Archives of Gerontology and Geriatrics 50 (2010) 292294

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Archives of Gerontology and Geriatrics

journal homepage: www.elsevier.com/locate/archger

Third degree of atrioventricular block: A rare geriatric complication that may

cause sudden death
Remarks on two clinical cases
N. Gueli, W. Verrusio, A. Linguanti, N. Marchitto, G. Longo, V. Marigliano, M. Cacciafesta *
Department of Aging Science, Policlinico Umberto I, University La Sapienza, viale del Policlinico, 155, I-00161, Roma, Italy

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 14 October 2008
Received in revised form 5 February 2009
Accepted 11 February 2009
Available online 19 May 2009

Two clinical cases are reported that have in common the electrocardiographic detection of a third degree
atrioventricular block (AVB), which occurred in the rst case in a man of 78 years, hospitalized in our unit
after an accidental fall with an ensuing head trauma, and in the second case, in a woman of 67 years, after
cataract surgery on her left eye. The complete or third degree AVB is a bradyarrhythmia characterized by
the absence of paroxystic or permanent atrioventricular conduction. Several studies conducted on
subjects between the ages of 60 and 85 pointed out that the incidence of AVB-type bradyarrhythmias of a
degree greater than the rst is extremely rare, i.e., it is close to zero. It is, however, necessary to make an
early diagnosis of the AVB, as in many cases it may complicate the patients clinical progress and may
often lead to sudden death. Clinical and experimental observations have shown that electrocardiographic alterations and arrhythmias are frequent complications of cerebral accidents such as head
traumas, or of ophthalmic surgery. It is therefore necessary, especially in elderly patients in whom
bradyarrhythmias are characterized by the presence of widespread histological alterations of the
conduction system, to perform a 24-h monitoring of all adverse events that may lead to an AVB.
2009 Published by Elsevier Ireland Ltd.

Keywords:
Arrhythmias
Bradycardia
Atrioventricular block in elderly
Head trauma
Pacemaker
Comorbidity

1. Introduction
The third degree (or complete) AVB is a bradyarrhythmia
characterized by the absence of paroxysmal or permanent
atrioventricular conduction. Several studies conducted on subjects
between the ages of 60 and 85 years, subjected to non-invasive
cardiological examinations, pointed out that the incidence of AVBtype bradyarrhythmias of a degree greater than the rst is very low
(close to zero) (Kojic et al., 1999). Many cases of chronic complete AV
blocks are ascribable to a sclerodegenerative process that is limited
to the conduction system, dened as Lenegres disease; the complete
AVB may arise in ischemic heart disease (especially in the case of
acute myocardic infarction), in hypertension, in cardiomyopathies,
in aortic valvulopathy, and less often in other diseases (myocarditis,
infective endocarditis, collagenopathies, amyloidosis). It may also be
congenital, and it may sometimes complicate the patients postoperatory progress or clinical conditions, as may be the case
following heart surgery (Kim et al., 2001), during cerebral accidents
with or without an increase in intracranial pressure (Grosse-

* Corresponding author at: Department of Aging Science, Policlinico Umberto I,

University La Sapienza, Via Panama, 102, I-00198, Roma, Italy.
Tel.: +39 06 4450 208; fax: +39 06 4456 316.
E-mail address: mauro.cacciafesta@uniroma1.it (M. Cacciafesta).
0167-4943/$ see front matter 2009 Published by Elsevier Ireland Ltd.
doi:10.1016/j.archger.2009.02.016

Wortmann et al., 2006) or during ophthalmic surgery under topical

or general anesthesia (Table 1) (Alexander, 1975; Katz et al., 2001).
Furthermore, in elderly patients, bradyarrhythmias are associated with the onset of widespread histological alterations of the
conduction system that may cause an atrioventricular block. We
report two clinical cases: a patient of 78 years, who came under our
observation after suffering a contusive head trauma, in whom an
electrocardiogram indicated the onset of a complete AVB; and a
woman of 67 years, treated in an opthalmology clinic to undergo
cataract surgery on her left eye and who, after surgery, displayed a
third degree AVB.
2. Case reports
A man of 78 years, suffering from arterious hypertension, in
treatment with sartanics, and multi-infarctual encephalopathy,
came under our observation for a contusive head trauma caused by
an accidental fall. At the rst aid unit he was subjected to
laboratory examinations that did not highlight any signicant
alterations of myocardionecrosis-indicating enzymes and to a CT of
the brain that gave evidence of a chronic ischemic encephalopathy
with subcortical atrophy and ruled out the presence of spaceoccupying lesions.
During a routine electrocardiogram, the onset of a complete
AVB was detected, so the implant of a temporary pacing device,

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293

eventually followed by a denitive pacemaker (PM), was urgently

required. In order to spread out the global cardiovascular risk and
to rule out the simultaneous presence of other vascular or valvular
pathologies, the patient was subjected to a series of instrumental
examinations: (i) an echo-Doppler of the supra-aortic trunks that
highlighted a 30% bilateral stenosis at the bifurcation of the
common carotid artery; (ii) an Echocardiogram that showed a
slightly dilated left ventricle with parietal hypertrophy and normal
kinesis (FE 52%), a slight mitral insufciency and a moderate aortic
insufciency; (iii) a 24-h pressure monitoring that indicated a
pressure prole at the upper limits of the normal reference values;
a nocturnal pressure drop was absent and variations in heart
frequency were not correlated to variations in arterial pressure.
After the implant of a PM, the patient displayed a regression of
his clinical situation and symptoms (Gregoratos et al., 1998).
A woman of 67 years, suffering from type-2 diabetes mellitus
and arterial hypertension, was subjected to cataract surgery on her
left eye under local anesthesia. After the operation, the patient
displayed a subconjunctival hemorrhage that regressed with
appropriate medical treatment and a narrow-QRS third degree
AVB, therefore a dual-chamber PM was immediately implanted.
During hospitalization, the patient was subjected to: (i) an
echocardiogram that displayed a concentric remodeling of the
left ventricle, satisfactory global performance with no clear local
kinetic alterations and a slight increase in the size of the left
atrium, with right cavities within normal limits; a slight mitral and
tricuspidal insufciency; (ii) a CT of the head that indicated a
situation compatible with chronic ischemic encephalopathy.
In this second case too, the implant of a PM caused an
improvement in clinical conditions that led to the patients
discharge (Gregoratos et al., 1998).

accidents (Keller and Williams, 1993) may be accompanied by

myocardic damage and electrocardiographic irregularities, such as
a shortening of the P-R interval, ventricular ectopic beats,
bradyarrhythmia and ventricular and supraventricular tachycardia
(Khogali et al., 2003).
The onset of bradyarrhythmia is less frequent compared to
tachycardia, but some studies indicate the presence of AVBs,
including the third degree AVBs. Changes in nerve functionality
following cerebral accidents are responsible for irregularities of the
heartbeat and of cardiac conduction: on one hand, the increase in
the plasmatic concentration of catecholamines may in fact
determine the onset of tachyarrhythmias, and on the other hand
the increased vagal activity may cause sinus bradycardia and AVB.
Abundant clinical evidence has also highlighted a frequent onset of
heartbeat irregularities after eye surgery, for example following
strabismus surgery (Gold et al., 1988), cataract surgery (Hampl
et al., 1993; Lumme and Laatikainen, 1994) or glaucoma (Merli
et al., 1986). Several causes have been suggested: from the
activation of the oculo-cardiac reex with vagal hypertone and
depression of cardiac activity with consequent bradycardia or
complete asystolia, to the effect of anesthesia, both topical and
general (Brinkley and Henrick, 1984; Schaffer et al., 1989;
Quantock and Goswami, 2007).
In the two cases examined, the decision to immediately implant
a pacing device, followed by a permanent pacemaker, was
absolutely necessary on the basis of the clinical situation
(Albertsen et al., 2008). The pacemakers implant must however
always take into account a possible reversibility of the AV block.
Reversible causes include dystonias, Lymes syndrome and
hypothermia, which should be included in differential diagnostics
before considering a possible pacemaker implant. In other
pathologies such as sarcoidosis, amyloidosis and neuromuscular
pathologies, a pacemaker implant is usually necessary, even in the
presence of a temporary regression of the AVB, due to the diseases
possible advancement (Edhag and Swahn, 1976; Veerareddy et al.,
2007).
In conclusion, the AVB is a rare event that may go undetected
and that generally leads to sudden death; it may often dramatically
complicate the patients clinical or post-operatory progress, and
elderly patients, in whom comorbidity is a major risk factor, should
always be tested for it.
The two clinical cases described highlight the importance,
during events not directly related to cardiovascular risk, of closely
monitoring patients, especially if elderly, considering that an
increase in age and histological alterations of the conduction
system predispose the subject to a greater risk of bradyarrhythmias.

3. Discussion

Conict of interest statement

Table 1
Conditions in which a third degree AVB may occur.
Degenerative alterations of the AV junction associated with organic and
non-organic heart disease: calcic valvulopathy
Cardiomyopathy
Collagenopathies
Ischemic heart disease
Myocarditis
Amyloidosis
Congenital block
Levs disease
Lene`gres disease
Acute myocardial infarction
Vagal hypertone (anesthesia, oculocardiac reex, etc.)
Head traumas
medications (beta-blockers, diltiazem, verapamil, digitalis, etc.)

From the age of 60 onwards, the number of pacemaker cells

present in the sino-atrial node gradually decreases, to the extent
that only approximately 10% of the cells that may be observed in
young adults are still present in elderly subjects. The sino-atrial
node is progressively surrounded by adipose tissue, with the
nodes partial or complete separation from the common atrial
muscle tissue. A similar phenomenon occurs with the atrioventricular node, with a loss of cells, an increase in adipose and brous
tissue and amyloid inltration. In some extreme cases, the ensuing
idiopathic brosis may lead to an atrioventricular block; this
phenomenon is the most frequent cause of atrioventricular blocks
in the elderly.
The literature conrms that strokes (Davis et al., 1993),
subarachnoidal hemorrhages (Andreoli et al., 1987; Sakr et al.,
2002), head traumas (Greenspahn et al., 1978; Wirth et al., 1988;
Wittebole et al., 2005; Koturoglu et al., 2006) and other cerebral

None.
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