Lyme Disease, caused by the spirochete Borrellia burgdorferi, is the most common vector-borne disease in the United States. Clinically, it primarily affects the skin, joints, nervous system, and heart. Lyme carditis occurs in 4%-10% of adults with Lyme disease. Transient variable-level atrioventricular blocks, occurring in 77% of adults with Lyme carditis, are the most common cardiac manifestation. Up to 50% of Lyme carditis patients may develop complete heart block. The incidence of Lyme carditis in the pediatric population is not well established. We present a pediatric patient with a transient asymptomatic complete heart block resulting from Lyme carditis, an under-recognized complication of Lyme disease in the pediatric population.
As Operation Iraqi Freedom enters its third year, the multinational military force remains engaged in a complex mission based on the military and political climate in the Middle East. As US Navy cardiologists deployed to Kuwait, our experiences proved diverse as we learned to practice in an austere environment. From the evaluation of chest pain to the treatment of coronary artery disease and arrhythmia, patient care was tempered by our ability to use our clinical acumen, physical exam and basic objective data to establish definitive dispositions. Given our younger patient population, involvement in primary prevention efforts was a large focus, allowing us to gain a new perspective on the role of the subspecialist in changing patients’ mindsets and lifestyles. By combining the basic tenets of our cardiology training with the practical aspects of diagnosing and treating in a war zone, we developed a great respect for the management of cardiac patients under challenging and often limited conditions. Our experiences as cardiologists in the desert were truly diverse and encompassed virtually every aspect of cardiovascular medicine, involving both current and historic treatment perspectives. Many unique, lifelong lessons were learned.
Atrioventricular block (AVB) continues to be an important problem after congenital heart surgery. In this issue of the Journal, Romer and colleagues 1 report on 15,901 patients who underwent cardiac surgery in 25 centers as part of the Pediatric Cardiac Critical Care Consortium (PC4) registry. They found that the incidence of postoperative AVB was 2.7% and that 1% of patients with postoperative AVB required a permanent pacemaker (PPM). Despite a laudable attempt, Romer and colleagues 1 were not able to create a model with significant discriminatory ability to identify FIGURE 1. Different types of second-and third-degree atrioventricular block. A, Mobitz I (Wenckebach) second-degree atrioventricular block-the PR interval increases with every beat until a ventricular beat is dropped. B, Mobitz II second-degree atrioventricular block with 2:1 atrioventricular conduction. C, Complete heart block.
A young girl with complex congenital heart disease underwent Fontan procedure and multiple pacemaker revisions, including abandonment of an intraabdominal pacemaker generator at age eight. She presented two years later with constipation and abdominal twitching. Radiographs, pacemaker interrogation, and laparoscopy confirmed dislocation of the abandoned generator and intraperitoneal migration into the pouch of Douglas. The device was removed surgically without incident.
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