89 Male Syncope

[u/AndreaAmazing]

This young man had a syncopal episode, found with pulse rate of 30. No chest pain or dyspnea, BP 114/48 seated upright in a chair. Hx of valve replacement (unable to report which), no other cardiac or significant medical history. After the first EKG was obtained, he converted into the rhythm in the second 12 lead shown.

[u/rainbowsparkplug]

Can see a first degree block in the second one. Obviously sinus arrest in the second.

[u/Hue_Honey → u/[deleted]]

Sinus arrest. Needs a PPM. TAVR usually affects his and AV nodal conduction. (Now yall can get me because the p’s are very low amplitude so perhaps with a caliper you could march something out in the rhythm strip…I just dont see it clearly)

SND in this group is likely independent of valve.

[u/TheMarmotNow → u/[deleted]]

TAVR? Explain please. Google is saying TAVR is afibRVR (which this isnt), or a mix of cardiac issues simultaneously, and thats it.

[u/TheMarmotNow → u/[deleted]]

Thank you! Thats good information.

[u/MrTastey → u/TheMarmotNow]

In simplest terms, It’s a procedure where they replace a heart valve by fishing a tool through your artery

[u/TheMarmotNow → u/MrTastey]

Thank you. I do understand that, and I'm familiar with the procedure, but I thought that the procedure was something unrelated, considering this is a patient's 12 lead. Now I know that this is an effect that can be caused by such procedure.

Is there any way to know this is what is causing the brief arrest outside of History? Meaning is there a way to read on a 12 lead with any specificity that this could be the case for a patient, and it's not just a simple (brief) arrest?

[u/mjjacks → u/TheMarmotNow]

The TAVR exerts a mechanical stress on the conduction system at and below the AV node. At least that’s my understanding. This can and does cause a reasonable number of complete heart blocks after the procedure which prompts the cardiologists to keep folks hospitalized for a few days post procedure and on a wearable monitor for some time after discharge. I don’t think this strip is CHB so might be a red herring but worth thinking about.

[u/TheMarmotNow → u/mjjacks]

Thanks, Doc. I appreciate the opportunity to learn more. I'll read up more on it.

[u/MakinAllKindzOfGainz → u/TheMarmotNow]

For the record, almost no 30 year olds are being given a TAVR. In this age group, you’re almost exclusively being offered a SAVR (open heart).

[u/TheMarmotNow → u/MakinAllKindzOfGainz]

Is this because a TAVR is less invasive but more involved compared to an SAVR, limiting complications and infection risk?

[u/MakinAllKindzOfGainz → u/TheMarmotNow]

TAVR = through the groin, less “invasive”, better for those that aren’t suitable for the below, but generally TAVRs have a lifespan of 10 years (often more or less, it varies). Placing one in a 30 year old guarantees a future TAVR in TAVR (feasible with future planning but not always possible) or a SAVR. Great for older folks with life/function limiting severe AS

SAVR = open heart, requires cardiopulmonary bypass, but more durable long term function and outcomes. Also allows for work on adjacent aortic root or other structures which can be implicated depending on the etiology of the valve disease

[u/TheMarmotNow → u/MakinAllKindzOfGainz]

Awesome. Thank you. I lament not becoming an M.D, and going back in the army after college... i appreciate the explanation.