Clin Res Cardiol (2021). 10.1007/s00392-021-01933-9

Case report: "Exertional dyspnea in a healthy woman: a systematic approach to problem solution"
L. Clasen1, J. Schmidt1, A. G. Bejinariu1, E. S. Kehmeier1, M. Kelm1, H. Makimoto1
1Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf;

Presentation: Chronotropic incompetence is considered to be a form of sinus node dysfunctions, in which a clinical decision for pacemaker implantation particularly in young patients can be difficult. Here we present a case for whom a temporary pacemaker revealed a clear indication of permanent pacemaker implantation. A 40-year-old woman without a previous history of cardiac disease presented for a second opinion to our institute with severe exertional dyspnea. She reported a physical performance decline impeding her to participate in competitive sports since half a year. There was no previous and familial history of cardiovascular, pulmonary or metabolic diseases. She did not take any medication on a regular base.

Diagnosis and Management: Comprehensive diagnostic tests revealed no obvious findings which could explain her symptoms except blunted heart rate profile during Holter electrocardiograms. Cardiovascular imaging with stress testing demonstrated no signs of structural heart disease except a mild aortic regurgitation or exertional ischemia. Invasive hemodynamic measurement to assess aortic regurgitation showed an elevated left ventricular end-diastolic pressure (18 mmHg), otherwise normal pulmonary arterial wedge pressure (12 mmHg) and mean pulmonary arterial pressure (15 mmHg). Pulmonary obstruction or restriction were absent. Additionally, laboratory tests did not show any signs of infectious condition, anemia or thyroid dysfunction. Repeated exercise tests revealed an insufficient physical performance due to a blunted heart rate acceleration (55 W [40%], heart rate 98bpm [54%], peak VO2 9.8 ml/min/kg). Using temporary pacing lead her exercise capacity was significantly improved under atrial stimulation at 170 bpm. Accordingly, we performed an implantation of a rate-adaptive dual-chamber pacemaker with blended sensors. One month after pacemaker implantation, the patient´s cardiac performance level was fully normalized (166 W [120%], heart rate 167 bpm [93%], peak VO2 25.4 ml/min/kg). She became able to participate in daily exercise again, and had no more residual exertional dyspnea during 6 months of follow-up. Her heart rate histogram remained in a normal range of 50-150 bpm.

Conclusion: Atypical sinus node disease with persistent chronotropic incompetence in a healthy woman could be treated effectively using a rate-responsive pacemaker with blended sensors. The use of a temporary atrial pacemaker during exercise test demonstrated the causality of symptoms. This case highlights the need of individual assessments for chronotropic incompetence to identify clear indication of pacemaker.


https://dgk.org/kongress_programme/ht2021/P155.htm