Therapeutical dilemmas in a patient with sick sinus node disease and multiple cardiovascular risk factors

Introduction: Sinus node disease refers to a series of impulse formation and propagation abnormalities in the sinoatrial node and includes a variety of electro-cardiographic manifestations consisting of sinus bra-dycardia, sinus pauses, chronotropic incompetence, and sinoatrial block. When associated with supraven-tricular tachyarrhythmias, it becomes the tachy-brady syndrome.
Methods: We present the case of a 63-year-old patient with multiple cardiovascular risk factors (dyslipidemic, with a chronic inferior myocardial infarction, coronary artery bypass graft because of the chronic occlusion of the circumflex coronary artery and right coronary artery), with sick sinus node disease, symptomatic by rapid and irregular palpitations, with a sudden onset and ending and a duration of 30 seconds – 5 minutes, for which the patient was addressed. On admission, the patient was stable hemodynamic (TA=120/70 mmHg) in sinus bradycardia 43/min. The echocardiography showed hypokinesia of the apical third of the inter-ventricular septum, but with a global systolic function at the lower limit of normal (EF=50%) and diastolic dysfunction of the left ventricle type 1. The left atrium was moderately dilated (63/58 mm). Holter monitoring documented sinus rhythm throughout the recording with medium HR=50/min and two episodes of atrial fibrillation were detected, with rapid passage into sinus bradycardia.
Results: Since the symptomatology was due to tachyar-rhythmic episodes and not to basal sinus bradycardia, in an elderly patient with degenerative, progressive si-nus node disease, we preferred to direct the patient to the electrophysiology laboratory for the implantation of a bicameral pacemaker in DDD mode with eventual VVI switching in case of permanent atrial fibrillation. Another treatment option would have been the radi-ofrequency ablation of atrial fibrillation, but the probability of maintaining long-term sinus rhythm is low in an obese, elderly patient with an important cardiac remodeling process, with wall motion abnormalities of the left ventricle and diastolic dysfunction, thus increa-sed filling pressures and, last but not least, an increased size and volume of the left atrium.
Conclusions: Patient with sinus node disease sympto-matic only during tachyarrhythmic episodes, with im-portant cardiac remodeling and multiple comorbidities who decrease probability maintence sinus rhythm in case of atrial f brillation radiofrequency ablation de-termined as to indicated bicameral pacemaker implan-tation in DDD mode for symptomatic control and the possibility of switching to VVI mode in case of atrial fibrillation.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)