ARC Session 2

Bradyarrhythmia and Pacemaker

좌장: 오세일

패널: 박승정, 박형욱, 위진, 현대우

Introduction:

Do not trust anyone

870 ms 950 ms 960 ms 900 ms 840 ms

What is this phenomenon?

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

DANGER

Case #1

Sweet but Dangerous

이웃이 준 벌꿀을 먹고 1시간 전부터 시작된 상기 증상을 주소로 내원

내원 당시 BP : 62/40 mmHg

• CK/CK-MB/Tn-T : 125/2.51/0.015 (0.0~0.014) • BUN/Cr : 18.5/0.96 (0.49~0.91) • Na/K/Cl/tCO2 : 137/4.3/100/28

TTE : normal chamber size normal systolic and diastolic function

F/55: 오심, 구토, 어지럼증

ECG

1. AMI with shock and bradycardia 이므로 direct PCI 를 준비한다.

2. 충분한 hydration 및 atropine을 정주한다

3. 최근 약물 복용력에 대해 자세히 물어본다.

4. 잘 모르겠으니 일단 CCU로 입원시킨다.

다음 취해야 할 action은?

내원 2일째 ECG

Grayanotoxin (GTX)

미주신경에 작용하여 서맥, 저혈압, 과다 침분비, 구토, 의식저하 등을 유발

대사와 배설이 매우 빠르므로 치명적인 경우는 거의 없으며 대부분 충분한 수액 공급과 atropine 투여로 24시간 이내에 회복

2005년부터 식약청에서 히말라야 석청의 수입금지 조치

히말라야 석청

Case #2

Hard to Find

82세 여자, Mild to moderate Aortic Stenosis Recurrent syncope (3 times/year) without prodromal symptoms

No significant findings: Treadmill, Holter monitoring, HUT,…

What would you do next ?

1. Electrophysiological study

2. Repeat examinations above

3. Implantation of ILR

4. Evaluation for neurologic causes

5. Observation

CAG, EPS: no significant findings

ILR implantation performed

Sinus arrest (about 6 sec.) with near syncope (day time: 17시 11분)

실신 환자의 실신 원인 진단 과정

실신

병력 조사, 체위 변화에 따른 혈압 측정, 신체 검사, 심전도 검사

의심 질환 심장신경성 실신 심장 질환, 심근 허혈

해당 검사 기립경사 검사 심초음파 검사,

운동부하 검사, 스트레스 심초음파 검사, 심근 스캔 검사

부정맥

홀터 검사, 이벤트 기록기 검사, 루프 기록기 검사

첫째 단계

둘째 단계

원인 불명의실신 평가단계

관동맥 조영술 검사 심전기생리학적 검사

병력 조사,진단적 검사 결과들 재평가

첫째, 둘째 단계

평가에서 원인 불명

의심 질환 부정맥

삽입형 루프 기록기 시술해당 검사

(실신, 순환기학 제 2판 최윤식.이영우편저, 일조각, 2010)

Case #3

Hidden Events

50세 남자 – ‘맥이 빠져요’

심전도 진단은?

1. PAC

2. PVC

3. Sinus pause

4. SA block

SAN

A

V

AVN

800ms 800ms

1400 ms<800X2

800ms 800ms 800ms

380 ms 400 ms

1500 ms<800X2

840ms 820ms

해설

Case #4

No Syncope

M/40, No symptom, Detected in Routine Exam

: 각차단이 심하니 전문의 진찰을 받으라고 들었음

What is your plan?

1.Pacemaker

2.Electrophysiological study

3.Observation

Bifascicular Block

RBBB + LAFB

RBBB + LPFB

LBBB (= LAFB + LPFB)

Left Anterior & Posterior Fascicular Blocks

Normal LAFB LPFB

rS rS qR qR

RBBB + LPFB

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 #5

Now Syncope

75세 남자, facial trauma를 동반한 syncope로 응급실 방문

응급실 심전도

Paroxysmal AF noted during Head-up Tilt Testing No previous AF history

Paroxysmal AF Spontaneous conversion to sinus rhythm 1.5 hour later

No significant BP drop During PAF episode

Conversion to sinus rhythm and 2.8 sec. pause

What would be the cause of syncope?

1. Vasovagal syncope

2. Bifascicular block trifascicular or

complete block

3. PAF with Rapid ventricular response

4. Tachycardia bradycardia syndrome

5. Unknown

PAF & Prolonged pauses with presyncope during Holter monitoring (1month later)

Recurrent pauses up to 8.44 sec.

Question

What would be the most appropriate treatment?

1. Catheter ablation for AF 2. Permanent pacemaker 3. Antiarrhythmic drug 4. Observation

Pacemaker Implantation & AAD

Class I • Symptomatic bradycardia, including frequent sinus pauses that produce symptoms. (Level of Evidence: C)

• Symptomatic chronotropic incompetence. (Level of Evidence: C)

• Symptomatic sinus bradycardia that results from required drug therapy for medical conditions. (Level of Evidence: C)

Class IIa • Heart rate <40bpm when a clear association between significant symptoms consistent with bradycardia and the actual presence of bradycardia has not been documented. (Level of Evidence: C)

• Syncope of unexplained origin when clinically significant abnormalities of SND are discovered or provoked in EP studies. (Level of Evidence: C)

ACC/AHA/HRS guideline summary: Indications for Sinus node dysfunction (SND) Circulation 2008; 117:e350.

CASE I-6

Class I • Advanced 2nd degree or intermittent 3rd degree AV block. (Level of Evidence: B) • Type II second-degree AV block. (Level of Evidence: B) • Alternating bundle branch block. (Level of Evidence: C)

Class IIa • Syncope that can be attributed to transient complete AV block, based upon the exclusion of other likely causes have been excluded, specifically ventricular tachycardia (VT). (Level of Evidence: B) • Incidental finding at EP study of a markedly prolonged HV interval (≥100 msec) in asymptomatic patients. (Level of Evidence: B) • Incidental finding at EP study of pacing-induced infra-His block that is not physiological. (Level of Evidence: B)

ACC/AHA/HRS guideline summary: Indications for permanent pacing in chronic bifascicular block Circulation 2008; 117:e350.

Case #6

Yellow Sky

60세 남자

주 증상

: 등산 가는 중 갑자기 하늘이 노랗게 되면서 주저 않음

3번 반복 후 이후 괜찮아짐

당뇨병/고혈압 : 없음

혈압 : 130/80 mmHg

ECG

Holter monitoring

TMT - Pretest

TMT

TMT

TMT

원인 진단 및 치료는 ?

1. Angina - PCI

2. AV block - Pacemaker

3. Vasovagal syncope - Observation

CAG

Holter monitoring

Permanent pacemaker implantation

Case #7

Common Cold ?

직업 : 자동차 정비공

무거운 물건을 싣던 도중 갑자기 띵하는 어지러운 느낌 및 chest discomfort와 함께 syncope

증상 당일 아침 꿀물 한컵을 마셨고 증상 발생 1주전 몸살 기운이 있어 감기약 복용했다고 함.

외부병원에서 CAG 및 temporary pacemaker 삽입 후 전원됨.

M/35, 3일전 발생한 syncope

전원 당시 심전도

Back-up Rate 30bpm

Echo 소견이 다음과 같을 때 plan은?

1. Permanent pacemaker implantation

2. CAG

3. Cardiac biopsy

1. Permanent pacemaker implantation

2. CAG

3. Cardiac biopsy

* Cardiac biopsy : Lymphocytic myocarditis

Echo 소견이 다음과 같을 때 plan은?

내원 5일째 심전도

Case #8

Electric Shock

M/36

Chief Complaint : Dizziness & DOE

Present Illness :

He received an electrical shock on his left hand during

his usual work, and then he fell down about 1 meter on

the ground 5 days before hospitalization.

The welding voltage was 380 volt (alternating current).

Five hours after the electrical injury, he felt dizziness

and DOE, but at that time he did not visit the hospital.

BP 120/80 mmHg, PR 36 bpm

Echocardiogram : Normal LV wall motion

ECG – 8 months before admission

ECG – On admission

ECG – Rhythm strips and Holter monitoring

TM test

TM test

향후 치료는 ?

1. 감전에 의한 일시적인 방실차단 이므로

경과 관찰한다.

2. 인공심장 박동기를 삽입한다.

Permanent pacemaker implantation

ECG – 2 months after Electric injury

Electric injury to the heart conducting tissue 1. Mechanism : Coronary artery spasm, Direct thermal injury Ischemia secondary to arrhythmia-induced hypotension Chemoreceptor stimulation, Catecholamine mediated injury Vascular injury 2. AC to be more dangerous than DC. 3. Effect to conducting tissue SA & AV node dysfunction AF, VF, Asystole 4. The incidence of VF following this AC injury was inversely proportional to voltage

(lower limit 50 v), whereas the incidence of AF and VT were directly proportional to voltage.

5. High voltage (500 volt) may cause sudden death from asystole, low voltage usually from VF. 6. Reasons for special vulnerability of the sinus and AB nodes ionic channels disruption ischemia or infraction following electrical injury (esp. RCA)

Robinson et al. Int J Cardiol 1996;53:273-7 Baileyet al. Forensic Sci Int 1995;76:115-9

Case #9

Fast and Slow

69세 여자, 어지럼증, 당뇨병/고혈압 (+/+)

1년전 심전도 5년전 CAG

심전도 진단은?

1. 완전우각차단 2. 심근경색

3. 완전방실차단 4. 이상 모두

ECG - Amiodrone

Permanent pacemaker implantation

Case #10

Break Dance

F/30, Recurrent syncope and dizziness

Pacemaker implantation (DDD) d/t complete AVB (2005/2/23)

Holter monitoring

What is the problem ?

1. A-sensing failure

2. A-pacing failure

3. V-sensing failure

4. V-pacing failure

5. No problem

Chest X-ray

Pacemaker Lead

Subclavian Crush Syndrome

Case #11

64세 여자

주소 : 흉부 불쾌감, 호흡곤란

현병력 : 3년 전 실신을 호흡곤란을 주소로

내원해 완전 방실차단으로 영구형 심박동기 (VDD) 삽입. 5일전 부터 호흡곤란과 흉부

불쾌감이 가끔 있어 내원

심전도

P P P P P P P P P P P

심박동기 기능 이상은?

1. Intermittent sinus pause and VVI pacing 2. Intermittent ventricular capture failure 3. Intermittent ventricular capture failure and

ventricular escape beat 4. Intermittent atrial sensing failure and VVI

pacing

박동기 조정 후 심전도

F/83 Palpitation s/p PM implantation, VVIR type (5 years ago) s/p AVR & CABG (3 years ago)

What is the problem ?

1. Undersensing

2. Oversensing

3. Pacing failure

4. No problem

Pacemaker analysis

V lead status (previous, 1 year ago) Measured threshold 0.5 V at 0.40 msec Measured R wave 8.0 mV

V lead status (Present) Measured threshold 0.5 V at 0.40 msec Measured R wave 1.4 mV

ECG after program change

Case #12

Pacemaker implantation (DDD) due to complete AV block (1999-06-15)

최근 수년간 follow-up loss 되었던 상태로 back pain으로 ER 내원 후 follow-up 위해 협진 의뢰됨.

F/72, Back pain

Before PM implantation

2 years ago

AsVp

1. 심박동기 기능이 정상적으로 유지되고 있으므로 본과적 문제는 없는 것으로 생각됩니다.

2. 심박동기 기능은 정상적으로 유지되고 있으나 오랫동안 follow-up loss 되었으므로 조만간 다시 follow-up 하겠습니다.

3. 심장내과로 입원해 manage 시행하겠습니다.

적절한 협진 answer는?

Is it really DDD ???

Battery depletion of previous pacemaker generator

(DDD -> VVI mode change due to EOL status)

ECG after Generator Change

AsVp

Case #13

79세 여자

17년 전 완전 방실전도차단

- 영구형박동기 (VVI)

이후 2년에 한차례 정도 병원 방문

최근 잦은 실신. 호흡곤란, 전신 부종

2009. 5

2012. 5

적절한 치료는?

1. IV lidocaine

2. IV amiodarone

3. IV aminophylline

4. Change pacemaker

Lead and generator replacement

Case #14

Two are not enough

62세 남자, 1999 AV replacement, 2003 redo AV replacement, 2011 Dyspnea on Exertion 발생

RAO LAO Lateral

DDDR Pacemaker Implanted DOE improved

However, DOE reappeared DOE improved

Paced rhythms following DDDR PPM

Rapidly aggravated LV systolic function following PPM implantation

LV EF LV EDV LV ESV NYHA Class

Pre-PPM 52% 218ml 105ml I

Post-PPM 6mo 44% 232ml 134ml I

Post-PPM 10mo 38% 251ml 155ml III

Post-PPM 11mo 23% 267ml 204ml III-IV

What could be the cause of the LV systolic dysfunction?

1. Mechanical AV dysfunction

2. Concomitant coronary artery disease

3. Pacemaker malfunction

4. Pacing-induced cardiomyopathy

No significant coronary artery disease Well functioning Mechanical AV Function & PPM Performed biventricular pacing (CRT)

QRSd 232 ms (DDDR)

QRSd 168 ms (CRT-D)

LV EF LV EDV LV ESV NYHA Class

Pre-CRT 23% 267ml 204ml III-IV

Post-CRT 1mo 29% 239ml 168ml I~II

Post-CRT 10mo 38% 229ml 148ml I

Significant improvement of symptoms and LV systolic function after CRT