Second degree atrioventricular block. A matter of definition

Atrioventricular block revisited

AV blocks, their definitions and significance, are discussed. Type II, second-degree AV block is infranodal, whereas 2/3 of Type I with BBB are infranodal, 2:1 AV block is neither Type I nor II block. Infranodal blocks require pacing regardless of symptoms.

2:1 Atrioventricular block: order from chaos

2:1 AV block can occur in either the AV node or the His-Purkinje system and cannot be classified into type I or type II second-degree AV block because there is only one PR interval to examine before the blocked P wave. It is inappropriate to use terms such as 2:1 or 3:1 type I or type II AV block because this characterization violates the accepted traditional definitions of type I and type II block based on electrocardiographic patterns and not on the anatomical site of block. Type I and type II second-degree AV block can progress to 2:1 AV block, and 2:1 AV block can regress to type I or type II block. Consequently, the site of the lesion in 2:1 block can often be determined by seeking the company 2:1 AV block keeps. An association with type I block and a narrow QRS complex almost always reflects AV nodal block but type I block with a wide QRS complex occurs more commonly in the His-Purkinje system than the AV node. Type II block, if correctly defined, is always infranodal. Outside of acute myocardial infarction, sustained 2:1 and 3:1 AV block with a wide QRS complex occurs in the His-Purkinje system in 80% of cases and 20% in the AV node. Administration of atropine in patients with His-Purkinje disease may increase the degree of AV block.

Second-degree atrioventricular block: a reappraisal

In this review, we discuss the various forms and causes of second-degree atrioventricular (AV) block and the reasons they remain poorly understood. Both type I and type II block characterize block of a single sinus P wave. Type I block describes visible, differing, and generally decremental AV conduction. Type II block describes what appears to be an all-or-none conduction without visible changes in the AV conduction time before and after the blocked impulse. Although the diagnosis of type II block is possible with an increasing sinus rate, absence of sinus slowing is an important criterion of type II block because a vagal surge (generally a benign condition) can cause simultaneous sinus slowing and AV nodal block, which can superficially resemble type II block. The diagnosis of type II block cannot be established if the first postblock P wave is followed by a shortened PR interval or is not discernible. A pattern resembling a narrow QRS type II block in association with an obvious type I structure in the same recording (e.g., Holter) effectively rules out type II block because the coexistence of both types of narrow QRS block is exceedingly rare. Concealed His bundle or ventricular extrasystoles confined to the specialized conduction system without myocardial penetration and depolarization can produce electrocardiographic patterns that mimic type I and/or type II block (pseudo-AV block). All correctly defined type II blocks are infranodal. A narrow QRS type I block is almost always AV nodal, whereas a type I block with bundle branch block barring acute myocardial infarction is infranodal in 60% to 70% of cases. A 2:1 AV block cannot be classified in terms of type I or type II block, but it can be nodal or infranodal. Infranodal blocks require pacing regardless of form or symptoms. The widespread use of numerous disparate definitions of type II block appears primarily responsible for many of the problems surrounding second-degree AV block. Adherence to the correct definitions provides a logical and simple framework for clinical evaluation.

Arrhythmias during spinal anesthesia for Cesarean section

PURPOSE

Spinal block has long been considered a safe anesthesia technique for surgery. However, severe bradycardia, cardiac arrest, and other arrhythmias during spinal anesthesia have been reported and the incidence of intraoperative arrhythmias is not well established. In this study the incidence of arrhythmias during spinal anesthesia was determined.

METHODS

We studied 254 healthy women undergoing Cesarean section under spinal anesthesia prospectively. Spinal anesthesia with 10 mg bupivacaine mixed with 0.2 mg morphine was performed at the L3-4 interspace. Intraoperative arrhythmias were recorded and verified later by a cardiologist.

RESULTS

First degree atrioventricular block developed in nine patients (3.5%), second degree atrioventricular block in nine (3.5%), severe bradycardia (heart rate < 50 beats x min(-1)) in seventeen (6.7%), multiple VPC in three (1.2%). The height and weight of patients with severe bradycardia, multiple VPCs, or atrioventricular block were not different from those of the other patients. However, the age of patients in the potentially dangerous arrhythmias group was greater than that in the other group (P = 0.006).

CONCLUSION

The incidence of arrhythmias as well as hypotension during spinal anesthesia for Cesarean section was higher than expected. Although most of these arrhythmias were transient and recovered spontaneously, they might unexpectedly occur and sometimes need immediate and prompt treatment. It is necessary to remain vigilant during spinal anesthesia for Cesarean section and careful monitoring of these patients is warranted, especially in older parturients.

Prevalence and clinical correlates of non-Wenckebach, narrow-complex second-degree atrioventricular block detected by ambulatory ECG

Among 113 patients with transient, narrow-complex second-degree atrioventricular (AV) block detected by ambulatory ECG, there were 20 with non-Wenckebach behavior. Based on the presence or absence of PR interval shortening after single blocked complexes, patients with narrow-complex non-Wenckebach patterns could be separated into a pseudo-Mobitz II group of 16 patients (greater than or equal to 20 msec of PR shortening after the blocked complex) and a classic Mobitz II group of four patients (constant PR interval). These groups had additional distinct ECG and clinical features. Patients with the pseudo-Mobitz II pattern had a 44% prevalence of associated Wenckebach block during the same ambulatory recording, whereas Wenckebach behavior did not occur in patients with classic Mobitz II block. Pseudo-Mobitz II block occurred at significantly longer cycle lengths (876 vs 585 msec) and with significantly longer PR intervals (225 vs 165 msec) preceding the blocked complex than did classic Mobitz II block. Syncope was the presenting symptom in 38% of patients with pseudo-Mobitz II block and in all patients with classic Mobitz II block. Patients with pseudo-Mobitz II block had a 56% prevalence of associated coronary disease and a 44% prevalence of congestive heart failure; the mortality rate was 38% in this group over 4 years of follow-up, but in all instances death was due to associated disease rather than to conduction itself. In contrast, patients with classic Mobitz II block had hypertensive or valvular disease but no evidence of coronary disease or congestive failure; all are alive with pacemakers after 3 years of follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Bedside evaluation of atrioventricular block with narrow QRS complexes: usefulness of carotid sinus massage and atropine administration

Second-degree intra-His bundle block is frequently of type I (Wenckebach periods) or 2:1. In this situation, the surface electrocardiogram does not permit distinction between intranodal (atrioventricular [A-V] and subnodal (intra-His) block. This study examined the value of bedside carotid sinus massage and atropine administration in diagnosing the site of block from the standard electrocardiogram in subjects with chronic A-V block and narrow QRS complexes. Fifteen patients had intra-His bundle block and 10 had intranodal block. The combination of two tests correctly located the site of block in 22 subjects, and was noncontributory in 3. Thirteen of the 15 intra-His bundle blocks and 9 of the 10 intranodal blocks were properly identified; in three cases the results were nondiagnostic, but no wrong diagnoses were made. The noninvasive bedside method of carotid sinus massage and the use of atropine permit both the localization and the determination of the type of block in the majority of cases of second degree A-V block and narrow QRS complexes. In a proper clinical context they can obviate the need for invasive electrophysiologic studies.

Atypical Wenckebach periodicity simulating Mobitz II AV block

Eleven patients were studied and a total of 144 Wenckebach cycles in the AV node and 118 Wenckebach cycles in the His-Purkinje system were analysed to determine the incidence of typical and atypical Wenckebach periodicity, with particular emphasis on one variant of atypical Wenckebach that may simulate a Mobitz type II block. This pseudo-Mobitz II pattern was defined as a long Wenckebach cycle in which, at least, the last three beats of the cycle show relatively constant PR intervals (variation of no more than 0.02 s in surface leads and no more than 10 ms in His bundle electrograms) and in which the PR interval immediately following the blocked beat is shorter than the PR interval before the block by 0.04 s or more. Atypical Wenckebach cycles were found to be more common than the typical variety at both the AV node (67%) and His-Purkinje system (69%). The pseudo-Mobitz II pattern was seen in 19 per cent of atypical AV nodal Wenckebach periods and in 17 per cent of atypical His-Purkinje system Wenckebach cycles. The need to discern a 'classical' Mobitz II block from a pseudo-Mobitz II pattern, especially in the setting of an acute inferior myocardial infarction, is emphasised.

An unusual form of the bradycardia-tachycardia syndrome: paroxysmal A-V block and ventricular tachycardia

An unusual case of alternating bradycardia-tachycardia, paroxysmal Mobitz II A-V block and ventricular tachycardia is described. The patient presented with a normal resting (control) electrocardiogram and intracardiac conduction times (A-H and H-V intervals). The clinical evaluation, electrophysiology, and importance of defining the cause of serious rhythm disturbances prior to therapy are discussed.

Unusual complication of bifascicular block during surgery under general anesthesia

This report describes the occurrence of Mobitz type II AV block during surgery under general anesthesia in a patient with apparently uncomplicated right bundle branch and left anterior fascicular block (RBBB and LAH). Although prophylactic pacing is not usually recommended in uncomplicated RBBB and LAH, the events in this case suggest that this abnormality may not always be benign during surgery. Continuous monitoring is essential and emergency equipment for temporary pacing should be readily available near the operating and recovery rooms.

[Clinical value of His bundle electrography (author's transl)]

Methodical problems, indication and clinical implication of His bundle electrography are discussed. In 200 successive patients undergoing His bundle electrography and atrial stimulation the indication was as follows: Intraventricular conduction defects in 24%, A-V block in 21%, sick sinus syndrome in 20%, preexcitation in 17%, and complex arrhythmias in the remaining cases. In 38% of the patients did the HBE prove to be of help by providing information not available after analysis of the surface ECG. In 22% this technique contributed essentially to the management of these patients. In spite of dificiencies of our knowledge of the basic mechanisms, specific therapy, and prognosis of various arrhythmias His bundle electrography is clinically useful in selected patients. Therefore, this method has become a routinely used clinical tool.

Atrioventricular block (first of two parts)

The development of His-bundle (H) electrocardiography and the concept of hemiblocks have prompted a re-examination of conventional thinking about the indications for treatment of atrioventricular (AV) block. The technic of treatment is not the issue; ventricular pacemaking is the only really effective and reliable method. The problem for this review is what these recent developments have contributed to deciding when and if a pacemaker should be installed.

An analysis of Wenckebach periodicity

His bundle electrograms of 40 patients developing Wenckebach block during atrial pacing and four with spontaneous Wenckebach block above the His were reviewed to determine the frequency of classical Wenckebach periodicity. Thirty patients had 143 Wenckebach cycles that were suitable for analysis. Cycles were evaluated for the following features: 1) the first A-H interval as the shortest, 2) the first R-R interval as the longest, 3) the last R-R interval as the shortest, 4) a progressive diminution of the increment of A-H interval prolongation, 5) a progressive diminution of the R-R interval and 6) the R-R interval containing the nonconducted A wave being equal to twice the A-A interval less the sum of the increments of A-H prolongation. Wenckebach cycles that occurred during atrial pacing were not significantly different from those that occurred spontaneously. Fifteen per cent of all cycles met all six criteria- 14% had five, 6% had four; 17% had three; 20% had two; 27% had one; and 1% had none. Short cycles were the most likely to show typical Wenckebach periodicity: 56% of the cycles with conduction ratios of 4:3, 28% with 5:4 and 4% with 6:5 met at least five criteria, whereas none of the 22 cycles having ratios 7:6 or greater had more than three features. The first A-H interval as the shortest was the most common feature occurring in 98% of cycles, whereas the features of a progressive diminution of the increments of the A-H interval prolongation or the progressive diminution of the R-R interval were the least common, occurring in 35% of cycles. These findings indicate, therefore, that classical Wenckebach periodicity is uncommon, especially when conduction ratios are 5:4 or greater. The implications of these observations and the suggested mechanisms are discussed and literature reviewed.

Mobitz type I atrioventricular block in the ventricular specialized conduction system

A patient with a history of multiple syncopal episodes had electrocardiographic findings of Wenckebach type of second degree atrioventricular block and left bundle branch block. He was thought to have intermittent complete heart block. His bundle recordings demonstrated the unusual occurrence of Mobitz type I block localized to the ventricular specialized conduction system. Based on the findings of this case and those of previous case reports, it is recommended that electrophysiologic studies should be performed on all patients with Mobitz type I atrioventricular block who also have bundle branch block.