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A 74-year-old Asian female with a history of hypertension and chronic obstructive pulmonary disease was admitted to hospital for coughing, shortness of breath and fatigue; her nasopharyngeal swab was positive for COVID-19. Lopinavir/ritonavir 800mg/200 mg, daily was started. On the third day of antiviral therapy, the patient complained of dizziness, nausea, she was disorientated, and electrocardiogram showed sinus arrest, junctional escape rhythm 36 beats per min. Patient was successfully treated by temporary pacemaker, normal sinus rhythm was reverted on a 3rd day after stopping the lopinavir/ritonavir treatment. She was discharged home in stable condition. Bradyarrhythmia in form of sinus arrest can develop during treatment with lopinavir/ritonavir. The temporal nature of the observed changes and the ECG finding suggests the use of L/R contributed to the changes. This case highlights off-label prescribing lopinavir/ritonavir outside of a clinical trial setting should be avoided until the data have proven that treatment benefit over placebo.

Introduction Although preoperative bradycardia has been reported in several pheochromocytoma cases, postoperative bradycardia has not. This is the first case report of complete atrioventricular dissociation and sinus arrest occurring after pheochromocytoma resection. Case presentation A 38-year-old woman was referred for a left adrenal incidentaloma. Twenty-four hour urinary collection showed elevated noradrenaline. Iodine-123-meta-iodobenzylguanidine scintigraphy showed high tracer uptake in the left adrenal region. Open left adrenalectomy was performed, and histopathological examination confirmed the diagnosis of pheochromocytoma. Thirty minutes following surgery, complete atrioventricular dissociation and sinus arrest developed. Vagal reflex attenuation due to decreased noradrenaline after tumor removal and perioperative pain and fear were believed to be the causes. A temporary pacemaker was implanted to prevent sudden death due to vagal overstimulation. Conclusion Vagal reflex attenuation after pheochromocytoma resection can result in complete atrioventricular dissociation and sinus arrest. Adequate preoperative preparation and close monitoring during and after surgery are imperative.

High dose melphalan is commonly used as a conditioning regimen for autologous stem cell transplantation in multiple myeloma. There are reports of adverse cardiac events with melphalan manifested by supraventricular tachycardia and atrial fibrillation. Here, we report a rare case of a 58 year old female with multiple myeloma, who developed sinus arrest after autologous stem cell transplantation using high dose melphalan as a conditioning regimen. It was severe and rare, therefore, monitoring for cardiac toxicity in patients receiving high-dose melphalan is mandatory.

Background Herpes simplex virus (HSV) encephalitis is a known cause of cognitive deterioration, neurological disturbances, and seizures though are rarely associated with sinus node dysfunction. Case summary We present a 54-year-old man admitted to the hospital with a 10-day history of fever, confusion, and fatigue, 1 week following a transient loss of consciousness. An initial workup suggested HSV encephalitis and the patient was started on intravenous Acyclovir. Due to his episode of syncope, a 24 h Holter electrocardiogram monitoring was performed. The Holter documented multiple episodes of sinus arrest, with a second episode of syncope noticed by the hospital staff concurrent with the last documented sinus arrest. Following antiviral treatment and resolution of the encephalitis we noticed complete resolution of sinus node dysfunction. We subsequently avoided permanent pacemaker implantation. Discussion Our case of proven HSV encephalitis complicated by sinus node arrest and syncope with complete resolution following antiviral treatment suggests no indication for permanent pacemaker implantation. This approach is consistent with data from previously reported cases.

Swallowing syncope is a rare medical condition. Even though it has been known as a neurally mediated syncope, the definitive mechanism of this condition remains unclear. We show in this study an additional case of swallowing syncope and review the 122 reported cases from the literature. A 47‐year‐old Japanese man had been suffering from recurrent syncopal attacks, when he fainted immediately after swallowing. Holter electrocardiogram monitoring demonstrated a sinus pause (maximum R‐R interval of 3.8 seconds) after he swallowed a noodle quickly. A permanent pacemaker was implanted because the frequency of syncope increased.

Despite the increasing use of permanent cardiac pacemakers in a younger patient population, there are little data related to pregnancy. Normal physiologic alterations of pregnancy need to be taken into account in the management of the pregnant woman with a pacemaker in place. Similarly, gestational events including the potential for surgical intervention require a basic knowledge of pacemaker technology and monitoring. We present a case of a patient with junctional escape rhythm and was implanted pacemaker during pregnancy. A 24 years old women referred from obstetric outpatient clinic with asymptomatic bradycardia and cryptogenic stroke 2 years earlier. ECG shows sinus arrest with junctional escape rhythm. After multi-disciplinary discussion, team decided to implant double chamber pacemaker implantation. The pacemaker setting is adjusted to prepare caesarean section at 39 weeks gestation with delivery of an aterm infant. The postoperative course was uneventful. Pre-pregnancy pacemaker settings were re-established after the postpartum period. The current literature on managing pregnant patients with pacemakers is quite limited. Such patients require a multidisciplinary approach to care. Electromagnetic Interference (EMI) should be noticed.

COVID-19 infection is a new disease mainly affecting the respiratory system but is also accompanied by many extra-pulmonary manifestations. A case of a 47-year old male with unique myocardial fibrosis after COVID-19 infection involving the left ventricular wall, intraventricular septum and almost complete damage of interatrial septum, in combination with asymptomatic severe sinus arrest episodes related to mild obstructive sleep apnea syndrome is described here., Highlights • Myocardial fibrosis may be a consequence of COVID-19 infection. • Almost complete fibrosis of interatrial septum is a unique complication of COVID-19. • Cardiac MRI is very useful in detecting myocardial complications. • Severe sinus arrest episodes are very unusual in patients with mild OSA syndrome.

Catheter‐based radiofrequency (RF) ablation targeting segments of the cardiac conduction system and/or selected regions of myocardium is an accepted treatment for many cardiac arrhythmias. On the other hand, while purposeful extension of RF ablation to include nearby cardiac neural elements, particularly epicardial ganglionated plexi (GP), remains a subject of ongoing study, inadvertent stimulation of such structures may occur during an otherwise conventional RF ablation procedure. Thus, asystolic pauses have been observed during RF ablation of left ventricular free‐wall accessory pathways, slow AV node pathways, and the left superior pulmonary vein. In this report, sinus arrest occurred within 3.3 s of RF application (40 W at 50°C) along the coronary sinus roof for treatment of an atypical “slow–slow” atrioventricular nodal reentrant tachycardia. Energy delivery was immediately terminated, but asystole persisted for 4.7 s followed by sinus bradycardia. The procedure was temporarily halted, but later was successfully resumed. Given the latency from terminating RF to return of sinus node function, the sinus arrest was likely a centrally mediated reflex vagal response. Consequently, while parasympathetic ganglia near the CS os are believed to principally innervate the AV node, not the sinus node, our observation highlights the neural cross‐communications that likely exist in this region of the heart.

Background COVID-19 infection is the most serious global public health crisis of the century. With no approved treatments against it, investigational treatments are being used despite limited safety data. Besides being at higher risk of complications of COVID-19 infection, patients with underlying cardiovascular disease are more likely to develop cardiac-related side effects of treatment. We present a case of sinus arrest with junctional escape related to lopinavir–ritonavir. Case summary A 67-year-old man, with underlying stable ischaemic heart disease, acquired COVID-19 infection. He had a prolonged duration of fever and cough. He subsequently developed acute respiratory distress and required intensive care unit (ICU) care. Given his severe infection, he was started on lopinavir–ritonavir. Hydroxychloroquine was not used as he had a prolonged QTc interval. During observation in the ICU, the patient developed recurrent episodes of sinus arrest with junctional escape. Initial concerns were of myocarditis, but he had no ST-segment changes on ECG, with mild elevations of highly sensitive troponin I and a normal transthoracic echocardiogram. A multidisciplinary team discussion involving the intensivist, infectious disease physicians, and cardiologist; the decision was made to stop treatment with lopinavir–ritonavir. Within 48 h, the bradyarrhythmia resolved. The patient did not require transvenous and permanent pacemaker insertion. Conclusion Current efficacy and safety evidence of lopinavir–ritonavir as a treatment in COVID-19 patients is limited. Although uncommonly reported, those with underlying cardiovascular disease are at increased risk of bradyarrhythmia-related adverse effects of lopinavir–ritonavir. When initiating investigational therapies, especially in patients with cardiovascular conditions, adequate counselling and close monitoring are required.

Background: Sleep apnea syndrome (SAS) and subarachnoid hemorrhage (SAH) are both considered possible causes of secondary arrhythmias. However, there are limited reports on the increased risk of bradyarrhythmia for arrhythmia-free SAS patients with SAH. Case Description: A 31-year-old woman with SAS developed low-grade SAH and underwent coil embolization on postbleed day 1. Following a coiling procedure, she experienced worsening episodes of sinus arrest lasting up to 12 s and required a temporary pacemaker. Frequent episodes of sinus arrest were detected for the next 4 days. Thereafter, all types of arrhythmias gradually decreased, and she eventually recovered to be arrhythmia free. Conclusion: Acceleration of sympathetic nervous activity caused by acute SAH may predispose patients to bradyarrhythmia with SAS and elicit asystole. The coexistence of SAS and SAH should be recognized as a cause of life-threatening sinus arrest, even if the severity of SAH is low grade.

BackgroundA 75-year-old woman with a past medical history significant for non-ischaemic cardiomyopathy status post orthotopic heart transplant, type II diabetes mellitus, hypertension, chronic kidney disease stage III, chronic anaemia, and chronic diarrhoea presented with nausea, vomiting, and an unexplained fall 23 years after original transplantation.Case summaryDuring her hospital stay, she had multiple episodes of sinus arrest with syncope, preceded by seizure like activity. She was stabilized, and broad work up revealed an occult brain mass that was ultimately resected and consistent with post-transplant lymphoproliferative disease.DiscussionFeatures that make this case study unique include the late onset and location of the malignancy, the absence of Epstein–Barr virus involvement, and asystole that was potentially neurologically mediated and induced by a brain space occupying mass. This case offers insight into potential late parasympathetic reinnervation of transplanted hearts, adds to the growing literature regarding the connection between the brain and the heart, and reviews potential complications in patients with a remote history of heart transplantation.

International audience; Aim; Although the efficacy of cardiac pacing in patients with neurally mediated syncope (NMS) and documented asystole is established, a more robust point estimate of the benefit, which is not possible with any individual study, is lacking.Methods and results: We undertook a meta-analysis of individual participant data from four studies that reported follow-up data on syncope recurrence with cardiac pacing in patients with NMS who had had an electrocardiographic (ECG) documentation of an asystolic event by means of implantable loop recorder (ILR). Of a total of 1046 patients, who had ILR implanted, 383 (36.6%) patients had an ECG documentation of a diagnostic event during mean follow-up of 13 ± 10 months. Of these, 201 (52%) patients, corresponding to 19.2% of the total ILRs, had an asystolic event of 12.8 ± 11.0 s duration documented and met the criteria for pacemaker therapy. Follow-up was available in 121 (60%) of those patients with asystolic events. Syncope recurred after pacing in 18 (14.9%) patients with an actuarial rate of 13% [95% confidence interval (CI) ±6] at 1 year, 21% (95%CI ±10) at 2 years, and 24% (95%CI ±11) at 3 years. On multivariable Cox regression analysis, positive tilt test response was the only significant predictor of syncope recurrence with a hazard ratio (95% CI) of 4.3 (1.4–13). On the contrary, type of asystolic event (sinus arrest or atrioventricular block), prodrome, cardiac abnormalities, number and duration of history of syncope, age, and gender were not predictors of recurrence of syncope.Conclusion: A long asystolic pause, suitable for pacemaker therapy, was found in one of five patients with ILR. After pacemaker implantation, most of these patients remained free of syncope recurrence for up to 3 years. The benefit of pacemaker was greater in patients with negative tilt test.

The sick sinus syndrome includes symptoms and signs related to sinus node dysfunction. This can be caused by intrinsic abnormal impulse formation and/or propagation from the sinus node or, in some cases, by extrinsic reversible causes. Careful evaluation of symptoms and of the electrocardiogram is of crucial importance, because diagnosis is mainly based on these 2 elements. In some cases, the pathophysiologic mechanism that induces sinus node dysfunction also favors the onset of atrial arrhythmias, which results in a more complex clinical condition, known as "bradycardia-tachycardia syndrome."

In general, sinus bradycardia or arrest, as well as atrio­ventricular block (AVB) at the nodal level, have a benign prognosis. Infranodal block (bundle of His or bundle branches) may lead to prolonged asystole without an escape rhythm. Proper clinical evaluation will lead to appropriate therapeutic measures, whereas mismanagement may have a fatal outcome.

We present a case of a rare complication of transvenous right ventricular pacing by temporary pacing wire causing iatrogenic interventricular septal perforation and left ventricular pacing in a 69-year-old man who was referred for recurrent syncope with sinus arrest.

Summary The electrocardiographic term ‘pause’ refers to the prolonged R-R interval that represents the interruption in ventricular depolarisation. This article presents a case of sinus node dysfunction and provides a diagnostic approach to pauses on the ECG.

Dysautonomia in Guillain-Barre syndrome (GBS) rarely causes serious cardiovascular complications, such as sinus arrest. Miller Fisher syndrome (MFS) is recognized as a variant of GBS. There have been few reports regarding the association between MFS and dysautonomia. We describe a case of a 68-year-old man with ophthalmoplegia, bulbar palsy, truncal ataxia, and areflexia. He was diagnosed with MFS because he exhibited the classical clinical triad and had elevated serum anti- GQ1b immunoglobulin G levels. A magnetic resonance imaging scan of his head was normal. His 24-hour Holter recording showed sinus arrest. He was treated with intravenous immunoglobulin, whereupon his symptoms gradually improved. This included the sinus arrest, which was considered a symptom of dysautonomia in MFS. Therefore, clinicians should be mindful of dysautonomia not only in GBS patients, but also in cases of MFS.

International audience; Background: Adenosine, an ATP derivative, may be implicated in some kinds of unexplained syncope. In patients with normal heart, normal ECG and recurrent sudden-onset syncope without prodromes have been shown to present with lowplasmatic adenosine levels and a high susceptibility to exogenous adenosine.The term “low-adenosine syncope” has been launched to describe this distinct clinical entity.Objectives: We decided to investigate whether chronic treatment of these patients with theophylline, a non-selective adenosine receptor antagonist, results in clinical benefit.Methods. We report on the prolonged clinical observation of 6 “low-adenosine” syncope patients (mean age 50±20 years, 4 females) treated with oral theophylline within the therapeutic range of 12-18 μg/ml. We were able to make an intrapatient comparison between a period with and a period without theophylline therapy.Results: In five patients, symptoms disappeared and the number of prolonged asystolic pauses detected by implantable loop recorder (ILR) fell impressively from a median of 1.11 per month (interquartile range 0.4 -1.8)during 13 months of no-treatment (range 2-36) to 0 per month(0-0.7) during 20 months of theophylline treatment (range 6-120). The 6th patient, was unresponsive to theophylline therapy, and a different mechanism of syncope was hypothesized.Conclusion: In this small series of highlyselected patients affected by syncope with low circulating adenosine levels, theophylline proved to be an effective therapy in most patients. The logical inference is that the adenosine pathway has a causal role in the mechanism of syncope in such patients.

Introduction Sinus arrest, atrio-ventricular block, supraventricular, and ventricular arrhythmias have been reported in patients with sleep apnea syndrome. The arrhythmias usually occur during sleep and contribute to the cardiovascular morbidity and mortality, and the treatment of sleep apnea usually results in the resolution of the brady- arrhythmias. Weight loss, continuous positive airway pressure (CPAP), oral appliances, and upper airway surgery are the recommended treatments, however, compliance and efficacy are issues. Case presentation A 58-year-old Arab man presented with recurrent presyncope. He was subsequently diagnosed with sleep apnea associated with frequent and significant sinus pauses. He presented a treatment challenge because he refused continuous positive airway pressure and pacemaker, however, he was successfully treated with theophylline. Conclusion Frequent and significant sinus pause associated with sleep apnea was successfully treated with theophylline in our patient when the standard treatment of care was refused.

A 39-year-old man with a seemingly non-remodeled, small heart suffered persistent atrial fibrillation (AF). Extensive isolation of the pulmonary vein, superior vena cava, and posterior left atrium, in conjunction with right atrium focal ablation, was performed to ablate multiple AF foci during two catheter ablation sessions. Sinus arrest occurred suddenly during follow-up, despite the absence of recurrent AF, ultimately necessitating pacemaker implantation. This case underscores the necessity of careful follow-up after catheter ablation, highlighting the risk of sudden, severe sinus node dysfunction, even in young AF patients with small hearts.

It is well known how migraine attacks are strictly associated to abnormalities of cardiac rhythm. Aygun et al[1] have studied 30 patients during migraine attacks, observing abnormalities of rhythm (including sinus arrhythmia, atrial premature contraction and ventricular premature contraction), intervals greater than 0.2 seconds, corrected QT intervals greater than 0.44 seconds, T inversion and ST-segment abnormalities. However, the role of autonomic nervous system variations in migraine attack-related electrocardiographic changes remains uncertain. Moreover, in patients with migraine parasympathetic nervous system alterations were observed during normal daily activity in the headache-free period[2]. In July 2015, a 45-year-old man was referred to us for evaluation because of a recurrent migraine associated with bradycardia. He referred recurrent migraine attacks, frequently occurring at night and in the supine position. During the acute phases of the attacks he described bradycardia, and sometimes, thoracic oppression. Furthermore, our patient told us about a clinical history of panic attacks and renal colics with syncope. He is currently taking topiramate and oxygen therapy at high doses (15 lt/min) during attacks. In order to better understand the previous episodes of syncope and the phases of bradycardia occurrence during the pain attacks, we monitored his electrocardiogram for 24h. During the 24h registration, he had three attacks of migraine preceded by warning signs, one of them at night time. Analyzing the ECG, we observed sinusal rhythm, medium CF 74 bpm (28-115 bpm), normal PR interval, rare supraventricular and ventricular premature contractions. In correspondence to the migraine attacks, we observed sinus bradycardia and sinus pauses with RR maximum interval of 5.5 seconds, sometimes with the occurrence of junctional rhythm, without loss of consciousness. Considering the results of this monitoring, we decided to implant a pace-maker. This case demonstrates the importance of autonomic dysregulation in a patient with migraine, showing the need of further studies to better understand the phenomenon. Written informed consent to publication was obtained from the patient(s).

金沢大学附属病院検査部, A 76-year-old woman was referred to our hospital for unresponsiveness and hypotension. She had developed constipation that had led to ileus and had received 34 g of magnesium citrate (Magcolol ®) orally the day before. She was lethargic, her blood pressure was less than 50 mmHg, and electrocardiogram (ECG) revealed sinus arrest with junctional escape rhythm. Her serum concentration of magnesium (Mg) was markedly elevated (16.6 mg/dl =13.7 mEq/l). Emergency colonoscopy revealed ischemic colitis. As her condition ameliorated, her renal function returned to normal. Hence, the present case suggests that severe hypermagnesemia can occur in the absence of pre-existing renal dysfunction in elderly patients with gastrointestinal diseases..

A 27-year-old man presented to our hospital with a 1-year-hisory of repeated syncope, which particularly occurred while bathing or on a hot day. The head-up tilt test did not induce arrhythmia; however, blood pressure decreased by 39mm Hg without any symptoms. Given that no bradycardia/tachycardia was induced on electrophysiological study and carotid sinus massage, an implantable loop recorder (ILR) was implanted. After 2 months, syncope again occurred during bathing at midnight. Sinus arrest and a maximum ventricular pause of 10.2s were documented using the ILR. After pacemaker implantation, the patient had not experienced syncope for 14 months.

Takotsubo cardiomyopathy (TCM) is characterized by a transient depression of contractile function of mid and/or apical segments of the left ventricle with compensatory hyperkinesis of the basal segment. It leads to ballooning of the apex in systole, resembling an octopus trap, hence the name. There have been many different arrhythmias associated with TCM. These occurrences are not benign, with atrial fibrillation, atrio-ventricular block, and ventricular fibrillation most commonly associated with inpatient mortality in that order. Here we present a unique case of TCM with respect to arrhythmia. After a literature review, this is the only case to our knowledge with the rare combination of asystole and sinus arrest with junctional escape rhythm during the patient's initial presentation.

Sinus node dysfunction occurs occasionally after heart transplantation and may be caused by surgical trauma, ischemia to the sinus node, rejection, drug therapy, and increasing donor age. However, the timing and indication of permanent pacemaker insertion due to sinus node dysfunction following heart transplantation is contentious. Here, we report a case of a permanent pacemaker insertion for syncope due to sinus arrest after heart transplantation, even with a bicaval technique, which has been known to associate with few incidences of sinus node dysfunction.

A 79-year-old male, with a history of percutaneous coronary intervention (PCI), was referred to our cardiovascular department for a detailed examination of blackout caused by sinus arrest only during meals. Ultrasound echocardiography showed normal cardiac contraction with no asynergy, irrespective of the remaining stenotic coronary lesion. An electrophysiological study revealed deteriorated atrioventricular nodal conduction at a Wenckebach point of 70 beats per minute. However, sinus node function was normal as demonstrated by a sinus node recovery time of 1369ms. Coronary angiography showed triple-vessel disease including the remaining stenotic coronary lesion, and a PCI was performed on the right coronary artery. Nevertheless, sinus arrest during meals was unchanged. Swallow syncope was partially improved by dietary modification; however, pacemaker implantation (PMI) was performed eventually, and the patient became asymptomatic after PMI.