From the Research
Patients with first-degree AV block can safely undergo surgery with total intravenous anesthesia (TIVA) using propofol and remifentanil, as it provides hemodynamic stability and minimal effects on cardiac conduction. The most recent and highest quality study 1 supports the use of TIVA in patients with cardiac conditions, although it focuses on rigid bronchoscopy. However, the principles of maintaining spontaneous breathing and avoiding muscle relaxants can be applied to other surgical procedures.
When using TIVA for patients with first-degree AV block, it is essential to:
- Continue cardiac medications, including beta-blockers and calcium channel blockers, preoperatively
- Obtain a 12-lead ECG before surgery to document the baseline PR interval
- Use standard ASA monitors with continuous ECG monitoring during the procedure to detect any worsening of the conduction block
- Have atropine (0.5-1 mg IV) and external pacing equipment immediately available in case the block progresses
- Avoid medications that can worsen AV conduction, such as high-dose halogenated anesthetics, dexmedetomidine, and certain antibiotics like erythromycin
First-degree AV block (PR interval >200 ms) represents delayed conduction through the AV node without missed beats and is generally benign. TIVA offers advantages in these patients as propofol has minimal effects on cardiac conduction compared to volatile anesthetics, and the titratability of TIVA allows for precise hemodynamic control, making it particularly suitable for patients with conduction abnormalities 2, 3.
It is also important to note that iatrogenic AV block can occur in the context of cardiac surgery or electrophysiologic procedures, and patients undergoing these procedures are at a higher risk of developing perioperative AV block requiring permanent pacemaker implantation 4. However, this is not directly relevant to the use of TIVA in patients with first-degree AV block.
In summary, TIVA using propofol and remifentanil is a suitable anesthetic approach for patients with first-degree AV block undergoing surgery, as it provides hemodynamic stability and minimal effects on cardiac conduction.