First degree AV block surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Salih, M.D., Cafer Zorkun, M.D., Ph.D. [2], Raviteja Guddeti, M.B.B.S. [3]

Surgery

Atrioventricular block

Profound First-degree AV block

Symptoms

Yes

No

Permanent pacing (class 2a)

Lamin A/C, neuromascular disease

Yes

No

Lamin A/C

Observation

Yes

No

Permanent pacing (class3:Harm)

Pemanent pacing (class2a)

Neuromascular disease

Yes

Permanent pacing (class2b)

The above table adopted from 2018 AHA/ACC/HRS Guideline

Recommendations for permanent pacemaker implantation for bradycardia associated atrioventricular block

(Class IIa, Level of Evidence B):

❑ In patients with Lamin A/C mutation such as limb girdle, emery dreifuss, muscular dystrophies, in the presence of prolonged PR interval>240 ms and LBBB ,permanent pacing with additional defibrillator therapy is recommended while life expectancy>1 year

(Class IIa, Level of Evidence C):

❑Permanent pacing is recommended in patients with symptomatic profound First-degree AV block when symptoms clearly related to atrioventricular block

(Class IIb, Level of Evidence C):

❑ In patients with neuromuscular disease such as myotonic dystrophy type 1 in the presence of prolonged PR interval>240 ms and QRS duration >120 ms or fascicular block, permanent pacing with additional defibrillator therapy is reasonable if life expectancy>1 year

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

• Common factors associated placement of permanent pacemaker include:

• Presence or absence of symptoms
• Level of atrioventricular block
• Unstable scaped ventricular rhythm with rapid progression to complete heart block

• First-degree AV block is typically a benign condition that do not progress suddenly to complete heart block.
• Placement of permanent pacemaker is reserved for the condition that symptomatic First-degree AV block affects quality of life.

Pacemaker

Indications

Special situations when placement of permanent pacemakers is indicated in first degree heart block are:

• Hemodynamic compromise
• Pacemaker syndrome (loss of atrioventricular synchrony)
• Some neuromuscular conditions associated with first degree heart block such as
  • Myotonic muscular dystrophy
  • Kearns-Sayre syndrome
  • Erb's dystrophy (limb-girdle)
  • Peroneal muscular atrophy

Contraindications

• Asymptomatic first degree heart block

A dual chamber DDD pacemaker is preferred over a single chambered VVI pacemakers as it maintains physiologic AV synchrony. 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.

References

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