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Arrhythmia Review Course 2
Bradycardia and Pacemaker
프로그램 디렉터: 신동구패널: 강기운, 노승영, 송인걸, 안진희
Female 80 YO, presyncope, dyspnea
KHRS 2018ARC II 2-1
24 Hours Holter
KHRS 2018ARC II 2-2
KHRS 2018ARC II 2-3
Permanent pacemaker implantation
KHRS 2018ARC II 2-4
Beta-blocker
KHRS 2018ARC II 2-5
Female 73 / Dyspnea (NYHA III)
KHRS 2018ARC II 2-6
심전도에서관찰되는소견은?
1. Sinus bradycardia
2. Sinus pause
3. 1st AV block
4. 2:1 AV blcok
KHRS 2018ARC II 2-7
TMT rest
KHRS 2018ARC II 2-8
TMT stage I
KHRS 2018ARC II 2-9
TMT stage III
KHRS 2018ARC II 2-10
Recovery
KHRS 2018ARC II 2-11
Pacemaker implantation
KHRS 2018ARC II 2-12
Post Implantation
KHRS 2018ARC II 2-13
2개월후
KHRS 2018ARC II 2-14
Female / 89 YO, dyspnea
KHRS 2018ARC II 2-15
3 months ago
KHRS 2018ARC II 2-16
Laboratory finding
•Potassium 8.6
•BUN/Creatinine 140/7.5
KHRS 2018ARC II 2-17
Post CRRT
KHRS 2018ARC II 2-18
Male / 59YO, dyspneas/p MVR/TAP (10 YA)
KHRS 2018ARC II 2-19
PM implantation
KHRS 2018ARC II 2-20
Post PM ECG
KHRS 2018ARC II 2-21
M/49. Consultation from Neuro Surgery
C-spine Fracture after Motor cycle TA
Admission ECG
KHRS 2018ARC II 3-1
Consult for bradycardia, HD#10
KHRS 2018ARC II 3-2
Intermittent bradycardia when airway suctionBP: 50/30 mmHg, seizure
Question, Next step?
1. Observation (because of vagal tone↑)
2. Saline hydration for shock
3. Coronary work up
4. Tempoary pacemaker for complete AV block
KHRS 2018ARC II 3-3
Intermittent bradycardia with shock
* * ** *
* * * * * * *
Complete AV block
KHRS 2018ARC II 3-4
Complete AV block & Long pause during airway suction
KHRS 2018ARC II 3-5
Temporary pacemaker
KHRS 2018ARC II 3-6
Recovered to sinus, 11 days later (HD#21)
KHRS 2018ARC II 3-7
Bradycardia and Cervical spine injury
Sympathetic n. system impairment with preservation of parasympathetic output via the vagus n.
Cardiac arrest & asystole, reported up to 15%Main cause of death wthin the first year: cardiac event
Atropine, inotropics usePacemaker indicatedAminophylline use, case reported
KHRS 2018ARC II 3-8
M/42. Syncope
** **
Complete AV block
KHRS 2018ARC II 3-9
키: 160 cm, 체중: 40 kg
12세부터 체력이 약하고 잘 뛰지 못함
20대 근력 저하, 빠른 걸음 못하고 시력저하와 안검하수
아버지가 40대 중반에 늦게 얻은 아들로 원래 몸이 약한줄 알고 가엽
게
생각했었다함
어머니: 소아마비와 심부전으로 사망
Brief history
CPK 2577 IU/mL
KHRS 2018ARC II 3-10
Tempoary & permanent pacemaker
TTE: WNL
CAVB sustained 3 days
KHRS 2018ARC II 3-11
Ptosis W/U: Nine-gaze photographs
KHRS 2018ARC II 3-12
Fundus photograph – pigmentary degeneration
KHRS 2018ARC II 3-13
Fluorescein angiography –salt and pepper like appearance
KHRS 2018ARC II 3-14
Muscle biopsy, Gomori trichrome stain – ragged red fiber
KHRS 2018ARC II 3-15
병리학교과서참고사진
Muscle biopsy (EM x 4,000)
RBC
KHRS 2018ARC II 3-16
Normal mitochondria
Gastrocnemius muscle biopsy [EM x 25,000]
KHRS 2018ARC II 3-17
Parking lot appearance
Very rare sporadic disease
Mitochondrial myopathy with a typical onset before twenty years of age
Clinical findings
Onset before age 20
Chronic progressive external ophthalmoplegia (CPEO)
Pigmentary retinopathy
Complete heart block
Cerebellar ataxia
Treatment
Supportive care and pacemaker implantation
Kearn-Sayre Syndrome
KHRS 2018ARC II 3-18
KHRS 2018ARC II 3-19
Kearn-Sayre Syndrome
F/72. Bradycardia, HR 32 bpm
* * * ** * * * * * * * *
Complete AV block
KHRS 2018ARC II 3-20
Permanent pacemaker implantation
KHRS 2018ARC II 3-21
After implantation
KHRS 2018ARC II 3-22
ApVs
* * *
KHRS 2018ARC II 3-23
AsVp
* * * *
KHRS 2018ARC II 3-24
AsVp, ApVp
** **
KHRS 2018ARC II 3-25
Fusion
* * *
KHRS 2018ARC II 3-26
Question, what phenomenon?
KHRS 2018ARC II 3-27
1. Noise
2. Atrial fibrillation with mode change
3. Lead dislodge and mechanical touch
4. Capture failure induced VF
5. Sensing failure induced VF
KHRS 2018ARC II 3-28
Sensing failure induced VF
**
KHRS 2018ARC II 3-29
Case. M/87 with dizziness
• HT 으로 ARB, diuretics 복용 중이던 분으로, gout 발생후 NSAIDs 복용 중 AKI hyperK sinus bradycardia 로 ER 내원한 분.
• TTE 상 LA size 35mm, LAV 68ml
(no definite LAE)
KHRS 2018ARC II 4-1
Sinus bradycardia (36bpm) d/t hyperK (6.8)
KHRS 2018ARC II 4-2
HyperK 교정후 ECG
SR (HR 72bpm) with 1st degree AVB
KHRS 2018ARC II 4-3
심전도에서 관찰되는 p wave 소견은?
1. LAE (left atrial enlargement)
2. RAE (right atrial enlargement)
3. Biphasic p wave on inferior leads
4. Shortened p wave duration
KHRS 2018ARC II 4-4
P wave morphology
II
V1
• Biphasic (±) p wave • P wave widening (180ms)
• Positive p wave• P-terminal force - normal
LAE 와는구분되는소견임
KHRS 2018ARC II 4-5
Atrial fibrillation was also noticed.
KHRS 2018ARC II 4-6
Bayes syndrome• Advanced inter-atrial block (IAB) associated with atrial arrhythmia (mostly AF)
• Advanced IAB– P-wave duration > 120ms without atrial enlargement or ischemia
– Atrial fibrosis : the anatomic substrate of advanced IAB
– Strong association with atrial arrhythmogenesis (AF or AFL) and even with strokeFront. Physiol 2016;7:188.
Circulation 2018;137:200-2.
V1
≠
*inter-atrial conduction via..- Bachmann’s bundle
- Foramen ovale- Coronary sinus
Left atrial enlargement
KHRS 2018ARC II 4-7
Case. M/51 with frequent near syncope
• Medical history
– 2004년 sick sinus syndrome으로 PM 삽입 (AAI)
– 2016년 generator change
• 6개월 뒤부터 near syncope 증상 발생
KHRS 2018ARC II 4-8
2016년 generator change 후 ECG 및 CXR
• AAI type 의 pacemaker• Pacemaker setting : lower rate 70bpm
• Atrial pacing burden 100%
KHRS 2018ARC II 4-9
증상있을때 Holter monitoring
LR 70bpm
KHRS 2018ARC II 4-10
증상있을때 Holter monitoring
KHRS 2018ARC II 4-11
Holter에서관찰되는소견은?
KHRS 2018ARC II 4-12
1. Sensing failure
2. Capture failure
3. Both
4. None of above
Chest x-ray 및 PM parameter 변화
A lead Sensing (mV)Pacing threshold
(V/ms)Impedance (ohm)
2016.3(generator
change)2.8 0.5/0.4 591
2018.2 NA d/t pacing 2.25/0.4 2582
Lead break
KHRS 2018ARC II 4-13
New A lead insertion + DDD upgrade
KHRS 2018ARC II 4-14
Subclavian Crush Syndrome
• A rare but known complication of pacemaker lead failure due to the compression of the lead between the first rib and clavicle.
• Subclavian venous approach can increase lead fracture, insulation failure or transection of the lead(s).
• Axillary venous access or
cephalic vein cut-down
are safer alternatives for
central venous access.
• Routine CXR and device
checking are needed.
Courtesy of Dr. J Mohammed
KHRS 2018ARC II 4-15
axillary artery
axillary vein
subclavian vein
Case. F/78 with dizziness
• Present illness
– Spinal stenosis 수술 후 pneumonia 로 타원에서supportive care 받던 분으로, dizziness 있어 본원방문함.
• Underlying diseases
– DM, HT, old CVA
KHRS 2018ARC II 4-16
ECG on admission
Complete AV block
KHRS 2018ARC II 4-17
Holter monitoring during syncope
KHRS 2018ARC II 4-18
가장먼저해야할처치는?
KHRS 2018ARC II 4-19
1. IV amiodarone
2. Catheter ablation for VT
3. ICD implantation
4. Temporary pacemaker insertion
Temporary PM
KHRS 2018ARC II 4-20
Permanent PM implantation
No more syncope / TdP
KHRS 2018ARC II 4-21
Bradycardia-dependent Torsades de Pointes
• Torsades de pointes (TdP)– A form of polymorphic VT occurred on QT prolongation
• Factors predicting development of TdP in bradycardia– Older age
– Female gender
– hypoK, hypoCa, HypoMg
– Exposure to QT prolonging drugs
– Underlying disease : HF, LVH, thyroid disease, MI, obesity,…
– Polymorphisms or mutations in genes
– Various ECG findings • QT prolongation, R on T PVC, QRS change, T wave change,…
KHRS 2018ARC II 4-22
TdP predicting factors in this patient
• Old age, female gender
• QT prolonging drug – fluoroquinolone 계 항생제
• QTc (512ms) > 500ms
• QRS morphology change
KHRS 2018ARC II 4-23
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