Sick Sinus Syndrome in Chronic Thromboembolic Pulmonary

Hypertension: A rare case report

S. Ng, D. Armein, R. Wiguna
BACKGROUND
Right heart failure symptoms with sick sinus syndrome in one patient was believed to
be caused by atrial fibrosis as the result of cardiac structural remodeling that can be
found in CTEPH patient. Therefore, correlation of sick sinus syndrome and CTEPH
maybe explained.
METHODS
A 55 years old male was admitted to outpatient department presented with fatigue,
feeling full and bloated, swelling of the abdomen, and one episode of near fainting,
for 4 months prior to admission. On examination, patient was hemodynamically stable
with blood pressure 110/70 mmHg, pulse 46 times per minute regular, thorax
examination was unremarkable, with distended jugular vein, ascites, and bilateral legs
edema. Further examination showed ECG with junctional rhythm without ST segment
changes. Echocardiography showed dilation of RA and LA with moderate TR. Patient
underwent pulmonary CT angiography, with result filling defect intermittent and
irregular wall of right lower anterobasal, left lower posterobasal, and left upper
subsegmental segment branch. Patient was diagnosed with CTEPH. Dual chamber
pacemaker implantation was scheduled.
RESULT:
During the procedure, pacemaker implantation at apex RV was successful with
threshold output 0.8 mA, R-wave sensing at 5-6 mV. However, no P wave signal was
found at RA. Patient was discharged after 4 days of hospitalization.
CONCLUSION
Sick sinus syndrome in this group of age is commonly caused by idiopathic
degenerative fibrosis. CTEPH rarely causes arrhythmia. During procedure, no P wave
signal was detected at RA, suggesting RA fibrosis. The precise mechanism of atrial
fibrosis still remains unknown, however RAAS and atrial dilation are believed to be
involved in cardiac structural remodeling, thus contribute to formation of fibrotic
tissue in atrial wall. The same condition can be found in CTEPH patient,
Keywords: chronic thromboembolic pulmonary hypertension, atrial fibrosis, sick
sinus syndrome, explaination