Microvascular decompression for a unique case of glossopharyngeal neuralgia with provokable symptomatic bradycardia: 2-Dimensional operative video

Background: Glossopharyngeal neuralgia is a rare neurovascular compression syndrome that can lead to paroxysmal craniofacial pain and sometimes cardiovascular symptoms.[1,2] The characteristic pathology involves a vessel (commonly a branch/loop of PICA) compressing the nerve at the root entry/exit zone at the brainstem.[1] Microvascular decompression is a commonly used treatment approach for patients that have failed conservative measures.[2] Case Description: A 72-year-old male presented to the ED following four episodes of syncope. The patient had a multi-year history of right-sided burning/stabbing pain involving the submandibular area and posterior throat. His syncope was related to symptomatic bradycardia that would occur during episodes of pain. His pain was exacerbated by speaking and swallowing and could be triggered by placing his finger in the right external auditory meatus. Interestingly, this maneuver would also trigger his bradycardia. The patient had failed previous pharmacotherapy, and a pacemaker had been placed to protect him from periods of hypotension. MRI/MRA of the brain and cervical spine were unremarkable. Due to his profoundly symptomatic status, the patient was offered a right retrosigmoid craniotomy for microvascular decompression of the right glossopharyngeal nerve. The patient had complete resolution of his pain and bradycardia immediately post-operatively. He was discharged on the second postoperative day and his pacemaker was ultimately removed. The patient continues to be pain free and off medication. Conclusion: Here we present a video case report of microvascular decompression with favorable outcome for an interesting presentation of glossopharyngeal neuralgia. The patient gave informed consent for surgery and video recording.

Paediatric rhombencephalitis presenting with bradycardia: a good recovery despite cardiac involvement

Rhombencephalitis is a rare condition, often caused by infection, commonly presenting with myoclonic jerks, ataxia and cranial nerve palsy. Typically, it has a high morbidity and mortality, with worse prognosis associated with cardiopulmonary involvement. Herein, we present the case of a 10-year-old boy, presenting with headache, vomiting, symptomatic bradycardia and rapidly progressing ophthalmoplegia from a sixth nerve palsy, without additional brainstem symptoms. Previously, pericarditis, myocarditis and heart failure have been associated with rhombencephalitis, but not bradycardia. The cause of his rhombencephalitis was presumed viral, but despite extensive screening, the virus responsible was never isolated. Following treatment with intravenous antibiotics and antivirals in a high dependency unit, he recovered well with no neurological deficit on discharge and marked radiological improvement on MRI 4 weeks later. Although rare, rhombencephalitis should be considered in a child presenting with neurological symptoms, particularly alongside a cranial nerve palsy, developing over a rapid time course.

Blind temporary pacemaker lead insertion using femoral access when fluoroscopy is unavailable: A case report

The temporary pacemaker (TPM) insertion must be done in symptomatic bradycardia to provide adequate heart rate and stable hemodynamic. Transvenous TPM is inserted under fluoroscopy guidance. However, in an extraordinary situation, such as the unavailability of the catheterization laboratory, transvenous TPM insertion can be performed using the blind approach. This case report focused on the procedural aspects of blind transvenous TPM insertion using femoral vein access when fluoroscopy is unavailable. By performing the blind transvenous TPM insertion, the patient should be stabilized as soon as possible. The confirmation of the lead placement using fluoroscopy was needed to ensure that the tip of the electrode was in the proper position.

Management of adolescent anorexia with symptomatic bradycardia and frequent premature ventricular contractions: a case report

Syncope associated with bradycardia and ventricular arrhythmia is an indication of cardiac intervention. However, in adolescent patients with anorexia nervosa, the management of syncope and arrhythmia can be different. We present a case of a 17-year-old boy who was admitted to the hospital because of syncope during exercise. Electrocardiographic monitoring showed that his mean heart rate was 41 beats/minute, with many long pauses and frequent premature ventricular contractions. These results suggested that the syncope was probably caused by arrythmia. He had been on a diet and had lost 20 kg in the past 6 months, with a body mass index of only 15.3 kg/m2. He was diagnosed with anorexia nervosa. Pacemaker implantation or ablation was not performed. Refeeding therapy was performed with mirtazapine. A follow-up showed a stepwise increase in his heart rate and a stepwise decrease in premature ventricular contractions, with an increase in his body weight. The findings from this case show that vagal hyperactivity associated with anorexia nervosa might lead to multiple premature ventricular contractions and bradycardia.

Clinically Significant Bradycardia and Hypotension Following Consumption of Betel Leaf in a Patient Treated for Chronic Atrial Fibrillation

Purpose A case of new onset bradycardia and hypotension following betel leaf consumption in combination with verapamil and metoprolol in an atrial fibrillation (AF) patient. Summary A 66-year-old Nigerian woman presented to the emergency department for evaluation of multiple near syncope episodes with underlying AF and slow ventricular response. After initial evaluation, the patient disclosed she had ingested several betel leaves that morning. She was admitted for observation of severe, progressive hypotension and symptomatic bradycardia. Her past medical history included AF, type 2 diabetes, asthma, obesity, hypertension and hypothyroidism. Her home medications consisted of spironolactone, metoprolol succinate, and verapamil ER. Upon admission, her home medications were held. She received IV fluids and atropine .4 mg IV as needed for symptomatic bradycardia. Approximately 18 h following admission, her vital signs stabilized and her labs returned to baseline. She remained stable and was discharged with a recommendation to continue her home medications at prescribed doses with reduced doses of verapamil and metoprolol and to follow-up with her primary care provider. Conclusion A patient with a history of AF developed significant hypotension and symptomatic bradycardia after betel leaf consumption resulting in an overnight critical care unit admission. The use of betel leaf is not common in the United States; however, practitioners should be cognizant of the use of complementary and alternative medications like betel leaf and incorporate this knowledge in patient evaluation. Patients consuming betel leaf or betel nut should be evaluated for cardiovascular effects as well as laboratory evaluation for organ damage.

Symptomatic atrial bigeminy masquerading as congenital complete heart block

Newborn male with symptomatic bradycardia initially diagnosed with complete atrioventricular block. Isoproterenol drip was initiated, and the patient was scheduled for pacemaker implantation. During the hospital course, repeat electrocardiogram and Holter monitor revealed evidence of near continuous blocked atrial bigeminy with occasional aberrantly conducted premature atrial contractions. Flecainide was started, resulting in normal sinus rhythm, and the pacemaker implantation was cancelled.

Improvement of Cognitive Function and Interleukin 1 Beta Serum Concentrations Following Cardiac Pacemaker Implantation in Patients with Symptomatic Bradycardia

Background and aim: Bradyarrhythmias cause a low cerebral blood flow with secondary neuronal ischemia and cognitive dysfunction. This study aims to assess the effect of cardiac pacemaker implantation (PI) on the cognitive function and inflammatory markers (TNF alpha, IL1β). Material and method: We conducted a prospective observational study on a number of 31 patients with symptomatic bradyarrhythmias. We performed the cognitive function assessment by two tests (Mini-Mental State Examination and Trail Making Test A), cardiac output assessment (echocardiographic), and determination of IL 1β and TNF alpha serum concentrations before pacemaker implantation and after an average period of 42 days from pacemaker implantation.Results: After pacemaker implantation we observed an increase in the cardiac index by 0.71 L/min/m2 (p < 0.001) and a better scoring in cognitive performance; the mean MMSE score increased by two points (p < 0.001), and Trail Making Test A had an improvement of 16 s (p < 0.001). Regarding the inflammatory markers, a significant decrease in IL-1β with 8.6 pg/mL (p = 0.049) after pacemaker implantation was observed. Additionally, we found statistically significant correlations between IL1β and TNF alpha (positive correlation, p = 0.005), between the MMSE and cardiac index (p < 0.001), between the Trail Making Test and cardiac index (p = 0.001), and between the MMSE and Trail Making Test (p = 0.003). Conclusions: Our findings suggest that cardiac pacemaker implantation was associated with improved cognitive function—possibly related to an increased cardiac output and with adecreased serum IL1β concentration in subjects with symptomatic bradycardia.

Feasibility and Safety of Left Bundle Branch Pacing for Advance Aged Patients: A Multicenter Comparative Study

Background: Left bundle branch pacing (LBBP) has been shown to be a safe and effective means to achieve physiological pacing. However, elderly patients have increased risks from invasive procedures and the risk of LBBP in elderly patients is not known. We aimed to investigate the safety and efficacy of LBBP in elderly patients &gt;80 years of age.Methods: From December 2017 to June 2019, 346 consecutive patients with symptomatic bradycardia, 184 patients under 80 years of age and 162 over 80 years, were included and underwent LBBP. The safety and prognosis of LBBP were comparatively evaluated by measured pacing parameters, periprocedural complications, and follow-up clinical events.Results: Compared with the younger, the elderly group had worse baseline cardiac and renal function. LBBP was achieved successfully in both groups with comparable fluoroscopic time and paced QRS duration (110.0 [102.0, 118.0] ms for the young vs. 110.0 [100.0, 120.0] ms for the elderly, P = 0.874). Through a follow-up of 20.0 ± 6.1 months, pacing parameters were stable while higher threshold and impedance were observed in the elderly group. In the evaluation of safety, overall procedure-related complication rates were comparable (4.4 vs. 3.8%, young vs. elderly). For prognosis, similar rates of major adverse cardiocerebrovascular events (7.1 vs. 11.9%, young vs. elderly) were observed.Conclusions: Compared to younger patients, LBBP could achieve physiological pacing in patients over 80 with comparable midterm safety and prognosis. Long-term safety and benefits of LBBP, however, necessitate further evaluation.