Cardiac pacing in left bundle branch/ bifascicular block patients

The primary concern in patients with bifascicular block is the increased risk of progression to complete heart block. Further, an additional first-degree A-V block in patients with bifascicular block or LBBB might increase the risk of block progression. Anesthesia, monitoring and surgical techniques can induce conduction defects and bradyarrhythmias in patients with pre-existing bundle branch block. In the setting of an acute MI, several different types of conduction disturbance may become manifest and complete heart block occurs usually in patients with acute myocardial infarction more commonly if there is pre-existing or new bundle branch block. The question that arises is whether it is necessary to insert a temporary pacing catheter in patients with bifascicular block undergoing anesthesia. It is important that an anesthesiologist should be aware of the indications for temporary cardiac pacing as well as the current recommendations for permanent pacing in patients with chronic bifascicular and trifascicular block. This article also highlights the recent guidelines for temporary transvenous pacing in the setting of acute MI and the different pacing modalities that are available for an anesthesiologist.