Late recovery of atrioventricular conduction after pacemaker implantation for complete heart block in congenital heart disease: fact or fluke?

OBJECTIVES: Pacemaker implantation is a standard recommendation for patients with persistent complete heart block with congenital heart disease. This study was performed to determine the incidence and clinical significance of late recovery of atrioventricular (AV) conduction following pacemaker implantation. METHODS: A retrospective study of patients with congenital heart disease needing pacemaker implantation was performed between 1977 and 2008 at our institution. The postoperative course of all patients with complete heart block, in whom a permanent pacemaker was implanted, was followed on a semi-annual basis by clinical follow-up. RESULTS: A total of 56 patients with complete heart block underwent pacemaker implantation. Indications for pacemaker implantation could be categorized in primary AV conduction block (n = 28 ; 50%) and surgically-induced AV conduction block (n = 28 ; 50%). After pacemaker insertion, recovery of AV conduction was recognized in two patients. The first patient was operated for atrial septal defect type ostium secundum with complete heart block preoperatively. AV block resolved 2 days after pacemaker implantation. The second patient underwent mitral valve replacement. Postoperatively, the patient developed second degree heart block, which progressed 3 years later into complete heart block. A recovery of AV conduction was seen 7.5 years later. In these patients, no late recurrence of complete heart block was found during follow-up after 8 and 4 months, respectively. CONCLUSIONS: Recovery of AV conduction was observed in one patient with primary AV conduction block and in one patient with complete heart block after congenital heart surgery. Lifelong cardiac pacing in these specific subsets of patients may not be necessary.

Isolated traumatic gallbladder rupture.

Blunt traumatic injury to the extrahepatic biliary system is a rare event usually recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon, but poses a potential life-threatening surgical emergency. Delay in the diagnosis of the injury for several days due to no or vague symptoms and an insidious course are common. Early diagnosis is essential, as protracted treatment may result in significant morbidity and mortality. We report the case of a patient who suffered an isolated gallbladder rupture due to blunt abdominal trauma from a fall. The subject of isolated traumatic gallbladder rupture is reviewed because of the rarity of this condition and the diagnostic challenges it poses.

Non-Meckel's ileal diverticulitis with perforation: a rare cause of acute right lower quadrant pain.

A man, aged 74, presented with a rare clinical entity of an acute surgical abdomen similar to acute appendicitis. This case showed a non-Meckel's ileal diverticulitis that was complicated with a diverticular perforation and associated peritonitis. This is a very rare but potential life-threatening surgical emergency, mimicking the clinical presentation of acute appendicitis. The subject of small bowel non-Meckel's diverticulitis is reviewed because of the rarity of this condition and the diagnostic challenges it poses.

"Twist & slide" bowel obstruction: two different rare causes of adult bowel obstruction in the same patient.

A man, age 68, presented with two rare clinical entities of adult bowel obstruction. This case showed a caecocolic intussusception (due to a caecal malignant lesion) with a small bowel volvulus secondarily. These are rare but potential life-threatening surgical emergencies.

Ruptured femoral pseudo-aneurysm through the skin: a rare vexing complication following aortobifemoral reconstruction.

A man, aged 73, presented with a pulsatile mass in his left groin area after an aortobifemoral reconstruction 24 years ago. This case showed a femoral pseudo-aneurysm that evolved very quickly to rupture through the skin requiring emergency operative repair.