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. · 2.50 Impact Factor