Atrial conduction delay detected and managed by echocardiography
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CASE IMAGE IN CARDIOVASCULAR ULTRASOUND
Atrial conduction delay detected and managed by echocardiography Akihiro Hayashida1 · Misako Toki2 · Motomi Tachibana1 · Takahiro Kawamoto1 · Atsushi Hirohata1 · Kiyoshi Yoshida1 Received: 23 June 2020 / Revised: 8 September 2020 / Accepted: 1 October 2020 © Japanese Society of Echocardiography 2020
An 80-year-old man presented with exertional dyspnea that had lasted for 1 month. His medical history included implantation of a dual-chamber (DDD) pacemaker for binodal dysfunction, with DDD pacing set to 60 bpm with atrioventricular (AV) delay of 170 ms. Physical examination showed signs of heart failure (HF) in terms of jugular venous distension and peripheral edema. An electrocardiogram revealed AV sequential pacing with P-wave prolongation (Fig. 1a). Echocardiography showed preserved left ventricular systolic function with moderate tricuspid and mitral regurgitation. Despite atrial pacing, atrial wave was absent in the transmitral flow (Fig. 1b). Atrial contraction delay due to atrial conduction delay was suspected based on the pulmonary venous (PV) flow (Fig. 1c), and HF was suspected to have been caused by masked systolic atrial contraction. The maximum AV delay of 350 ms caused preserved diastolic atrial
contraction (Fig. 1d, e). Follow-up conducted after 6 months showed resolution of HF symptoms. Brain natriuretic peptide had decreased from 156 to 68 pg/ml, and stroke volume measured by echocardiography had increased from 64 to 98 ml. Atrial conduction delay can be diagnosed using electrocardiograms, but this may cause hemodynamical effects of delayed atrial contraction during systole to be overlooked. However, an echocardiogram of PV flow can also be used to detect atrial conduction delay [1]. Thus, we recommend echocardiographic monitoring, which combines transmitral flow and PV flow [2] for the treatment of HF with AV sequential pacing.
* Akihiro Hayashida h‑[email protected] Misako Toki [email protected] Motomi Tachibana [email protected] Takahiro Kawamoto [email protected] Atsushi Hirohata [email protected]‑net.ne.jp Kiyoshi Yoshida [email protected] 1
Department of Cardiology, The Sakakibara Heart Institute of Okayama, 2‑5‑1 Nakaichou, Okayama 700‑0804, Japan
Department of Clinical Laboratory, The Sakakibara Heart Institute of Okayama, Okayama, Japan
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Vol.:(0123456789)
Journal of Echocardiography
Fig. 1 a Electrocardiogram in lead V1. We noted an atrioventricular (AV) sequential pacing with AV delay of 170 ms. b Transmitral flow with atrioventricular delay of 170 ms by echocardiography. Despite atrial pacing, atrial wave was absent in the transmitral flow. c Pulmonary venous flow with atrioventricular delay of 170 ms by echocardiography. Delayed atrial contraction (arrow) was noted. d Transmi-
tral flow with atrioventricular delay of 350 ms by echocardiography. Preserved diastolic atrial contraction was noted. e Pulmonary venous flow with atrioventricular delay of 350 ms by echocardiography.
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