Progression of first degree heart block to high-grade second degree block during spinal anaesthesia

A case is presented in which a patient with pre-existing first degree heart block developed high-grade second degree heart block during spinal anaesthesia. Progression of the block was associated with blockade of cardiac sympathetic neurons induced by spinal anaesthesia. This suggests that patients with pre-existing heart block may be at increased risk for development of higher grade block during spinal anaesthesia.     

Late recovery of atrioventricular conduction after pacemaker implantation for complete heart block associated with surgery for congenital heart disease

OBJECTIVES: Pacemaker implantation is a standard recommendation for patients with persistent complete heart block following surgery for congenital heart disease. This study was performed to determine the incidence and clinical significance of late recovery of atrioventricular conduction following pacemaker implantation. METHODS: Between 1990 and 2001, 5662 open cardiac procedures for congenital heart defects were performed at our institution. The postoperative course of all patients with complete heart block in whom a permanent pacemaker was implanted was followed on a monthly basis, by either clinical or transtelephonic follow-up. RESULTS: A total of 72 patients with persistent postoperative complete heart block underwent pacemaker implantation. After insertion of the pacemaker, recovery of atrioventricular conduction was recognized in 7 of 72 patients (9.6%) at a median of 41 days (18-113 days) after the initial cardiac operation. These included 3 patients with ventricular septal defect, 2 with ventricular inversion or single ventricle, and 1 each with left ventricular outflow tract obstruction and atrioventricular septal defect. During a mean follow-up of 4.4 +/- 2.6 years, there was no late recurrence of heart block. Three patients had residual right bundle branch block and 1 had first-degree atrioventricular block. CONCLUSIONS: Atrioventricular conduction may return in a small but significant percentage of patients following pacemaker implantation for complete heart block associated with congenital heart surgery. When recovery of atrioventricular conduction occurs within the first months after surgery it appears reliable, which suggests that lifelong cardiac pacing may not be necessary in these individuals.     

Perioperative management of children with third degree heart block undergoing pacemaker placement: a ten year review

It has been suggested that children with third degree heart block require insertion of a temporary pacemaker prior to general anaesthesia. This recommendation needs to be reevaluated with the availability of noninvasive transcutaneous cardiac pacing. We undertook a retrospective ten-year chart review of anaesthesia in children with third degree heart block undergoing pacemaker insertion or revision. Forty-eight children with complete heart block underwent seventy anaesthetics of which fifty three were in children without pacemakers or with nonfunctioning pacemakers. One child had a temporary pacemaker placed preoperatively following asystole in the emergency room. In children who were not being paced, 60% had baseline heart rates less than 60 bpm. Complications seen in this study, including hypotension, would not have been prevented by temporary pacemaker placement. We conclude that there is no benefit to routine preoperative temporary pacing in children with third degree heart block.     

Congenital complete heart block in the setting of severe pre-eclampsia requiring urgent cesarean section

Congenital complete heart block is a rare phenomenon that may be discovered during pregnancy in patients who were previously asymptomatic. Peripartum management of these patients mandates a multidisciplinary approach with careful planning regarding indications for pacing, appropriate anesthetic technique, and contingency planning. Approaches to anesthetic management for congenital complete heart block have been described, but management in association with severe pre-eclampsia has not been reported. We describe the anesthetic management of a parturient with complete heart block who presented with severe pre-eclampsia requiring urgent cesarean section.     

Heart block after coronary artery bypass--effect of chronic administration of calcium-entry blockers and beta-blockers

We evaluated risk of heart block after cardiopulmonary by-pass (CPB) in patients with normal conduction undergoing coronary artery bypass grafting who chronically received calcium-entry blockers, beta-blockers, or combined therapy. Before CPB, calcium-entry blockers alone produced an increase in P-R intervals but no change in heart rate; calcium-entry blocker effects were undetectable after CPB, beta-Blockers alone or with calcium-entry blockers produced lower heart rates and longer P-R intervals throughout the entire perioperative period when compared to no therapy (control) or calcium-entry blockers alone. Complete heart block did not occur; one control patient had transient second degree block after CPB. First degree block appeared transiently in 5% of the patients after anesthetic induction and in 15% on emergence from CPB, but was unrelated to drug therapy. We conclude that chronic calcium-entry blocker therapy has minimal effects on conduction perioperatively; beta-blocker effects persist for up to 10 hr after CPB; and the risk of heart block with either drug or combination is low and should not be a factor in their continued administration preoperatively.     

Perioperative risk of complete heart block in patients with bifascicular block and prolonged PR interval.

Because there is a paucity of information on the perioperative risk of developing complete heart block among patients with bifascicular block (either right bundle branch block and left anterior hemiblock or left bundle branch block) and a long PR interval on the surface electrocardiogram, we undertook an analysis of 76 such patients. Twenty-three patients had right bundle branch block and left axis deviation with a long PR interval and 53 had left bundle branch block with along PR interval. Thirty patients had 37 general anaesthetics, 23 had 32 spinal anaesthetics, and 50 had 64 local anaesthetics or endoscopic procedures. No patient developed complete heart block. Four patients developed sinus bradycardia during general anaesthetics, responsive to atropine or isoproterenol. Similarly, none of the 23 such patients in the literature reviewed had developed complete heart block. Because placement to temporary pacemakers is not without risk, we conclude that prophylactic pacing is not necessary in asymptomatic patients with bifascicular block even in the presence of a long PR interval. Since we did not study patients with recent syncope or myocardial infarction, caution should be exercised in applying these results to such patients.     

41例心脏双束支阻滞围术期处理与文献回顾

目的 提高麻醉医生对手术患者心脏双束支传导阻滞的认识.方法 回顾我院近5年41例双束支传导阻滞患者围手术期处理情况,并复习双束支传导阻滞有关问题的研究进展.结果 40例双束支阻滞患者麻醉手术经过顺利,术中发生低血压和心动过缓时均对药物治疗有效;1例左前分支阻滞患者在二次手术麻醉时心电图证实发展为完全性左束支阻滞,最终抢救无效死亡.结论 术前无症状不伴有房室传导阻滞的慢性双束支阻滞患者不必常规安装临时起搏器,但准备适当的药物及临时起搏设备是必要的.     

Pacemaker therapy in Kearns-Sayre syndrome

Kearns-Sayre syndrome is regarded as a type of mitochondrial encephalomyopathy accompanied with mitochondrial DNA abnormality of the muscle. Diagnosis of this disease is based upon the progressive external ophthalmoplegia, atypical retinal pigmentation and cardiac conduction block. We report two clinical cases of this disorder treated with permanent pacemaker implantation at a 20 year old man (patient 1) and a 27 years old woman (patient 2). Patient 1 with bifascicular block at 19 years old progressed into complete heart block at 20 years old. Patient 2 with complete heart block was occurred "torsade de pointes." Several problems of this disease in permanent pacing should be considered the patients' small size, pacing mode selection and coexistence of congenital heart disease. Routine electrocardiography is recommended for these patients and bifascicular block in this disease constitutes a definite indication for prophylactic pacemaker implantation.     

Heart block in patients after bariatric surgery accompanying sleep apnea

Backround: Heart block and bradycardia during sleep has been reported in patients with obesity. The occurrence of bradyarrythmias in patients after undergoing bariatric surgery has not been reported. Methods: Over a period of 6 months, 3 patients who underwent laparoscopic weight reduction surgery developed prolonged heart block during sleep. Clinical course and follow-up are presented. Results: All 3 patients were diagnosed with sleep apnea. For 2 of these patients this was a new diagnosis. The episodes of heart block coincided with their episodes of sleep apnea. During follow-up of at least 6 months, no patient has had any adverse consequences related to their nocturnal heart block. Conclusion: Heart block during sleep is sometimes seen in patients undergoing bariatric surgery. The cause is sleep apnea, which often is worsened in the postoperative state due to narcotic analgesics. These patients require treatment of their sleep apnea, not pacemakers.     

Anesthetic management of the surgical patients with complete left bundle branch block

For last ten years twenty three cases of anesthesia were performed in twenty surgical patients with complete left bundle branch block (CLBBB) ranging in ages from 58 to 82 years. The CLBBB in these patients included 16 cases of permanent block, 6 cases of transient block and one case of alternative block. Two of these patients had no past history of heart disease, but the remaining patients had hypertension, ischemic heart disease, cardiomegaly, cardiac hypertrophy or others. Transient episodes of CLBBB were detected on the preoperative examination, on arrival at operating room or after the emergence from anesthesia at a recovery room, and some of which were provoked by elevated blood pressure or increased heart rate. A transient CLBBB in the patient changed to permanent CLBBB two years later. Complete atrioventricular (A-V) block appeared suddenly in the patient with alternative CLBBB four months after the surgery. Complete A-V block did not develop during anesthesia and surgery in our patients with CLBBB. Therefore we consider a routine prophylactic temporary pacemaker is not necessary during anesthesia and surgery in patients with asymptomatic CLBBB. However, a temporary pacemaker equipment should be at hand in case of complete A-V block. Appropriate perioperative management of circulatory system is important for the patients with CLBBB because most of these patients have underlying heart disease.     

Combined paravertebral lumbar plexus and parasacral sciatic nerve block for reduction of hip fracture in four patients with severe heart failure

We experienced four cases of anesthesia for hip fracture reduction in patients with severe heart failure, where anesthesia was attempted with combined paravertebral lumbar plexus and parasacral sciatic nerve block instead of spinal anesthesia. The anesthesia was successful without any sequelae. The patients' characteristics are as follows. Case 1: 97-year-old woman with severe heart failure and old myocardial infarction. Case 2: 91-year-old man with pacemaker, heart failure and heart valve disease. Case 3: 93-year-old woman with severe heart failure and multi-vessel coronary artery stenosis. Case 4: 83-year-old woman with congestive heart failure and heart valve disease. Paravertebral lumbar plexus block was performed with Touhy needle which was directed to lumbar transverse process, then re-directed caudally. Psoas compartment was felt with loss of resistance. Twelve ml of 0.25% bupivacaine was injected. Sciatic nerve block was performed with a needle which was inserted at the midpoint between the greater trochanter and the sacral hiatus without (case 1, 2) or with nerve stimulator (case 3, 4). Eight ml of 0.25% bupivacaine was injected. During the anesthesia, propofol was injected for light sedation. Although this combined nerve block is difficult to perform compared with spinal anesthesia, this could be applicable for hip fracture reduction anesthesia, especially in patients with severe heart failure.     

Reversão do bloqueio neuromuscular com sugamadex em cinco receptores pediátricos de transplante cardíaco

Heart transplantation is a frequent procedure in the treatment of end‐stage cardiac dysfunction. Therefore, these patient populations will also be more frequent exposed to other more common surgical procedures after their transplantation. Anesthesiologist should be aware in their assessment of these patients, especially regarding some specific issues related to patients with a history of heart transplantation, like reversal of neuromuscular block. Several reports described that cholinesterase inhibitors drugs, like neostigmine, may produce a dose‐dependent life‐threatening bradycardia in heart transplant recipients while other publication described the safe use of neostigmine. Reversal of neuromuscular block with sugammadex is another possibility, but limited data exists in literature. We describe five cases in which successful reversal of neuromuscular block was performed with sugammadex in heart transplant pediatric recipients without sequelae and discuss the reversal of neuromuscular block in this patient population.     

Percussion pacing in a three-year-old girl with complete heart block during cardiac catheterization

Complete heart block frequently requires emergency pacing torestore systemic perfusion. We report the case of a 3-yr-oldgirl undergoing interventional atrial septal defect closurewho suffered from transient complete heart block with circulatoryarrest. Transthoracic mechanical pacing for more than 3 minprovided temporary support, sustaining an adequate cardiac outputuntil sinus rhythm resumed.     

Multiple electrocardiographic anomalies during anaesthesia in an athlete

A 22-year-old athlete was scheduled for a minor surgical procedure under general anaesthesia. During anaesthesia, his electrocardiogram demonstrated multiple episodes of dysrhythmias including complete bundle branch block, atrioventricular (AV) block, isorhythmic atrioventricular dissociation with junctional rhythm. Administration of atropine 1.0 mg IV terminated the last episode of dysrhythmias. Postoperatively, a resting 12-lead electrocardiogram showed first degree AV block, ST-segment elevation and prominent U waves. A 24 hour Holter recording demonstrated first degree atrioventricular block, episodes of marked sinus arrhythmias and one episode of sinus tachycardia at a rate of 152 beats ·min^-1. Treadmill stress testing revealed peak achieved heart rate of 200 beats·min^-1 without ischaemia. These findings collectively indicated athletic heart syndrome. Implications of athletic heart syndrome for the anaesthetist are reviewed and discussed.     

A method of taking the heart and a block from both lungs of one donor for transplantation to two recipients (experimental study)

A method allowing a heart and block of two lungs of one donor to be transplanted to two recipients was elaborated on 20 human cadavers. First the heart and then the lung transplants are removed. The main peculiarity of the method consists in optimal separation of the left atrial wall between the donor's heart and the block of two lungs. A method for the formation of a cuff of the left atrium which makes inspection and orientation in the anatomical structures easier is suggested.     

Type I second-degree AV block after neostigmine administration in a child with renal failure.

Neostigmine is commonly used to reverse neuromuscular blockade. A side effect can be parasympathetic stimulation, which may result in heart block. Renal failure can decrease the clearance and increase the half-life of the drug, thus increasing the likelihood of a vagomimetic response. A case is presented where a child with renal failure developed a type I second-degree heart block after neostigmine was given.     

Tertiary hyperparathyroidism associated with metastatic cardiac calcification in a haemodialyzed patient

A 32-year-old man undergoing haemodialysis treatment for 10 years was referred to our hospital because of intractable heart failure with atrioventricular block. On the 5th hospital day he was found dead in bed. Autopsy revealed extensive metastatic calcification involving the myocardium and the cardiac conduction system, and a parathyroid adenoma with hyperplastic parathyroid glands. Retrospectively, first-degree heart block developed 14 months before death, and was subsequently associated with intraventricular conduction defect and atrioventricular block (Wenckebach type). Throughout the 3 years the patient received 1α-hydroxycholecalciferol (1α-OH-D3) and the calcium-phosphorus product (Ca×P) exceeded 70. 1α-OH-D3 should not be prescribed when patients develop an increase in Ca×P and exploration of the parathyroid glands should not be delayed if heart block presents in long-term haemodialyzed patients.     

Complete heart block during central venous catheter placement in a patient with pre-existing left bundle branch block

Heart block and arrhythmia are complications of pulmonary arteryand cardiac catheterization. Injury to the conducting systemof the heart often involves the right bundle causing right bundlebranch block (RBBB). If patients already have left bundle branchblock (LBBB), complete heart block (CHB) may result. After trauma,impairment of the right bundle is usually transient with recoveryin hours, but complete heart block can lead to symptoms requiringinvasive treatment. Similar complications are rare with insertionof central venous catheters, as they should not enter the heart.Injury to the right bundle during central venous catheter insertioncan be by trauma from the guide wire or from the catheter itself.The function of the AV node and bundle of His in these patientshas not been studied before. We report a patient with LBBB whodeveloped CHB during insertion of a central venous cannula.Conduction through the AV node and His–Purkinje systemwas intact, showing that the transient RBBB was caused by traumaticinjury rather than by other disease of the conduction system. Br J Anaesth 2003; 91: 747–9     

胸段硬膜外阻滞防治心肌梗死后心室重构探讨

心肌梗死(myocardial infarction,MI)后左心室重构(left ventricular remodeling,LVRM)是导致心肌梗死后心力衰竭的主要因素,严重影响患者的生活质量和生存率。因此,减缓或逆转左心室重构是防治心肌梗死后心力衰竭的关键[1]。心室重构的防治目前主要采用药物、溶栓和血运重建术等,但心室重构是多因素、多系统、多环节参与的过程,其发生机制尚不完全清楚,因此目前对心室重构仍缺乏有效防治措施。近年来随着麻醉治疗学的发展,国内外学者将胸段硬膜外阻滞(thoracic epidural block,TEB)用于防治心绞痛、心肌梗死取得了良好的效果,而胸段硬…     

Peri-operative management and administration of anaesthesia in children with congenital complete heart block. A case report and review

The clinical presentation and natural history of congenital complete heart block (CHB) differ from those of acquired third-degree heart block. Although perioperative prophylactic cardiac pacing is considered mandatory in patients with acquired CHB, it is not usually necessary in children with asymptomatic congenital heart block. The anaesthetist should be able to identify which patients require temporary perioperative pacing, and should modify his anaesthetic technique appropriately for patients who do not. An 8-year-old patient with congenital CHB who required emergency surgery for acute appendicitis is presented and the anaesthetic management, including the indications for pacing, is discussed.