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Pacemaker management for acute onset of heart block in childhood
Insights
Stokes-Adams syndrome in children, often caused by viral myocarditis, can lead to complete heart block. Prompt cardiac pacing is crucial for managing this rare condition.
Area of Science:
- Pediatric Cardiology
- Infectious Diseases
- Electrophysiology
Background:
- Stokes-Adams syndrome, characterized by syncope due to extreme bradycardia, is a rare manifestation of complete heart block in childhood.
- Acquired complete heart block in pediatric patients is uncommon and can present without overt signs of congestive heart failure.
Observation:
- Four pediatric patients (ages 2-15) presented with Stokes-Adams syndrome as the primary cardiac issue of complete heart block.
- Two patients showed elevated viral neutralizing antibody titers (coxsackievirus B1 and B2), suggesting a viral etiology.
- Electrocardiography revealed complete heart block with various conduction abnormalities, including ventricular standstill and transient second-degree heart block.
Findings:
- Nonsurgical acquired complete heart block, potentially due to myocarditis, was the underlying cause in these children.
- Temporary transvenous pacemakers were necessary to prevent life-threatening Stokes-Adams episodes.
- Two patients required permanent pacemakers due to persistent complete heart block, while two recovered to sinus rhythm.
Implications:
- This study highlights that acquired complete heart block can be the sole cardiac finding in pediatric myocarditis.
- Immediate cardiac pacing is essential for managing symptomatic bradycardia and preventing syncope.
- The need for permanent pacemaker implantation should be considered for persistent complete heart block in children.
Abstract:
Four children aged 2 to 15 years are described who had Stokes-Adams syndrome as the primary cardiac manifestation of complete heart block. All had mild, nonspecific antecedent symptoms without signs of congestive heart failure. Viral neutralizing antibody titers (coxsackievirus B1 and B2) rose significantly in two patients. Electrocardiography demonstrated complete heart block associated with one or more of the following: right bundle branch block, left anterior hemiblock, left bundle branch block, intraventricular conduction delay, and ventricular standstill. In addition, second-degree heart block was seen during the initial or resolving phases of illness. To prevent further life-threatening episodes of Stokes-Adams syndrome, temporary transvenous pacemakers were placed. Two patients with persisting complete heart block required permanent pacemakers. At last examination, the remaining two patients had sinus rhythm and normal conduction. Nonsurgical acquired complete heart block is unusual in childhood, and may be the only manifestation of myocarditis. Extreme bradycardia, which causes syncope, requires immediate temporary cardiac pacing; if the bradycardia persists, a permanent pacemaker should be implanted.