Complete Atrioventricular Heart Block From an Epilepsy Treatment

Abstract

Atrioventricular (AV) heart block without adequate escape rhythm can result in sudden cardiac arrest and death. We report complete (third degree) AV block in a 16 year-old boy as a late effect of vagus nerve stimulation (VNS). He experienced brief, daily, complex partial seizures, treated with lamotrigine, levetiracetam, and the placement of Model 102 VNS at age 4. Electroencephalography (EEG) showed generalized slow spike-and-wave discharges consistent with Lennox-Gastaut syndrome. At age 12, his VNS was changed to Model 303 PereniaDURA/Model 103 Demipulse generator, set at an output current of 2.25 mA on a standard 30 seconds on, 5 minutes off paradigm. At age 16, he experienced episodes of sudden collapse followed by unconsciousness. Holter monitor showed 15 second symptomatic complete AV block without escape (Figure 1). The patient was taking psychotropic medication with potential cardiac side effects: methylphenidate (tachycardia), guanfacine (first degree AV block), and haloperidol (prolonged QT interval, Torsades de Pointes). Haloperidol, methylphenidate, and VNS were stopped without further symptoms. Off these medications, the VNS was resumed at reduced current (1.25 mA), with re-occurrence of symptomatic AV block. Again, the VNS was stopped and symptoms/heart block ceased. Psychotropic medication was resumed without any side effects.