Perioperative Trifascicular Block

72-year-old man for Lumbar Laminectomy


  • L5/S1 synovial cyst resulting in a radiculopathy.
  • Severely limited by pain, unable to drive.
  • Hypertension and hypercholesterolaemia
  • CVA 12 years ago, on lifelong clopidogrel. No residual symptoms


  • Phone consult, anaesthetist requested an ECG preoperatively
  • ECG reviewed at a later date and Trifasicular block noted
  • Patient denied any symptoms
  • ECG discussed with cardiologist and decision made to proceed due to lack of symptoms
  • Patient unable to make it to hospital on day of surgery due to floods
  • Collapsed at home 2 days later and required emergency pacemaker insertion


  • Very interesting sequence of events!
  • Perioperative assessment of distance patients via phone can present difficulties.
  • In this case the ECG was viewed by a different anaesthetist at a later date but was still picked up and acted upon effectively.
  • Patients may often have symptoms but are unaware or symptoms developed insidiously
  • Discussion around risk of asymptomatic Bifasicular and Trifasicular block intraoperatively
  • Majority of the opinion that there was significant risk of complete heart block
  • AHA 2018 Guidelines on Bradycardia state; “In the setting of non-cardiac surgery, intraoperative bradycardia is most commonly attributable to SND and only rarely attributable to worsening atrioventricular conduction.”
  • Recommendations do state that many anaesthetic drugs and surgical procedures can exacerbate existing bradycardia and should consider transcutaneous or Permanent pacing perioperatively
  • AHA Management Algorithm for AV Block (2018)