Journal of Cardiology Cases 6 (2012) e84e87

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Journal of Cardiology Cases

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Case 'e$ort

(ffe tive delayed $er utaneous oronary intervention for advan ed atrial ventri ular blo ) in $atients wit# re ent !yo ardial infar tion
*o!onori +to# (,-) . *os#i#ide ,ifune (,-). /entaro /o!uro (,-). *etsuya 0usa1a)i (,-). 2iros#i (ndo# (,-). ,otoyu)i 3a)a!ura (,-. 0JCC)
*#e -e$art!ent of +nternal ,edi ine. -ivision of Cardiology. ,e!orial 2eart Center. +wate ,edi al 4niversity. 1561 4 #i!aru. ,orio)a. +wate 02068707. Ja$an

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8rti le #istory% 'e eived 19 -e e!ber 2011 'e eived in revised for! 10 ,ar # 2012 8 e$ted 25 ,ay 2012 /eywords% 8dvan ed atrio6ventri ular blo ) 'e ent !yo ardial infar tion :er utaneous oronary intervention ;ate re$erfusion

<e $resent a ase of effe tive late re$erfusion for atrio6ventri ular ondu tion re overy in a $atient wit# re ent !yo ardial infar tion o!$li ated by advan ed atrio6ventri ular blo ) (8=>). 8 706year6 old Ja$anese !an was transferred to our #os$ital wit# a re ent diagnosis of !yo ardial infar tion 44 # after onset. <e $erfor!ed e!ergent oronary angiogra$#y on -ay 7 be ause #e develo$ed brady ardia wit# two to one advan ed 8=> resistant to atro$ine wit#out #est $ain or ?*6* #anges. Coronary angiogra$#y s#owed t#e rig#t oronary artery ('C8) wit# total $ro@i!al o lusion. (!ergent $er utaneous oronary intervention (:C+) was $erfor!ed to t#e 'C8. Just after :C+. t#e :' interval was s#ortened to 0.27 s. ,oreover. t#e :' interval was s#ortened to 0.18 s at -ay 16. *#is re$ort s#ows t#e new Anding t#at delayed :C+ !ay be effe tive in $atients wit# re ent !yo ardial infar tion o!$li ated by new 8=> outside of t#e usual t#era$euti window of 12 #. B 2012 Ja$anese College of Cardiology. :ublis#ed by (lsevier ;td. 8ll rig#ts reserved.

Case re$ort <e $resent a ase of effe tive late re$erfusion for atrio6 ventri ular ondu tion re overy in a $atient wit# re ent !yo ardial infar tion o!$li ated by advan ed atrio6ventri ular blo ) (8=>). 8 706year6old Ja$anese !an was transferred to our #os$ital wit# a re ent diagnosis of !yo ardial infar tion 44 # after onset. 2is oronary ris) fa tors were #y$ertension and dysli$ide!ia. ;abora6 tory data s#owed elevated reatine )inase (2925 +4&;) and la tate de#ydrogenase (786 +4&;). 8t ad!ission. we $erfor!ed onserva6 tive !edi al t#era$y be ause #e #ad no #est $ain and ?* elevations #ad been resolved. 0ig. 1 s#ows ele tro ardiogra$#y at ad!ission. <e $erfor!ed e!ergent oronary angiogra$#y on -ay 7 be ause #e develo$ed brady ardia wit# #eart rate 46&!in and two to one advan ed 8=> resistant to atro$ine wit#out #est $ain or ?*6* #anges. Coronary angiogra$#y s#owed t#e rig#t oronary artery ('C8) wit# total $ro@i!al o lusion and good ollateral Cow fro! t#e left oronary artery (0ig. 2) to t#e distal 'C8. (!ergent $er6 utaneous oronary intervention (:C+) was $erfor!ed to t#e 'C8 (0ig. 9). Just after :C+. t#e :' interval was s#ortened to 0.27 s. ,ore6 over. t#e :' interval was s#ortened to 0.18 s at -ay 16 (0ig. 4). *#e 126lead ele tro ardiogra! ((CD) results after 8 !ont#s of follow u$ s#owed al!ost nor!al atrio6ventri ular ondu tion. 8lt#oug#

an a!bulatory (CD was not re orded in t#e out$atient lini . t#ere were no lini al sy!$to!s due to brady ardia. -is ussion >e ause t#e ad!ission of t#is ase was delayed and was t#ere6 fore outside t#e ideal window for :C+. t#ere was no indi ation for t#is $ro edure. 2owever. be ause #is ondition was o!$li6 ated by advan ed 8=> Ave days after ad!ission. we $erfor!ed e!ergent :C+. +n t#is ase. t#e advan ed 8=> i!$roved "ust after :C+. :ri!ary :C+ was not indi ated in t#is ase be ause #e #ad no Andings of $ersistent is #e!ia or #est $ain. :ri!ary :C+ is a$$roved for a ute !yo ardial infar tion wit#in 12 # after onset a ording to several guidelines H1.2I. ,oreover. t#e effe tiveness of re$erfusion t#era$y 1224 # after onset of a ute !yo ardial infar tion is li!ited to $atients wit# #e!odyna!i and ele tri6 al instability (i.e. ventri ular arr#yt#!ia). 2owever. t#ere is no state!ent regarding 8=> as ele tri al instability in t#e guidelines. 0urt#er. t#e effe tiveness of ele tive :C+ for infar t6related arteries in $atients in a stable ondition is lass ++> H1I. and t#e effe tive6 ness of e!ergent :C+ is un)nown in $atients w#ose ondition is o!$li ated by advan ed 8=> at -ay 7 wit#out an is #e!i event or #e!odyna!i instability. *#e $at#ogenesis of advan ed 8=> at -ay 7 is t#oug#t to in lude a new is #e!i event. in reased vagal tone. lo al atrio6ventri ular nodal #y$er)ale!ia H9I. and a negative effe t of adenosine on atrio6 ventri ular ondu tion after is #e!ia H4I. <e t#oug#t t#e reason for t#is advan ed 8=> !ig#t $ossibly

Corres$onding aut#or. *el.% E81 15 671 7111F fa@% E81 15 624 8971. (6!ail address% t ito#Gi!u.n v .go."$ (*. +to#).

187867405&J see front !atter B 2012 Ja$anese College of Cardiology. :ublis#ed by (lsevier ;td. 8ll rig#ts reserved. #tt$%&&d@.doi.org&10.1016&"." ase.2012.06.002

*. +to# et al. & Journal of Cardiology Cases 6 (2012) e84e87

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0ig. 1. (le tro ardiogra$#y at ad!ission (-ay 9 fro! onset). K waves and inversion * waves are in leads ++. +++. a=0. and =76. :' interval is 0.20 s. 'e!ar)able ?* elevation is not observed.

0ig. 2. (!ergen y oronary angiogra$#y for left oronary artery.

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*. +to# et al. & Journal of Cardiology Cases 6 (2012) e84e87

0ig. 9. (!ergen y oronary intervention for rig#t oronary artery.

#ave been in reased vagal tone. lo al atrio6ventri ular nodal #y$er6 )ale!ia. and a negative effe t of adenosine. not to !ention ongoing is #e!ia. 2owever. t#e li)eli#ood of ongoing is #e!ia is relatively low be ause #e #ad no re urren e of is #e!i #est $ain or ?*6 * #anges during t#is $eriod. Coronary re$erfusion after :C+ !ay i!$rove lo al atrio6ventri ular nodal #y$er)ale!ia or adenosine $rodu tion. Denerally. t#is ase was treated wit# a te!$orary transvenous de!and $a e!a)er until atrio6ventri ular ondu tion re overy.

2owever. regular t#era$y using a transvenous de!and $a e6 !a)er reLuires fro! several days to one or two wee)s for 8= ondu tion re overy and an early dis #arge fro! t#e #os6 $ital is i!$ossible. *#is re$ort s#ows t#e new Anding t#at delayed :C+ !ay be effe tive in $atients wit# re ent !yo ardial infar tion o!$li ated by new 8=> outside of t#e usual t#er6 a$euti window of 12 #. 0urt#er study is needed for ob"e tive eviden e t#at veriAes t#e effe tiveness of delayed :C+ in t#is sit6 uation.

0ig. 4. ?erial ele tro ardiogra$#y #anges in lead ++. Just after oronary intervention. t#e :' interval was s#ortened to 0.27 s wit# Arst degree atrio6ventri ular blo ). ,oreover. t#e :' interval was s#ortened to 0.20 s and 0.18 s at -ays 11 and 16. res$e tively. (8) -ay 9 (at ad!ission% 42 # after onsetF :' interval 0.20 s). (>) -ay 4 (75 # after onsetF :' interval 0.24 s). (C) -ay 4 (67 # after onsetF <en #eba # atrio6ventri lar blo ).) (-) -ay 7 (89 # after onsetF two to one atrio6ventri ular blo )). (() -ay 7 ("ust after $er utaneous oronary intervention% :' interval 0.27 s. wit#out advan ed atrio6ventri ular blo )). (0) -ay 11 (:' interval 0.20 s). (D) -ay 16 (:' interval 0.18 s).

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0ig. 4. (Continued ).

-is losure 3one de lared. 'eferen es

H1I /us#ner 0D. 2and ,. ?!it# Jr ?C. /ing +++ ?>. 8nderson J;. 8nt!an (,. >ailey ?'. >ates ('. >lan)ens#i$ JC. Casey Jr -(. Dreen ;8. 2o #!an J?. Ja obs 8/. /ru!#ol1 2,. ,orrison -8. et al. 2005 0o used u$dates% 8CC&828 guidelines for t#e !anage!ent of $atients wit# ?*6elevation !yo ardial infar tion (u$dating t#e 2004 guideline and 2007 fo used u$date) and 8CC&828&?C8+ guidelines on $er utaneous oronary intervention (u$dating t#e 2007 Duideline

and 2007 fo used u$date)% a re$ort of t#e 8!eri an College of Cardiology 0oundation&8!eri an 2eart 8sso iation *as) 0or e on :ra ti e Duidelines. Cir ulation 2005F120%2271906. H2I =an de <erf 0. >a@ J. >etriu 8. >lo!stro!6;undLvist C. Crea 0. 0al) =. 0ili$6 $atos D. 0o@ /. 2uber /. /astrati 8. 'osengren 8. ?teg :D. *ubaro ,. =er#eugt 0. <eidinger 0. et al. ,anage!ent of a ute !yo ardial infar tion in $atients $re6 senting wit# $ersistent ?*6seg!ent elevation% t#e tas) for e on t#e !anage!ent of ?*6seg!ent elevation a ute !yo ardial infar tion of t#e (uro$ean ?o iety of Cardiology. (ur 2eart J 2008F25%250547. H9I Co#en 2C. Do1o Jr (D. :i ) 8. *#e nature and ty$e of arr#yt#!ias in a ute e@$eri!ental #y$er)ale!ia in t#e inta t dog. 8! 2eart J 1571F82%77787. H4I >elardinelli ;. ;inden J. >urne ',. *#e ardia effe ts of adenosine. :rog Cardio6 vas -is 1585F92%7957.