Download Temporary Pacemaker setting consideration in myocarditis: A Case

Temporary Pacemaker setting consideration in myocarditis: A Case Report
M Yusuf Fathoni, Cut Azlina, Niken Anthea Sugiarto, Nabila Gusrina, Teuku Thoriq,
Muhammad Husin, Farial Indra, Ismi Purnawan
Department of Cardiology, Gatot Soebroto Central Army Hospital, Jakarta
Introduction
Myocarditis is defined as inflammation of the heart muscle. The most common causes
are infectious agents such as viruses or parasites or autoimmune conditions.
Myocarditis could result in rapidly progressive heart failure and arrhytmia.
Case Description
A 21-year-old male patient referred from RS Simpangan Depok with chief complaint
lost of consciousness and drowned while swimming. Physical examination shows
patient alert with heart rate only 54 bpm, leucocyte 18000 and treated with
Meropenem 3x1gr IV. ECG showed sinus bradicardia; chest x-ray showed
cardiomegaly; Blood Gas Analysis(BGA) showed Metabolic Acidosis. patient
diagnosed with mild head injury with pneumonia and observed in Intermediate Care
Unit. On the 4th day of observation the patient was referred to cardiologist with
bradycardia , and the ECG showed sinus arrest with junctional escape rhytm.
Leucocyte 9600, CPK 1360, CKMB 37 Procalcitonin 0.12 and D-Dimer 940, Lactate
2.10. This patient was suspected myocarditis and treated by temporary
pacemaker(TPM). Post TPM BGA showed uncompensated metabolic acidosis with
arterial Saturation 98% and vein 50%. TPM then configured with faster Heart rate to
100 ppm. On the 9th day patient then observed in cardiology ward, and was given
intravenous Meropenem 3x1 gr, Lovenox 2x0.4 ml, Captopril 3x12.5, and Prednison
3x20 mg. Echocardiography showed normal Right and Left Ventricular contractility
with a mild Tricuspid Regurgitation. Peripheral Blood Smear showed Toxic granule,
Euisinophilia, mielocyte, and giant thrombocyte. Faeces examination found no
paracyte/larvae.
Discussion
The diagnosis of myocarditis is established with criteria present in four categories.
The patient was found syncope, elevated CK-MB and normal coronary angiography,
Cardiac MRI and Myocardial Biopsy could not be performed due to patient condition.
This patient is diagnosed as suspected myocarditis because this patient only meet two
criteria of myocarditis. In this patient the TPM are not solely set to normal heart rate.
This patient needs faster heart rate because post TPM the patient’s condition inclined
to metabolic acidosis with normal lactate level, with normal arterial Oxygen
saturation we expect oxygen delivery is sufficient. Unfortunately Vein Oxygen
saturation is 50% showing an excessive oxygen consumption which uncompensated
with heart rate around 70-80 bpm causing metabolic acidosis. With this basis the
TPM set to 100 BPM, afterwards the metabolic acidosis corrected.
Conclusion
TPM configuration should be considered with patient clinical and laboratorium value
present to optimize the benefit.
Keywords : Myocarditis, Temporary Pacemaker