A PDF file should load here. If you do not see its contents
the file may be temporarily unavailable at the journal website
or you do not have a PDF plug-in installed and enabled in your browser.
Alternatively, you can download the file locally and open with any standalone PDF reader:
https://link.springer.com/content/pdf/10.1007%2Fs12471-017-1049-1.pdf
Fatal elective DDD pacemaker implantation
Fatal elective DDD pacemaker implantation
B. Klop 0
L. J. P. M. van Woerkens 0
M. Bijl 0
0 Department of Cardiology, Albert Schweitzer Hospital , Dordrecht , The Netherlands
-
Answer
The initial electrocardiogram obtained immediately
after implantation of the dual chamber (DDD) pacemaker
showed normal atrioventricular pacing with a premature
atrial complex after every two beats and an expected left
bundle branch block pattern (LBBB) (Fig. 1a). The repeat
electrocardiogram showed a similar rhythm with an LBBB,
but with concordant ST segment elevation in lead aVR
and concordant ST segment depression in leads V2 to V6
(Fig. 1b). The patient developed a refractory cardiogenic
shock and a coronary angiography was obtained, which
revealed extensive three-vessel disease without thrombi
or acute occlusions. Fluoroscopy did not show any signs
of lead displacement. The patient died during emergency
percutaneous coronary intervention.
The modified Sgarbossa criteria are specific for cardiac
ischaemia in patients with ventricular pacing and LBBB:
concordant ST segment elevation in any lead, concordant
ST segment depression in leads V1 to V3 and discordant
ST segment elevation >5 mm in any lead or a ratio of ST
segment elevation to S-wave amplitude of 0.25 or more
[
1–3
].
The patient was asymptomatic before implantation of
the pacemaker. The low heart rate probably protected him
against myocardial ischaemia. After inducing ventricular
pacing, the heart rate was normalised to 70 beats per minute,
which resulted in panischaemia with subsequent refractory
cardiogenic shock due to extensive three-vessel disease. In
retrospect, early intervention with lowering of the basal
pacing rate might have reversed the development of ischaemia
and subsequent cardiogenic shock.
Conflict of interest B. Klop, L.J.P.M. van Woerkens and M. Bijl
declare that they have no competing interests.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
made.
a The initial electrocardiogram obtained directly after implantation of the DDD pacemaker, b The repeat electrocardiogram
Neth Heart J
1. Maloy KR , Bhat R , Davis J , et al. Sgarbossa criteria are highly specific for acute myocardial infarction with pacemakers . West J Emerg Med . 2010 ; 11 : 354 - 7 .
2. Schaaf SG , Tabas JA , Smith SW . A patient with a paced rhythm presenting with chest pain and hypotension . JAMA Intern Med . 2013 ; 173 : 2082 - 5 .
3. Sgarbossa EB . Recent advances in the electrocardiographic diagnosis of myocardial infarction: left bundle branch block and pacing . Pacing Clin Electrophysiol . 1996 ; 19 : 1370 - 9 . (...truncated)