ECG - AV Block

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ECG - AV Block

  1. 1. DR.SENTHAMIZHSELVAN. K PROF.DR.RAMASAMY’S UNIT ECG OF THE WEEK
  2. 2. CLINICAL PICTURE <ul><li>14 year old girl presented to opd with </li></ul><ul><li>H/O giddiness and transient LOC for few secs </li></ul><ul><li>followed by spontaneous recovery </li></ul><ul><li>No H/O chest pain ,palpitation, breathlessness, </li></ul><ul><li>head ache </li></ul><ul><li>No H/O drug intake </li></ul><ul><li>H/O 3 similar episodes over the past 6 months </li></ul><ul><li>Not a k/c of heart disease </li></ul><ul><li>O/E Pulse was 52/min ,irregular </li></ul><ul><li>BP 110/70 mmHg </li></ul><ul><li>CVS,RS,CNS –NAD </li></ul>
  3. 3. ecg
  4. 4. FINDINGS <ul><li>Rate :45/min </li></ul><ul><li>axis :+110 </li></ul><ul><li>p wave morphology and duration - normal </li></ul><ul><li>Alternate P waves are not conducted </li></ul><ul><li>PR interval =0.16 s ,RR interval and PP interval are regular and constant </li></ul><ul><li>QRS duration 0.10s , QTc interval =0.60s </li></ul><ul><li>Bizarre T wave inversion in V3-V6,L2,L3,aVF </li></ul>
  5. 5. IMPRESSION <ul><li>A case of 2:1 AV block, with bizarre and giant T wave inversion ,QTc prolongation </li></ul><ul><li>Level of the block to be confirmed by HIS –BUNDLE electrogram </li></ul><ul><li>Recurrent syncopal attacks can be attributed to </li></ul><ul><li>STOKES-ADAMS-ATTACKS </li></ul>
  6. 6. ATRIO-VENTRICULAR BLOCK <ul><li>Atrial conduction to ventricle is blocked at a time when AV </li></ul><ul><li>junction is not physiologically refractory; </li></ul><ul><li>Normal AV nodal delay is 0.1 sec.; </li></ul><ul><li>Fast SV rhythm like AF,AFL,has a barrier at AV </li></ul><ul><li>node to reduce ventricular rate ; </li></ul><ul><li>Block occurs at AV node or HIS Purkinje system to be confirmed by HIS electrogram; </li></ul>
  7. 7. HIS BUNDLE ELECTROGRAM PA 20-50 msec; AH 50-140 msec HV 35-55 msec;
  8. 8. CLASSIFICATION <ul><li>INCOMPLETE - 1 st degree;2 nd degree; </li></ul><ul><li>COMPLETE - 3 rd degree; </li></ul><ul><li>FIRST DEGREE AV BLOCK </li></ul><ul><li>- Prolongation of PR interval beyond 0.2 secs(adults),0.18secs(children); </li></ul><ul><li>- No change in underlying rhythm; </li></ul><ul><li>- If QRS normal – block in AV node 87% cases, prolonged AH interval; </li></ul><ul><li>- If QRS abnormal – block in infranodal region, prolonged HV interval </li></ul>
  9. 9. SECOND DEGREE AV BLOCK <ul><li>Some sinus impulses are conducted to ventricles & </li></ul><ul><li>some are not; </li></ul><ul><li>MOBITZ TYPE I BLOCK(WENCKEBACH) </li></ul><ul><li>-progressive prolongation of PR interval prior to non conducted P waves; </li></ul><ul><li>- PR interval prolongation is in decreasing increments; </li></ul><ul><li>- progressive shortening of RR interval; </li></ul><ul><li>- the pause comprising the blocked P wave is < the </li></ul><ul><li>sum of two P-P intervals </li></ul><ul><li>- this pattern occurs regularly – ’group beating ’ </li></ul>
  10. 10. <ul><li>CONDUCTION RATIO /WENCKEBACH PERIOD </li></ul><ul><li>- Ratio of number of P waves to number of QRS in a sequence ; </li></ul><ul><li>- Normal QRS- block almost always in AV node; </li></ul><ul><li>- QRS abnormal- block in infranodal pathways; </li></ul>
  11. 11. MOBITZ TYPE II BLOCK <ul><li>Constant PR,PP interval; </li></ul><ul><li>No wenckebach phenomenon; </li></ul><ul><li>Fixed block, QRS abnormality present; </li></ul><ul><li>Pause including blocked P wave = 2× PP interval; </li></ul><ul><li>Mostly infranodal block; </li></ul><ul><li>2:1 AV BLOCK </li></ul><ul><li>MT1 MT2 </li></ul><ul><li>- carotid sinus massage - no change,fixed </li></ul><ul><li>atropine,exercise can unmask it 2:1 block </li></ul><ul><li>(2:1 -3:2) </li></ul><ul><li>-HIS electrogram- nodal - infra nodal </li></ul>
  12. 12. COMPLETE AV BLOCK <ul><li>Third degree block; </li></ul><ul><li>Failure of all P waves to reach the ventricles </li></ul><ul><li>Two independent pacemakers one in atria,other in ventricles </li></ul><ul><li>function in asynchronous manner </li></ul><ul><li>Block at AV node-escape rhythm is junctional (40- </li></ul><ul><li>60/mt)narrowQRS </li></ul><ul><li>Block at HIS system –escape rhythm is ventricular (20- </li></ul><ul><li>40/mt)wide QRS </li></ul>
  13. 13. STOKE-ADAMS ATTACKS <ul><li>Morgagni synd. @ Spens synd. @ Stokes synd . </li></ul><ul><li>sudden transient syncope ,due to cardiac dysrhythmia; </li></ul><ul><li>occasional seizures; </li></ul><ul><li>respiration is normal throughout </li></ul><ul><li>-hence on recovery ,pt. appears flushed; </li></ul><ul><li>-posture independent; </li></ul><ul><li>-multiple attacks per day; </li></ul><ul><li>-asystole/VF/CHB/--- possible triggers </li></ul><ul><li>Treatment;--Drugs – DDI pacing </li></ul>
  14. 14. CAUSES OF AV BLOCKS <ul><li>REVERSIBLE PERMANENT </li></ul><ul><li>PHYSIOLOGIC; CAD; </li></ul><ul><li>CAD; MATERNAL SLE; </li></ul><ul><li>INF. ENDOCARDITIS; CMP; </li></ul><ul><li>MYOCARDITIS; INFILTRATIVE; </li></ul><ul><li>METABOLIC; TRAUMATIC; </li></ul><ul><li>TRAUMATIC; TUMOURS; </li></ul><ul><li>DRUG INDUCED; NM DISORDERS; </li></ul><ul><li>IDIOPATHIC; </li></ul>
  15. 15. MANAGEMENT <ul><li>Identify transient causes and treat; </li></ul><ul><li>PERMANENT PACING IF </li></ul><ul><li>- symptomatic +advanced block; </li></ul><ul><li>-asymptomatic +complete heart block / </li></ul><ul><li>infranodal second deg. block </li></ul><ul><li>TEMPORARY /PROPHYLACTIC PACING IF </li></ul><ul><li>-block with hemodynamic compromise </li></ul><ul><li>-AMI with development of new blocks </li></ul><ul><li>----permanent pacing to be considered </li></ul><ul><li>later </li></ul>
  16. 16. <ul><li>Thank </li></ul><ul><li>u </li></ul>

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