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Perioperative transcutaneous pacemaker in patients with chronic bifascicular block or left bundle branch block and
A Gauss1, C Hübner, R Meierhenrich
1Department of Anesthesiology, University of Ulm, Germany.
Insights
Transcutaneous pacing is safe for patients with chronic bifascicular block or left bundle branch block (LBBB) undergoing surgery. Routine prophylactic use is not recommended, but emergency pacing equipment should be readily available.
Area of Science:
- Cardiology
- Perioperative Medicine
- Electrophysiology
Background:
- Complete heart block poses a significant perioperative risk for patients with chronic bifascicular block or left bundle branch block (LBBB) and first-degree atrioventricular block.
- The necessity, efficacy, and safety of transcutaneous pacing in this patient population require investigation.
Purpose of the Study:
- To evaluate the necessity, efficacy, and safety of transcutaneous pacing in patients with chronic bifascicular block or LBBB undergoing surgery.
- To assess the feasibility and patient tolerance of perioperative transcutaneous pacemaker application.
Main Methods:
- Prospective enrollment of 39 patients with asymptomatic chronic bifascicular block or LBBB and prolonged PR interval undergoing surgery.
- Preoperative application and testing of a transcutaneous pacemaker, with efficacy assessed by intra-arterial blood pressure and pain levels.
- 24-hour Holter monitoring to track block progression or significant bradycardia.
Main Results:
- Transcutaneous pacing was successfully applied in 95% of patients, though 85% experienced moderate to severe pain.
- No perioperative block progression was observed.
- Three instances of bradycardia with hemodynamic compromise occurred but were managed with drug therapy, not pacemaker stimulation.
Conclusions:
- Perioperative transcutaneous pacemaker application and testing are safe and feasible in most patients.
- Routine prophylactic transcutaneous pacing is not deemed necessary for patients with chronic bifascicular block or LBBB and first-degree AV block.
- Readily accessible emergency drugs and temporary pacemaker equipment are essential for managing potential complications.
Background:
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.
Methods:
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.
Results:
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.
Conclusion:
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.