Pediatric Heart Expert Forum
2:1 AV block
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2:1 AV block

my scan at 28 weeks showed low amniotic fluid with an index 2 to 3,with a comment fetal cardiac activity good 147 bpm,(2 doses of steroids were given as i had low AFI to prepare the baby for c section).l arginine was was also prescribed along with IV fructodex.second opinion at 29 weeks. AFI was 9 . but they detected irregular heart beat with 145 bpm (IAS movement irregular).followed up at 33 weeks and found intermittent bradycardia and premature closure of foramen ovule.(145 to 70 bpm).emergency c section performed.the baby was stable but the heart rate was between 60 to  90 bpm based on the on 3rd day of life . followup at 15 days. ECG was normal with 128 bpm. stopped alupent. followup at 4th month showed 2:1 av block with heart rate 53 to 70 bpm based on activity.(AV nodal block-infact doctor mentioned above AV node).holter reports show lowest heart rate as 53 bpm and highest 162 bpm. doctors mentioned that when the baby is activly playing or crying every signal is conducted(no block) when baby is at rest (awake and less active)or at sleep 2:1 av block is seen

the baby is not under medication from 15 days of age to 7 months, stable, active asymptomatic and feeding well and crossing all developmental milestones at correct age.doctors expressed uncertainity about future.
what should i expect. is this block reversible. any advice or instruction for baby care people(as i go for work) and educating the baby
serum electrolytes in range, structurally good heart with normal ventricular function. spo2 100%
why did irregular heart beat progress to intermittent bradycardia and heart block(2:1)
(doctors were seeing through the decrement in heart function and have not adopted any therapy during pregnancy or in neonatal care)waiting for my SLE report. will these results make any difference to my son's present condition or treatment.

Is there anything we can help the baby with except waiting and watching for it to go worse and use pacemaker.this decision troubles me
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773637_tn?1327450515
Dear Shabna,

As best as I can interpret from your posting, it appears that there were several things going on with your baby.  First, you had oligohydramnios (low amniotic fluid), which can occur for several different reasons that I won’t address in this forum.  However, it sounds like this may have improved somewhat after treatment.  Then, there was evidence of premature closure of the foramen ovale, the flap valve between the upper two chambers of the heart that allows blood to bypass the fetal lungs.  There was also bradycardia, or a slow heart rate; these two things sound like they may have led to the emergency C-section.  After birth, it was noted that your baby was demonstrating atrioventricular block at a rate of 2:1, which means that every other heart beat originating from the natural pacemaker of the heart (the sinus node) was getting through the atrioventricular node (AV node), the single electrical connection from the top of the heart to the bottom of the heart.  This means that the actual heart rate and cardiac output was decreased.

Without seeing your child’s ECG and evaluating your child, I cannot give you specific information.  However, it sounds like the heart block is intermittent and that the baby’s heart is tolerating this well.  The likelihood that this will spontaneously resolve is quite low; if you had evidence of lupus, or SLE, during the pregnancy, this would also be associated with a much lower likelihood of spontaneous improvement.  SLE is associated with permanent antibody damage to the AV node.  That said, the steroids that you received may have potentially helped slow any damage to the AV node.  I cannot say why your doctors managed what they were seeing with your son’s heart rate the way that they did, though.  However, I can say that the AV block is progressive, as the AV node gets more and more damage.  This can be manifest by bradycardia.

Typically the decision to implant a pacemaker is based upon several things, including whether the baby has structural heart disease, how the ventricular function is, how low the heart rate is, if there are any other abnormalities on the ECG or on 24 hour Holter monitor that would suggest that the heart is not tolerating the AV block, and how the baby is doing clinically (e.g. ability to eat without getting out of breath or getting sweaty, or to exercise/keep up with other peers once he is older).  Pacemaker placement is an invasive procedure, and as such, though they are easy to place and able to function for a fair period of time, are typically delayed until there is some aspect of deterioration listed above.  Therefore, these babies are typically raised as normally as possible, with routine follow-up with their pediatric cardiologist for surveillance of worsening clinical or electrocardiographic status.
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Thanks for the reply..

My blood tests showed I do not have SLE, but my son developed syncopal attack - 2 episodes in a week.next day of 2nd episode emergency permanent pacemaker was implanted. It is 8th day after the surgery and the child is doing well.

My father also has pacemaker, but he has only one incision for the pacemaker, but my son has two incisions.Why is it so.My son is 7 months old.

Operation notes read : Primary median sternotomy.thymus split. pericardial stays taken. the atrial lead was fixed over the right appendage firmly using interrupted 6-0 proline sutures. the ventricular lead was fixed over RV apical surface.
meanwhile , a subcutaneous pocket behind the rectus sheath was made to accomadate the pulse generator.......

I am worried why was this procedure adopted.when it could have been done with one incision. I asked my doctor's assistant, she explained me but I did not understand her explanation.

Is this something to be worried about.. otherwise my child is doing great except the pain because of surgery.



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773637_tn?1327450515
Dear Shabna,

The reason that there are 2 incisions for the pacemaker placement is that your child is an infant, which means that the pacemaker is an epicardial pacemaker system.  This means that the pacemaker leads have to be attached to the outside of the heart, and this is separate from the placement of the pacemaker generator in the abdomen.  Your father, as an adult with large blood vessels, has a transvenous pacemaker system.  This means that the pacemaker and electrical leads can be inserted in one location, with the leads going through the veins and self-attaching to the inside of the heart.  Transvenous systems cannot be placed in infants and small children because their blood vessels and bodies are just too small; thus, epicardial systems are the standard approach.
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Avatar_f_tn
Dear Dr Jeffrey R Boris,

Unfortunately today my son has a seizure which lasted for 15 to 30 secs again, exactly the same symptoms before pacemaker implantation.
went to the doctors office, called the pacemaker representative and events were checked. Pacemaker is functioning good. 100% pacing as the limits are set as 90- 160 bpm.( my son had 50 to 70 bpm with out PM). No abnormal cardiac event recorded during the episode and pacemaker has tracked good) Now it is suspected that it a kind of absence seizure and not stokes Adams attack. I am asked to consult neurologist tomorrow. If it is controlled by neurologist how should the pacemaker be programmed is my concern. As my son's heart has been tolerating it well for 7 months, and pacemaker has been no good in controlling syncope. Is 100% pacing required. Further we have a family history of seizures (resolving spontaneously within 1 to 3 years - in fact 90 percent of us have had seizures resolving spontaneously(though i would definitely take prescribed treatment), including me and all my siblings). further for my father second degree heart block which had no reversible cause also resolved spontaneously within a period of 10 years and his pacemaker is out of battery for 18 years(till date).

I understand its a hard situation to suggest, but i would like to hear your opinion so that i would discuss the same with my cardiologist.
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773637_tn?1327450515
Without reviewing the rest of his or the family's history, I cannot say at this point how his pacemaker should be programmed.  This is something that will have to be discussed in the context of his neurologic evaluation, his EEG and head imaging results, and with his specific cardiac findings.
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Marie M Gleason, M.D.Blank
The Children’s Hospital of Philadelphia
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The Children’s Hospital of Philadelphia
Philadelphia, PA
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