High-grade Atrioventricular Block in Pilot
To Pace or Not to Pace
Background: Atrioventricular (AV) block is a threatening condition that caused sudden loss of consciousness and death, notably if happened to aircraft pilot will compromise the reliability of flight operations and safety. Cardiac arrhythmia is well known as one of the main disqualifier for loss of flying license, and discriminating between benign and potentially significant rhythm abnormalities remains a challenge. The present case describes the electrophysiological feature of a high-grade AV block in an aircraft pilot.
Case illustration: A 60-year-old male worked as commercial aircraft pilot presented with asymptomatic high-grade AV block during inflight Holter monitoring. He had never experienced any remarkable symptoms nor history of near syncope, but had a history of percutaneous coronary intervention (PCI) with one stent at left circumflex (LCx) coronary artery. Electrophysiology (EP) study revealed AH interval of 105 ms, HV interval of 50 ms, AV node effective refractory period of 280 ms and Weckenbach point of 330 ms, suggesting a normal EP study. Stimulation with atrial pacing and ATP showed prolongation of AH interval without changes in HV interval, showing the presence of a supra-Hisian AV node dysfunction. The highly demanding physiological environment in aircraft elucidate the likelihood of vagotonic cause of his condition and pacemaker implantation was not warranted.
Conclusion: Atrioventricular (AV) block is an AV conduction disorder that can manifests in various symptoms and severity. Electrophysiology study is considered as a modality to locate the site of block that allows the avoidance of unnecessary permanent pacing and the appropriate prophylactic pacing.
2. Guettler N, Bron D, Manen O, Gray G, Syburra T, Rienks R, et al. Management of cardiac conduction abnormalities and arrhythmia in aircrew. Heart.2018;105:38-49.
3. Lim Y, Singh D, Poh KK. High-grade atrioventricular block. Singapore Med J. 2018;59(7):346-50.
4. Josephson ME. Atrioventricular conduction. In: Josephson ME, editor. Josephson's Clinical Cardiac Electrophysiology. 5th ed: Lippincott Williams & Wilkins; 2015. p. 96-115.
5. Katritsis DG, Josephson ME. Electrophysiological Testing for the Investigation of Bradycardias. Arrhythmia & Electrophysiology Review. 2017;6(1):24-8.
6. Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay - A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2018;140:382-482.
7. Menon SMD, Ribas CS, Meneclier CAR, Morillo CA. Intermittent atrioventricular block: What is the mechanism? Heart Rhythm. 2012;9:154-5.
8. Katrisis DG. Second-degree Atrioventricular Block: Conceptions and Misconceptions. Arrhythmia & Electrophysiology Review. 2018;7(2):77-8.
9. Sherif NE, Jalife J. Paroxysmal atrioventricular block: Are phase 3 and phase 4 block mechanisms or misnomers? Heart Rhythm. 2009;6(10):1514-21.
10. Murgatroyd FD, Khran AD, Klein GJ, Yee RK, Skanes AC. The Basic Electrophysiology Study. Handbook of Cardiac Electrophysiology: A Practical Guide to Invasive EP Studies and Catheter Ablation: ReMEDICA; 2004. p. 15-9.
11. Federal Aviation Administration. Guide for Aviation Medical Examiners. Decision Considerations - Aerospace Medical Dispositions - Item 36. Heart - Arrhythmias United States: United States Department of Transportation; [Available from: https://www.faa.gov/about/office_org/headquarters_offices /avs/offices/aam/ame/guide/app_process/exam_tech/item36/amd/arrhythmias/
12. Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt O-A. 2013 ESC Guidelines on Cardiac Pacing and Cardiac Resynchronization Therapy. Eur Heart J. 2013;34:2281-329.
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