Geleidingsstoornissen, bradycardie en PM

Rik Willems

Intraventriculaire geleidingsstoornissen

•  QRS-duur ≥ 100 ms– volledig ≥ 120 ms

– onvolledig 100 - 120 ms

•  Rechter bundel•  Linker bundel

• Aspecifiek

DD/ breed QRS

•  Geleidingsstoornissen•  Atrioventriculaire extraverbinding (Kent-

bundel)•  Ventriculair ritme•  Elektrolietenstoornissen

–  Hyperkaliëmie

•  Hypothermie•  Antiaritmica

–  Klasse 1C (flecainide, propafenone)

Linker bundeltakblock

•  QRS duur ≥ 120ms•  rS of QS beeld in V1

•  Brede positieve QRS complexen metnotching of slurring zonder intiële q in I en V6

–  afwezigheid normale septale activatie

•  Diagnose van myocardinfarct enlinkerkamerhypertrofie kan niet gesteldworden !

LBTB

LBTB

Rechter bundeltak block

•  QRS duur ≥ 120ms

•  rSR’ patroon of notched R in V1

–  altijd hoge en brede terminale R of R’ ! DD/VT

•  Brede S in I en V6

•  ST daling en neg T in precordialen

•  Diagnose van myocardinfarct blijft mogelijkomdat de initïele vectoren normaal verlopen

•  Geen uitspraak over rechterkamerhypertrofie

• • • • • • 

normale variante bij kinderen en adolescentente hoge plaatsing V1pectus excavatumrechterkamerhypertrofielongembolie“True posterior” infarct

DD/ RSR’ in afleiding V1

RBTB

RBTB

•  ECG criteria–  linker as <-30

–  kleine q wave in lead I–  diepe S in II en III

Linker anterior hemiblock

•  ECG criteria–  Rechter as > +120–  grote S in lead I

–  qR in lead II, III en aVF•  Grote R•  Kleine q

Linker posterior hemiblock

Gevorderde geleidingsstoornissen

•  Bifasciculair block– VRBTB + LAH– VRBTB + LPH

•  Trifasciculair block– 1e gr AV block + VRTBT + LAH of LPH

•  CAVE: ontstaan vangeleidingstoornissen bij infarct

Het normale geleidingssysteem

Sinus knoop gerelateerde bradycardie

•  Sinoatriaal (SA) block•  Sinus arrest

•  Sick sinus syndroom (SSS)

Sino-atriale (SA) geleidingsstoornissen

•  Minder frequent dan AVgeleidingsstoornissen

•  Moeilijkere diagnose•  Klinische relevantie?

•  Ingedeelde in 1st, 2de, and 3de graad,maar enkel 2degraad SA block isdedecteerbaar op EKG.

1st graads SA Block

•  ECG geeft geen aanwijzing vanactiviteit van de sinusknoop, en daaromniet zichtbaar.

•  EFO noodzakelijk voor diagnose, maarniet klinisch relevant

Type 1 2de graads SA Block

• Progressive shortening of the PP interval until a pause inthe sinus rhythm appears.

• The pause will be less than the two preceding PP interval.• The PP interval following the pause is greater than the PP

interval just before the pause.

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

Type 2 2de graads SA Block

• Abnormal pauses between 2 sinus P waves

• Length of pause is a multiple of the shortest PP interval(usually 2x)

• PP interval is otherwise constant.

• DD/ blocked AES!

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

3de graads SA Block

•  Niet te onderscheiden van sinus arrestop ECG.

•  EFO noodzakelijk voor diagnose, maarniet klinisch relevant

Sinus Aritmie

• Presence of sinus P waves

• Variation of the PP interval which cannot be attributed to either SA nodalblock or PACs

• When the variations in PP interval occur in phase with respiration, this isconsidered to be a normal variant. When they are unrelated to respiration,they may be caused by the same etiologies leading to sinus bradycardia.

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

Sinusknoopziekte

•  Characterized by a collection of symptoms and ECGfindings due to chronic dysfunction of the sinoatrial (SA)node:–  Chronic and severe sinus bradycardia–  Sinus pauses–  Sinus arrhythmia–  Complete sinus arrest–  Progressive development of atrial arrhythmias (a-

flutter, a-fib, atrial tachycardia)•  Patients are usually elderly and present with

lightheadedness and/or syncope, but it can also manifestas angina, dyspnea, and palpitations.

•  About 50% of people with SSS also display some degreeof dysfunction of the AV node

Sick Sinus Syndrome

Sinus bradycardia (rate of ~43 bpm) with a sinus pause

Etiologie van SSSMore Common

Sinus node firbosis

Atherosclerosis of theSA arteryCongenital heartdiseaseExcessive vagal tone

Drugs

Less CommonFamilial SSS (due tomutations in SCN5A)Infiltrative diseases

Pericarditis

Lyme disease

Hypothyroidism

Rheumatic fever

Tachycardia-Bradycardia Syndrome•  Common variant of sick sinus syndrome

severe bradycardia alternates withparoxysmal tachycardias, most often atrialfibrillation.

•  There is usually a prolonged pause in thecardiac rhythm following cessation of thetachyarrhythmia.

Tachycardia-Bradycardia Syndrome

Abrupt termination of atrial flutter with variable AV block,followed by sinus arrest with a junctional escape beat.

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

Spoedgevallensinusknoop gerelateerde brady

•  Enkel spoedeisend zo symptomen vanhypotensie, draaierigheid of(pre)syncope

• Atropine 0.04 mg/kg iv

•  Sluit onderliggende ischemie uit•  Denk aan intoxicatie en

elektrolietenstoornissen

AV block

• AV Block (relatively common)– 1st degree AV block: PR > 200 ms– Type 1 2nd degree AV block

– Type 2 2nd degree AV block

– 3rd degree AV block

Plaats van AV block

his

infra-his of subnodaal

supra-his of nodaal

Supra-his Infra-his

atropine

inspanning

carotismassage

beter

beter

slechter

slechter

slechter

beter

Niet invasieve methodes om de plaats vanblock te bepalen

•  ECG– PR interval > 280 ms = supra-his

– Verbreed QRS = infra-his

•  interventies

EKG Characteristics: Prolongation of the PR interval, which is constant

All P waves are conducted

1st Degree AV Blockeigen geen echt block!

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

2nd Degree AV BlockType 1

(Wenckebach)

EKG Characteristics:

EKG Characteristics:

Progressive prolongation of the PR interval until a Pwave is not conducted.

As the PR interval prolongs, the RR interval actuallyshortens

Type 2

Constant PR interval with intermittent failure to conduct

EKG Characteristics: No relationship between P waves and QRS complexes

Relatively constant PP intervals and RR intervals

Greater number of P waves than QRS complexes

3rd Degree (Complete) AV Block

www.uptodate.com

Wisselend bundeltakblock

Paroxysmaal AV block

• • • • • • 

Na kritische verlenging PP intervalLokalisatie is infra-his of subnodaal

Phase 4 block in conductiesysteem

Onbetrouwbaar escaperitme

Paroxysmaal karakter

Geen duidelijke AV geleidingsstoornissen

Bradycardie afhankelijk block

SpoedgevallenAV block

•  Ernst afhankelijk van localisatie•  Tijdelijke pacemaker

–  Syncope–  Hypotensie/Cardiogene shock–  hartfalen

•  CAVE ischemie–  Inferior infarct: supra-his– Anterior infarct: infra-his

•  Denk aan intoxicatie en elektrolietenstoornissen

Reanimatie

Reanimatiespecifieke aandachtspunten

• Atropine 0.5 mg iv/3-5 min– totale dosis 3 mg

•  Isuprel 0.5 - 2 µg/min– als 1mg in 250 ml gluc 5% is dit 15 ml/u

•  Transcutane pacing– pijnlijk

– misleiding door artefacten op ecg!

Tijdelijke pacing

•  Beste acces– Rechter Vena Jugularis Interna– Linker Vena Subclavia

•  Blinde positionering met “drijvende”katheter– EGM

– Fluoroscopie

•  Best niet > 72u

PM Code1st Letter

Chamber(s) PacedA = atriumV = ventricle

D = dual (both atriumand ventricle)

2nd Letter

Chamber(s) SensedA = atrium

V = ventricle

D = dual

O = none

3rd Letter

Response to SensingI = inhibit

(Demand mode)T = triggered

D = dual

O = none (Asynch)

V V I

Chamber paced

Chamber sensed

Action or response to a sensed event

Tijdelijke pacing

•  VOO met hoge output tijdens plaatsing•  Ken uw toestel !

•  Dagelijks pacing en sensing drempelbepalen

Andere dia