Estimulación ventricular permanente desde ápex de ventrículo derecho en paciente chagásico.

MERSCHON FM; MARTÍNEZ DA; VELARDE MARISCAL JL; DÍAZ CJ; PONZIO MF

Jornada; XV Jornadas de Investigación Científica de la Fac. Cs. Médicas, U.N.C.; 2014

In some cases, the presence of sinus node disfunction or atrio-ventricular block in chagasic cardiopathy requires the indication of artificial ventricular pacing; if this stimulation is permanent in time, it could provoke dyssynchrony . Therefore, in this patients group the utility of resynchronization therapy is still a matter of debate. We report the case of a 60 years-old female with a history of Chagas disease from 1978, sinus node dysfunction (1986), Medtronic single chamber ( VVI ) pacemaker implant, generator replacement every 10 years, hypotiroidism, paroxism atrial fibrillation and atrial flutter, which was referred to our emergency room by the medical emergency service who restored sinus rhythm alternating with pacemaker rhythm RBBB, LAHB, first grade AVB by using electrical cardioversion  in her home. The patient was diagnosed with unstable ventricular tachycardia. We decided to admit the patient to the coronany care unit, with uncomplicated favorable clinical evolution. A doppler echocardiogram, and a coronary angiography was perfomed, reporting left chambers dilatation, moderate mitral insufficiency, global hypokinesia, basal-inferior dyskinesia and left ventricular ejection fraction = 21%, with bilateral stenosis in the yugular-subclavia union. The request for a cardiac resynchronization device was not approved by the health insurance, reason why an AV node radiofrequency ablation was performed 12 days latter. Two weeks latter, a left subclavia vein angioplasty with single chamber ICD implantation was realized in the same procedure, with discharge after 48h. Six days latter the patient present unstable heart failure with favorable response to continuous furosemide and nitroglycerine infusion. The patient fulfills the treatment although five months latter returns with the same symptoms as before, but presenting a sudden death episode which was successfully treated by the ICD. The woman does not respond to the treatment, finally presenting irreversible cardiogenic shock and death. Permanent right ventricular pacing in patients with RBBB like in this case, can lead to inter and intra ventricular dyssynchrony with progressive deterioration of the left ventricular function, and deleterious effects upon hemodynamic parameters.