rbbb

[unikrish]

Hi,
I am a 52 year old commercial pilot. I was diagonised with RBBB in Nov 2004.  
A full diagnosis was done as under :
Holter report - RBBB, occasional VPCs, episodes od sinus pauses an AV blocks seen, maximal duration 2.9 sec, no escape rhythm, no ST T changes S/O reversible ischemia. no episodes of malignant tachycardia, no prolonged episodes of bradycardia
2. tetrofosmin myocardiodiaal perfusion scan -  over all quality of study good. no evidence of abnormal lung activity.  Post stress - mild perfusion in mid and bal anterior wall and inferior wall of myocardium. No stress induced L.V dysfunction.
3. 2 D Echo - Normal 2-D Echo and colour doppler
4. CT coronory Angi0 - LAD mild smooth segmental narrowing in mid LAD. Everything else normal
5. Calcium Score : The score was Zero in LMA, LAD, LCX,RCA, PDA, A,B and C
6.Corononary Angiography : Left Main - Normal, LAD- Type III normal vessal, LCX - non dominant and normal, LV Angio not done,
7. Resting  ECG shows - RBBB and LPFB

I would like to know the chances that my problem would escalate to  cause problems in  my flying career.

Regards,

[Davidlika]

A related discussion, Left anterior fascicular block was started.

[Michael J. McWilliams, M.D.]

Great, thanks for responding.  it would have taken me hours to find that.  it is very helpful.

happy flying.

[unikrish]

I found the following on pacemaker for pilots :
Heart - JAR Certification Following Insertion of a Heart Pacemaker
  Procedure to gain recertification following pacemaker insertion

  
JAR certification following insertion of a heart pacemaker
The normal heartbeat originates as an electrical impulse in a natural “pacemaker”, a collection of specialised conducting cells in one of the upper chambers of the heart (the right atrium).   The impulse travels from the upper to the lower chambers (the ventricles) leaving in its wake a rhythmical muscular contraction of the heart muscle, which, in turn, pumps blood to the lungs and to the rest of the body.  If this natural pacemaker fails, or if there is a failure to conduct the electrical impulse, then heart muscle contraction does not occur and blood does not circulate.  If this pause in the circulation is prolonged, incapacitation can occur.  Clearly this is not a situation that is acceptable in pilots.  

The pilot who is suspected of having, or is likely to have, such pauses will be grounded and will undergo a series of heart tests.  These should reveal no obvious abnormality or cause of the heart rhythm disturbance.  For such pilots the fitting of an artificial heart pacemaker, which senses a pause and then stimulates the heart to beat, may allow a return to flying.  However the pilot’s heart must not be “pacemaker dependent”.  This means that all the heart beats are initiated by the artificial pacemaker, and if it stops, so does the heart.  The artificial pacemaker should only be there as an insurance against a pause in the normal heart rhythm which, if prolonged, could lead to incapacitation.  

The artificial pacemaker is an electronic device which can generate a pulse of electricity.  It is powered by a battery that can last for many years.  It is usually positioned just under the skin in the upper chest.  Wires are led to the heart chambers via a vein, and anchored to the muscle wall.  They sense the normal heart beat, and initiate an artificial beat if the normal one fails.  It is important that both positive and negative electrodes are placed within the heart itself (bipolar electrodes) as this minimises any interference from external electromagnetic waves, which could occur in an aircraft cockpit.

The exact requirements for JAR Class 1 or Class 2 certification following the implantation of a cardiac pacemaker and the pilot’s subsequent follow up are outlined in a cardiac pacemaker protocol.  Certification of Air Traffic Controllers is similar.

December 2006"

Regards,

[unikrish]

Thanks. I did show it to an electrophysiologist and he told me not to worry. I have not heard of an EP study nor was it recommended.
Regards,

[Michael J. McWilliams, M.D.]

That is a tough question.  You are considered a high risk profession because you fly planes. Have you seen a cardiac electrophysiogist yet?  If you were in a normal profession, no additional testing is indicated at this time.  Your risk of developing complete heart block is low enough that you would not be considered for a pacemaker unless you were have symptomatic pauses longer than 3 seconds.  The risk of a right bundle branch block progressing to complete heart block is less than 6% per year, your risk is probably slightly higher since you have a left posterior fascicular block as well.

As a pilot that makes it a bit harder.  If I saw a patient such as yourself in clinic, I would consider doing an invasive study to measure your conduction times.  If your intervals were too long, you might need a pacemaker.  What I don't know is if you can pilot with a pacemaker.  Do you know the answer to that one?

I think you need further testing, but i do not think there is a consensus on how to treat an individual like yourself.

Was an EP study discussed?

I hope this helps.