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ARC Session 2
Bradyarrhythmia and Pacemaker
좌장: 오세일
패널: 고점석, 심재민, 진은선, 최의근
Case #1: F/52, General weakness & DOE
What is your answer?
1. Sinus bradycardia
2. 2:1 AV block
3. Junctional rhythm
4. Complete AV block
What is your plan?
1.Pacemaker
2.Electrophysiological study
3.Observation
ECG after pacemaker implantation
Case #2: F/24, ECG (routine check), No symptom
What is your answer?
1. Sinus bradycardia
2. 2:1 AV block
3. Junctional rhythm
4. Complete AV block
Marked sinus bradycardia
Isorhythmic AV dissociation
What is your plan?
1.Pacemaker
2.Electrophysiological study
3.Observation
Pacemaker for Sinus Node Dysfunction
Class I Indication
1. SND with documented symptomatic bradycardia,
including frequent sinus pauses that produce
symptoms
2. Symptomatic chronotropic incompetence
3. Symptomatic sinus bradycardia that results from
required drug therapy for medical conditions
ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities
Case #3: F/65, chest discomfort and DOE
Question: Most possible diagnosis?
1. Sinus pause
2. SA block
3. Nonconducted atrial premature beat
4. Second-degree AV block
5. Atrial fibrillation
심전도 해설
1160ms 2320ms 1160ms 1160ms 1160ms 1260ms
SA conduction abnormalities
2nd degree SA block (Mobitz type 1)
: the P-P interval shortens until one P wave is dropped
2nd degree SA block (Mobitz type 2)
: the P-P intervals are an exact multiple of the sinus cycle,
and are regular before and after the dropped P wave
Sinus pause
: P-P interval delimiting the pause does not equal a
multiple of the basic P-P interval
Type I 2nd-Degree SA Block
A
AVN
V
SAN
Type II 2nd-Degree SA Block
A
AVN
V
SAN
Case #4: F/28, Presyncope following palpitation
Question
What would be the most appropriate
treatment?
1. Catheter ablation
2. Permanent pacemaker
3. Antiarrhythmic drug
4. Observation
Case #5: F/59, Presyncope
F/59, Presyncope
Question
What would be the most appropriate
treatment?
1. Catheter ablation
2. Permanent pacemaker
3. Antiarrhythmic drug
4. Observation
식사 도중 수초간 의식 소실
운전 중 빵을 먹다가 실신
Echo: normal
Neck CT : normal
GFS : WNL
Case #6: M/44, syncope during meal
M/44, syncope during meal
6-7:00PM
12-1:00PM
What is your plan?
1.Pacemaker
2.Electrophysiological study
3.Avoid solid meal
4.Observation
Deglutition Syncope (Swallow Syncope)
Repeated episodes of
symptomatic bradycardia
and asystole during
swallowing
Sinus arrest, A-H interval
prolongation, and
complete AV block
Abnormal reflex of
glossopharyngeal or
vagus nerve
Case #7: M/69, DOE
Question
Most possible diagnosis?
1. 2:1 AV block
2. Sinus bradycardia
3. Nonconducted atrial premature beats in bigeminy
4. Complete AV block
5. Brugada-type ECG
M/69, DOE
ECG 2
During treadmill test
: warm-up
#34365801
During treadmill test
: stage 1
#34365801
During treadmill test
: stage 2 (peak exercise)
Summary of treadmill test
Noninvasive methods for
determining site of AV block
Intervention AV nodal
conduction
Subnodal conduction
Exercise Improves Worsens
Atropine Improves Worsens
Carotid sinus massage
Worsens Improves
Case #8: M/43, S/P VSD Op.(22 YA), No Symptom
Bifascicular Block
RBBB + LAFB
RBBB + LPFB
LBBB (= LAFB + LPFB)
Left Anterior & Posterior Fascicular Blocks
Normal LAFB LPFB
rS rS qR qR
RBBB + LAFB
RBBB + LPFB
Trifascicular Blocks
Complete AV block
Alternating bifascicular blocks
Bifascicular block with 1st- or 2nd-degree
AV block
What is your plan?
1.Pacemaker
2.Electrophysiological study
3.Observation
Pacemaker for Chronic Bifascicular Block
Class I Indication
1. Intermittent third-degree AV block
2. Advanced second-degree AV block
3. Type II second-degree AV block
4. Alternating bundle-branch block
ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities
Case #9: F/64, DOE
Alternating long and short PP intervals
850 ms 840 ms 840 ms 860 ms
990 ms 960 ms 970 ms 960 ms
Question: What is this phenomenon?
1. Sinus arrhythmia
2. Atrial bigeminy
3. I don’t know
4. None of the above
Ventriculophasic Sinus Arrhythmia
The PP interval enclosing a QRS complex is shorter than a
PP interval not enclosing a QRS.
Proposed mechanisms:
Increased blood flow into the sinus nodal artery during
ventricular systole
Producing an early pacemaker activity
Shortening the sinus cycle length
Increased arterial pressure
Baroreceptor mediated vagal input to the sinus node
Inducing phasic change
Circulation 1955;11:240–61
Am Heart J 1944;27:676–87
Ventriculophasic Sinus Arrhythmia:
Examples in Advanced AVB & Complete AVB
790 ms
880 ms 840 ms
800 ms
820 ms 840 ms 850 ms 840 ms
760 ms
Case #10: M/25, dizziness
Temporary Pacemaker Insertion
ECG, temporary pacing
Question: Where is the pacing site?
1.RVOT
2.RV apex
3.LVOT
4.LV apex
5.How can I know it?
Question: What is your plan?
1.Keeping current pacing
2.Repositioning
3.Open heart surgery
4.Blaming the fellow
Echocardiography
RV
LV
LA
RA
BEFORE AFTER
Echo (2010-4-23): Severe AS (AVA 0.8cm2,
mean PG 48mmHg), EF 58%
Regular f/u 중, 2011.1 등산 갔다가 현기증 나면서 syncope
Echo (2011-2-18): AV mean PG 59 mmHg,
AVA 0.62 cm2
Case #11: 70-year-old-man with syncope
ECG (2 days prior to procedure)
Transcatheter AV Implantation (2011-7-27)
CoreValve System
Indication • Severe symptomatic aortic stenosis
• High risk for conventional surgery
ECG, immediate post-TAVI
ECG (2011-12-8)
2011/12/08 After TAVI
2011/2/18 Before TAVI
“증상 없이 잘 지냅니다”
Echo (2011/12/8)
mild AR
AV mean PG =
14.4 mmHg
45/68/56%
TAVI & AV block requiring pacemaker
CoreValve system
Piazza et al.: 18% (7/40)
Haworth et al. : 29.6% (8/33)
Khawaja et al. : 33.3% (81/270)
Edwards valve
Sinhal et al. : 5.7% (7/123)
Webb et al. : 5.4% (9/168)
cf. Surgical AVR: 3-8% Piazza et al. J Am Coll Cardiol Intv. 2008;1:310–6.
Haworth et al. Catheter Cardiovasc Interv. 2010;76(5):751-6. Khawaja et al. Circulation. 2011;123:951-960.
Sinhal et al. J Am Coll Cardiol Intv. 2008;1:305–9. Webb et al. Circulation. 2009;119:3009-3016.
TAVI & LBBB / AV block
Depth of implanted valve
Proximal end of frame - lower edge of
NCC
Significantly greater in patients with new-
onset LBBB
10.3 ± 2.7 mm vs. 5.5 ± 3.4 mm
Depth < 6.7 mm no LBBB
Khawaja et al. Circulation. 2011;123:951-960. Piazza et al. J Am Coll Cardiol Intv. 2008;1:310–6.
Survival free of AVB requiring PM
Survival free of AVB within 14 days of TAVI
Non-RBBB vs. RBBB at baseline : 78% vs. 10%, p <0.001
Implantation depth ≤ 6 mm vs. > 6 mm : 85% vs. 22%, p <0.001
Combined (RBBB + implantation depth) : 90% vs. 0%, p <0.001
Guetta V et al. Am J Cardiol. 2011;108(11):1600-5
CoreValve TAVI & AVB
AVB requiring PM: 18-36%
Independent predictors
Baseline RBBB
Deep valve implantation (> 6 mm)
Suggestions
Preventive pacemaker for patients with RBBB
Only a few millimeters below the annulus
Case #12: Clinical History
A/S : 68/F
C/C : Exertional dyspnea (onset : 1 month ago)
PHx : Non-specific
2DE : EF=64%, no RWMA
Lab : W.N.L
OPD ECG 1
OPD ECG 2
Escape rhythm in AVB
Level of AV block Origin of escape
rhythm QRS morphology
AV nodal block AV junction Narrow
Infranodal block Ventricle Wide
AV nodal block
His bundle block Bundle branch
block RB and LB block
Infranodal block
Permanent pacemaker implantation
ECG after pacemaker implantation
Case #13: 69-Year-Old Female with Recurrent Syncope
History
− AAI pacemaker implantation for sick
sinus syndrome (1990-6-20)
− Atrial lead repositioning due to
dislodgement (1994-10-19)
− Generator replacement (AAI, 1996-9-15)
− Generator replacement (AAIR, 2007-9-17)
Pacing threshold: 0.4ms x 1.75V
Sensing: 1.4 mV
Lead Impedance: 543 ohm
Chest PA
Lead insulation damage
DDD Pacemaker Implantation
ECG after DDD Implantation
Case #14
M/69
운동시 호흡곤란 및 흉부 불편감
과거력: 당뇨병, 고혈압, 전립선 비대증
투약력: amlodipine, glimepiride, aspirin,
propranolol 40mg, Januvia
ECG
Holter monitoring
ECG (2010-06)
ECG (2010-06)
Holter
DDDR Pacemaker Implanted
Post-op #1
Post-op #1, ECG change
Device Interrogation
A Lead
No change
V Lead
Decreased R wave 12.0
to 4.0 mV
Increased Capture
Threshold
0.5V at 0.4ms to 5.0 V at
1.0 ms
Chest CT
RV Perforation by V lead
What is your plan?
1. Simple traction at EP lab
2. Open chest surgery at OR
3. Just keep it
Symptoms & Signs of Lead Perforation
Capture failure / Sensing failure
Chest pain / Abdominal pain
Inappropriate ICD shocks
Muscle or diaphragm stimulation
Hiccup d/t phrenic nerve stimulation
Pericardial effusion / Cardiac tamponade
Predictors of Lead Perforation
Temporary pacemaker implantation
Corticosteroid use
Active-fixation leads
Low body-mass index
Older age
Longer fluoroscopy times