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: Cafer Zorkun, M.D., Ph.D. [2]; Raviteja Guddeti, M.B.B.S. [3] Soroush Seifirad, M.D.[4] Qasim Khurshid, M.B.B.S [5]

Overview

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.

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 patents 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 Management of bradycardia or pauses attributable to chronic atrioventricular block algorithm       Atrioventricular block                                   Complete heart block (aquired) Advanced AV block, Mobitz type2 Evidence for infranodal block                                   Permanent pacing (class1)                                   Consider risk for ventricular arrhythmia (class1)                                   Cardiac resynchronization therapy Is LVEF<35%?                                               NO Infrequent pacing? Other comorbidities?   Yes Medical therapy                                         Yes Single chamber ventricular pacing (class1)   N0 Permanent atrial fibrillation                                                     Yes Single chamber ventricular pacing (class1)   NO Dual chamber pacing (class1)                                                     LVEF>50%                                                                       Yes Right ventricular pacing lead (class 2a)   NO Is predicted pacing <40%                                                                   NO Pacing to reach physiologic activation of left ventricle (class2a)   Yes Righr ventricular pacing (class2a)                                                   His bundle pacing (class2b)         The above algorithm adopted from 2018 AHA/ACC/HRS Guideline 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 Surgery A permanent pacemaker insertion is a minimally invasive procedure. The procedure is typically performed in a cardiac catheterization lab or an operating room. Transvenous access to the heart chambers under local anesthesia is the preferred technique, most commonly via the subclavian vein, the cephalic vein, or the internal jugular vein or the femoral vein.The pacing generator is most commonly placed subcutaneously in the pre-pectoral region. Placement of pacemaker leads, surgically via thoracotomy, is rarely used these days. Types of permanent pacemaker systems All cardiac pacemakers consist of two components: a pulse generator that provides the electrical impulse for myocardial stimulation; and one or more electrodes that deliver the electrical impulse to the myocardium. The original cardiac pacing system was used to place surgically in the abdomen. Over time, pacemaker systems evolved to predominantly placing the pulse generator in the infraclavicular region of the chest with transvenous-placed endocardial leads. Transvenous leads have potential long-term complications, including venous thrombosis, infection, and lead malfunction. Leadless cardiac pacing systems are currently in development and offer the promise of long-term pacing capability without lead-associated complications. Transvenous systems The majority of cardiac pacing systems use transvenous electrodes to transmit pacing impulses from the generator to the myocardium. Transvenous leads are usually placed percutaneously or with a cephalic cutdown, without the need for intrathoracic surgery. Long term complications of transvenous electrodes include infection,venous thrombosis, lead malfunction, and tricuspid valve injury. Epicardial systems Epicardial cardiac pacemaker systems utilize a pulse generator with leads attached surgically directly to the epicardial surface of the heart. These systems are occasionally used in patients with vascular access problems and have been replaced by transvenous systems. Leadless systems In response to the limitations of existing pacings systems, leadless systems are developed. Leadless systems consist of a self-contained system that includes both the pulse generator and the electrode within a single unit that is placed into the right ventricle via a transvenous approach. Leadless cardiac pacing system was approved in April 2016 in the United States INDICATIONS FOR PERMANENT PACEMAKERS The American College of Cardiology, the American Heart Association, and the Heart Rhythm Society (ACC/AHA/HRS) published guidelines for implantation of cardiac pacemakers. Some of these indications are certain, while others require considerable expertise and judgment.Similar and concordant guidelines have also been established by the European Society of Cardiology . The ACC/AHA/HRS guidelines divided these guidelines for pacemaker implantation into three specific categories. ●Class I – Conditions in which permanent pacing is definitely recommended, beneficial, and useful. ●Class II – Conditions in which permanent pacing may be reasonable, but there is conflicting evidence and/or divergence opinion. ●Class III – Conditions in which permanent pacing is not beneficial/useful and, in some cases, maybe harmful. Class-I Symptomatic sinus bradycardia (usually with a heart rate below 40 beats per minute) Symptomatic chronotropic incompetence Patients with symptomatic sinus bradycardia as a consequence of guideline-directed management for which there is no alternative treatment and continued treatment is clinically necessary; a permanent pacemaker is recommended to improve symptoms. Complete heart block with or without sysmptoms Symptomatic second degree AV block, Mobitz type II Symptomatic second degree AV block, Mobitz type I Exercise induced second or third degree AV block in absence of myocardial ischemia Advanced second degree AV block (block of two or more consecutive P waves) Patients with the following neuromuscular diseases with evidence of second-degree or third-degree atrioventricular block require permanent pacemaker regardless of the symptoms. Myotonic dystrophy type 1 Kearns-Sayre Syndrome Erb's dystrophy (limb-girdle) peroneal muscular atrophy Patients with permanent atrial fibrillation and symptomatic bradycardia. Patients with alternating bundle branch block Patients with postoperative sinus node dysfunction or atrioventricular block associated with persistent symptoms that do not resolve after isolated coronary artery bypass surgery Class-II Asymptomatic Mobitz II second degree AV block with a narrow QRS interval First degree AV block with hemodynamic compromise because of effective AV dissociation secondary to a very long PR interval. Patients with infiltrative cardiomyopathies, such as cardiac sarcoidosis or amyloidosis, and second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block with a life expectancy of greater than one years. Patients with marked first-degree or second-degree Mobitz type 1 AV block with symptoms that are attributable to the atrioventricular block. Patients with Anderson-Fabry disease and QRS prolongation more significant than 110 ms with a meaning life expectancy greater than one year Bifascicular or trifascicular block associated with syncope that can be attributed to transient complete heart block Congenital heart block Class-III Sinus bradycardia without significant symptoms Sinoatrial block or sinus arrest without significant symptoms. Syncope of undetermined etiology Asymptomatic prolonged RR intervals with atrial fibrillation Asymptomatic bradycardia during sleep Long QT syndrome or torsades de pointes due to reversible causes Asymptomatic second degree Mobitz I AV block Reversible atrioventricular block A hyperactive cardioinhibitory response to carotid sinus stimulation in the absence of symptoms References