How to manage a patient with 2nd degree heart block scheduled for elective Laparoscopic Cholecystectomy (Lap Chole) with open sigmoid colectomy?

Management of Second-Degree Heart Block in a Patient Scheduled for Elective Surgery

The elective laparoscopic cholecystectomy with open sigmoid colectomy should be postponed until the patient undergoes a complete cardiac evaluation and appropriate management of the second-degree heart block. 1

Assessment of Second-Degree Heart Block

First, it's crucial to determine the type of second-degree heart block:

• Type I (Wenckebach/Mobitz I): Progressive PR interval prolongation before a blocked P wave
• Type II (Mobitz II): Constant PR interval with intermittent non-conducted P waves

This distinction is critical as Type II heart block carries a higher risk of progression to complete heart block and requires more aggressive management.

Immediate Steps:

1. Continue monitoring vital signs - Ensure continuous cardiac monitoring
2. Obtain a 12-lead ECG - To confirm the type of second-degree block
3. Review medications - Identify any drugs that may exacerbate AV block (beta-blockers, calcium channel blockers)
4. Cardiology consultation - Immediate cardiology consultation is mandatory

Management Algorithm Based on Block Type

If Type I (Wenckebach/Mobitz I):

• If asymptomatic with narrow QRS:

  • Consider postponing surgery for further evaluation
  • Cardiology consultation for risk assessment

• If symptomatic OR wide QRS complex:

  • Surgery should be postponed
  • Electrophysiological study (EPS) is recommended to identify the level of block 1
  • Temporary pacing may be required before surgery

If Type II (Mobitz II):

• Immediate cardiology consultation
• Surgery must be postponed
• Permanent pacemaker placement is generally indicated before proceeding with elective surgery 1

Perioperative Considerations

The planned procedure carries significant cardiovascular risk factors:

1. Pneumoperitoneum during laparoscopy can cause:

   • Increased systemic vascular resistance
   • Decreased cardiac output
   • Increased mean arterial pressure 2, 3

2. Open sigmoid colectomy involves:

   • Significant fluid shifts
   • Potential blood loss
   • Prolonged operative time 4, 5, 6

These factors could exacerbate cardiac conduction abnormalities and potentially precipitate complete heart block during surgery.

Recommended Management Plan

1. Postpone the elective procedure

2. Complete cardiac evaluation:

   • Echocardiogram to assess for structural heart disease
   • Exercise stress test to evaluate AV conduction during increased heart rate
   • Consider 24-hour Holter monitoring to assess the frequency of the block

3. Pacemaker consideration:

   • For Type II second-degree AV block: permanent pacemaker placement before surgery
   • For Type I with wide QRS or symptoms: EPS to determine if pacemaker is needed
   • For asymptomatic Type I with narrow QRS: individualized decision based on cardiology consultation

4. Pre-operative optimization:

   • If pacemaker placed, ensure proper function before surgery
   • Have atropine readily available during surgery
   • Consider temporary pacing capability in the operating room

Common Pitfalls to Avoid

1. Misclassifying the type of block - Obtain a clear, diagnostic ECG
2. Proceeding with elective surgery without addressing the conduction abnormality
3. Failing to recognize the hemodynamic challenges of laparoscopic surgery in patients with conduction disorders
4. Inadequate intraoperative monitoring - Continuous ECG, invasive blood pressure monitoring, and possibly transesophageal echocardiography may be needed

The presence of a second-degree heart block in a patient scheduled for elective surgery represents a significant risk that must be addressed before proceeding with the operation. The patient's currently stable condition provides an opportunity for proper evaluation and management to ensure optimal surgical outcomes.