1. Case report no. 2, Department Pathological Physiology V. Danzig, MD, PhD, 2 nd Dept. Internal Medicine Cardiology and Angiology Division 1 st Med.F CUNI

2. Patient history 74 year old female For tens of years overweight, growing to clinical obesity, current weight 105 kg, height 165 cm 30 years ago gastroduodenal ulcer 15 year ago arterial hypertension, on medication Since 15 year ago registered at 1 st Dept. Internal Med. w. multiple myeloma, skeletal symptoms since last year 2002 total endo-prosthesis of hip right side

3. Patient history - questions What is BMI value in this patient? What is her nutrition state? What does the abbreviation BMI mean? What are its limit values? What is the relation of obesity and hip replacement? What are the two types of obesity complications? What other anthropometric value is needed for the planned cytostatic therapy?

4. Current disorder Three months ago atrial fibrillation has been incidentally recorded on ECG during her stay in spa ECG recording two months earlier, when processing spa recommendations, showed no pathology and normal sinus rhythm She was not annoyed by this condition, yet after questioning she admits worsening of dyspnea in last months and time by time a chest oppression

5. Current disorder – ECG record

6. Current disorder - questions What is atrial fibrillation? Describe it and classify it within context of other arrhythmias. What is motility of atria and of ventricles in atrial fibrillation? What are hemodynamic effects? What are consequences of atrial fibrillation? What are possible complications? What are clinical manifestations of these complications? Are patients aware of their condition?

7. Current disorder II It is confirmed that the arrythmia is present continuously in time Echo-cardiographic investigation finds medium left atrium dilation (size 52 mm, LAVi – Left Atrial Volume index 39 ml/m 2, per body surface area) Patient is referred to electrical cardio-version (ECV, DC-cardioversion) in 4 weeks after usual preparation

8. Left atrium size M-mode imaging trailing edge leading edge

9.  36 ml/m 2 ESC textbook, 2006  32 ml/m2 Leung D, oral ESC 2007  29 ml/m2 ASE guidelines 2005 Normal volume of left atrium

10. Why volume and not size of left atrium? Relation to Body Surface Area eliminates differences of left atrium volumes between sexes * Only weak correlation exists between size and volume of left atrium ** A stronger correlation exists between volume of left atrium and prognosis *** * Khankirawatana et al., Heart 2004  147: 369 ** Protchett et al. JACC 2003  41: 1036 *** Tsang et al., JACC 2006  47: 1018

11. Current disorder II - questions Why before electrical cardioversion it must be confirmed that the arrythmia is persistent? What investigation method we use for this? What is the reason for echo-cardiographical investigation? Why the electrical cardio-version is planned after several weeks and what does „usual preparation“ mean? Cannot be the patient harmed by postponing the procedure? What are possible alternatives?

12. LAA sludge Sludge = dense spontaneously stagnating echo- contrast without manifested solid thrombotic formation Wazni J Am Coll Cardiol 2006;48:2077– 84

13. Minutes of electrical cardioversion Fasting patient gets introduced peripheral venous cannula Personal and instrumental preparations include equipment for emergency resuscitation. „Neuroleptanalgetic anesthesia“ by drug combination Application of direct current electrical discharge with 200 J energy After the electrical discharge, asystolia developed

14. Electric discharge and following asystolia

15. Minutes of electrical cardioversion - questions What is the length of asystolic flat line? What is the flat line diferential diagnosis? (roll back one slide) The patient underwent “absolute hemodynamic deficit” due to immobility of heart ventricles called asystolia. In what other arrythmias such a deficit occurs? What are the symptoms of the patient, respectively what is her overall condition at given moment? What is the required reaction of medical staff?

16. Minutes of electrical cardioversion II After the brief heart massage the effective heart activity has been restored Peripheral pulse rate was about 35/ min. Monitor showed regular narrow QRS complexes with no P waves. Such ECG recording marks junctional rhythm

17. ECG several minutes after ECV

18. Minutes of electrical cardioversion II - questions Was starting the cardio-pulmonal resuscitation by chest compression correct? Should it not be accompanied or preceded by the artificial ventilation? Is the chest massage alone useful? What are „narrow QRS complexes“ in general, what is the opposite? What is the origin of the substitution rhythm in this patient? What are the physiologically present secondary pacemakers and what heart rates they produce?

19. Return of the patient to normal life Patient gained consciousness, this was restful and without difficulties The secondary junction rhythm with slow rate (which cannot be left for long) lasted several minutes. Diagnosis: tachycardic -bradycardic form of sick sinus syndrome (SSS). This means an indication for pacemaker implantation, the DDDR type (dual chamber) was applied.

20. ECG after pacemaker implantation

21. Return of the patient to normal life - questions Why leaving the patient with the junction rhythm of 40/ min would be disadvantageous for her? Is not the previously introduced anti-coagulation therapy contraindication against the pacemaker implantation? What would be the procedures at the clinic without the pacemaker center? What are advantages and disadvantages of the current procedure? What are the risks from the point of view of hemo-coagulation? Why the ECG record shows only one stimulation spike, preceding with 200 ms QRS complex, compared to the notion that the DDD type pacemaker has two electrodes introduced into two heart cavities?

22. Conclusions Heart rate disorders in elderly patients are frequently caused by degeneration of the pacemaker and conduction tissue Association of tachy-arrythmias with brady-arrythmias is not that rare, is denoted as tachycardic -bradycardic form of sick sinus syndrome (SSS). Disorders of generation and conduction of impulses are present as well. The treatment of choice is the pacemaker implantation, this controls bradycardia and tachycardias can be controlled pharmacologically. The prognosis is good from the point of view of cardiologist. The patient with the properly treated SSS can lead normal life.