ΓΕΝ ΝΟΣΟΚΟΜΕΙΟ ΑΓΙΟΣ ΠΑΥΛΟΣ ΘΕΣΣΑΛΟΝΙΚΗ /ΝΤΗΣ : ΤΣΟΥΝΟΣ ΙΑΝΝΗΣ ΓΕΝΙΚΗ ΕΠΙΜΕΛΕΙΑ : ΛΑΖΑΡΙΟΥ ΦΤΕΙΝΗ (ΕΠΙΜ. Β ) ΜΠΑΝΤΟΛΑΣ ΕΜΜΑΝΟΥΗΛ : ΕΙ/ΝΟΣ Κ/

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1 ΓΕΝ ΝΟΣΟΚΟΜΕΙΟ ΑΓΙΟΣ ΠΑΥΛΟΣ ΘΕΣΣΑΛΟΝΙΚΗ ΚΑΡΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ /ΝΤΗΣ : ΤΣΟΥΝΟΣ ΙΑΝΝΗΣ ΓΕΝΙΚΗ ΕΠΙΜΕΛΕΙΑ : ΛΑΖΑΡΙΟΥ ΦΤΕΙΝΗ (ΕΠΙΜ. Β ) ΜΠΑΝΤΟΛΑΣ ΕΜΜΑΝΟΥΗΛ : ΕΙ/ΝΟΣ Κ/

2 ΠΑΡΟΥΣΙΑΣΗ ΠΕΡΙΣΤΑΤΙΚΟΥ Γυναίκα 45 ετών Αρτηριακή υπέρταση? Ατομικό αναμνηστικό : Κάπνισμα Υπέρβαρη 2 φυσιολογικοί τοκετοί Οικογενειακό ιστορικό ελεύθερο SCD Ασυμπτωματική σε πλήρη δραστηριότητα Δεν αναφέρεται πρόσφατη λοίμωξη ΗΚΓ : Πλήρης Κολποκοιλιακός Αποκλεισμός (αγνώστου ενάρξεως, συγγενής?) Κλινική Εξέταση : ΑΠ: mmhg(υπό αγωγή με Α-ΜΕΑ) Ακρόαση: Πνεύμονες κ.φ, Καρδιά S1-S2 ρυθμικοί ευκρινείς, ήπιο ΣΦ κορυφής SaO2: 98%

3 ECHO ΚΑΡ ΙΑΣ

4 ECHO ΚΑΡ ΙΑΣ ΠΟΡΙΣΜΑ Αυξημένες διαστάσεις καρδιακών κοιλοτήτων Φυσιολογική συσταλτικότητα LV Συγκεντρική υπερτροφία LV AR min MR μικρή PASP 25mmHg Ελάχιστο περικαρδιακό υγρό

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7 ΟΚΙΜΑΣΙΑ ΚΟΠ ΣΗΣ

8 ΟΚΙΜΑΣΙΑ ΚΟΠ ΣΗΣ

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12 ΠΟΡΙΣΜΑ ΟΚΙΜΑΣΙΑΣ ΚΟΠΣΗΣ Η ασθενής κοπώθηκε κατά Bruce για 9:28 Επίτευξη 90% του στόχου. Καλή ινότροπος χρονότροπος απάντηση. εν ανέφερε συ5πτώ5ατα ούτε αλλαγές ST T διαστή5ατος. Κατά την διάρκεια της ανάνηψης ε5φάνισε αρκετές κοιλιακές έκτακτες συστολές, 5ονό5ορφες 5ονοεστιακές 5ε την 5ορφολογία ζευγών διδυ5ίας. Επίσης κατά την ανάνηψη ε5φάνισε κολποκοιλιακό Επίσης κατά την ανάνηψη ε5φάνισε κολποκοιλιακό αποκλεισ5ό 2:1 (δευτέρου βαθ5ού Mobitz II) ο οποίος εκφυλίστηκε σε πλήρη κολποκοιλιακό αποκλεισ5ό.

13 ΣΥΖΗΤΗΣΗ Συγγενής πλήρης κολποκοιλιακός αποκλεισός? Ένδειξη διενέργειας δοκιασίας κόπωσης? Ένδειξη εφύτευσης όνιου βηατοδότη?

14 CONGENITAL COMPLETE ATRIOVENTRICULAR BLOCK (CCAVB) CAVB most often occurs in patients who are older (>70 years) who may have injury to or degeneration of the fibers in the conduction system. The estimated incidence of CCAVB(congenital complete AV block) is 1 in live births, but in a study by Siren et al, the incidence in Finland during the 1990 s had increased to 1 in births CCAVB affects males and females equally The overall mortality rate for CCAVB is 4% to 29% Europace. 2002;4: Eur Heart J. 1984;5: J Rheumatol. 1998;25: Crit Care Nurse 2009;29:45-56

15 COMPLETE ATRIOVENTRICULAR BLOCK (CAVB) CAUSES Complete heart block due to: drug toxicity (digitalis), electrolyte abnormalities, diseases with periatrioventricular node inflammation (Lyme disease), and transient injury to the conduction system at the time of open heart surgery Myocardial involvement occurs in 25% of patients with sarcoidosis, as many as 30% of whom develop complete heart block

16 Complete AV Block - Exercise stress test Acquired complete AV block at rest is a relative contraindication to exercise testing. Exercise testing can be conducted in subjects with congenital complete AV block if there are no coexisting significant congenital anomalies. Circulation 2001, 104:

17 ACC/AHA 2002 Guideline Update for Exercise Testing A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) Investigation of Heart Rhythm Disorders Class I 2. Evaluation of congenital complete heart block in patients considering increased physical activity or participation in competitive sports. (Level of Evidence: C)

18 Treadmill stress test in CCAVB Treadmill exercise testing is done mainly to evaluate functional capacity. In patients with CCAVB without structural heart disease, up to 90% have normal results in exercise treadmill tests. During exercise testing, ventricular ectopy occurs in 50% to 70% of patients, but its importance in sudden cardiac death has not been determined. Patients whose peak exercise or target heart rates were less than 123/min had more cardiac deaths and/or pacemaker insertions than did patients with higher rates. Can J Cardiol. 1996;12(3): Circulation. 1995;92:

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21 Insertion of a pacemaker is recommended for patients with symptomatic bradycardia. Prevention of sudden cardiac death and an increase in functional capacity are the primary goals of pacemaker insertion.

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23 ECHO ΚΑΡ ΙΑΣ ΠΟΡΙΣΜΑ

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25 Because of incomplete ventricular emptying, mitral regurgitation and left ventricular dilatation are also associated with CCAVB. Cardiac output = stroke volume heart rate. To maintain cardiac output, the stroke volume increases, and the increased force of contraction contributes to ventricular hypertrophy Cardiac dilatation as a compensatory mechanism may also predisposepatients to ventricular ectopy similar to the way atrial dilatation predisposes patients to atrial dysrhythmias. Risk of sudden cardiac death may increase in patients with a prolonged QT interval, which predisposes them to development of the ventricular arrhythmia torsades de pointes. Studies have suggested that chronic RVA pacing in young patients, primarily those with congenital complete heart block, can lead to adverse histological changes, LV dilation, and LV dysfunction Crit Care Nurse 2009;29:45-56

26 A narrow complex (<120 ms) indicates a block in the atrioventricular node with the escape pacemaker at the atrioventricular junction, a condition that is considered stable and usually does not progress to asystole. Rakel R, Bope E. Conn s Current Therapy. Philadelphia, PA: WB Saunders Co; 2001:285.

27 Nonrandomized studies strongly suggest that permanent pacing does improve survival in patients with third-degree AV block, especially if syncope has occurred. Circulation May 27, 2008

28 Congenital complete AV block CCAVB is thought to be causedby destruction of the conductionsystem by myocarditisand is associatedwith maternal autoimmune disease, structural heart diseasel(transposition of great arteries, ventricular inversion, and atrioventricular septal defect in which the atrioventricular node ends blindly), and, when diagnosed in utero, neonatal lupus syndrome. CCAVB is stronglyassociated with maternal connectivetissue disorders(ctds), especially those involving autoantibodies to Ro/SS-A, which have been detectedin maternal sera in up to 98% of casesof CCAVB. Europace. 2002;4: Europace. 2002;4: Lupus.2007;16: J Am Coll Cardiol. 2001;37:

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