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Key Clinical Updates in Atrioventicular Block

For patients in permanent atrial fibrillation who require pacing for symptomatic bradycardia or pauses, catheter-based implantation of a leadless pacemaker directly to the right ventricular endocardium may be considered.

ESSENTIALS OF DIAGNOSIS

  • Conduction disturbance between the atrium and ventricle that can be physiologic (due to enhanced vagal tone) or pathologic.

  • Block occurs in the AV node (first-degree, second-degree Mobitz type I) or below the AV node (second-degree Mobitz type II, third-degree).

  • Symptomatic AV block or block below the AV node in the absence of a reversible cause usually warrants permanent pacemaker implantation.

GENERAL CONSIDERATIONS

AV block can be physiologic (due to increased vagal tone) or pathologic (due to underlying heart disease such as ischemia, myocarditis, fibrosis of the conduction system, or after cardiac surgery). AV block is categorized as first-degree (PR interval greater than 200 msec with all atrial impulses conducted), second-degree (intermittent blocked beats), or third-degree (complete heart block, in which no atrial impulses are conducted to the ventricles). Second-degree AV block is further subclassified into Mobitz type I (Wenckebach), in which the AV conduction time (PR interval) progressively lengthens before the blocked beat, and Mobitz type II, in which there are intermittently nonconducted atrial beats not preceded by lengthening AV conduction. When only 2:1 AV block is present on the ECG, the differentiation between Mobitz type I or Mobitz type II is more difficult. If the baseline PR interval is prolonged (greater than 200 msec) or the width of the QRS complex is narrow (less than 120 msec), the block is usually nodal (Mobitz type I); if the QRS complex is wide (greater than or equal to 120 msec), the block is more likely infranodal (Mobitz type II).

AV dissociation occurs when an intrinsic ventricular pacemaker is firing at a rate faster than or close to the sinus rate (accelerated idioventricular rhythm, ventricular premature beats, or ventricular tachycardia), such that atrial impulses arriving at the AV node when it is refractory may not be conducted. This phenomenon does not necessarily indicate AV block. No treatment is required aside from management of the causative arrhythmia.

CLINICAL FINDINGS

The clinical presentation of first-degree and Mobitz type I block is typically benign and rarely produces symptoms. Normal, physiologic block of this type occurs in response to increases in parasympathetic output. This is commonly seen during sleep, with carotid sinus massage, or in well-trained athletes. It may also occur as a medication effect (calcium channel blockers, beta-blockers, digitalis, or antiarrhythmics). Pathologic causes, including myocardial ischemia or infarction (discussed earlier), inflammatory processes (ie, Lyme disease), fibrosis, calcification, or infiltration (ie, amyloidosis or sarcoidosis), should be excluded.

Mobitz type II block and complete (third-degree) heart block are almost always due to pathologic disease involving the infranodal conduction system, and symptoms including fatigue, dyspnea, presyncope or syncope are common. With complete heart block, ...

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