Second degree AV block pathophysiology: Difference between revisions
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{{Second degree AV block}} | {{Second degree AV block}} | ||
{{CMG}}; {{AE}} {{RT}} | {{CMG}}; {{AE}} [[User:Mohammed Salih|Mohammed Salih, M.D.]] {{RT}} | ||
==Overview== | ==Overview== | ||
In Mobitz type I (Wenckebach) there is a progressive prolongation of the PR interval (AV conduction) until eventually an atrial impulse is completely blocked. When an atrial impulse is completely blocked there will be a P wave without a QRS complex. This pattern is often referred to as a “dropped beat.” Mobitz type I occurs because each depolarization results in the prolongation of the refractory period of the atrioventricular (AV) node. When an atrial impulse comes through the AV node during the relative refractory period, the impulse will be conducted more slowly, resulting in a prolongation of the PR interval. Eventually, an impulse comes when the AV node is in its absolute refractory period and will not be conducted. This will manifest on the ECG as a P wave that is not followed by a QRS complex. This non-conducted impulse allows time for the AV node to reset, and the cycle continues. This phenomenon leads to a grouped beating. In Mobitz type II there is a constant PR interval across the rhythm strip both before and after the non-conducted atrial beat. Each P wave is associated with a QRS complex until there is one atrial conduction or P wave that is not followed by a QRS. Mobitz type II is often a problem in the infra-nodal conduction system, and therefore, is associated with a widened QRS complex, bundle-branch block, or fascicular block. | In Mobitz type I ([[Wenckebach]]) there is a progressive prolongation of the [[PR interval]] ([[AV conduction]]) until eventually an [[atrial]] impulse is completely blocked. When an [[atrial]] impulse is completely blocked there will be a P wave without a [[QRS complex]]. This pattern is often referred to as a “dropped beat.” Mobitz type I occurs because each depolarization results in the prolongation of the refractory period of the [[atrioventricular]] ([[AV]]) node. When an [[atrial]] impulse comes through the [[AV node]] during the relative refractory period, the impulse will be conducted more slowly, resulting in a prolongation of the [[PR interval]]. Eventually, an impulse comes when the [[AV node]] is in its absolute refractory period and will not be conducted. This will manifest on the [[ECG]] as a [[P wave]] that is not followed by a [[QRS complex]]. This non-conducted impulse allows time for the [[AV node]] to reset, and the [[cycle]] continues. This phenomenon leads to a grouped beating. In Mobitz type II there is a constant [[PR interval]] across the [[rhythm]] strip both before and after the non-conducted [[atrial]] beat. Each [[P wave]] is associated with a [[QRS]] complex until there is one [[atrial]] conduction or [[P wave]] that is not followed by a [[QRS]]. Mobitz type II is often a problem in the [[infra-nodal]] [[conduction system]], and therefore, is associated with a widened [[QRS]] complex, [[bundle-branch block]], or a [[fascicular block]]. When more than one [[P wave]] is not conducted this is no longer a Mobitz type II and is considered a [[high degree AV block]]. | ||
==Pathophysiology== | ==Pathophysiology== | ||
===Mobitz Type I=== | ===Mobitz Type I=== | ||
The classic site of block in [[Mobitz type I]] second degree block is the AV node (70%-75%). In the remaining 25%-30% of the cases the site is infra-nodal (His bundle, bundle branches or fascicles). | *The classic site of block in [[Mobitz type I]] second degree block is the AV node (70%-75%). | ||
*In the remaining 25%-30% of the cases the site is infra-nodal (His bundle,[[ bundle branches]] or [[fascicles]]). | |||
* Mobitz type I is again composed of two variations which show Wenckebach periodicity: classic and atypical.<ref name="pmid1176840">{{cite journal| author=Friedman HS, Gomes JA, Haft JI| title=An analysis of Wenckebach periodicity. | journal=J Electrocardiol | year= 1975 | volume= 8 | issue= 4 | pages= 307-15 | pmid=1176840 | doi=10.1016/s0022-0736(75)80003-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1176840 }}</ref><ref name="pmid29083636">{{cite journal |vauthors=Kashou AH, Goyal A, Nguyen T, Chhabra L |title= |journal= |volume= |issue= |pages= |date= |pmid=29083636 |doi= |url=}}</ref><ref name="pmid29850368">{{cite journal |vauthors=Li X, Xue Y, Wu H |title=A Case of Atrioventricular Block Potentially Associated with Right Coronary Artery Lesion and Ticagrelor Therapy Mediated by the Increasing Adenosine Plasma Concentration |journal=Case Rep Vasc Med |volume=2018 |issue= |pages=9385017 |date=2018 |pmid=29850368 |pmc=5933017 |doi=10.1155/2018/9385017 |url=}}</ref><ref name="pmid378457">{{cite journal |vauthors=Zipes DP |title=Second-degree atrioventricular block |journal=Circulation |volume=60 |issue=3 |pages=465–72 |date=September 1979 |pmid=378457 |doi=10.1161/01.cir.60.3.465 |url=}}</ref> | |||
====Classic==== | ====Classic==== | ||
Classic variety usually occurs within the AV node. It can be observed in antegrade AV conduction and also in retrograde VA conduction across the [[AV node]]. | * Classic variety usually occurs within the [[AV node]]. | ||
* It can be observed in antegrade [[AV conduction]] and also in retrograde [[VA conduction]] across the [[AV node]]. | |||
* There is a gradually increasing [[PR interval]] and eventually a dropped [[beat]]. | |||
* There is also usually a gradually decreasing [[R-R interval]]. | |||
* The [[PR interval]] is usually shortest in the initial [[beat]] and gradually increases ending in a dropped [[beat]] and the cycle repeats. | |||
* If the interval between the last conducted beat and the first beat of the next cycle is very long, the first beat may be a [[junctional escape rhythm]] rather than a conducted [[beat]]. This classic Wenckebach phenomenon occurs usually with ratios of 3:2, 4:3 or 5:4. This results in grouped beating<ref name="pmid28823599">{{cite journal |vauthors=Tuohy S, Saliba W, Pai M, Tchou P |title=Catheter ablation as a treatment of atrioventricular block |journal=Heart Rhythm |volume=15 |issue=1 |pages=90–96 |date=January 2018 |pmid=28823599 |doi=10.1016/j.hrthm.2017.08.015 |url=}}</ref><ref name="pmid26745972">{{cite journal |vauthors=Schernthaner C, Kraus J, Danmayr F, Hammerer M, Schneider J, Hoppe UC, Strohmer B |title=Short-term pacemaker dependency after transcatheter aortic valve implantation |journal=Wien. Klin. Wochenschr. |volume=128 |issue=5-6 |pages=198–203 |date=March 2016 |pmid=26745972 |doi=10.1007/s00508-015-0906-4 |url=}}</ref>. | |||
====Atypical==== | ====Atypical==== | ||
This variant of Wenckebach pattern is defined as long Wenckebach and is also called pseudo-Mobitz type II pattern as it simulates [[Mobitz type II]] block. In this pattern the conduction ratios usually exceed 6:5 or 7:6 and the last few beats of the cycle, before a dropped beat, show a relatively constant [[PR interval]] (maximum variation of 0.02 sec among them). The beats after the dropped beat again show gradually [[prolonged PR|prolonging PR interval]]s.<ref name="pmid737095">{{cite journal |author=El-Sherif N, Aranda J, Befeler B, Lazzara R |title=Atypical Wenckebach periodicity simulating Mobitz II AV block |journal=Br Heart J |volume=40 |issue=12 |pages=1376–83 |year=1978 |month=December |pmid=737095 |pmc=483582 |doi= |url=}}</ref> | *This variant of Wenckebach pattern is defined as long Wenckebach and is also called pseudo-Mobitz type II pattern as it simulates [[Mobitz type II]] block. | ||
* In this pattern the conduction ratios usually exceed 6:5 or 7:6 and the last few beats of the cycle, before a dropped [[beat]], show a relatively constant [[PR interval]] (maximum variation of 0.02 sec among them). | |||
* The [[beats ]] after the dropped beat again show gradually [[prolonged PR|prolonging PR interval]]s.<ref name="pmid737095">{{cite journal |author=El-Sherif N, Aranda J, Befeler B, Lazzara R |title=Atypical Wenckebach periodicity simulating Mobitz II AV block |journal=Br Heart J |volume=40 |issue=12 |pages=1376–83 |year=1978 |month=December |pmid=737095 |pmc=483582 |doi= |url=}}</ref><ref name="pmid28857929">{{cite journal |vauthors=Buttà C, Tuttolomondo A, Di Raimondo D, Giarrusso L, Miceli G, Brunori G, Pinto A |title=Episodes of second-degree ventriculo-atrial block during ventricular tachycardia |journal=J Cardiovasc Med (Hagerstown) |volume=18 |issue=10 |pages=826–827 |date=October 2017 |pmid=28857929 |doi=10.2459/JCM.0000000000000035 |url=}}</ref> | |||
===Mobitz Type II=== | ===Mobitz Type II=== | ||
Conduction delay in Mobitz type II second degree block is almost always infra-nodal (His bundle [20%], bundle branches or fascicles). | * Conduction delay in Mobitz type II second degree block is almost always infra-nodal (His bundle [20%], bundle branches or fascicles). | ||
* Usually the morphology of the [[QRS]] complex is wide, except when the site of block is the [[His bundle]]. | |||
* In this variant of [[second-degree]] [[heart block]] the PR interval is constant with occasional dropped [[beats]] as compared to the gradually [[prolonging PR interval]] in [[Mobitz type I]]. | |||
* Bifascicular or trifascicular block is seen in two thirds of the patients with Mobitz type II.<ref name="pmid6544636">{{cite journal| author=Puech P, Wainwright RJ| title=Clinical electrophysiology of atrioventricular block. | journal=Cardiol Clin | year= 1983 | volume= 1 | issue= 2 | pages= 209-24 | pmid=6544636 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6544636 }}</ref><ref name="pmid8445186">{{cite journal |vauthors=Wogan JM, Lowenstein SR, Gordon GS |title=Second-degree atrioventricular block: Mobitz type II |journal=J Emerg Med |volume=11 |issue=1 |pages=47–54 |date=1993 |pmid=8445186 |doi=10.1016/0736-4679(93)90009-v |url=}}</ref> | |||
==References== | ==References== | ||
Latest revision as of 04:55, 12 July 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Salih, M.D. Raviteja Guddeti, M.B.B.S. [2]
Overview
In Mobitz type I (Wenckebach) there is a progressive prolongation of the PR interval (AV conduction) until eventually an atrial impulse is completely blocked. When an atrial impulse is completely blocked there will be a P wave without a QRS complex. This pattern is often referred to as a “dropped beat.” Mobitz type I occurs because each depolarization results in the prolongation of the refractory period of the atrioventricular (AV) node. When an atrial impulse comes through the AV node during the relative refractory period, the impulse will be conducted more slowly, resulting in a prolongation of the PR interval. Eventually, an impulse comes when the AV node is in its absolute refractory period and will not be conducted. This will manifest on the ECG as a P wave that is not followed by a QRS complex. This non-conducted impulse allows time for the AV node to reset, and the cycle continues. This phenomenon leads to a grouped beating. In Mobitz type II there is a constant PR interval across the rhythm strip both before and after the non-conducted atrial beat. Each P wave is associated with a QRS complex until there is one atrial conduction or P wave that is not followed by a QRS. Mobitz type II is often a problem in the infra-nodal conduction system, and therefore, is associated with a widened QRS complex, bundle-branch block, or a fascicular block. When more than one P wave is not conducted this is no longer a Mobitz type II and is considered a high degree AV block.
Pathophysiology
Mobitz Type I
- The classic site of block in Mobitz type I second degree block is the AV node (70%-75%).
- In the remaining 25%-30% of the cases the site is infra-nodal (His bundle,bundle branches or fascicles).
- Mobitz type I is again composed of two variations which show Wenckebach periodicity: classic and atypical.[1][2][3][4]
Classic
- Classic variety usually occurs within the AV node.
- It can be observed in antegrade AV conduction and also in retrograde VA conduction across the AV node.
- There is a gradually increasing PR interval and eventually a dropped beat.
- There is also usually a gradually decreasing R-R interval.
- The PR interval is usually shortest in the initial beat and gradually increases ending in a dropped beat and the cycle repeats.
- If the interval between the last conducted beat and the first beat of the next cycle is very long, the first beat may be a junctional escape rhythm rather than a conducted beat. This classic Wenckebach phenomenon occurs usually with ratios of 3:2, 4:3 or 5:4. This results in grouped beating[5][6].
Atypical
- This variant of Wenckebach pattern is defined as long Wenckebach and is also called pseudo-Mobitz type II pattern as it simulates Mobitz type II block.
- In this pattern the conduction ratios usually exceed 6:5 or 7:6 and the last few beats of the cycle, before a dropped beat, show a relatively constant PR interval (maximum variation of 0.02 sec among them).
- The beats after the dropped beat again show gradually prolonging PR intervals.[7][8]
Mobitz Type II
- Conduction delay in Mobitz type II second degree block is almost always infra-nodal (His bundle [20%], bundle branches or fascicles).
- Usually the morphology of the QRS complex is wide, except when the site of block is the His bundle.
- In this variant of second-degree heart block the PR interval is constant with occasional dropped beats as compared to the gradually prolonging PR interval in Mobitz type I.
- Bifascicular or trifascicular block is seen in two thirds of the patients with Mobitz type II.[9][10]
References
- ↑ Friedman HS, Gomes JA, Haft JI (1975). "An analysis of Wenckebach periodicity". J Electrocardiol. 8 (4): 307–15. doi:10.1016/s0022-0736(75)80003-3. PMID 1176840.
- ↑ Kashou AH, Goyal A, Nguyen T, Chhabra L. PMID 29083636. Missing or empty
|title=(help) - ↑ Li X, Xue Y, Wu H (2018). "A Case of Atrioventricular Block Potentially Associated with Right Coronary Artery Lesion and Ticagrelor Therapy Mediated by the Increasing Adenosine Plasma Concentration". Case Rep Vasc Med. 2018: 9385017. doi:10.1155/2018/9385017. PMC 5933017. PMID 29850368.
- ↑ Zipes DP (September 1979). "Second-degree atrioventricular block". Circulation. 60 (3): 465–72. doi:10.1161/01.cir.60.3.465. PMID 378457.
- ↑ Tuohy S, Saliba W, Pai M, Tchou P (January 2018). "Catheter ablation as a treatment of atrioventricular block". Heart Rhythm. 15 (1): 90–96. doi:10.1016/j.hrthm.2017.08.015. PMID 28823599.
- ↑ Schernthaner C, Kraus J, Danmayr F, Hammerer M, Schneider J, Hoppe UC, Strohmer B (March 2016). "Short-term pacemaker dependency after transcatheter aortic valve implantation". Wien. Klin. Wochenschr. 128 (5–6): 198–203. doi:10.1007/s00508-015-0906-4. PMID 26745972.
- ↑ El-Sherif N, Aranda J, Befeler B, Lazzara R (1978). "Atypical Wenckebach periodicity simulating Mobitz II AV block". Br Heart J. 40 (12): 1376–83. PMC 483582. PMID 737095. Unknown parameter
|month=ignored (help) - ↑ Buttà C, Tuttolomondo A, Di Raimondo D, Giarrusso L, Miceli G, Brunori G, Pinto A (October 2017). "Episodes of second-degree ventriculo-atrial block during ventricular tachycardia". J Cardiovasc Med (Hagerstown). 18 (10): 826–827. doi:10.2459/JCM.0000000000000035. PMID 28857929.
- ↑ Puech P, Wainwright RJ (1983). "Clinical electrophysiology of atrioventricular block". Cardiol Clin. 1 (2): 209–24. PMID 6544636.
- ↑ Wogan JM, Lowenstein SR, Gordon GS (1993). "Second-degree atrioventricular block: Mobitz type II". J Emerg Med. 11 (1): 47–54. doi:10.1016/0736-4679(93)90009-v. PMID 8445186.