Natural History of Nonsurgical Complete Atrioventricular Block in Children and Predictors of Pacemaker Implantation

Abstract

Background: Data on the natural history of complete atrioventricular block (CAVB) in children are scarce, and criteria for pacemaker (PM) implantation are based on low levels of evidence.

Objectives: This study aimed to evaluate the natural course and predictors of PM implantation in a nationwide cohort of pediatric patients with nonsurgical CAVB.

Methods: All children with CAVB in the absence of structural heart disease presenting from 1977 to 2016 were retrospectively identified, yielding 95 subjects with a mean age of 4.05 years at the first presentation with a follow-up median of 0.80 years (IQR: 0.02-6.82 years). PM implantation was performed according to the available guidelines. Serial 24-hour Holter recordings and echocardiograms were reviewed. Predictors of PM implantation performed >1 month after the first presentation were evaluated.

Results: The minimum and mean 24-hour heart rates and maximum RR intervals had a nonlinear correlation with age (P < 0.0001 for all). The left ventricular (LV) size was moderately increased, and the shortening fraction was normal in the majority throughout follow-up. PM implantation was performed in 62 patients (65.3%) reaching guideline criteria. The mean 24-hour heart rate at presentation was a predictor of subsequent PM implantation (HR: 0.938; 95% CI: 0.894-0.983; P = 0.003 per unit increase) regardless of age at presentation. Patients presenting with a mean 24-hour heart rate >58 beats/min (>75th percentile) had a high probability of freedom from PM within the subsequent 5 years (91.7% vs 44.4%; P < 0.001).

Conclusions: Pediatric patients with CAVB showed an age-dependent decrease in heart rate, moderate LV dilation, and preserved LV function. The probability of subsequent PM implantation could be predicted by the heart rate profile at presentation, defining a low-risk group and allowing for individualized follow-up.

Keywords: children; complete atrioventricular block; natural history; pacemaker.