Intermittent complete atrioventricular block associated with typical atrioventricular nodal reentrant tachycardia.
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Adult↗
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[Progression to 2d and 3d grade atrioventricular block in patients after electrostimulation for bundle-branch block and syncope: a long-term study].
BACKGROUND: Patients with bundle branch block and syncope, especially those with abnormal electrophysiologic study, are at high risk of progression to second-or third-degree atrioventricular block and therefore they often receive a permanent back-up pacemaker. The aim of this study was to evaluate of the incidence of bundle branch block progression to second or third-degree atrioventricular block during long-term follow-up. METHODS: A retrospective study was performed on 60 patients (49 males, age 77 +/- 9 years) with bundle branch block and permanent back-up pacemaker. The patients were subdivided into 3 groups: 13 patients, at pre-implant electrophysiologic study had HV interval > or = 100 msec and/or second- or third-degree atrioventricular block induced by ajmaline i.v. administration (Group 1); 20 patients with HV interval of 70-100 msec and/or HV > or = 120 msec after ajmaline administration (Group 2); 27 patients who had received a permanent pacemaker because of carotid sinus syndrome or sick sinus syndrome (22 patients) or because of recurrent syncopes and negative electrophysiologic study (5 patients) (Group 3). RESULTS: During a mean follow-up of 62 +/- 41 months, 17/60 patients (28%) had progression to second- (n = 4) or third-degree (n = 13) atrioventricular block: atrioventricular block occurred in 54% of Group 1 patients in 25% of Group 2 patients and in 19% of Group 3 patients. The actuarial rate of progression to atrioventricular block for the overall population was, at 5 and 10 years, 25% and 58% respectively; in Group 1 it was 46% and 62%; in Group 2 it was 22% and 55% and in Group 3 it was 21% and 59% (p = 0.06). The patients with right bundle branch block and left anterior hemiblock were at higher risk of progression to atrioventricular block than those with right bundle branch block or left bundle branch block (risk 42% vs 14%, p = 0.06). The presence of an abnormal electrophysiologic study did not increase the progression rate either in the patients with right bundle branch block and left anterior hemiblock (risk of 43%), nor did it in those patients with other types of bundle branch block (risk of 18%). Moreover, the induction of second- or third-degree atrioventricular block during ajmaline administration was associated with a higher risk of block during the follow-up (60% vs 25%, p = 0.06). CONCLUSIONS: Patients treated with pacemaker because of symptomatic bundle branch block have a high risk of progression to second- or third-degree atrioventricular block in the long-term follow-up. The results argue against the practical usefulness of electrophysiological study since a risk stratification could be obtained by the simpler surface electrocardiogram; moreover, risk of block was also present in the patients affected by carotid sinus syndrome or sick sinus syndrome, and in those affected by unexplained syncope with negative electrophysiologic study.
Age Factors↗
Spontaneous transition of 2:1 atrioventricular block to 1:1 atrioventricular conduction during atrioventricular nodal reentrant tachycardia: evidence supporting the intra-Hisian or infra-Hisian area as the site of block.
INTRODUCTION: The incidence of spontaneous transition of 2:1 AV block to 1:1 AV conduction during AV nodal reentrant tachycardia has not been well reported. Among previous studies, controversy also existed about the site of the 2:1 AV block during AV nodal reentrant tachycardia. METHODS AND RESULTS: In patients with 2:1 AV block during AV nodal reentrant tachycardia, the incidence of spontaneous transition of 2:1 AV block to 1:1 AV conduction and change of electrophysiologic properties during spontaneous transition were analyzed. Among the 20 patients with 2:1 AV block during AV nodal reentrant tachycardia, a His-bundle potential was absent in blocked beats during 2:1 AV block in 8 patients, and the maximal amplitude of the His-bundle potential in the blocked beats was the same as that in the conducted beats in 4 patients and was significantly smaller than that in the conducted beats in 8 patients (0.49 +/- 0.25 mV vs 0.16 +/- 0.07 mV, P = 0.007). Spontaneous transition of 2:1 AV block to 1:1 AV conduction occurred in 15 (75%) of 20 patients with 2:1 AV block during AV nodal reentrant tachycardia. Spontaneous transition of 2:1 AV block to 1:1 AV conduction was associated with transient right and/or left bundle branch block. The 1:1 AV conduction with transient bundle branch block was associated with significant His-ventricular (HV) interval prolongation (66 +/- 19 ms) compared with 2:1 AV block (44 +/- 6 ms, P < 0.01) and 1:1 AV conduction without bundle branch block (43 +/- 6 ms, P < 0.01). CONCLUSION: The 2:1 AV block during AV nodal reentrant tachycardia is functional; the level of block is demonstrated to be within or below the His bundle in a majority of patients with 2:1 AV block during AV nodal reentrant tachycardia, and a minority are possibly high in the junction between the AV node and His bundle.
Adult↗
Second-degree atrioventricular block: Mobitz type II.
Acute atrioventricular (AV) block occurs frequently in patients with myocardial infarction. Atrioventricular block is also a common manifestation of sclerodegenerative conduction system disease. Occasionally, heart block results from drug toxicity, hyperkalemia, cardiac valvular calcification, myocarditis, or infiltrative cardiomyopathy. Second-degree AV block is a form of "incomplete" heart block, in which some, but not all, atrial beats are blocked before reaching the ventricles. Mobitz type II second-degree block is an old term, which refers to periodic atrioventricular block with constant PR intervals in the conducted beats. The distinction between type II and type I block is descriptive; of greater importance to the clinician is the anatomic site of the block and the prognosis. In Mobitz type II block the site is almost always below the AV node; in Mobitz type I block the site is usually within the AV node. Type II AV block is more likely to progress to complete heart block and Stokes-Adams arrest. In most cases of second-degree heart block, including cases of 2:1 conduction, it is possible to determine the site of the AV block (intranodal or infranodal) using information about the age of the patient, the clinical setting, and the width of the QRS complex on the surface electrocardiogram. Second-degree atrioventricular block must be distinguished from other "causes of pauses." Nonconducted premature atrial contractions and atrial tachycardia with block are common conditions, which may mimic second-degree AV block.
Aged↗
Inadvertent atrioventricular block during radiofrequency catheter ablation. Results of the Pediatric Radiofrequency Ablation Registry. Pediatric Electrophysiology Society.
BACKGROUND: Inadvertent atrioventricular block is a complication of radiofrequency ablation. The present study is an analysis of the incidence, significance, and factors associated with inadvertent atrioventricular block during radiofrequency catheter ablation in childhood and adolescence. METHODS AND RESULTS: The records of the Pediatric Radiofrequency Ablation Registry were reviewed. Between January 1, 1991, and April 1, 1994, atrioventricular block occurred in 23 of 1964 radiofrequency ablations (1.2%): 14 as third-degree block (3 transient) and 9 as second-degree block (5 transient). Atrioventricular block occurred from 5 seconds to 2 months (mean, 4.1 days; median, 15 seconds) after the onset of the energy application. Eight transient cases lasted 1 hour to 1 month (mean, 9.4 days; median, 7 days). Inadvertent atrioventricular block was related to the ablation anatomic site: 3 of 111 (2.7%) anteroseptal, 11 of 106 (10.4%) midseptal, and 2 of 197 (1.0%) right posteroseptal sites (P = .0007) for anteroseptal, P = .0001 for midseptal, and P = .17 for right posteroseptal versus nonright septal sites). Five of 314 (1.6%) ablations for atrioventricular nodal reentrant tachycardia resulted in atrioventricular block (P = .004 versus nonright septal sites). Compared with a matched subgroup, radiofrequency ablation experience was the only significant risk factor (32.7 versus 106.6, P = .002) for the occurrence of atrioventricular block. CONCLUSIONS: Inadvertent atrioventricular block may occur during or late after radiofrequency catheter ablation. It is associated with ablations for (1) anterior and midseptal accessory pathways and atrioventricular nodal reentry and (2) relative institutional inexperience.
Adolescent↗
Single-chamber versus dual-chamber pacing for high-grade atrioventricular block.
BACKGROUND: In the treatment of atrioventricular block, dual-chamber cardiac pacing is thought to confer a clinical benefit as compared with single-chamber ventricular pacing, but the supporting evidence is mainly from retrospective studies. Uncertainty persists regarding the true benefits of dual-chamber pacing, particularly in the elderly, in whom it is used less often than in younger patients. METHODS: In a multicenter, randomized, parallel-group trial, 2021 patients 70 years of age or older who were undergoing their first pacemaker implant for high-grade atrioventricular block were randomly assigned to receive a single-chamber ventricular pacemaker (1009 patients) or a dual-chamber pacemaker (1012 patients). In the single-chamber group, patients were randomly assigned to receive either fixed-rate pacing (504 patients) or rate-adaptive pacing (505 patients). The primary outcome was death from all causes. Secondary outcomes included atrial fibrillation, heart failure, and a composite of stroke, transient ischemic attack, or other thromboembolism. RESULTS: The median follow-up period was 4.6 years for mortality and 3 years for other cardiovascular events. The mean annual mortality rate was 7.2 percent in the single-chamber group and 7.4 percent in the dual-chamber group (hazard ratio, 0.96; 95 percent confidence interval, 0.83 to 1.11). We found no significant differences between the group with single-chamber pacing and that with dual-chamber pacing in the rates of atrial fibrillation, heart failure, or a composite of stroke, transient ischemic attack, or other thromboembolism. CONCLUSIONS: In elderly patients with high-grade atrioventricular block, the pacing mode does not influence the rate of death from all causes during the first five years or the incidence of cardiovascular events during the first three years after implantation of a pacemaker.
Aged↗
Second degree type II and complete atrioventricular block due to hyperkalemia.
An 83-year-old woman was hospitalized with complete atrioventricular block and a pulse of 20/min. Three days earlier an electrocardiogram had revealed right bundle branch block with classic type II second degree atrioventricular block. Admission potassium was 7.8 meq/L; within 24 hours the potassium was lowered to 4.9 meq/L and the atrioventricular block disappeared. The patient was followed for nineteen months and remained normokalemic without recurrence of atrioventricular block, although the right bundle branch block persisted. She was then readmitted with bradycardia due to complete atrioventricular block despite normokalemia. We conclude that hyperkalemia can produce the classic picture of progressive bilateral bundle branch disease leading to high degree atrioventricular block, although this seems to occur in patients with extensive intrinsic disease of the conduction system.
Aged↗
[Paroxysmal atrioventricular block].
The authors analyzed paroxysmal atrioventricular blocks which were not frequency-dependent. It was a clinical, electrocardiographic and electrophysiological evaluation. The authors draw attention to the pitfalls of diagnosis and emphasize that the problem of interpretation of atrioventricular (intraventricular) conductivity is unequivocally associated with the problem of indication of permanent cardiac pacing. Based on their own experience, the authors describe the procedure used for establishment of the diagnosis of paroxysms of atrioventricular blocks. What are the main conclusions? 1. In the first place it is necessary to pay attention to the history of syncopes. 2. On the conventional ECG we find usually disorders of atrioventricular and intraventricular conductivity. 3. Electrophysiological examination should be always supplemented also by pharmacological intervention, using Gilurytmal by the i.v. route.
Aged↗
Atrioventricular block and problems with atrioventricular conduction.
This chapter has summarized briefly the current state of our knowledge on the incidence, etiology, presentation, investigation, and management of patients with AV block. The scope of the material covered has been widened intentionally to include a plethora of AV-conduction abnormalities because of the increases in the understanding of their clinical importance and contribution to left ventricular dysfunction. Under this heading, the critical importance of heart rate, maintenance of AV synchrony, and the sequence of ventricular activation and relaxation have been introduced and summarized briefly. The authors make a strong plea that, in the future, the reader consider AV-conduction abnormalities to be the parent topic, with the more-traditional, narrower subject of AV block forming a subunit thereof.
Aged↗
Perinatal outcome of fetus with isolated congenital second degree atrioventricular block without maternal anti-SSA/Ro-SSB/La antibodies.
OBJECTIVE: We determined the perinatal outcomes of fetuses with isolated congenital second degree atrioventricular block detected in utero and born to mothers seronegative for anti-SSA/Ro-SSB/La antibodies. METHODS: Isolated second degree atrioventricular block was defined as second degree atrioventricular block detected in utero without the accompanying structural cardiac anomaly, tachyarrhythmia, non-conducted premature atrial beats or long QT syndrome. We review our own cases and search from Medline using keywords such as atrioventricular block, arrhythmia, bradycardia and congenital to collect cases of congenital isolated second degree atrioventricular block. RESULTS: Two cases were from our institution and five cases from a Medline search; in total seven cases of isolated second degree atrioventricular block without maternal anti-SSA/Ro-SSB/La antibodies were analyzed. Six of the seven fetal arrhythmias reverted to sinus rhythm by delivery and did not recur during the follow-up period. The prognosis of the fetus with isolated second degree atrioventricular block without maternal anti-SSA/Ro-SSB/La antibodies is better than that of the fetus with maternal anti-SSA/Ro-SSB/La antibodies or the fetus of congenital long QT syndrome with second degree atrioventricular block detected in utero. CONCLUSION: The fetus with isolated congenital second degree atrioventricular block carries a good prognosis in the absence of maternal anti-SSA/Ro-SSB/La antibodies.
Antibodies, Antinuclear↗
Complete atrioventricular block in patients with atrioventricular discordance.
Although patients with atrioventricular (AV) discordance (corrected transposition) have abnormal conduction pathways and may spontaneously develop high-grade AV block, no quantitative assessment of the risk of this happening is available. We reviewed the data on 107 patients with AV discordance ages 2-76 years (mean 22 years) at follow-up. Eighty-two patients (77%) had a ventricular septal defect, 57 (53%) had pulmonary stenosis, 35 (34%) had tricuspid insufficiency and 24 (23%) had dextrocardia. Twenty-three patients (22%) had complete AV block. This condition was present in four patients at birth and developed in 19 patients at ages 4 months to 53 years (mean 18.1 years). Nine of these patients had permanent pacemaker implantation, four at the onset of complete block and five an average of 11 years later. Nine patients have AV block but no pacemaker. One patient died suddenly. Detailed data analysis showed that with increasing follow-up the risk of natural onset AV block continued at a rate of approximately 2% per year after diagnosis. The presence of an intact ventricular septum made AV block more likely. We conclude that patients with AV discordance are at risk of developing complete AV block throughout their lives. With increasing age, this risk is approximately constant and is probably not significantly increased by corrective or palliative surgery if acute surgical AV block does not occur. Pacemaker implantation is not necessary in some children with spontaneous AV block.
Actuarial Analysis↗
Pace mapping of Koch's triangle reduces risk of atrioventricular block during ablation of atrioventricular nodal reentrant tachycardia.
INTRODUCTION: Slow pathway (SP) ablation of AV nodal reentrant tachycardia (AVNRT) can be complicated by second- to third-degree AV block. We assessed the usefulness of pace mapping of Koch's triangle in preventing this complication. METHODS AND RESULTS: Nine hundred nine consecutive patients undergoing radiofrequency ablation of AVNRT were analyzed. Group 1 (n=487) underwent conventional slow pathway ablation. Group 2 (n=422) underwent ablation guided by pace mapping of Koch's triangle, which located the anterogradely conducting fast pathway (AFP) based on the shortest St-H interval obtained by stimulating the anteroseptal, midseptal, and posteroseptal aspects of Koch's triangle. In group 2, AFP was anteroseptal in 384 (91%), midseptal in 33 (7.8%), and posteroseptal or absent in 5 (1.2%). In 32 of 33 patients with midseptal AFP, slow pathway ablation was performed strictly in the posteroseptal area. In 4 of 5 patients with posteroseptal or no AFP, retrograde fast pathway was ablated. Two patients refused ablation. Persistent second- to third-degree AV block was induced in 7 (1.4%) of 487 group 1 patients versus 0 (0%) of 422 group 2 patients (P=0.038). Ablation was successful in all patients in whom ablation was performed. CONCLUSION: Pace mapping of Koch's triangle identifies patients in whom the AFP is absent or is abnormally close to the slow pathway. In these cases, guiding ablation helps to avoid AV block.
Cardiac Pacing, Artificial↗
Prognostic significance of transient complete atrioventricular block during radiofrequency ablation of atrioventricular node reentrant tachycardia.
One hundred eighty-six consecutive patients underwent radiofrequency ablation and were divided into 2 groups: group 1 included 19 patients (13 women, mean age 50 +/- 15 years) with transient atrioventricular (AV) block during the procedure. The duration of AV block ranged from 4 seconds to 30 minutes (mean 2.8 +/- 7.0 minutes); and group 2 included 167 patients (142 women, mean age 40 +/- 17 years) without transient AV block. Follow-up was 8.6 +/- 8.3 months in group 1 and 10.1 +/- 9.4 months in group 2. No significant differences were observed between the 2 groups concerning the ablation approach (fast or slow pathway), the number of radiofrequency applications, and recurrences of tachycardia. Four patients from group 1 who underwent fast pathway ablation developed late complete AV block, whereas no patient in group 2 had such a complication (p = 0.0001). Late complete AV block occurred 20 hours, 6 days, 1 month, and 25 days after ablation, respectively, and was not related to the duration of transient AV block. Another patient from group 1 developed an asymptomatic 2:1 AV block during exercise, 3 months after slow pathway ablation. Transient AV block, a common finding occurring as often during fast as during slow pathway ablation, did not preclude recurrences of tachycardia but was associated with late complete AV block.
Adolescent↗
Chronic bifascicular block with intermittent complete atrioventricular block induced by hyperthyroidism.
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Aged↗
Atrioventricular block occurring late after heart transplantation: presentation of three cases and literature review.
Sinus node dysfunction is a well-known occurrence following orthotopic heart transplantation, but atrioventricular block is rarely described. We compare the incidence and clinical presentation of atrioventricular block and sinus node dysfunction among the first 200 consecutive patients receiving heart transplantation at the University of Utah. Two of 200 patients (1%) required pacemaker implantation for symptomatic atrioventricular block compared to 13 of 200 (6.5%) who required pacemaker for symptomatic sinus node dysfunction. Of the patients with atrioventricular block, one had intermittent Mobitz II second-degree atrioventricular block and one had high grade atrioventricular block without ventricular escape. The most striking difference between the patients with atrioventricular block and those with sinus node dysfunction was the interval between transplantation and pacemaker implantation; time to pacemaker implantation in the atrioventricular block patients was 955 and 810 days compared to a median time of 26 days for sinus node dysfunction patients (P = 0.037). The patients requiring permanent pacemaker implantation were similar to those not requiring pacemaker implantation with respect to age, sex, ischemic time, and donor age. None of the patients requiring permanent pacemaker implantation was on amiodarone therapy within 2 months of transplant.
Adult↗
The long-term outcome of children with isolated congenital complete atrioventricular block.
Patients with isolated congenital complete atrioventricular block (CCAVB) may revert to a lower degree of atrioventricular block and do not require pacemaker treatment. The change of rhythm is less well studied in pediatric patients. The aim of this study was to report the long-term outcome of pediatric patients with isolated CCAVB at our institution, with emphasis on restoration of sinus rhythm. We reviewed the medical records of 16 consecutive children with isolated CCAVB at our institution. They were divided into a prenatal group (n=9) and a postnatal group (n=7). In the prenatal group, with follow-up of 28 months (median, range 1-154 months), one patient without symptoms had transient restoration of sinus rhythm and did not require pacemaker therapy, five patients required pacemaker therapy and three of them died, and the remaining three patients without symptoms did not require pacemaker therapy. In the postnatal group, with follow-up of 84 months (median, range 14-133 months), one patient without symptoms had restoration of sinus rhythm and did not require pacemaker therapy, three patients required pacemaker therapy and survived, and the remaining three patients without symptoms did not require pacemaker therapy. Compared to the postnatal group, the prenatal group needed earlier pacing and had higher rate of maternal autoantibodies. There were no significant differences in sex, pacemaker implantation rate, dilated cardiomyopathy, and mortality rate between the two groups. Pacemaker implantation is indicated in most patients with isolated CCAVB, but a change to a lower degree of block can occur in some pediatric patients who may not require pacemaker implantation.
Child, Preschool↗
[Atrial tachycardia with atrioventricular block].
A clinico-electrocardiographic analysis of 25 cases with atrial tachycardia and atrioventricular block was conducted. Confirmation was established of the connection between the development of atrial tachycardia with atrioventricular block and changes in the myocardium, circulatory insufficiency, acute coronary failure and toxicosis with cardiac glucosides. Such signs of atrial tachycardia with atrioventricular block as the rate of atrial rhythm of 150 to 250 per minute, the possibility of fluctuations in the P-P interval, the presence of an isoelectric PP segment, and atrioventricular block of various degree were found to be of the highest diagnostic value. It is presumed that the development of atrioventricular block in atrial tachycardia is linked with changes in the conducting system of the heart.
Adult↗
[Atrioventricular block at nodal and infrahissian level during atrial tachycardia. Apropos of a case].
The authors report the case of a patient with atrial tachycardia and surface electrocardiographic signs of left anterior hemiblock and complete right bundle branch block with 10/3 atrioventricular block. The regularity of the RR intervals which were an exact multiple of the atrial cycle suggested the absence of a Wenckebach phenomenon. The sequence of atrioventricular conduction cannot be explained by classical models of intranodal conduction. Endocavitary recordings confirmed this hypothesis. They showed block at 2 levels: supra- and infrahisian. The suprahisian block functioned in the 2/1 mode and the infrahisian block in the 5/3 mode without incremental conduction distal to the His potential before the apparition of block. A double zone of intrahisian block could explain the observed sequence of atrioventricular conduction. The absence of Wenckebach phenomenon on the surface ECG during tachycardia could be a sign of infrahisian block. The authors suggest that the association of this sequence of atrioventricular conduction with intraventricular conduction defects is a formal indication for electrophysiological studies.
Aged↗