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REVEAL®Xf
Παρουσίαση περιστατικού
Ελένη Νάκου
Καρδιολογική Κλινική,
Πανεπιστημιακό Νοσοκομείο Ηρακλείου
Disclloossuurerses
None
On admiisssto
ionn…
.....
A 67-year old woman with history of diabetes mellitus
and hyperlipidemia and without a known history of
coronary artery disease was admitted to our hospital due
to chest pain the last 8 hours.
ionn
On admiisssio
ECG
Inferior myocardial infarction
1
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On admiissfoionn
BP = 115/85
Physical examination: normal findings
 Increase in troponin TI and CPK-MB levels
Trannssththoroarcaiccic Echooccaardrdioigorgarpahpyhy
Coronaarryy anggiiooggrraapphhyy
Coronaarryy anggiiooggrraapphhyy
Coronaarryy anggiiooggrraapphhyy
D
osns…
Du rri ng ccooronaarryy i nntteerrvveenntitoin
...
junctional escape rhythm
Junctlonal Escape Rhythm
"idiojunctlonal rhythm"
Sinus Rhythm
40-60/mln .
Sinus
00
Arrest
DDuurrinngg ccoorroonnaaryry i nntteerv
rven
etniotn
iosns…
...
DDuurrinngg ccoorroonnaaryry i nntteerv
rven
etniotn
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...
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SOCltl'Y
o,
European Heart Joumal (2013) 34. 2281-2329
IUlll'O,l?AN
ESC GUIDELINES
doi: 10.1093/eurneartj/eht150
tM!)IOl.()GY'
2013 ESC Guidelines on cardiac pacing and cardiac
resynchronization therapy
The Task Force on cardiac pacing and resynchronization therapy of the
European Society of Cardiology (ESC). Developed in collaboration
with the European Heart Rhythm Association (EHRA).
AV block complicating acute myocardial infarction most often resolves
itself spontaneously within 2–7 days. Permanent cardiac pacing
does not influence the prognosis of these patients and therefore is not
recommended.
Ischemic sinus arrest?
Electtrropphhyysisoio
lolo
gygy studdyy
Halo Catheter
Pace low lateral R~
Pace proximal CS
TV isthmus
~
Octapolar steerable catheter
cs
Eleccttrroopphyhsyiosliogloygy stuuddyy
Electtrroopphhysyisoiloolgoygy stuuddyy
Aft err atrrooppininee inffussiioonn
Eleccttrroopphyhsyiosliogloygy stuuddyy
Eleccttrroopphyhsyiosliogloygy stuuddyy
Holterr κ
Kαaτ-cαaγyρ
pα
acφpή
qςs ρ
pυuθ
8μ
µοou
ύ
RESULTS
HEART RATE: ( Total QRS: 60743)
Average
RR
66 bpm
Max. H.R
Day (08 00 - 21 00) 68 bpm
(All)
( Analyzed Time: 15:24)
Min HR:
Max.
98 bpm at (1 )17·55:55
Min. RR:
40 bpm al (1)07:49:30
N1ghl (23 00 • 06 00) 64 bpm
BRADYCARDIA
0
: 0
MISSED BEATS:
PAUSES:O
o
VENTRICULAR
EVENTS
:
Isolated
00%
ECTOPIC BEA TS :
TACHYCARDIA: 0
Couplets
00%
Bl & TRIGEMINY
: 0 & 0
O
Runs O
00%
Total O
SUPRAVENTRICULAR
EVENTS:
ECTOPIC BEA TS :
INSTABILITY: 0
lsolated 9
Couplets O
%
Runs 2
Tolal 27
Vt1111icul,tt
p,cmatunlyc
Bl & TRIGEMINY
: 0&0
TACHYCARDIA:
00%
OO
00%
orr
Venlncular
tachycardia>
SObpm
0
RR
Exerciisee strressss tesstt
='.Fcmalc
67yrs
Mcds:
4£
Test Reason:
Medical History:
Ref. MO: Ordering MD:
Technician: Test Type:
Comment:
SlageName
Time
in Slage
SUPINE
STAGE 1
STAGE2
Olr.53
03:00
01:01
03:33
Speed
(km/h)
Grade
(%)
0.00
2.70
1-_00
0.00
0.00
10.00
12.00
0.00
1-0
4.6
7,0
LO
i
81
103
136
n
1
120/80
130/80
mo
140/80
10780
1
13390
r.
2
II
0
0.10
-0.35
0.10
0.90
+
AAfftteerr 3 m
onntthhs s…
mo
...
Atrial escape rhythm
,, ......
~
AAfftteerr 6 m
onntthhs s…
mo
...
Sinus rhythm
Heart Vessels (2007) 22:38~392
DOI 10.Hl07/s00380-007-0990-0
ORIGINAL ARTICLE
:\1uncnorl Kotoku • Akim Tamura · Sblgeru Naone
Junichl Kadotn
Sinus arrest caused by occlusion of the sinus node artery
during
percutaneous coronary intervention for lesions of the
proximal right coronary artery
C.udiovascul>r Revascul•rlz,ulon Medicine 14 (2013)
270-274
Contents I ists available at ScienceDirect
Cardiovascular Revascularization
Medicine
Atrial coronary artery occlusion during elective percutaneous
coronary angioplasty*"*·*·**
Jesus Alvarez-Carda*. Miquel Vives-Borras, Andreu Ferrero, Dabit Arzamendi
Aizpurua, Antoni Serra Pefiaranda, Juan Cinca
Side-branch occlusion of the SN artery occurred during PCI in 17.5% patients
21.5% of patients undergoing elective PTCA presented accidental occlusion of atrial branches with a
comparableincidence wheneverthe right or the circumflex coronary arteries were treated (22% and 20%,
Key pointtss
 The mechanisms by
which SN artery branch may be occluded
during PTCA
The predictors of SN artery branch occlusion during PTCA
The prognosis of SN artery occlusion during PTCA
The management of these patients in clinical practice
niiss1m
Mechan
11ss of S artteerryy occllussiioonn
durriingg PTCA
 Persistent coronary spasm
The displacement of the atheroscleroticplaque
Direct scratching of the diseased endothelium during stent
progression
Lumen of
blood vessel
~----::r--
Endothelium
Subendothelium
Smooth muscle
Interstitial fluid
Key pointtss
 The mechanisms by
which SN artery branch may be occluded
during PTCA
The predictors of SN artery branch occlusion during PTCA
The prognosis of SN artery occlusion during PTCA
The management of these patients in clinical practice
Preedicttoorrss of SN arttery branch occlluussioionn
durriingg PTCA
Procedural PTCA characteristics.
Balloon predilatation
Balloon postdilatation
Stent types
BMS
Titan®
Genous®
Pro-kinetic®
Others
DES
Xience®
Cypher®
Taxus®
Others
PTCA without stent
Max inflation pressure
0.014 during stenting (attn)
Length of the stent (mm)
Stent diameter (mm)
Stent platform
Stainless steel
Cobalt-chrome
(63%)
Platinum-chrome
(3.4%)
Strut thickness (µm)
Open/dosed-cell stent,
0.126 n (%)
Predictors
Cases
(n = 43)
Controls
(n = 157)
p Value
35 (81.4%)
26
(60.5%)
126 (80.3%)
71
(45.8%)
0.867
0.089
15 (34.9%)
52 (33.1 %)
3
2
9
9
0.886
5
29
27 (62.8%)
95 (60.5%)
9
42
6
16
4
11
9
26
1 (23%)
10 (6.4%)
17.7
16.6
22.7 ± 7.7
3.1 ± 0.5
21.1 ± 72
3.0 ± 0.5
0.234
0.063
15 (35.7%)
27 (64.3%)
49 (33.6%)
92
0.474
0 (0%)
962
30 (71.4%)/
Odds ratio
Maximal inflation
during sterning
AB ostium plaques
AB diameter
A
2
8
5
94.1
0.535
120 (82.2%)/
12 (28.6%)
26(17.8%)
of atrial branch occlusion.
pressure
1.27
95%(1
1.07-1.52
50.44
0.63
11.76-216.33
0.51-0.77
B
p Value
0.006
<0.0001
<0.0001
Key pointtss
 The mechanisms by
which SN artery branch may be occluded
during PTCA
The predictors of SN artery branch occlusion during PTCA
The prognosis of SN artery occlusion during PTCA
The management of these patients in clinical practice
Subttyyppees s of S
artteerryy
RCA 65% LCX
25% RCA+LCX
10%
Berdajs D, et al, Ann Thorac Surg. 2003;76:732-5
Yalcin B, et al Cardiovasc Thorac Surg 2004;3:249-53
IInn oouurr ppaattiieennt t …
...
Collatteerraal l coroonaaryry circcuullaatitoinon
What you see...
What you don't see ...
“It is the network and not the artery of the pacemakerthe
major responsible for the nutrition of the sinoatrial node"
Berry C, Eur Heart J. 2007 Feb;28:278-91
ugh celllullaarr m
naen?e?
Diffusiionn thrrou
11e1m
e1b1a1b
Concentrated
sugar solution
(Waterle
concentrat
e
d)
ss
o
•
0
0
0
Plasma Membrane
glycoprotein
y
Dilute sugar
solution
(Water more
concentrated)
0
Sugar
molecules
0
0
0
0
0
0
0 0
0
0
00 ..
0
0
0
o~
.
I
0 0
0
0
0
0
Movement
of water
Selectively
permeable
membrane
•
0
0
Diffusion
q,toplasm or axoplHm
Passive transport
protein
Facilitated diffusion
cholesterol
v
cytoskeleton
filament$
iW
•
df::• • •
...,.i--• •
Active transport
•_,...
•••
TThhee ssi noatrriall nnoode, aa hheeterogenneeoouuss
maakkeerr
ppaacceem
...
ssttrruucctuurreSVC
e…
SVC
SEP
RA
RAA
1mm
Endo
Epi
··
IVC
··
····
-···•
······
compact
·····-
#
nodal cells
···•
I
•
1mm
1
I
CT IVC
mm
Key pointtss
 The mechanisms by
which SN artery branch may be occluded
during PTCA
The predictors of SN artery branch occlusion during PTCA
The prognosis of SN artery occlusion during PTCA
The management of these patients in clinical practice
Recoovveeryry of sinuuss
rhyytthhmm
./ Kotokkuu M, Heartt Vessellss 200077
./ Ando G, Heartt vessseellss 200033

./ Morakhiiaa J, Int J Clin Med 201155

./ Park JS,, Koreann J Inteernrn Med 200066

3 dayss
2 dayss
2 dayss
2 dayss
4 dayss
./ D’'Ascennzzii Clin.. Cardiiooll 20100

2 days
./ Deepraasseerrtktkulul P, Int Arch Med 20,12

International Journal of
Cardiology
Volume 203, 15 January 2016, Pages
432-433
I:.L.5EVIER
Long-standing
node
sinus arrest due to the occlusion of sinus
artery during percutaneous
implications
coronary intervention: Clinical
and management
E.S. Nakou, E.N. Simantirakis iii·~,
E.M. Kaller~is, E.I. Skalidis, P.E. Vardas
M,t-:
t
1-1
A trip to Epirus….