Síncope e bloqueio atrioventricular total relacionado a tromboembolismo pulmonar

Abstract

The co-occurrence of syncope and complete atrioventricular block associated with pulmonary thromboembolism is very rare, and only a few cases have been reported in the literature [4][5][6][7][8] . This association was a complicating factor for the initial diagnosis of pulmonary thromboembolism and had clear implications in the outcome of most cases reported 5,7 . This study aimed at reporting the case of a patient with this form of presentation and at discussing the clinical, electrocardiographic, pathophysiological, prognostic, and therapeutic aspects of that rare manifestation of pulmonary thromboembolism. Case ReportWe report the case of a 68-year-old male patient with diabetes mellitus and systemic arterial hypertension, who was bedridden due to the treatment of an infected ulcerated lesion in the right lower limb and was followed up at home. The patient regularly used insulin, oral antidiabetic drugs, and an angiotensin-converting enzyme inhibitor. He experienced a sudden episode of chest pain followed by syncope and was referred to the emergency service of the Hospital Geral. His findings were typical of shock: cutaneousmucous paleness, disorientation, tachydyspnea, blood pressure of 70/40 mmHg, heart rate of 34 bpm, and no significant alterations on pulmonary auscultation. He did not have signs and symptoms suggestive of deep venous thrombosis. The electrocardiogram showed complete atrioventricular block and idioventricular rhythm ( fig. 1). The patient underwent provisory artificial pacemaker implantation through puncture of the right subclavian vein, which allowed, in association with general measures, the initial stabilization of the clinical parameters. The curve of the MB fraction of creatine phosphokinase (CKMB) was normal. Lactic dehydrogenase (DHL) was 518, glycemia was 476, and the leukogram showed 12,600 leukocytes with a shift to the left. Two-dimensional Doppler echocardiography was performed for the etiological stratification of cardiovascular shock. The relevant findings on 2-dimensional Doppler echocardiography were normal left atrial and ventricular thickness, volume, and systolic functions, and significant hypokinesia of the inferior wall. The right ventricle showed an enlarged volume and severe diffuse hypokinesia. The right atrial volume was enlarged. Moderate tricuspid insufficiency was observed, and the estimated pulmonary artery pressure was 64 mmHg. The initial diagnostic hypothesis was inferior infarction with right ventricular impairment.The patient evolved with progressive clinical worsening. After

Case report: The presence of third-degree atrioventricular block caused by pulmonary embolism masquerading as acute ST-segment elevation myocardial infarction

“…By using echocardiography, regional segmental ventricular wall dyskinesia can be identified. Specifically, in PE patients, it is possible to observe RV hypokinesia and/or dilation ( 14 ). In the case of our patient, during the emergency bedside echocardiography, attention was primarily focused on LV movements and functions, inadvertently neglecting the assessment of RV movements and functions.…”

Third-Degree Heart Block Associated With Saddle Pulmonary Embolism: A Rare Sequelae of COVID-19-Induced Hypercoagulable State

“…Thus, one mechanism leading to the current complete heart block is that the massive PE significantly obstructed blood flow such that it limited coronary artery filling and subsequently AV nodal ischemia. Another possible explanation is the proposed mechanism of the Bezold-Jarisch reflex leading to transient bradycardia or complete AV block [11][12][13]. Also possible, would be the severe right heart strain and dilation directly compromising Purkinje fibers and other cardiac conduction apparatus.…”

“…The common EKG presentations of acute PE usually include sinus tachycardia, S1Q3T3, negative T wave in lead 3, incomplete or complete right bundle branch block [ 10 - 11 ]. EKG findings generally reflect reactive compensation and right heart strain.…”