arc session 2 bradyarrhythmia and...

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