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Cardiac Pacing in Incomplete Atrioventricular Block with Atrial Fibrillation

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Cardiac Pacing in Incomplete Atrioventricular Block with Atrial Fibrillation Br Heart J: first published as 10.1136/hrt.35.11.1154 on 1 November 1973. Downloaded from British Heart journal, I973, 35, I154-1I60. Cardiac pacing in incomplete atrioventricular block with atrial fibrillation D. S. Reid, S. J. Jachuck, and C. B. Henderson From the Department of Cardiology, Newcastle General Hospital, Newcastle upon Tyne Three cases with a slow irregular ventricular response to atrialfibrillation, who benefitedfrom cardiac pacing, are described; two had ischaemic heart disease, and one had cardiomyopathy. In thefirst case the slow ventricu- lar response to atrialfibrillation was a result of incomplete atrioventricular nodal block, and in the other two His bundle electrograms demonstrated that the slow ventricular response was due to bilateral bundle-branch block. The association of atrial fibrillation and conduction delays in the atrioventricular node and bundle- branches is discussed. The value of His bundle recordings in the investigation of these cases is shown and the importance of cardiac pacing in treatment is stressed. Cardiac pacing is now a generally accepted method hypotension. Intravenous atropine given before transfer of treatment in patients with complete heart block or had resulted in a paroxysm of ventricular tachycardia. bilateral bundle-branch block who have Adam- On admission there was no evidence of cardiac failure Stokes attacks or a low output to and the blood pressure was I05/50 mmHg. An electro- syndrome leading cardiogram showed atrial fibrillation with an irregular angina or cardiac failure. cardiac is However, pacing ventricular response of 40 to 44 beats a minute and acute now also becoming more widely used in the treat- inferolateral myocardial infarction (Fig. i). ment of patients with sinoatrial node disease ('sick Over the subsequent three days the ventricular rate sinus syndrome') who have disabling symptoms fell to 30 beats a minute and he developed cardiac fail- to or non-responsive atropine the sympathomimetic ure, hypotension, and oliguria. A slow infusion of iso- http://heart.bmj.com/ drugs (Bayley, I97I; Easley and Goldstein, I97I; prenaline resulted in ventricular fibrillation which re- Cheng, I968). In some patients with sinus node verted to atrial fibrillation with a single DC shock. disease the sinus bradycardia or sinoatrial block is Transvenous demand cardiac pacing was started and associated with rapid supraventricular arrhythmias over the next 5 days he gradually improved. The pacemaker was removed on the ioth day at including atrial fibrillation with a rapid ventricular which time he was in atrial fibrillation with a ventricular response - the bradycardia-tachycardia syndrome rate of go beats a minute (Fig. 2), and there was no evi- (Schulman et al., I970). Atrial fibrillation with a dence of cardiac failure. On discharge 5 weeks after slow ventricular rate is not a generally accepted admission and when seen 3 months later, he was well on October 1, 2021 by guest. Protected copyright. feature of this syndrome, though Ferrer (I968) but in atrial fibrillation with a ventricular rate of 8o to go included this in her definition, unless drugs affecting beats/minute. atrioventricular nodal conduction have been given as in one of the cases described by Bayley (I97I). Case 2 To our knowledge there has been no report of who have for atrial fibrilla- A 7i-year-old man was admitted with a one-year history patients requlired pacing of exertional chest pain and occasional syncope. In the tion with a slow irregular ventricular response and week before admission syncope had occurred daily and it is the purpose of this paper to report 3 such he had become breathless on effort. patients. Examination revealed mild cardiac failure, left ven- tricular hypertrophy, a blood pressure of I50/80 mmHg, Case reports and a slow irregular pulse. An electrocardiogram showed atrial fibrillation with an Case I irregular ventricular response of 50 beats a minute, com- A 69-year-old man who had sustained an acute myo- plete right bundle-branch block, a mean frontal QRS cardial infarction 24 hours previously was transferred to axis to the left with an initial vector directed inferiorly this hospital because of a slow heart rate associated with suggesting left anterior hemiblock (Fig. 3). A chest x-ray Received I4 May I973. showed a cardiothoracic ratio of 6o per cent and promi- Br Heart J: first published as 10.1136/hrt.35.11.1154 on 1 November 1973. Downloaded from Cardiac pacing in incomplete atrioventricular block with atrial fibrillation 155 aVR *....... ... 'n aVL M.' aVF ............ VI. ... ............ V4 .....^. ... .... ......... l,l V7 http://heart.bmj.com/ FIG...........~~~~~~~~~~~~~~~~~~~~~~.I Case i. Electrocardiogram 24 hours after myocardial infarction. I n II oVaR aVL aVF on October 1, 2021 by guest. Protected copyright. VI V2 V3 V4 VS V6 V7 V3 ; days a m infart FIG. 2 Case I. Electrocardiogram I4 days after myocardial infarction. Br Heart J: first published as 10.1136/hrt.35.11.1154 on 1 November 1973. Downloaded from II56 Reid, Jachuck, and Henderson I II HI aVR oV L oVF V4R VA VS V6 V7 V2 V4 V3 I FIG . 2. 3 Case Electrocardiogram showing atrial fibrillation, complete right bundle-branch http://heart.bmj.com/ block, and left anterior hemiblock. nence of the upper lobe veins. Shortly after admission (Fig. 4b). Sudden cessation of ventricular pacing was the heart rate fell to between 6 and 20 beats/minute and followed by a period of ventricular asystole during which he became pale and confused, but recovered spon- His potentials were present in the His bundle electro- taneously. An isoprenaline infusion was started but this cardiogram. As the standard electrocardiogram showed resulted in frequent ventricular extrasystoles without right bundle-branch block and left anterior hemiblock any increase in heart rate. A temporary pacemaker was these findings indicate second-degree block Mobitz II on October 1, 2021 by guest. Protected copyright. inserted and in the subsequent 2 days the heart rate and 2: i block in the posterior division of the left bundle, increased and remained at 6o to go beats/minute. The these findings being concealed in the standard electro- pacemaker was therefore removed after I2 days and the cardiogram by the presence of atrial fibrillation. patient was discharged. However, one month later he A permanent demand pacemaker was implanted and had a recurrence of syncope and he was readmitted. in the 12 months follow-up he has had no further Electrophysiological studies were carried out on this syncopal episodes and there has been no evidence of admission at the time of insertion of the permanent cardiac failure. transvenous pacing electrode. The technique for record- ing His bundle electrograms was essentially the same as that described by Scherlag et al. (I969). All recordings Case 3 were made with the frequency response set at 40-500 A 68-year-old woman was first admitted to another cycles/second and a paper speed of Ioo mmsec. The HV hospital in January i969 after a syncopal episode. She time was measured from the onset of the His bundle had a short history of chest tightness on effort but no deflection to the earliest ventricular deflection (normal other symptoms of heart disease. On examination the 35-55 msec). blood pressure was i60/go mmHg, pulse was irregular The HV time was normal in the conducted beats (40 at 46 beats a minute, and there was no evidence of heart msec) but there was intermittent block distal to the failure. Electrocardiograms showed 2:i and 3:I sino- bundle of His (Fig. 4a) and at times 2: i post H block atrial block with a junctional escape rhythm, at times Br Heart J: first published as 10.1136/hrt.35.11.1154 on 1 November 1973. Downloaded from Cardiac pacing in incomplete atrioventricular block with atrial fibrillation 13157 Lead II I N.1 H V .j 1.. Lead r- ____j .: Load II ~ HB8E-? NIV HVNN LeadI __ _ _ _ _ _ _ _ _ FIG. 4 Case 2. His bundle electrogram recorded at ioo mm/sec with simultaneous leads I and II (a) Irregular His response to atrial fibrillation and Mobitz II post H block. HV normal in conducted beats (40 msec). (b) 2:i block distal to bundle of His. HBE=His bundle recording; = V = ventricular H His bundle electrogram; electrogram. http://heart.bmj.com/ with retrogijade P waves (Fig. 5a). Chest x-ray showed A His bundle electrogram (Fig. 6) demonstrated a cardiac enlargement. She had no further syncopal epi- prolonged HV time (6o msec) in the conducted beats and sodes and within 2 days the sinus rhythm was resumed variable post H block; at times 2: post H block at other with a normal PR interval (o1i8 sec) and complete left times post H block without prolongation of the HV timne bundle-branch block (Fig. 5b). in the preceding beats as is usual in Mobitz type II In July 1971 she was admitted to the same hospital second-degree block (Narula and Samet, 1970). with .cardiac failure. Electrocardiograms on this admis- A Devices permanent demand pacemaker was inserted, sion showed atrial fibrillation with an irregular ventricu- and in the 6 months after this there has been no clinical on October 1, 2021 by guest. Protected copyright. lar response of ioo beats/min and complete left bundle- evidence of heart failure. branch block. She was treated with digoxin and diuretics and improved to some extent. Discussion She was initially seen at this hospital in November I972 because of breathlessness on minimal effort that The drug resistant bradycardias which require had persisted since July 197i. The digoxin had been cardiac pacing usually fall into two groups. In the stopped several months before this admission because of first group the bradycardia is due to atrioventricular a slow ventricular rate and isoprenaline had been given node, His bundie, or bilateral bundle-branch disease in a dose of 6o mg 8-hourly without any improvement mn resulting in a slow but regular idioventricular or the symptoms or heart rate.
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