Symptomatic bradycardia – should we pace or ablate?

Mohd Shah, Azarisman Shah and Mohd Said, Mohd Ridzuan and Abdullah, Aszrin (2024) Symptomatic bradycardia – should we pace or ablate? Medicine and Health Journal, 19 (5 (Suppl)). p. 73. ISSN 1823-2140 E-ISSN 2289-5728

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Abstract

Introduction: A 63-year-old male was admitted 6 months post-angioplasty with a threeday history of palpitations and fainting spells. He has been well, asymptomatic and physically active with daily clopidogrel 75 mg and rosuvastatin 10 mg. At the Emergency Department he was in atrial flutter with 2:1 atrio-ventricular block and cardioverted with intravenous amiodarone and oral bisoprolol 5.0 mg. Overnight, he developed symptomatic bradycardia with a heart rate of 32 bpm which persisted despite discontinuation of the β-blocker. Further scrutiny of his 12-lead electrocardiogram revealed atrial bigeminy with blocked premature atrial contraction (PAC) and a heart rate of 32 to 52 bpm. Repeated Troponin measurements were normal and echocardiogram showed good left ventricular ejection fraction of 64% with no regional wall motion abnormality. He then consented for electrophysiology study with the standard procedure using three electrode catheters, namely a decapolar catheter in the coronary sinus, a quadripolar catheter in the Hisbundle region, and a mapping catheter positioned in the right ventricle. The right atrium (RA) was mapped using a multipolar PentaRay electrode catheter and a three-dimensional, CARTO mapping system to identify the origin of the PACs. PAC was eventually eliminated by ablating the right, superior and anterior ganglionated plexi which increased the sinus rate from 1200 ms to 800 ms. Post-ablation 24-hour electrocardiogram monitoring revealed no recurrence of either the atrial flutter with 2:1 atrio-ventricular block or the atrial bigeminy with blocked PAC. Conclusion: Symptomatic bradycardia in the elderly associated with episodes of tachycardia is almost always attributed to the tachy-brady, Sick Sinus syndrome. This portends eventual atrioventricular nodal dysfunction and is usually remedied by insertion of a permanent pacemaker. However, this is not always the case and a careful scrutiny of the electrocardiogram and fastidious ruling out of potential differentials will eventually lead to the actual diagnosis and appropriate management.

Item Type:	Article (Abstract)
Uncontrolled Keywords:	Bradycardia, bigeminy, electrophysiology, ablation.
Subjects:	R Medicine > R Medicine (General) R Medicine > RB Pathology R Medicine > RC Internal medicine R Medicine > RC Internal medicine > RC66 Clinical cases R Medicine > RC Internal medicine > RC667 Specialties of Internal Medicine-Diseases of Circulatory (Cardiovascular) System
Kulliyyahs/Centres/Divisions/Institutes (Can select more than one option. Press CONTROL button):	Kulliyyah of Medicine > Department of Basic Medical Kulliyyah of Medicine
Depositing User:	DR Aszrin Abdullah
Date Deposited:	26 Jan 2025 14:37
Last Modified:	26 Jan 2025 14:37
URI:	http://irep.iium.edu.my/id/eprint/118885

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