Atrioventricular Conduction Disturbances and Bradyarrhythmias

Dr Mohammad Fadhly bin Yahya Emergency and Trauma Department Hospital Melaka

Components of Atrioventricular (AV) Conduction

AV Node

HisPurkinje System

Sites of Disturbances in Impulse Formation or Conduction Leading to Bradyarrhythmias

SA Node

AV Node His-Purkinje System

Intraventricular Conduction Disturbances

Intraventricular (His-Purkinje) Conduction System

(AV node) His bundle Right bundle branch Left bundle branch Septal fascicle Left anterior fascicle

Left posterior fascicle

Bundle Branch Blocks

Right Bundle Branch Block (RBBB)

Late right ventricular activation, with slow muscle-to-muscle conduction

RV is activated via the left bundle

Complete RBBB Pattern

V1 V6 Broad S wave (Lead I similar)

rsR complex

Note T wave pointing in direction opposite to late rightward component (2r repolarization effect)

Left Bundle Branch Block (LBBB)

Delayed left ventricular activation, with slow muscle-to-muscle conduction

LV is activated via the right bundle

Complete LBBB Pattern

V1 V6 Broad R wave (Lead I similar)

Broad S wave

Note absence of septal-q in V6; andT wave pointing in direction opposite to QRS (2r repolarization effect)

Fascicular Blocks

Left Anterior Fascicular (/Hemi-) Block (LAFB)

LV is activated via the left posterior fascicle 1) Initial QRS forces directed inferiorly to the right 2) Bulk of QRS forces directed superiorly to the left
Lead I Lead AVF

Left Axis Deviation (to -45r or beyond)

3) Minimal or no QRS widening

Left Anterior Fascicular (/Hemi-) Block (LAFB)

qR
I II

rS
III

rS

Initial QRS forces directed rightward (negative in Lead I) and inferiorly (positive in Leads II and III Subsequent predominant forces directed leftward (positive in I) and superiorly (negative in II and III)

Left Posterior Fascicular (/Hemi-) Block (LPFB)

LV is activated via the left anterior fascicle 1) Initial QRS forces directed superiorly to the left 2) Bulk of QRS forces directed inferiorly to the right
Lead I Lead AVF

Right Axis Deviation (beyond +90r)

3) Minimal or no QRS widening

Left Posterior Fascicular (/Hemi-) Block (LPFB)

rS
II

qR
III

qR

I Initial QRS forces directed leftward (positive in Lead I) and superiorly (negative in Leads II and III Subsequent predominant forces directed rightward (negative in I) and inferiorly (positive in II and III)

Causes of Intraventricular Conduction Disturbances

Ischemic heart disease or cardiomyopathic scarring Degenerative changes in the conduction system Antiarrhythmic drugs that depress the inward sodium current  Hyperkalemia (oK ) Myocardial infection, infiltration (e.g., tumor) Trauma (e.g., cardiac surgery) Congenital abnormality

AV Block

AV Block - Definitions
First Degree: Prolonged conduction time Second Degree: Intermittent non-conduction Third Degree: Persistent non-conduction

First Degree AV Block (PR > .20 sec [1 big box])

II P P P

.36
Site of delay most commonly the AV node, but may be localized to the His-Purkinje system

Second Degree AV Block - Type I (Wenkebach or Mobitz I Block)

II P P P P Block P

4:3 conduction ratio Note first RR longer than second RR

Second Degree AV Block - Type II (Mobitz II)

II P P P Block P P P Block

Example of 3:2 conduction ratio; general pattern, n:n-1 Note fixed PR for all conducted beats Characteristic of His-Purkinje system site of block

Second Degree AV Block - Type II

P Block

4:3 conduction ratio

Junctional and ventricular (= idioventricular) escape beats or rhythms

Are suppressed (inhibited) as long as their intrinsic rates are overdiven by a faster pacemaker tissue or rhythm process capturing the heart Become manifest (escape from suppression) in the absence of faster competing rhythms But, firing of these pacemakers at rates faster than their upper-limit escape rates is abnormal (i.,e., accelerated rhythm or relative tachycardia )

Idioventricular rhythm

Third Degree AV Block (Complete Heart Block)

II P P P P P P

P waves at 60 beats/min QRS complexes (junctional escape rhythm) at 45 beats/min Atrial and ventricular activity are completely unrelated Junctional escape rhythm suggests AV nodal site of block

Third Degree AV Block (Complete Heart Block)

V1 P P P P P

P waves at 50-60 beats/min QRS complexes (ventricular escape rhythm) at 35 beats/min Atrial and ventricular activity are completely unrelated Ventricular escape rhythm suggests His-Purkinje site of block

Physiologic AV Block
First and second degree AV block may occur physiologically at an AV Nodal level:
in response to premature atrial impulses or atrial tachyarrhythmias in settings of increased vagal tone (e.g., sleep, Valsalva maneuver, well-trained athletes)

BUT persistent 3rd degree AV block is never physiologic

Causes of NON-Physiologic AV Block

Ischemic heart disease, cardiomyopathy and degenerative changes Drugs that depress AV conduction
AV Node: digoxin, beta blockers, calcium channel blockers, adenosine His-Purkinje System: Antiarrhythmic drugs that depress the inward sodium current

Myocardial infection, infiltration (e.g., tumor) Trauma (e.g., surgery; therapeutic ablation) Congenital abnormalities

Sinus Bradyarrhythmias

Sinus Arrhythmia
Inspiration Expiration

SA nodal acceleration

SA nodal deceleration

Sinus Bradycardia

II

P wave upright in leads I and II, just as in normal sinus rhythm

Causes of Sinus Bradycardia

Increased vagal tone Drugs: beta blockers, calcium channel blockers, amiodarone, digoxin (indirect effect) Myocardial ischemia/infarction Hypothyroidism Sick sinus syndrome - degenerative/fibrotic atrial process

Sinus Arrest

Sinus bradycardia p Sinus arrest p Slow junctional escape rhythm (with retrograde p waves)

Tachycardia-Bradycardia (Form of Sick Sinus) Syndrome

Atrial Flutter

Atrial Flutter terminates

Sinus arrest

Junctional escape (tardy)

Sinus Arrest p Asystole

Sinus rhythm
P P P

Sinus brady. p Sinus arrest p V. escape rhythm Failure of V. escape rhythm p Asystole

P P

TQ