DEMONSTRATII TULBURARI

DE CONDUCERE/RITM
- CATEDRA DE CARDIOLOGIE, SPITALUL CLINIC DE URGENTA
BUCURESTI –

MAI 2020

AS. UNIV. DR. RADU DAN-ANDREI

 CAZ CLINIC 1
SINCOPA DE ETIOLOGIE “CERTA”
PROFILUL PACIENTULUI
• Barbat, 72 ani;
• FR: HTA, dislipidemie; APP: AVC ischemic in urma cu 1 an
• Tratament cronic: 25 mg Metoprolol b.i.d, Indapamid 1.5 mg, Atorvastatina 20 mg
• Mentioneaza “puls scazut” la automonitorizarea insotita masurarii TA de ~ 2 luni
• Motivele prezentarii:

• Sincope recente (7 episode/2 luni) cu TCC precedate de palpitatii (?)

• Fatigabilitate + dispnee in repaus (agravate intermitent?)

• Neaga istoric anginos de repaus/efort

OBIECTIV
• TA = 100/70 mm Hg simetric brahial

• AV = 32 bpm

• SpO2 = 99 % aer ambiant

• MV prezent bilateral, egal simetric, fără raluri pulmonare, FR = 18/min

• Zgomote cardiace ritmice insa cu intensitate variabila (?), bradicardice sever, suflu holosistolic fo Ao slab
audibil, pulsuri periferice palpabile cu amplitudine redusa

• Multiple contuzii traumatice periferice + semne de TCC in diverse stadia rezolutive

BIOLOGIC

• Hb. 8.9 g/dl (anemie hipocroma, microcitara)

• Cr. 1.5 mg/dl
• In rest irelevant
ELECTROCARDIOGRAMĂ LA PREZENTARE
DIAGNOSTIC DE ETAPA?

• Bloc atrioventricular complet infrahissian cu debut incert

• Sincope recurente
• In observatie boala aortica
• Hipertensiune arteriala (?)
• Dislipidemie
• AVC ischemic in antecedente
DIN DOCUMENTELE MAI VECHI…
ECHOCARDIOGRAFIE IN CAMERA DE GARDA

FEVS 60%
IN TIMPUL ECHOGRAFIEI…
POST-CONVERSIE
DIAGNOSTIC DE ETAPA (2)?
• Bloc atrioventricular complet infrahissian cu debut incert complicat cu TdP necesitand
cardioversie asincrona
• Asistola post-conversie cu instabilitate hemodinamica secundara
• …
• Sincope recurente
• Fibrilatie atriala paroxistica recurenta
• Boala aortica cu stenoza aortica stransa
• Hipertensiune arteriala (?)
• Dislipidemie
• AVC ischemic in antecedente
ATITUDINEA IN ACUT…
CE FACEM IN CONTINUARE?
REVERSIBIL PRO SI CONTRA…?

• Betablocant?

• Cl. Renal?

• Anemia? + FR ateroscleroza?

• Pacientul are totusi o boala degenerativa severa cunoscuta ca induce BAV…

DACA BANUIM REVERSIBIL – PACING TEMPORAR
ENDOVENOS
TOTUSI…?
DECI…?
IMPLANT DEFINTIV
RX POST-IMPLANT
 ATITUDINE TERAPEUTICA IN CONTINUARE (1)

• Control FR

• Optimizare tratament

• ANTICOAGULANT? -> CHA2DS2VASc/HASBLED

ATITUDINE TERAPEUTICA IN CONTINUARE (2)
DISCUTII SUPLIMENTARE (1) - TDP
DISCUTII SUPLIMENTARE (2) – SD. HEYDE?
INTREBARI?
 CAZ CLINIC 2
SCR RESUSCITAT LA O PACIENTA TANARA
PROFILUL PACIENTULUI
• Femeie, 41 de ani
• dislipidemie; APP: LES (cc. + imunosupresoare)
• AHC: 2 MSC in familie, tata si frate la varste de < 40
de ani
• Motivele prezentarii:

• Adusa la CG IOT+VM dupa SCR resuscitat in strada

OBIECTIV
• TA = 120/70 mm Hg simetric brahial

• AV = 110 bpm

• SpO2 = 100% in BiPAP cu 80% FiO2; pO2 pe EAB 328 mm Hg, pH = 7.32, Lac = 2.1 mmol/L, pCO2
N

• MV prezent bilateral, egal simetric, fără raluri pulmonare, FR = 20/min; afebrila

• Zgomote cardiace ritmice, tahicardice, galop protodiastolic; zgomot 2 dedublat, cu disparitia dedublarii
in inspire

• Marca toracica de defibrilare

BIOLOGIC

• Usoara leucocitoza

• Enzime miocardice usor crescute, nespecific; ionograma normala

TRASEU ECG ECHIPAJ PRIM AJUTOR
ELECTROCARDIOGRAMĂ LA PREZENTARE IN CG
RX LA PAT IN CG
ECHOCARDIOGRAFIE LA PAT IN CG (1)
ECHOCARDIOGRAFIE LA PAT IN CG (2)
ECHOCARDIOGRAFIE LA PAT IN CG (3)
DIAGNOSTIC DE ETAPA?

• SCR resuscitat prin FiV necesitand IOT si suport ventilator

• CMD de etiologie neprecizata cu DSSVS
• BRS major atipic
• In observatie cardiomiopatie structurala cu disfunctie biventriculara
• LES in tratament (stabil clinic)
• Dislipidemie
CE FACEM MAI DEPARTE?
DUPA STABILIZARE - EVALUARE
MSC, CMD, CORO N, ECG FRANC PATHOLOGIC,
INDICATIE DE IMPLANT… ->
RMN CARDIAC (1) – CE CAUTAM?
RMN CARDIAC (2)
DIAGNOSTIC ACTUAL

• SCR resuscitat prin FiV necesitand IOT si suport ventilator

• CMD non-ischemica (LVNC) cu DSSVS (FEVS ¬ 10-15%)
• BRS major atipic cu asincronism prezent
• LES in tratament (stabil clinic)
• Dislipidemie
ATITUDINE TERAPEUTICA (1)

• Factori reversibili/triggeri ai FiV?

• In primul rand OMT

• DAR…? MSC -> ?

ATITUDINE TERAPEUTICA (2)
ESTE ICD SUFICIENT LA ACEASTA PACIENTA?
IN CONSECINTA…
ECG POST-IMPLANT
SI CE EFECT AM AVUT?
DISCUTII SUPLIMENTARE
 (LEFT) VENTRICULAR NON-COMPACTION…
• Rare co-CM +/- other co-aN
• Dg: any age!
• ↓ epicardial compact layer
• ↑↑ endocardial “spongy” layer “Genetic testing is recommended (Class I)
• Trabeculation/recesses for relatives and appropriate family members when
a mutation-specific gene has been identified in the
Nunez, JI.; Feltes-Guzman, G.; On behalf of ESC, 2012 index case”

Ackerman, MJ. - HRS/EHRA expert consensus; Heart Rhythm, 2011

“Based on echocardiographic
studies, reported prevalence is
between 0.014 and 1.3% in
Petersen, SE; J Am Coll Cardiol, 2005/Jacquier, A; Eur Heart J, 2010
the general population” But
…

Nunez, JI.; Feltes-Guzman, G.; On behalf of ESC, 2012

Sharma, S.; JACC, 2015

 IMPLICATIONS + WHAT IS DIFFERENT…
• HF
• SCD (V. arrhythmia) !!!
• Systemic emboli +
• ⁓ ys at diagnosis: 47 ± 13
Nunez, JI.; Feltes-Guzman, G.; On behalf of ESC, 2012 Iliyasse, A.; J Saudi Heart Assoc, 2016 • ⁓/> 2/3 males
• ⁓ LVEDD 67.7 ± 6.6 mm

But…

LBBB highly suggestive of SHD (personal)

+ No comprehension of the poor genotype- +OFu when applicable!!!
phenotype correlation
THE 1YEAR FOLLOW-UP TRENDS…

P < 0.05
P < 0.05

P < 0.05
 RR (%) = [(VTSVSi-VTSVSf)/VTSVSi]*100

RESPONSE PROFILE Δ… •
•
SUPER-RESPONDER: >30%
RESPONDER: 15-29%
• NON-RESPONDER: 0-14%
• NEGATIVE-RESPONDER: <0%

• 82% (Overall) vs. 37.5%

(LVNC) responders
• Overall: SR/R ratio > 3/1 (!!!)
• LVNC: SR/R ratio < 1
ANY EXPLANATION…? AND WHAT IS MANDATORY??

• Early diagnosis -> better prognosis!

• OMT!!!
• CRT when mandated
• AGGRESSIVE control of non-
response culprits
P < 0.001!!! P = NS!!!

+ Consider EARLY referral for

cardiac transplantation!
INTREBARI?
VA MULTUMESC