Download Resposta para Martin

Estimado Martin existen varias cosas dudosas. Tu mencionas que se le realizo un
electroencefalograma ( EEG) del sueño?. El EEG se utiliza para ayudar a diagnosticar
si el paciente está presentando convulsiones y, de ser así, de qué tipo?. Un EEG
también se emplea para encontrar las causas de confusiónconfusión y evaluar
traumatismos cranealestraumatismos craneales, tumores, infecciones, enfermedades
degenerativas como el mal de Alzheimer, al igual que cambios anormales en la
química corporal que afectan el cerebro.
También se usa para:

Evaluar problemas con el sueño (trastornos del sueñotrastornos del sueño)

Investigar períodos de pérdida del conocimiento ( seria el caso síncope)

Monitorear el cerebro durante una cirugía cerebral
El EEG puede realizarse para mostrar que el cerebro no tiene ninguna actividad, en el
caso de alguien que esté en un coma profundo.
Finalmente el EEG, puede servir cuando se trata de decidir si alguien tiene muerte
cerebral.
Este paciente tiene en el ECG una repolarización en silla de montar ostensible en V2,
lo que en la gran mayoría de los casos es una variante normal y mas frecuente todavia
en personas portadoras del pectus excavatum. A pesar de esto como tuvo síncope no
sabemos si de causa desconocida, aparentemente no porque está siendo usado
anticomiciales.
Como bien lo ha dicho Adrian el pectus escavatum puede originar un patrón tipo1
Brugada-like o fenocopia.
Por ese motivo yo realizaria en esta paciente un ECG con precordiales derechas altas
que en algunos casos desenmascara el patrón tipo 1 colocando los electrodos de V1
V2 y V3 en el primer, segundo y tercero espacios para esternal. Este proceder
comparando con V1-V2 standard aumenta a sensibilidad para desenmascarar el
patrón lo que torna relevante este barato y reporducible test(1).
1.
Márquez MF, Allende R, Cazares-Campos I, Cárdenas M. Utility of high
parasternal electrocardiographic leads in the diagnosis of Brugada syndrome
Arch Cardiol Mex. 2009 Dec;79 Suppl 2:40-3.
2.
Richter S, Sarkozy A, Paparella G, Henkens S, Boussy T, Chierchia GB,
Brugada R, Brugada J, Brugada P. Number of electrocardiogram leads
displaying the diagnostic coved-type pattern in Brugada syndrome: a diagnostic
consensus criterion to be revised. Eur Heart J. 2010 Mar 16. [Epub ahead of
print
A seguir para os que leem ingles mando um ressumo do pectus e Brugada
THE DIFFENTIAL DIAGNOSIS OF BRUGADA ECG PATTERN WITH
ECG OF PECTUS EXCAVATUM
By Andrés Pérez Riera
Chest wall deformities are the most common congenital chest deformities and
are more popularly known as 'funnel chest' or “sunken chest” (pectus
excavatum) or “pigeon chest” (pectus carinatum). Pectus deformities occur in 18 per 1000 individuals and are more frequent in boys than girls. Pectus
excavatum is defined as an abnormal formation of the rib cage where the
breastbone caves in, resulting in a sunken chest appearance. Pectus
excavatum would therefore seem to be the expression of a minor form of
dystrophy of collagen and elastin tissues and a clinical marker of possible mitral
valve prolapse1 Marfand syndrome, Kyphoescoliosis, straight back syndrome
and others.
In pectus excavatum (funnel chest) the sternum (breastbone) is depressed in a
concave shape and in pectus carinatum (pigeon chest) the sternum protrudes in
a convex shape. In pectus excavatum, it is believed that the heart is displaced
to the left side of the chest. There is a restriction of movement of the heart and
lungs. Patients complain of a decrease in stamina and endurance during
strenuous exercise (67%), frequent respiratory infections (32%), chest pain
(8%), and asthma (7%).
ECG FEACTURES IN PECTUS EXCAVATUM AND ITS RELATION WITH
BRUGADA SYNDROME
1) Rhythm: sinus rhythm is the rule, but paroxysmal tachycardia has been
reported.
2) P waves: entirely negative in lead V1, because the relation between the
atria and the location of lead V1 electrode is altered: This is explained by
atrial activation proceeding in a direction away form the site of the lead
V1 because of leftward displacement of the heart owing to the chest
deformity. Become similar to aVR frontal unipolar lead2.
3) ÂQRS: Occasionally extreme left ÂQRS deviation.
4) QRS:
 Sometimes SI-SII-SIII pattern or SI-SII-SIII syndrome: predominantly
negative deflection of the S wave type in the standard limb leads, with
S wave greater or equal to the R wave in each lead. The SI-SII-SIII
syndrome is typical of straight back syndrome3;4.
 Occasionally, an r end wave is observed in aVR lead.
 A triphasic rSr’ pattern in lead V1 is one of the characteristics ECG
changes: PSEUDO INCOMPLETE RIGHT BUNDLE BRANCH
BLOCK PATTERN. The last r’ wave is usually small5.
 d) Clockwise rotation of the QRS complex in the precordial unipolar
leads.
 In some patients, a Qr pattern is recorded.
 Complete RBBB have been reported.
 Abnormal Q waves are seen most often in the right and mild-unipolar
precordial leads or in inferior leads (pseudo anteroseptal or inferior
infarction)6.
5) ST-segment elevation in the right precordias ECG leads.
6) Nonischemic-type T wave inversion in right or mild precordial leads7.
7) Brugada-type ECG pattern, i.e., RBBB pattern and ST-segment elevation
in the right precordial ECG leads have been descibed 5. So, a clinically
benign Brugada-type ECG pattern may appear in some patients with pectus
excavatum8.
8) Eventual false positive exercise test.
RIGHT
SHOULDER
aVR
P
P waves entirely
negative in lead V1
V1
P
Brugada-type
ECG pattern
aVR
V1
V2
V2
Brugada-type
ECG pattern
ECG OF AN 18 YEAR-OLD MALE PATIENT WITH PECTUS EXCAVATUM
BRUGADA-TYPE 1 ECG PATTERN
Qr pattern in V1
Negative P wave in lead V1
Triphasic rSr’ pattern in lead V2
PSEUDO-IRBBB PATTERN: the last r’ wave is small.
ST-segment elevation in the right precordial ECG leads and V2.
Non ischemic-type T waves inversion in right precordial leads.
Embryonic final r wave in aVR lead and coved type ST segment elevation.
aVR
P
r
References
1) Saint-Mezard G, Chanudet X, Duret JC, et al. Mitral valve prolapse and
pectus excavatum. Expressions of connective tissue dystrophy? Arch
Mal Coeur Vaiss 1986;79:431-4.
2) De Oliveira JM, Sambhi MP, Zimmerman HA. The electrocardiogram in
pectus excavatum. Br. Heart J 1958; 20:495-501 .
3) Pileggi F, Tranchesi J, Grandiski B, Ebaid M, Rodríges JR, Germiniani
H.; Decourt, L.V.: Análise vectocardiográfica da ativação ventricular em
individuos com electrocardiogramas do tipo S1 S2 S3. Arq. Bras.
Cardiol.1961; 14:373.
4) de Leon, A. C.; Perlof, J. K.; Twigg, H et al.: The Straigth back syndrome:
Clinical cardiovascular manifestations. Circulation,1965; 32:193-8.
5) Camerini, F.; Davies, L. G.: Secondary R waves in right chest leads.
Br.Heart J. 1955;17:28.
6) Dessler W, Roesler H. Electrocardiographic changes in funnel chest. Am
Hear J 1950; 4: 877-883.
7) Elisberg EI.: Electrocardiographic changes associated with pectus
excavatum. Ann. Intern. Med.1958; 49:130-141.
8) Kataoka H. Electrocardiographic patterns of the Brugada syndrome in 2
young patients with pectus excavatum. J Electrocardiol 2002; 35:169-71.