Pre-operative prophylactic transvenous cardiac pacing for bifascicular heart block.
ABSTRACT Some authorities consider that the combination of right bundle-branch block with left axis deviation (bifascicular block) is not an indication for prophylactic insertion of a pacing generator in patients undergoing non-cardiac surgery. Five patients who developed peri-operative progression of bifascicular block to complete heart block are described. Bifascicular block, together with any other cardiovascular condition, advanced age or surgery in regions that promote vagal stimulation, merit consideration for prophylactic pacing. A cardiological opinion is an essential aspect of the pre-operative preparation of patients with this abnormality.
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ABSTRACT: To the Editor, The natural progression of asymptomatic bifascicular block to complete heart block (CHB) in elderly patients occurs with a frequency of approximately 1% per year, and the risk of developing CHB in this population under general anesthesia has not been shown to be accelerated, thus preoperative permanent pacemaker placement is not recommended. Recently, an 87-year-old female with asymptomatic bifascicular block developed ventricular asystole and CHB during upper gastrointestinal (GI) endoscopy under propofol sedation at our institution. Her medical history was significant for dysphagia, weight loss, hypertension, and a 60% right coronary artery stenosis. Previous nuclear medicine stress testing revealed normal left ventricular systolic function and no ischemia. The preprocedure electrocardiogram demonstrated normal sinus rhythm with right bundle branch block and left anterior fascicular block (bifascicular block). She was not taking any medications with atrioventricular nodal-blocking activity and routine laboratory screening tests were within normal limits. The patient denied a history of syncope or other symptoms suggestive of CHB. Her blood pressure was 171/83 mmHg and heart rate was 83 beats min -1 .I n the endoscopy suite, standard American Society of Anesthesiologists monitors were applied. Oxygen 6 l min -1 was administered via facemask and the patient was positioned left lateral decubitus. During the 13-min endoscopy a registered nurse titrated 80 mg of propofol iv, as directed by the gastroenterologist performing the procedure. Patient response to sedation was maintained at purposely responsive to either verbal or tactile physical stimuli throughout the brief procedure. Her heart rate ranged from 77 to 90 beats min -1 , there was no hypotension, and no ST segment changes. Oxygen saturation was maintained at 98–100%Canadian Journal of Anaesthesia 02/2009; 56(1):83-4. DOI:10.1007/s12630-008-9014-5 · 2.50 Impact Factor
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ABSTRACT: Complete heart block is dreaded perioperatively in patients with chronic bifascicular or left bundle branch block (LBBB) and additional first-degree A-V block. Our aim was to investigate the necessity as well as the efficacy and safety of transcutaneous pacing in the perioperative setting. Thirty-nine consecutive patients with asymptomatic chronic bifascicular block or LBBB and prolongation of the P-R interval scheduled to undergo surgery under anesthesia were prospectively enrolled in the study. Preoperatively, a transcutaneous pacemaker (PACE 500 D, Osypka Co.) was applied; its efficacy was checked with intra-arterial blood pressure measurement; the pain level was recorded. Additionally, 24-h Holter monitoring (CM2, CM5) was applied. Occurrences of a block progression or a bradycardia of <40 beats/min with hemodynamic impairment were the defined end points. Thirty-seven of the 39 patients (95%) could be successfully stimulated with a median current strength of 70 mA; whereby 33 of the 39 patients felt moderate to severe pain. There was no perioperative block progression. Three cases of brady-cardia of <40 beats/min with a critical drop in blood pressure occurred; but these patients were successfully treated with drug therapy without pacemaker stimulation. The perioperative application and testing of the pacemaker was safe and could be performed in nearly all patients successfully. However, we do not consider a routine prophylactic transcutaneous placement in patients with chronic bifascicular or LBBB and additional first-degree A-V block justified. Nevertheless, appropriate drugs and temporary pacemaker equipment should be easily accessible.Acta Anaesthesiologica Scandinavica 09/1999; 43(7):731-6. DOI:10.1034/j.1399-6576.1999.430708.x · 2.31 Impact Factor