Arrhythmias – Bradycardia Explained (Part One)

This week former Cardiac Nurse, Carol Raimondi, provides us with the first of a two-part resource on arrhythmia and the various diagnosis and treatment. Up this week: Bradycardia.

 

 

 

 

Congenital heart defects are frequently accompanied by issues with the electrical conduction of the heart. These issues can cause a slow heart rate( bradycardia), a fast heart rate (tachycardia), or an irregular heart rhythm, also referred to as an arrhythmia. There may be one of these conduction defects present, or several at the same time.This can be due to the structural defects that were present at birth, or related to scar tissue that develops with each surgical intervention.  Fortunately, there are options to treat these irregularities.
Here we will be discussing the most common types of issues related to the electrical system of the heart. In order to discuss these abnormalities, first you should understand how things are supposed to work.
In normal conduction of the heart, the impulse is initiated in a group of specialized cells, called the sinus or sinoatrial (SA) node. This is located in the right atrium, or upper chamber, of the heart. Once initiated, is causes the both the right and left atria to contract. The signal then continues to the Atria-Ventricular (AV) Node. This is found between the upper and lower chambers. The signal slows slightly through here, allowing the blood to empty from the atria and enter the ventricles, or lower chambers. From there, the signal continues down through the lower chambers via the left and right Bundle of His, causing the ventricles to contract. Each time this cycle occurs, it results in one complete heart beat. When working properly, it should repeat this cycle without interruption 60-100 times per minute.
Bradycardias
Sinus Bradycardia:
This describes a regular rhythm with a rate of less then 60 beats per minute. Sinus bradycardia is usually a benign finding. It is frequently seen in athletes or during sleep. There is generally no treatment for this unless the patient has symptoms, such as lightheadedness or fatigue. In such cases, further evaluation is done to determine an underlying cause, such as medication side effects or metabolic disorders.
First degree AV block:
This refers to a prolonged delay in conduction between the atria and ventricles. Generally, there are no symptoms associated with this, as the ventricle still does contract with every beat. No treatment is required for this type of heart block.
Second degree AV block:
Type 1- This is the less critical of the two types of second degree blocks and rarely requires treatment. In type 1, there is a progressive lengthening of the time it takes for the signal to travel from the sinus node to the AV node. With each contraction, it takes longer and longer until the ventricle “skips” a beat and resets the cycle.
Type 2-  In type 2 AV block, there is no specific pattern to when the signal is blocked from the atria to the ventricles. When this signal is blocked, the ventricles do not get the message to contract, and thus the blood is not pumped to the body. This often leads to third degree heart block. A pacemaker is implanted to treat type 2 AV block.
Third degree AV block:
Third degree, or complete heart block, refers to when the signal between the top and bottom chambers of the heart is absent. The ventricles use a “back up” electrical system, which produces a much slower heart rate then normal. The atria continue to contract as well, but there is complete dissociation between the top and bottom chamber, so the amount of blood being sent to the body is lessthen usual. Symptoms associated with complete heart block include lightheadedness and fainting. If left untreated, this block can cause death. This type of heart block  is critical and requires emergent treatment with a pacemaker. Often a temporary, external pacemaker is placed until the patient receives the permanent pacemaker.
Bundle Branch Blocks (BBB):
The Bundle branches are the fibers that carry the electrical signal from the AV node down through each ventricle. They are described as either the right or left bundle branch. When there is an interruption in this pathway, it is referred to as a bundle branch block(BBB). Generally, bundle branch blocks themselves do not cause any symptoms or require treatment. Further cardiac assessment should be done, however, to determine if there is an underlying cardiac condition. Right BBB is often seen in Congenital Heart Defects, especially in atrial or ventricular septal defects. Left BBB can frequently be seen in patients with coronary heart disease, or with weakening of the heart muscle.
Diagnosis
The cardiac conduction irregularities listed above can be diagnosed in several ways. The most common is by performing a 12 lead electrocardiogram (ECG) This is a non-invasive test where patches, connected to leads, are placed on the skin. The technician ensures that the patient lays still for 15-30 seconds while a reading of the electrical signals through the heart is done. A printout of these readings can immeadiately show the heart rate, rhythm, and any damage to the muscle of the heart.
A holter monitor, similar to an ECG, involves applying electrodes to the skin in specific locations. Generally, there are 5 leads or less. These leads are connected to a small device that has recording capabilities. The patient can wear this device for 24-48 hours, depending on the physicians preference.  The device continuously records during the time that it is worn. Once returned, the ECG recordings are downloaded to a computer for a physician to review. The advantage to this test is that  with a prolonged recording period, there may be abnormalities detected that an ECG, which gives a “snapshot” can not detect.
An event monitor is similar to a holter monitor, in that it it is a small portable device that allows for prolonged recording of heart rate and rhythm. This device is usually worn for up to 30 days, and usually the patient can push a button on the device when he/she is experiencing any symptoms. Then they can call in to the device monitoring company and transmit the reading, which is reviewed and forwarded to the patients physician.
Treatment for Bradycardia and Heart Block
Of the above conduction issues, treatment is generally only required for second degree type 2 and third degree heart block. A small, electronic  device, known as a pacemaker, is used to restore normal conduction. This device is surgically implanted in the upper chest or abdomen, just under the skin, in a “pocket” the physician creates. Leads connected to the pacemaker are then threaded through a vein into the heart, where it is attached. The pacemaker “watches” the heart rhythm, and when it detects abnormal conduction, it sends an electrical signal to the heart. The pacemaker is programmed to not let the heart drop beneath a certain rate. Newer pacemakers transmit data wirelessly to their doctor or pacemaker clinic via a small device that can be kept near the patients bedside at home, This allows the physician office to monitor the functioning of the device without requiring the patient to call in, as was done in the past . Usually, every 6-12 months, an in-office pacemaker check is required to do full testing on the device, but this is quick and non-invasive. Pacemakers can last 7-10 years on average, depending on what percentage of time the pacemaker is in use.
Please join us next week for Part Two – Tachycardia.

Carol Raimondi is an adult CHD patient and nurse, living with Congenitally Corrected Transposition of the Great Arteries.  She has had 4 open heart surgeries in her 40 years, as well as a pacemaker since the age of 6. After spending a large part of her childhood in and out of hospitals, she developed a passion for nursing. She went to school to become a cardiac nurse. Carol’s many hospital experiences helped her as a nurse to better understand what her patients were going through and  to care for them with that much more compassion and empathy.

Due to worsening medical issues, Carol had to give up the profession she loved. That did not stop her from being a patient advocate, however. She joined her local hospital’s’ Patient Family Advisory Council, which she now co-chairs, and shortly thereafter she joined Mended Little Hearts Chicago(MLHC) as an adult CHD liaison. She then expanded her work in the CHD community by starting an adult and teen CHD group within MLHC and became an  Ambassador for the Adult Congenital Heart Association. Currently she sits as the Pediatric Congenital Heart Association of IL(PCHA-IL)  President. Her proudest moments are when she is advocating and raising awareness for the CHD community, both on Capitol Hill in D.C. and locally.

The Promise of Research for CHD, and Our Responsibility to Advocate

Advancement in standards of care and best practices can only happen with research.  This week, Margaret King discusses the implications increased CHD research has on not only the community but society as a whole, as well as how important it is for each one of us to contact our representatives to increase research funding. 

 

 

The Promise of Research for CHD, and Our Responsibility to Advocate

 

This past month, I and a group of several other local heart families were treated to an astonishing behind-the-scenes tour of the Mitchells’ research lab at Children’s Hospital of Wisconsin, where we learned about the vital work they are doing to identify the genetic processes, risks, and factors in CHD. Just a few weeks prior, I also had the opportunity to attend Mayo Clinic’s Feel the Beat event, where the HLHS Program shares research updates with heart families. Both of these research programs are committed to improving treatment of CHDs across the lifespan, with the further goal of exploring targeted treatments based on individual risk factors.

 

Many leading pediatric cardiology centers are working tirelessly behind the scenes to make game-changing breakthroughs for current and future CHD patients. From stem cells to genetics, new medical devices and drug therapies, and of course, developing best practices for everyday care and management, research underlies almost all aspects of CHD care. It has enormous implications for the quality of life and outcomes CHD patients will experience.

 

As members of the CHD community, we can advocate for lifesaving research funding to our representatives, as well as urge our friends, families, neighbors, and colleagues to do the same.

 

Research Breakthroughs: A ripple effect

 

With 1 in 100 babies being born with a heart defect, there is an urgent need for research breakthroughs in preventing and optimally treating CHD of all kinds. However, studying individual types of CHDs can have tremendous implications that extend far beyond CHDs themselves. For example, understanding the possible cascade of genetic events that causes hypoplastic left heart syndrome (HLHS) sheds light on the broader process of cascades that cause a number of complex diseases, many of which have stumped researchers for decades.

 

If we can offer anything from targeted stem cell therapy to genetically-tailored drugs for one disease, it is just a matter of time until these technologies can be used to treat a wider and wider range of illnesses.

 

These cutting-edge research discoveries have great potential to alleviate suffering, not just in the CHD community, but across entire our society. They offer hope that we truly can “conquer CHD” and many other conditions that have proved to be extremely challenging to treat and manage using the life-saving advancements of the twentieth century. While the breakthroughs of the past were revolutionary, we now know that we can do so much more if we put resources into the proper channels.

 

Advocating for Research: Our responsibility

 

Researchers and doctors cannot shoulder the burden of advocating for research alone. The more we help advocate, the more time they can spend on research and collaboration. As it is, researchers often spend a lot of time identifying avenues of funding and writing grant applications for scarce funds, which takes valuable time from their work in the lab.

 

Many of us understand the importance of advocating to our political representatives, but do we talk to our friends, families, neighbors, and colleagues about how important it is to fund public research through institutions like the National Institute of Health (NIH)?

 

The NIH is the largest source of biomedical research funding in the entire world, but the process is fiercely competitive, with less than 20% of applications being approved at any level of funding. The number of projects the NIH can fund, as well as what level of funding projects receive, fluctuates with the national budget.

 

Advocating not only for increased funding, but stability in the NIH budget from year to year, is of utmost importance to make sure the lights stay on in some of our most promising, dedicated labs. After all, when the lights stay on at the lab, researchers can shed light on life-and-death health problems that affect many of us personally, and all of us as a society.

 

Research takes an enormous amount of time, especially when dealing with pediatric populations and small pools of patients. Simply gaining approval for a clinical study is a complicated process, because researchers have to demonstrate their studies will not cause foreseeable harm to their subjects. With today’s advanced technologies, the studies we need in key areas like genetics and stem cell research are expensive, and can even face ethical and political hurdles. Many of them have several phases, each taking years to complete.

 

When scientific and medical studies of repute are finally completed, they must undergo peer review to withstand scrutiny from professional colleagues in their field. After that, usually further studies are needed, and even the most promising results need to be duplicated elsewhere before becoming mainstream practice. Each promising finding is simply a building block for further findings, hopefully leading to an eventual “big picture.”

 

Sharing Research with CHD Families: An institutional necessity

 

Touring the lab at Children’s Hospital of Wisconsin, and seeing firsthand how dedicated the researchers there are to helping CHD patients gave me new hope as a heart parent, as well as an inspiration to keep advocating for all the lives that will be touched by CHD. It gave me hope that there is either a cure or a radical shift in how we understand and treat CHD on the horizon.

 

Many heart parents rely on social media posts from other parents in order to learn about important research findings and the results of the latest studies. Many of us only hear about this vital work after the fact, and have little means of learning about the latest, cutting-edge discussions and studies that are happening at our own centers.

 

I commend Mayo Clinic’s Todd and Karen Wanek Family Program for Hypoplastic Left Heart Syndrome (HLHS) for their dedication to sharing their current research with families. Their blog and Facebook posts, as well, as their annual Feel the Beat gathering, which includes a science fair and demonstrations of their current projects for all ages, is refreshingly accessible. The biennial Heart Parent Education Day at the Medical College of Wisconsin/Herma Heart Institute also strives to inform heart parents about standards of care in pediatric cardiology, as well as their latest programs for patients.

 

I urge all pediatric cardiology institutions to get the word out about the great work they are doing–whether through a newsletter, blog, social media page, or in-person events–to the CHD community. Making in-person events family-friendly helps heart parents attend these events without the stress and expense of finding childcare. When heart parents are empowered not only with knowledge, but also the hope of such inspiring research, they are even more motivated to spread the word to their social and advocacy circles–which is a win/win for everyone.

 

 

 

 

Margaret King is the mom to the 9- year old mighty K-man, a spirited boy with half a heart who is determined to live fully, and is married to the awesome heart dad, Shawn. A content marketer and writer in Wisconsin, her other interests include hiking and being outdoors, reading, and avoiding going down the thrill water slides her son is passionate about. She hopes to have a small goat farm someday

Cardiac Devices – The Elephant in the Room

With each CHD, there is no certain path, no one course looks like the next, and complications vary widely. Though a patient may have a specific structural diagnosis, different arrhythmias may develop over time, however patients and families are not always made aware of this possibility immediately. That’s why the diagnosis of an arrhythmia may surprise parents and send them for a loop, just when they think they’ve seen it all.  This also makes it difficult for parents to know just how much to share with teacher and other adults in their children’s lives, just as Alison Connors shares with us this week.

I’m often wondering what to tell people when they ask me about our children. It’s something most parents think about I’m sure. What details will help this teacher, this coach, this babysitter take care of my child? What can I share with them that will give them a view of who they are while they are in their care? For me there is always this looming question of what to say when discussing my children. On one hand I want them to treat my children as the unique individuals they are, discover new things about them, but on the other hand we do have this elephant in the room which is CHD.

I am a mother of three with two children who have faced Congenital Heart Defects. Like most Heart Parents it’s not something you plan, but it’s our life and we do a pretty good job at navigating C.H.D. It is always on my mind what and how much to share especially since two of my children have irregularities in their heart rhythms or arrhythmia.

Arrhythmia isn’t something I thought about when my children had their open heart surgeries. Actually, it was never mentioned when they told me about their hearts and never mentioned until few years ago. I think in the medical profession they are more of the approach of “we will get to that hurdle when and if we get to it.” Even the vague definition for Congenital Heart Defects is ‘problems with the heart’s structure present at birth’ that doesn’t really lead you to believe you may also have “electrical” issues as well or it didn’t in my non-doctor mind. CHD has so many forms and complexities that there isn’t a one size fits all explanation or treatment, so I see their hesitation to lay it all out there. Unfortunately that makes CHD affecting your family a situation of having to roll with the punches of what is going to happen, or at least that is how I have felt.

About two years ago, we were told our daughter had 1st degree heart block. After 4 years of seemingly good appointments, it flung me back into that intense worrying state of mind that we were in for her first year of her life.1st degree heart block, once again something was affecting my child that I had never even heard of before. I remember thinking, “ok, block doesn’t sound good, especially when describing my daughter’s unique heart.” “Why wasn’t this mentioned as a possibility? Or was it, is that the same thing as a murmur? Maybe they mentioned it? No, I would have remembered that.” We were told not to worry, but of course one of my favorite quotes is ‘telling a mother not to worry is like telling water not to get wet.’ I remember crying in the bathroom after we got home from the appointment. Although I knew CHD was lifelong I felt like we were ahead of it or at least had it under control. Arrhythmia seemed like the scariest effect of her surgery. I may or may not have googled how much an AED costs.

With this new information we did what we could and I quickly learned that we did not in fact need our own AED. We did our research and we asked questions. It turns out that arrhythmia is pretty common among some patients who are affected by CHD. That was reassuring for some reason, at least she wasn’t the only one and her pediatric cardiologist was very familiar with this. We followed up about Holter monitor results and asked what to symptoms to look for in the future. We were told that pacemakers would most likely be in her future, but time would tell on when. We were met with some ifs and buts since, unfortunately, our cardiologist is not a fortune teller. Wouldn’t that be nice though? Note to self: google physic pediatric cardiologist. Just kidding. Fast forward just 6 months later and our youngest and second heart warrior was too experiencing irregular heart rhythms. This time, I was more prepared and less shocked. Of course his arrhythmia is not the same as our daughters, but arrhythmia was now on our radar so to speak. Isn’t it weird how things like this become your new normal? Now we had a new discussion point when it came to our kids and how to approach this new element of their health concerns added a new layer to who our kids are.

 

Thinking about my children at school and how to explain CHD and arrhythmia to their teachers worried us. I would go back and forth on how much to disclose at their schools. I wanted to keep them safe of course, but I didn’t want them to be known for just one thing, that being just their special hearts. We decided to air on the side of caution and give specific details about our children’s hearts to their teachers and school nurse. I am so glad we did because our daughter’s school nurse kept referring to it as congestive heart failure. Yikes, right? While we were worried what to share, our kids were busy telling everyone about their hearts and showing off their Holter monitors. They decided to take the lead and give full disclosure to anyone they met. We were surprised, proud and kind of felt silly. We worried what to say about the “elephant in the room” and how to say it, but when it came down to it, it didn’t matter. To their teachers, they were still just two happy kids in their school and their friends think it’s cool they had heart surgery. At this moment, we have things figured out, but of course life has a way of happening while we’re busy pretending we know what we’re doing and planning.

 

Two of our children are affected by CHD and have irregular heart rhythms. So where does this lead us? Like most Heart Parents we just don’t know what our children will experience next. This CHD journey isn’t written in stone and we will always have looming questions on what will happen and how to handle social situations well into adulthood. Will I one day have a heart warrior grandchild? Whoa, ok, slow down, but it’s already on my radar. We just have to stay tuned because with CHD we just don’t know exactly what path we will take. At least we no longer see CHD as an elephant in the room.

 

 

 

 

Alison Connors is a mother of three children: McKenzie, Jackson and Archer. Her oldest McKenzie and youngest Archer both had open heart surgery for congenital heart defects. McKenzie and Archer have been in the care of the PSHU team at Advocate Children’s Hospital in Oak Lawn, Illinois since birth. Alison has been married since 2009 to her best friend Christopher, and she recently went back to work as a 1:1 teacher’s aide for children with special needs. She and her family have a busy life, but she has a passion for volunteering and believes that there is healing power in taking part in something that is bigger than yourself. Having two children with CHD threw Alison onto a path she never expected to be on, but a path her family is very grateful to be on. It’s an honor for Alison and her family to share resources, give hope, and support to others who face the same situations that they have.