1. Trifascicular Block Candice ReyesCardiology July 17, 2009

2. Subjective 57 y/o male transferred to RLAH for eval and treatment of R 3rd met plantar ulcer and gangrene of R 3rd toe Pt has no h/o cardiac dz, he has no cardiac sx PMHx: DM x2yrs w/o tx 3. Objective Vitals: BP 128/75 P 86 T99 O2Sat 99% Wt 95.6 F.S. 286 CV: decr heart tones w/RRR S1S2 w/o murmur Resp: LCTA B/L Extremities: RLE has erythema and 2+ pitting edema 4. EKG Discussion Prolongation of PR interval 1st Degree AV Block RBBB LAFB Findings suggest trifascicular block 5. Trifascicular Block Conduction blocks in all 3 fascicles Can be permanent or transient Criteria: 1) RBB and LASF w/1st degree AV block 2) RBB and LPIF w/1st degree AV block 3) LBB w/1st degree AV block or 4) Alternating RBBB and LBBB 6. Trifascicular Block Trifascicular, along w/bifascicular, blocks indicate advanced heart dz BUT long-term follow-up studies of ambulatory patients indicate that risk of sudden progression to complete heart block and sudden death d/t ventricular asystole is not greatBolton Edmund, "Chapter 28. Disturbances of Cardiac Rhythm and Conduction" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: http://www.accessmedicine.com/content.aspx?aID=587596. 7. Assessment and Plan Dr. Quesadas Assessment and Plan: These findings suggest a trifascicular block. Progression of chronic bifasicular or trifascicular block to complete heart block is infrequent. This pt is asx and was very active prior to hospitalization Per guidelines, the pt has intermediate to high clinical predictors (DM asx trifascicular block) and is scheduled for a low risk surgical procedure