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