Med Pregl 2017; LXX (5-6): 167-169. Novi Sad: maj-juni.

167

CASE REPORTS
PRIKAZI SLUČAJEVA
University Clinical Center Tuzla, Clinic of Internal Diseases, Case report
Department of Cardiology, Tuzla, Bosnia and Herzegovina1 Prikaz slučaja
Medical School Tuzla, Tuzla, Bosnia and Herzegovina2 UDK 616.125-089.84-06:616.8-009.832-07
https://doi.org/10.2298/MPNS1706167D

SYNCOPE DUE TO SINUS NODE DYSFUNCTION AFTER SURGICAL PATCH

CLOSURE OF ATRIAL SEPTAL DEFECT – A CASE REPORT

SINKOPA ZBOG DISFUNKCIJE SINUSNOG ČVORA NAKON HIRURŠKOG ZATVARANJA ATRIJAL-

NOG SEPTALNOG DEFEKTA – PRIKAZ SLUČAJA

Larisa DIZDAREVIĆ HUDIĆ1, Zumreta KUŠLJUGIĆ1, Irma BIJEDIĆ1 and Igor HUDIĆ2

Summary
Introduction. Sick sinus syndrome, a frequent cause of syn-
cope, refers to a combination of symptoms caused by sinus node
dysfunction. Case report. We report the case of a 38-year-old
female patient presenting with recurrent syncope, who under-
went surgical patch closure of atrial septal defect three years
before admission. Ambulatory twenty-four-hour Holter moni-
toring was done capturing only sinus tachycardia. A series of
examinations were warranted after admission, and recurrent
syncope was found to be the result of sinus node dysfunction.
This syndrome rarely occurs after surgical closure of atrial sep-
tal defect. The patient underwent permanent pacemaker implan-
tation. Conclusion. A rigorous search for every possible cause
of syncope is mandatory. A structural, multidisciplinary ap-
proach is required in order to achieve an optimal outcome.
Key words: Sick Sinus Syndrome; Syncope; Tachycardia; Post-
operative Complications; Pacemaker, Artificial; Heart Septal De-
fects, Atrial
Sažetak
Uvod. Sinkopa je iznenadni i kratki gubitak svesti sa gubitkom pos-
turalnog tonusa i najčešće spontanim oporavkom. Postoje brojni
uzroci sinkope. Sindrom bolesnog sinusnog čvora, tzv. sik sinus sin-
drom, odnosi se na kombinaciju simptoma kao što su konfuzija ili
sinkopa uzrokovane bolešću sinusnog čvora. Prikaz slučaja. Prikazan
je slučaj 38-godišnje bolesnice sa istorijom sinkope. Pre tri godine
podvrgnuta je hirurškom zahvatu zatvaranja pretkomorskog septalnog
defekta. Ambulantni 24-satni monitoring holterom kod naše pacijent-
kinje pokazao je samo sinusnu tahikardiju. Ostale ambulantne analize
takođe su bile u granicama normale. Nakon niza pretraga, uz multi-
disciplinarni pristup i ponavljanje monitoringa holterom utvrđeno je
da je sinkopa rezultat disfunkcije sinusnog čvora kao retke komp-
likacije hiruškog zatvaranja pretkomorskog septalnog defekta. Potom
je podvrgnuta implantaciji veštačkog vodiča srčanog ritma − pejsme-
jkera. Zaključak. Treba pomno istražiti sve moguće uѕroke sinkope
uz poseban akcenat na multidisciplinarni pristup pacijentu.
Ključne reči: disfunkcija sinusnog čvora; sinkopa; postopera-
tivne komplikacije; pejsmejker; pretkomorski septalni defekt

Introduction sion etc. (symptoms and signs of end-organ hypop-

erfusion) caused by sinus node dysfunction (SND).
Syncope is a sudden and brief loss of conscious- SND is a frequent cause of syncope, and in this case
ness followed by spontaneous recovery. Syncope it was a result of cerebral hypoperfusion.
develops because of temporary reduction in blood We report here the case of a patient with history of
flow to the brain with consecutive cerebral oxygen syncope and dizziness. Three years before admission
deprivation. Therefore, syncope is defined as a tran- the patient underwent surgical repair of atrial septal
sient, self-limited loss of consciousness with an in- defect (ASD) by pericardial patch closure of ASD. Re-
ability to maintain postural tone that is followed by current syncope was a result of SSS and this syndrome
spontaneous recovery. Various causes are well de- rarely occurs after surgical patch closure of ASD.
scribed in the literature and include cardiac, vascular,
neurological, metabolic and miscellaneous origins Case report
[1]. Sometimes it is difficult to determine the real
cause of syncope, so numerous analyses need to be A 38-year-old woman was referred to our depart-
performed. Sick sinus syndrome (SSS) refers to a ment due to repeated episodes of syncope during
combination of symptoms such as dizziness, confu- the past month. Three years before, she underwent
Corresponding Author: Dr Larisa Dizdarević-Hudić, Univerzitetsko klinički centar Tuzla, Klinika za interne bolesti,
75000 Tuzla, Trnovac bb, Bosna i Hercegovina, E-mail: ldhudic@gmail.com; laradiz@yahoo.com
168 Dizdarević Hudić L, et al. Syncope due to Sinus Node Dysfunction
Abbreviations
SSS – sick sinus syndrome
SND – sinus node dysfunction
ASD – atrial septal defect
ECG – electrocardiogram
DDDR – dual chamber rate adaptive pacemaker
CHD – congenital heart disease
SVASD – sinus venosus atrial septal defect
a surgical patch closure of secundum ASD. She
denied having other medical issues in the past and
she was a non-smoker. She did not use any medica-
tions during the previous year.
Several months prior to admission, she started
having symptoms of dizziness and weakness, and
three months ago, she had the first episode of syn-
cope. She did not have a chest pain, typical for an-
gina. The patient was evaluated by a neurologist in
ambulatory settings. A transcranial Doppler ex-
amination showed bilateral patency of carotid arter-
ies, without significant stenosis. Computed tomog-
raphy of the brain and electroencephalogram were
requested. Ambulatory 24-hour Holter monitoring
was done and it showed only sinus tachycardia with
maximum heart rate 135/min during physical effort.
On admission, the patient was fully alert and ori-
ented. Her vital signs (blood pressure, pulse and res-
piration) unremarkable. Physical examination of the
heart, chest, abdomen and extremities were normal.
No neurological deficit was present. Laboratory test
results were within the normal range.
The chest X-ray showed no abnormalities. Both
awake and asleep electroencephalography showed
normal results. Computed tomography (CT) of the
brain did not show any signs of intracranial hemor-
rhage or ischemia. Echocardiography showed slight-
ly dilated right ventricle (3,5 cm) and patch closure
of ASD, essentially preserved left-ventricular systo-
lic function and no other abnormalities. Several
electrocardiograms (ECG) were within normal lim-
its (Figure 1).
Figure 1. Electrocardiogram of our patient on admission
(no significant abnormalities)
Slika 1. Elektrokardiogram pacijentkinje na prijemu
(bez značajnih abnormalnosti)
During the 24-hour Holter recording, the patient
was in normal sinus rhythm with an average heart
rate of 68/min, and maximum heart rate 137/min.
PQ (time it takes for the sinus impulse to travel from
the atria to the ventricles) and QT (measure be-
tween Q wave and T wave in the heart’s electri-
cal cycle) interval were within normal ranges, with-
out signs of pre-excitation. Only rare atrial prema-
ture contractions were recorded. In the morning
hours (08h 03 min to 08h 25min) a few significant
sinus pauses were registered that correlated with
the occurrence of syncope. The longest episode was
12820 ms (Figure 2).
The patient was diagnosed with symptomatic
SND and underwent permanent pacemaker implan-
tation (dual chamber rate adaptive pacemaker -
DDDR). She did not suffer from syncope, weakness
or dizziness after the treatment.
Discussion
Sinus node dysfunction is a term used for nu-
merous rhythm abnormalities such as: persistent
sinus bradycardia, persistent sinus arrest with es-
cape rhythms, and chronotropic incompetence [2,
3]. This disorder is often associated with conduction
system diseases and supraventricular tachyarrhyth-
mias (in this case, SND is termed tachy-brady syn-
drome) [3]. Most people with SSS are asymptomat-
ic or oligosymptomatic. Well-described symptoms
of SND are bradycardia, fainting (syncope), fatigue,
weakness, dyspnea, angina, disturbed sleep, confu-
sion, and palpitations.
The most common cause of SND is idiopathic
sinoatrial node fibrosis, sometimes accompanied
by degeneration of lower elements of the conducting
system. Risk factors for development of SND in-
Figure 2. Holter monitoring - a few significant sinus
pauses were registered in the morning hours (08 h 03
min to 08 h 25 min); the longest episode was 12820 ms,
as shown above. This figure shows only the beginning
of this longest episode, the whole pause is not shown due
to technical circumstances
Slika 2. Monitoring holterom – nekoliko značajnih si-
nusnih pauza u jutarnjim satima (8 h i 3 min. do 8 h i 25
min.); najduža epizoda trajale je 12 820 ms (prikazano
gore). Na slici je prikazan samo početak najduže epiz-
ode; cela pauza nije prikazana iz tehničkih razloga
Med Pregl 2017; LXX (5-6): 167-169. Novi Sad: maj-juni.
clude: age, medications, hyperkalemia, myocardial
infarction, heart surgery, sleep apnea, diphtheria,
hemochromatosis, muscular dystrophy, amyloidosis
(many ischemic, inflammatory and infiltrative dis-
orders). In younger patients, SND is often second-
ary to other cardiac processes/disease [4] and it may
be present in patients who have undergone surgery
for congenital heart disease, including ASD. In ad-
dition, the later in life ASD is repaired, the more
likely arrhythmia will develop. The cause of SND
in these patients is probably related to the underly-
ing structural heart disease and surgical trauma (of
the sinus node and/or sinus node artery). When re-
pairing ASDs, sinus venosus atrial septal defect
(SVASD), SND often occurs because ASD is close-
ly related to the sinus node tissue [4, 5]. Postopera-
tive SND is more common in patients after SVASD
repair than after secundum ASD repair [6].
The only effective treatment for patients with
chronic symptomatic SND is pacemaker implanta-
tion. It is important to mention that asymptomatic
patients do not require device therapy. Pacemakers
are indicated in patients with certain symptomatic
bradyarrhythmias caused by SND and in patients
with frequent, prolonged sinus pauses [3]. Sympto-
matic bradyarrhythmias are the most common indi-
cations for pacemaker placement. Approximately
one-half of devices are implanted for SND. Our pa-
tient was symptomatic, with very significant periods
of asystoles (12 820 ms), so she underwent pacemak-
er implantation (DDDR) as mentioned above.
We believe that a certain number of syncope pa-
tients remain misdiagnosed. For example, in our case,
a psychiatrist made a diagnosis of anxiety-depressive
References
1. Kuo FY, Hsiao HC, Chiou CW, Liu CP. Recurrent syn-
cope due to carotid sinus hypersensitivity and sick sinus syn-
drome. J Chin Med Assoc. 2008;71(10):532–5.
2. Ferrer MI. The sick sinus syndrome in atrial disease.
JAMA. 1968;206(3):645-6.
3. Gillis AM, Russo AM, Ellenbogen KA, Swerdlow CD,
Olshansky B, Al-Khatib SM, et al. HRS/ACCF expert consen-
sus statement on pacemaker device and mode selection: devel-
oped in partnership between the Heart Rhythm Society (HRS)
and the American College of Cardiology Foundation (ACCF)
and in collaboration with the Society of Thoracic Surgeons.
Heart Rhythm. 2012;9(8):1344–65.
4. Dobrzynski H, Boyett MR, Anderson RH. New insights
into pacemaker activity: promoting understanding of sick sinus
syndrome. Circulation. 2007;115(14):1921-32.
Rad je primljen 18. VI 2016.
Recenziran 10. I 2017.
Prihvaćen za štampu 2. II 2017.
BIBLID.0025-8105:(2017):LXX:5-6:167-169.
169
disorder with panic attacks and dissociative reactions.
On the other hand, it was difficult to establish the real
diagnosis because the ambulatory Holter monitoring
and serial ECG-s showed no abnormalities, as well as
laboratory reports and neurological examinations. It
is often difficult to capture the moment when syncope
occurs on Holter or ECG. Differentiating true syn-
cope from other similar non-syncopal conditions (e.g.
epilepsy, severe metabolic disorders, intoxications,
psychogenic pseudo-syncope etc.) is the first diagnos-
tic step with huge influence on the subsequent diag-
nostic strategy. Among the neutrally mediated inves-
tigations, the tilt-test and carotid sinus massage are the
most useful. The most useful cardiac examinations
here are echocardiography, prolonged ECG monitor-
ing, stress test, electrophysiological study and implant-
able loop recorder [7]. Patients with unexplained syn-
cope are more likely to have an underlying arrhythmia
mechanism than unselected patients with syncope.
However, arrhythmias causing syncope may occur at
varying and long intervals, giving standard ECG-a
and short–lasting ECG monitoring little chance of
providing symptoms vs. ECG correlation when com-
pared with continuous long term ECG-monitoring
(sometime a few days of ECG monitoring may be
valuable). A structured, multidisciplinary approach to
evaluation of syncope is the best model to achieve an
optimal outcome [8].
Conclusion
In conclusion, a structured multidisciplinary ap-
proach to syncope of unexplained origin is the best
model to achieve an optimal outcome.
5. Gatzoulis MA, Freeman MA, Siu SC, Webb GD, Harris
L. Atrial arrhythmia after surgical closure of atrial septal de-
fects in adults. N Engl J Med. 1999;340(11):839–46.
6. Attenhofer Jost CH, Connolly HM, Danielson GK, Bai-
ley KR, Schaff HV, Shen WK, et al. Sinus venosus atrial septal
defect: long-term postoperative outcome for 115 patients. Cir-
culation. 2005;112(13):1953-8.
7. Brignole M, Alboni P, Benditt DG, Bergfeldt L, Blanc JJ,
Bloch Thomsen PE, et al. Guidelines on management (diagno-
sis and treatment) of syncope-update 2004. Europace. 2004;
6(6):467-537.
8. Edvardsson N, Wolff C, Tsintzos S, Rieger G, Linker NJ.
Costs of unstructured investigation of unexplained syncope:
insights from a micro-costing analysis of the observational PIC-
TURE registry. Europace. 2015;17(7):1141-8.