Cardiac Conduction Disease Perioperative New Onset Complete Heart Block Matthew C. Wixson, MD 7 February 2014 University of Michigan Department of Anesthesiology Puerto Vallarta Objectives • Case presentation • Review basic cardiac conduction pathway • Review various types of heart block and their implications • Review current guidelines of screening patients with bradyarrhythmias and conduction abnormalities • Educate regarding evidence supporting current practice guidelines • Review basic management of heart block in the urgent/emergent setting Case Presentation • S.B is a 92 year old ASA 2 male who presents for elective laparoscopic right inguinal hernia repair • PMHx – – – – – Mild aortic regurgitation LBBB HTN GERD Transverse and descending colon CA • PSHx – Inguinal hernia repair – Colon resection – Moh’s resection of SCC • Medications – – – – – – – ASA Vitamin B12 Losartan MVI Omeprazole Tamsulosin Triamterene-HCTZ • Allergies – Lisinopril – Sulfa antibiotics • SHx – Former pipe smoker (45 years, quit 1990) No EtOH or illicit drug use • Studies: EKG– sinus rhythm with occasional PVCs, LBBB • TTE (5/2013): EF ~65%, moderate aortic regurgitation, grade 1 diastolic dysfunction Preoperative EKG Clinical Course • Patient presented for surgery on 7/23/2013 • Intraoperative Record: without issues until reversal given (glycopyrrolate 0.4mg, neostigmine 2.5mg) • Patient noted to become bradycardic with HR ~40 beats/minute PACU Course • Arrived to PACU; report received that patient had been bradycardic since emergence • Had received 0.2mg glycopyrrolate prior to transfer from OR PACU • Arrival vitals: – – – – HR 41 beats/minute BP 104/48 mmHg SpO2 (6L NC) 99% T 36.4 C Differential Diagnosis Investigations • EKG • Cardiac labs • Telemetry PACU EKG • Patient noted to remain with HR 30s-40s beats/minute throughout PACU course • Had several 4-8 second sinus pauses noted on telemetry • Patient hemodynamically stable and mentating throughout sinus pauses • Transcutaneous pacing pads placed on patient and LifePak20 attached Telemetry Cardiology/EP Consult • Initial evaluation: patient noted to be in complete heart block – Requested access for transvenous pacing (if needed) • Patient admitted to SICU for further hemodynamic monitoring – 6 Fr catheter placed into IJ – Arterial line placed – Asymptomatic overnight SICU EKG Follow-up • Uneventful atriobiventricular pacemaker placement on POD#1 • Episode of atrial fibrillation while hospitalized – Resolved with amiodarone • Patient seen in Cardiology clinic and doing quite well Pacemaker EKG Cardiac Conduction System Review • Major features of EKG – – – – – 1 P wave, QRS complex, and T wave PR interval PR segment ST segment QT interval Cardiac Conduction SA Node AV Node Bundle of His Left Bundle L Anterior Hemibundle Right Bundle Image courtesy B. Woodcock L Posterior Hemibundle Types of Heart Block First Degree 2 Types of Heart Block Second Degree Type I 2 Types of Heart Block Second Degree Type II Image courtesy B. Woodcock Types of Heart Block Third Degree 2 Bundle Branch Block • Any conduction block in the His-Purkinje system SA Node AV Node Bundle of His Left Bundle L Anterior Hemibundle Right Bundle L Posterior Hemibundle Bundle Branch Block • Any conduction block in the His-Purkinje system SA Node AV Node Bundle of His Left Bundle L Anterior Hemibundle Right Bundle L Posterior Hemibundle Bundle Branch Block • Any conduction block in the His-Purkinje system SA Node AV Node Bundle of His Left Bundle L Anterior Hemibundle Right Bundle L Posterior Hemibundle Bundle Branch Block • Any conduction block in the His-Purkinje system SA Node AV Node Bundle of His Left Bundle L Anterior Hemibundle Right Bundle L Posterior Hemibundle Bundle Branch Block • Any conduction block in the His-Purkinje system SA Node AV Node Bundle of His Left Bundle L Anterior Hemibundle Right Bundle L Posterior Hemibundle Bundle Branch Block • Any conduction block in the His-Purkinje system SA Node AV Node Bundle of His Left Bundle L Anterior Hemibundle Right Bundle L Posterior Hemibundle Bundle Branch Block Recognition • Right Bundle Branch Block – R and R’ in leads V1 or V2 • Left Bundle Branch Block – R and R’ in leads V5 or V6 • Axis Deviation – Simple rule: thumb test Screening Guidelines ASA Screening Guidelines ACC/AHA (2007) “High-grade cardiac conduction abnormalities, such as complete atrioventricular block, if unanticipated, can increase operative risk and may necessitate temporary or permanent transvenous pacing. On the other hand, patients with intra- ventricular conduction delays, even in the presence of a left or right bundle-branch block, and no history of advanced heart block or symptoms rarely progress to complete heart block perioperatively.” 3 • Circulation 1978 – 44 patients undergoing 52 operations – 6 temporary pacemakers (TV) placed due to PR prolongation on preoperative EKG – 1 episode of transient CHB observed – 2/6 with TV pacemaker had ventricular irritability 4 • Retrospective study of patients with – Prolonged PR interval >0.2s PLUS – RBBB and LAHB (left anterior hemiblock) OR LBBB • 76 patients underwent general, local, or spinal anesthetic • Group 1 (RBBB and LAHB) – 1 patient with sinus bradycardia responsive to atropine • Group 2 (LBBB) – 3 patients with sinus bradycardia responsive to atropine – 3 patients with prophylactic TV pacemaker inserted preoperatively, none of which were utilized • Conclusion: risk>benefit of placing TV pacer 5 • Prospective study at University of Ulm, Germany • Aim: to determine whether presence of 1st degree AV block increases risk of progression to CHB • 103 patients with bifascicular or LBBB – Group 1: 56 patients without AV prolongation – Group 2: 47 patients with AV prolongation • Operations under general or regional anesthesia • Primary endpoint: progression to Mobitz Type II or CHB • Secondary endpoint: asystole >5s or severe bradycardia (<40 bpm) with hemodynamic compromise 6 Results • Group 1 – Two patients progressed to Wenkebach – Three patients had asystole >5 seconds • One progressed to cardiac arrest and was resuscitated • Group 2 – Four patients with HR <40 bpm and hemodynamic compromise • All responsive to atropine • Conclusions: progression is rare – Patients with pre-existing CAD more at risk • Retrospective review of >34,000 cases • 279 patients had complete RBBB – 70/279 had complete RBBB with left or right AD • Results – 1 patient progressed to CHB – On-pump CABG • Conclusion: prophylactic placement of gel pads is not cost-effective 7 • Prospective study – Enrollment criteria: asymptomatic bifascicular block OR left bundle branch block – Concurrent 1st degree AV block • Preoperative pacing pads – Increased milliamperes until capture obtained – Scored patient’s pain level 8 Results • 37/39 patients successfully paced – Two patients did not have capture at 120mA – One patient required • 5mg midazolam • 300mcg fentanyl • Assistance with ventilation – Could not increased further due to patient discomfort – 92% reported moderate to intolerable discomfort • No block progression in any patients Atropine • • • • • • Anticholinergic (parasympatholytic) Useful for symptomatic bradycardia Increases SA nodal rate and automaticity Increased induction via AV node Dose 0.5-1.0mg q3-5 minutes Not helpful in 2nd degree Type II block (Mobitz II) or CHB – Block is normally below AV node in those rhythms 12 Management of Complete Heart Block • Transcutaneous Pacing (TCP) – Non-invasive – Fast – Can initiate while waiting for response to drugs – Useful in hemodynamic instability due to bradycardia – Difference between electrical vs. mechanical capture 12 TCP Diagram Image courtesy B. Woodcock Image courtesy B. Woodcock Transvenous Pacing • More useful for longer-term pacing • Catheter placed in right ventricle – Can place in right atria if atrial pacing necessary • Venous access – IJ – Subclavian – Femoral vein • If prosthetic tricuspid valve, access can be obtained via left side through coronary sinus 13 Complications of TV Catheter Placement • • • • • • • • • • • 13 Pneumothorax Hemothorax Arterial puncture Air embolism Serious bleeding Myocardial perforation Cardiac tamponade Nerve Injury Thoracic duct injury Infection Arrhythmia Indications for Permanent Pacemaker • Class 1 – Generally agreed pacing is indicated • Complete or advanced second degree heart block with symptomatic bradycardia • Persistent complete or advanced second degree heart block following MI • Sinus node dysfunction with symptomatic bradycardia • Class II – Pacemakers frequently used but consensus as to necessity is not clear • Asymptomatic 2º or complete AV block – HR > 40 • Asymptomatic sinus node dysfunction – HR > 40 • Class III –Generally agreed pacing is not indicated • First degree AV block • Transient post-MI AV block without bundle branch block • Asymptomatic fascicular blocks without 2nd or 3rd degree AV block Final Thoughts • Was glycopyrrolate/neostigmine imbalance causative? • Should we have given atropine? • Is it worth placing transcutaneous pads on all patients at risk? References 1. Sinus Rhythm Labels. www.wikipedia.com/commons 2. Gomella LG, Haist SA. Clinician’s Pocket Reference, Eleventh Edition. 3. ACC/AHA GuidelineACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation.2007; 116: e418-e500 4. J O Pastore, P M Yurchak, K M Janis, J D Murphy and L M Zir. The risk of advanced heart block in surgical patients with right bundle branch block and left axis deviation. Circulation. 1978;57:677-680 5. Mikell FL, Weir EK, Chesler E. Perioperative risk of complete heart block in patients with bifascicular block and prolonged PR interval. Thorax 1981; 36: 14-17 6. Gauss A, Hubner C, Radermacher P, Georgieff M, Schutz W. Perioperative risk of complete heart block in patients with bifascicular block and prolonged PR interval. Anesthesiology 1998; 88: 679-87 7. Okamoto A, Inoue S, Tanaka Y, Kawaguchi M, Furuya H. Application of prophylactic gel-pads for transcutaneous pacing in patients with complete right bundle-branch block with axis deviation when surgical procedures are performed: 10year experience from a single Japanese university hospital. J Anesth (2009) 23:616–619 8. Gauss A, Hubner C, Meierhenrich R, Rohm HJ, Georgieff M, Schutz W. Perioperative transcutaneous pacemaker in patients with chronic bifascicular block or left bundle branch block and additional first-degree atrioventricular block. Acta Anaesthesiol Scand 1999; 43: 731–736. 9. Maniya R, Aono J, Manabe M. Complete atrioventricular block. Canadian J Anesthesia 1999; 46:3, 265-67 10. Thomson IR, Dalton BC, Lappas DG, Lowenstein E. Right Bundle-Branch Block and Complete Heart Block Caused by the Swan-Ganz Catheter. Anesthesiology 1979; 51: 359-62 11. Unnikrishnan D, Idris N, Varshneya N. Complete heart block during central venous catheter placement in a patient with pre-existing left bundle branch block . British Journal of Anaesthesia 91 (5): 747±9 (2003) 12. Giesecke M, Hosur S. Chapter 55. Cardiopulmonary Resuscitation. In: Butterworth IV JF, Butterworth IV JF, Mackey DC, Wasnick JD, Mackey DC, Wasnick JD, eds. Morgan & Mikhail's Clinical Anesthesiology. 5th ed. New York: McGraw-Hill; 2013. http://www.accessmedicine.com.proxy.lib.umich.edu/content.aspx?aID=57239900. Accessed September 22, 2013. 13. Hongo RH, Goldschlager N. Chapter 22. Conduction Disorders & Cardiac Pacing. In: Crawford MH, ed. CURRENT Diagnosis & Treatment: Cardiology. 3rd ed. New York: McGraw-Hill; 2009. http://www.accessmedicine.com.proxy.lib.umich.edu/content.aspx?aID=3648856. Accessed September 22, 2013. Questions?