A 60-year-old female with a history of hypertension, CKD, and atrial fibrillation with RVR s/p AV node ablation and placement of ventricular pacemaker presented to our ED with complaints of chest pain. The chest pain started 2 hours prior to arrival and was associated with SOB and diaphoresis. She described the pain as a constant chest pressure that felt like someone was standing on her chest and radiating down her left arm. She received mild relief with sublingual nitroglycerin x3 en route to the hospital.
Initial VS: P 80, BP 154/95, RR 20, SpO2 98% on RA
Physical exam revealed an obese woman, sitting up in bed appearing uncomfortable. Chest pressure was not reproducible and lungs were clear to auscultation.
A work-up with a CBC, chemistry panel, troponin, ECG, CXR, and bedside cardiac echo was initiated.
Here is the ECG that was obtained:
This ECG was difficult to interpret because of the ventricular pacemaker, but appeared to be grossly unchanged from her most recent ECG.
Her chemistry panel was significant for a creatinine of 2.28. This appeared to be at her baseline. CBC was normal and initial troponin was 0.019.
Beside ultrasound was performed and was somewhat difficult because of the patient’s body habitus. See the best images obtained below.
Parasternal long view:
Apical 4-chamber view:
Apical 3-chamber view:
How would you interpret these images?
To the providers taking care of the patient it appeared as though she had a large apical wall motion abnormality. This can be seen best in the Apical 3 and 4-chamber views. Look closely and see how the base of the heart is moving, but it does not appear like the apex is. If this is hard for you to see, cover the apex of the heart with your hand. Look at how the base is moving, and then cover the base of the heart with your hand. See the difference now?
She had a previous echo done by cardiology a few months prior that showed no WMA, but that echo was done before the pacemaker was placed. The patient was in sinus rhythm when the previous echo was done.
Do you think that this new wall motion abnormality could be from being paced from the right ventricle?
The providers taking care of the patient were not sure if the new pacemaker could explain the large wall motion abnormality, but because of the ultrasound findings and ongoing chest pain they decided to talk with cardiology after her second troponin came back at 0.024. This was slightly higher than the first, but still a normal value.
Cardiology felt as though the echo could be explained by the new ventricular pacing.
The patient was admitted to the hospital for an ACS rule out. Her troponins remained negative. Formal echo revealed regional WMAs of the distal septum and apex. EF was estimated to be 63%.
Her chest pain was deemed non-cardiac. Her WMA was felt to be more of an artifact from the asynchronous right to left electrical activity from the pacemaker. No other cause of the chest pain was found.
Have you seen large regional WMAs like this before secondary to a pacemaker?