Heart Block After ASD Device Closure

Abstract

4 years old boy with weight of 10.5 Kg and height of 100 cm, he is known case of moderate to large ASD secondum with recurrent chest infections and failure to thrive under treatment with frosimed and close follow up in the clinic. Cardiovascular examination reviled: normal S1+fixed and splitting of S2+ejection systolic murmur at left upper sternal border, per-procedure electrocardiogram showed normal sinus rhythm with heart rate 95-100/min ,incomplete right bundle brunch block. His echocardiography reviled large ASD secondum of 15-16 mm with adequate SVC, IVC and aortic rims and slightly short AV valve rim associated with dilated right atrium and ventricle with sings of increased pulmonary blood flow. During cardiac catheterization under general anesthesia and transesophaygeal echocardiography guidance we confirmed the accurate size of the defect and decided to precede and close this ASD by 18 mm Amplatzer septal occluder (the device/height ratio is : 0.18 )The procedure went smoothly without any complications in the cath lab and the patient was observed in the recovery area then in PICU with stable vital sings, sinus rhythm around 99-101/ min and after 24 h of the closure electrocardiography showed normal sinus rhythm with same degree of PRBBB ( Figure 1). Echocardiography showed big ASD device insite without any residual shunt or interacting with adjacent structures ( Figure Heart Block After ASD Device Closure 2).Patient was discharged home on aspirin 50 mg daily and given appointment after one week for follow up in the clinic. After one week he came to pediatric cardiology for follow up, he was asymptomatic with no complain, his heart rate was 66/min with regular rhythm, other vital signs were stable. Echocardiography at that time showed ASD device in good position without any residual shunt or interfering with A-V valves or other structures. His ECG showed dominant sinus rhythm with HR = 66/min , prolonged PR interval l0.18 -0.2 sec (first degree heart block) and occasional 2:1 heart block ( Figure 3). 24 hour holter monitor also confirm the finding of first degree heart block with occasional second degree as 2:1 but no escape rhythm or long pauses. The parents refused the admission for observation and they preferred to come daily for close follow up so we started him on oral prednisolone 1 mg/kg/day with ECG monitoring every 2 days. After 5 days from this plan the patient remain stable with no complain but his ECG showed normal sinus rhythm with shorter PR interval 0.16 -0.17 sec and no signs of heart block (recovered normal sinus rhythm) (Figure 4). 24 hour holter monitor also confirm the normal sinus rhythm without any arrhythmias so we stopped the prednisolone and kept him under observation every week with new ECG.After one month he was stable,no complains and started to gain some weight on aspirin only.ECG at that time showed normal sinus rhythm with normal PR interval 0.16 sec and no signs of heart block ( Figure 5). Echocardography revealed the device inn place, no residual shunt, no interfering wi...