradycardia]] | :* [[Symptoms]] related to [[atrioventricular bradycardia]] | ||
:* [[Infranodal atrioventricular block]] | :* [[Infranodal atrioventricular block]] that may progress to [[complete AV block]] with unstable [[ventricular scape]] [[rhythm]] | ||
:* Side effects of [[right ventricular]] [[pacing]] | :* 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]] | * [[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. | |||
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==References== | ==References== | ||
Latest revision as of 10:41, 21 July 2021
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Second degree AV block Microchapters |
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Risk calculators and risk factors for Second degree AV block surgery |
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] |
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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 (wenchebache), 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 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.[2]
- 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
- ↑ 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.
- ↑ 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.