Case
Sorry to call you this evening but you are on call for pediatric electrophysiology right? I am the ICU fellow covering the CICU tonight along with my attending. We brought back a 3 month-old infant with Down Syndrome after surgery for an AV canal defect about an hour ago. The surgeon said that the surgery was uneventful except for a moment where the patient went into complete heart block but conduction came back after a few minutes. But just in case the surgeon left us some ventricular pacing wires. The patient has been hemodynamically stable since getting here but now we are noting that the heart rate is dropping to about 80 bpm and blood pressure is a bit low. The rhythm is steady but I’m not sure that every p wave is being conducted. I’ve decided to ventricular pace at 100 bpm and that has helped the blood pressure. My attending asked me to give you a call.
What am I thinking?
Surgical AV block is the most common form of acquired heart block in the young. This most commonly affects repairs where the conduction system is at risk of damage due to anatomic location such as ventricular septal defects or AV canal repairs. However, AV block has been seen in other surgical repairs in which the conduction system has not been manipulated (e.g., Fontan operation). While the most likely event here is heart block, it would be important to categorize it by using an electrocardiogram or rhythm strip (see Fig. 21.1 ). In scenarios where surgical heart block is a risk, cardiac surgeons will attach temporary pacing wires in case pacing is needed. Ideally, both atrial and ventricular pacing wires are provided to assist in a more physiologic approach to pacing but if ventricular wires are all that are provided, you work with what you have.
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