Wenckebach-type Atrioventricular Block Research Articles

Repeated complete atrioventricular block during remifentanil administration in a pediatric patient with brain tumor and acute hydrocephalus: a case report

BackgroundRemifentanil, an ultra-short-acting µ-opioid receptor agonist, is commonly used for anesthetic management due to excellent adjustability. Remifentanil is known to cause sinus bradycardia, however, because it has a direct negative chronotropic effect on the cardiac conduction system and there is an indirect negative chronotropic effect via the parasympathetic nervous system.Case presentationAn 8-year-old Japanese boy was diagnosed with acute hydrocephalus due to a brain tumor in the fourth ventricle and underwent emergency surgery. Imaging examination showed brainstem compression. Endoscopic third ventriculostomy and ventriculoperitoneal shunt surgery were scheduled. Remifentanil was started during induction of general anesthesia, but electrocardiogram showed sinus bradycardia, then Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was immediately discontinued, and we administered atropine sulfate. Complete atrioventricular block was restored to sinus rhythm. When remifentanil was restarted, however, the electrocardiogram again showed sinus bradycardia, Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was again immediately discontinued, we administered adrenaline, and then complete atrioventricular block was restored to sinus rhythm. Fentanyl was used instead of remifentanil with continuous infusion of dopamine. There has since been no further occurrence of complete atrioventricular block.ConclusionsThis is the first known case of complete atrioventricular block in a pediatric patient with increased intracranial pressure seemingly caused by administration of remifentanil.

Subclinical Arrhythmias and Conduction Disturbances in Children with Myopericarditis: A 24-hour Holter Monitorization Study.

Myopericarditis is reported as a benign clinical entity in children and adolescents. However, there is no study investigating specifically the arrhythmias in these children. In the present study, we aimed to investigate the frequency of arrhythmias and conduction disturbances from surface electrocardiography and 24-hour Holter monitor, in children with myopericarditis. The medical records of the children with the diagnosis of myopericarditis between 2016 and 2021 were retrospectively reviewed. Clinical features, surface electrocardiography, and 24-hour Holter recordings were evaluated in terms of rhythm and conduction abnormalities. Mean troponin level was 7980.52 ± 14880.27 ng/L at admission. At discharge, the mean troponin level was 8.27 ± 10.73 ng/L and it was above the upper limit of normal in 19/27 (70.4%) patients. Surface electrocardiography was normal in terms of arrhythmias and conduction disturbances in all patients. Twentyfour-hour Holter monitarization was found to be normal in 23 patients. In 4 patients, there were clinically insignificant arrhythmias; nonsustained accelerated idioventricular rhythm=1, ventricular couplet with low rate=1, infrequent supraventricular premature contractions=1, and infrequent ventricular premature contractions+Wenckebach type atrioventricular block=1. Our findings support that myopericarditis is a benign clinical problem in children also in terms of arrhythmia.

Fast-slow atrioventricular nodal reentrant tachycardia phenotype mimicking the slow-slow type

Abstract Background Fast-slow (F/S-) atrioventricular (AV) nodal reentrant tachycardia (AVNRT) is characterized by a short atrio-His (AH) interval and the earliest site of atrial activation (EAA) in the proximal coronary sinus (EAA-CS), while slow-slow (S/S-) AVNRT presents a long AH interval and EAA-CS. Those intracardiac appearances are initial indicators for making a diagnosis. Purpose To identify an unknown phenotype of F/S-AVNRT. Methods Among 46 consecutive patients with F/S-AVNRT, 6 patients (1 man, age 59±9) had an apparent but not typical (pseudo-) S/S-AVNRT during an electrophysiologic study. In 2 patients, pseudo-S/S-AVNRT was clinically documented. Results In all 6 patients, the diagnosis of F/S-AVNRT was made by an exclusion of atrial tachycardia with findings of 1) a V-A-V response following ventricular entrainment or 2) termination without atrial capture by ventricular pacing, and an exclusion of AV reentrant tachycardia with a ventriculoatrial dissociation during an initial (so-called QRS transition) zone of ventricular entrainment. An initial A-A-V activation sequence on atrial induction of F/S-AVNRT observed in 1 patient and Wenckebach-type AV block during ongoing F/S-AVNRT developing in 3 patients suggested the presence of the lower common pathway (LCP). Like the typical S/S-AVNRT, pseudo-S/S-AVNRT was induced with atrial stimulation after a jump in the AH interval or double ventricular response. However, in all patients, the pseudo-S/S-AVNRT transited to F/S-AVNRT following AV block in a single cycle and/or pseudo-S/S-AVNRT transited from spontaneously or triggered by atrial contractions. Importantly, on these transitions, the atrial cycle length (CL) and EAA-CS remained unchanged, that is, the atrial CL of S/S-AVNRT was almost identical to that of F/S-AVNRT, suggesting that the essential circuit of both tachycardias was identical. Actually, both tachycardias were cured by ablation at a single site in the traditional slow pathway (SP). Collectively, the pseudo-S/S-AVNRT was diagnosed as another phenotype of F/S-AVNRT accompanied by sustained antegrade conduction via another bystander (likely the left-sided or superior) SP breaking through the His bundle owing to the repetitive antegrade block at the LCP occurring by linking phenomenon, thus representing a long AH interval during the ongoing F/S-AVNRT. When the antegrade conduction is blocked at the bystander SP during the pseudo-S/S-AVNRT, releasing the linking phenomenon, the subsequent antegrade conduction reach the His-bundle via the fast pathway, thus returning to F/S-AVNRT. Conclusions An unknown, but not rare F/S-AVNRT phenotype exists that apparently mimics the typical S/S-AVNRT and is also an unknown subtype of apparent S/S-AVNRT. The presence of this pseudo-S/S-AVNRT suggests the limitation of classifying types of AVNRT based on AH and HA intervals during tachycardia. Understandings of this phenotype can advance a diagnosis of atypical AVNRT with multiple phenotypes. Funding Acknowledgement Type of funding sources: None.

Superior-Type Fast-Slow Atrioventricular Nodal Reentrant Tachycardia Phenotype Mimicking the Slow-Fast Type.

Superior-type fast-slow (sup-F/S-) atrioventricular nodal reentrant tachycardia (AVNRT) is a rare AVNRT variant using a superior slow pathway (SP) as the retrograde limb. Its intracardiac appearance, characterized by a short atrio-His (AH) interval and the earliest site of atrial activation in the His-bundle, is an initial indicator for making a diagnosis. Among 22 consecutive patients with sup-F/S-AVNRT, 3 (age, 68-81 years) patients had an apparent slow-fast (S/F-) AVNRT characterized by a long AH interval and the earliest site of atrial activation in or superior to the His-bundle region (tachy-long-AH). The diagnosis of sup-F/S-AVNRT was based on the standard criteria in 2 patients and on the occurrence of Wenckebach-type atrioventricular block during tachycardia, which was attributable to a block at the lower common pathway (LCP) below the circuit of the AVNRT, detected owing to the lower common pathway potentials, in one patient. As with the typical S/F-AVNRT, tachy-long-AH was induced after a jump in the AH interval. In contrast to typical S/F-AVNRT, fluctuation in the ventriculoatrial interval was observed during the tachy-long-AH. Ventricular overdrive pacing was unable to entrain or terminate the tachy-long-AH. Moreover, the tachy-long-AH reciprocally transited to/from sup-F/S-AVNRT spontaneously or was triggered by ventricular contractions while the atrial cycle length and earliest site of atrial activation remained unchanged. Both tachycardias were cured by ablation at a single site in the right-side para-Hisian region of 2 patients and the noncoronary aortic cusp of one patient. Collectively, the essential circuit of both tachycardias was identical, and the tachy-long-AH was diagnosed as another phenotype of sup-F/S-AVNRT accompanied by sustained antegrade conduction via another bystander slow pathway breaking through the His-bundle owing to the repetitive antegrade block at the lower common pathway, thus representing a long AH interval during the ongoing sup-F/S-AVNRT. An unknown sup-F/S-AVNRT phenotype exists that apparently mimics the typical S/F-AVNRT and is also an unknown subtype of apparent S/F-AVNRT.

High-degree atrioventricular block in acute ethanol poisoning: a case report

IntroductionAcute ethanol ingestion can prolong the PR interval, but searching Medline, we have found only one report of Wenckebach-type atrioventricular block in ethanol poisoning. We present a high-degree atrioventricular block in an ethanol-poisoned patient.Case presentationA 17-year-old woman with a non-contributory medical history ingested 3dcl of vodka and was found comatose. On arrival she was somnolent with nausea, tympanic temperature 36.0°C, pulse 70 counts/min, blood pressure 90/60 mmHg, respiratory rate 12 counts/min and SpO2 96% on room air. Her blood ethanol level was 130 mg/dL; other blood laboratory test results were normal. ECG revealed sinus rhythm, first-degree atrioventricular block with a PR interval of 0.32 seconds and intermittent second- and third-degree atrioventricular blocks with up to 4-second-long pauses that appeared 15-30 seconds after each vomiting. She was given thiethylperazine and vomiting resolved within an hour. ECG 12 hours after admission revealed a first-degree atrioventricular block with a PR interval of 0.24 seconds. One month later Holter monitor showed a sinus rhythm and first-degree atrioventricular block with a PR interval of 0.21 seconds. Vagal maneuvers did not provoke high-degree atrioventricular block. The echocardiogram was normal.ConclusionAcute ethanol poisoning has the potential to prolong the PR interval in adults with first-degree atrioventricular block and provoke intermittent second- and third-degree atrioventricular blocks, possibly by its direct inhibitory action on the conduction system and increasing parasympathetic tone due to nausea and vomiting.

Electrocardiographic findings after acute absinthe intoxication

A 29-year-old comatose patient was brought to Emergency Department with severe alcohol intoxication. No risk factors or cardiac abnormalities were documented. The analysis was negative for other drugs. Plasma electrolyte and cardiac enzymes were normal. The electrocardiogram showed Mobitz type-I atrioventricular block that developed to a rapid junctional rhythm. The patient was stabilized and recovered completely, electrocardiogram then showed sinus rhythm. He admitted important absinthe consumption. Although tachyarrhythmias are frequently developed in acute alcohol intoxication, bradyarrhythmias are exceptional in this context. We present a Wenckebach-type atrioventricular-block in severe alcohol intoxication with absinthe that developed to a rapid junctional rhythm, never described before.

抗てんかん薬内服中に外傷により誘発されたと思われるＷｅｎｃｋｅｂａｃｈ型房室ブロックの１症例

抗てんかん薬内服中に外傷により誘発されたと思われるＷｅｎｃｋｅｂａｃｈ型房室ブロックの１症例

Prognostic evaluation in young patients with first degree and/or Wenckebach type atrioventricular block

Prognostic evaluation in young patients with first degree and/or Wenckebach type atrioventricular block

Second degree Wenckebach type atrioventricular block due to block within the atrium

Second degree Wenckebach type atrioventricular block due to block within the atrium