STOKES-ADAMS SYNDROME :

BEDSIDE USE OF THE PA'CEMAKER

By R. W. CHILDERS, m.D., Cardiac Unit, Royal City of Dublin Hospital.

T HE long-established treatment of S tokes-~Adams syndrome with adrenalin and uther sympathomimetie drugs, has been revolu- tionised with the development of the artificial electrical pacemaker

(Zoll e~ al.). The syndrome is most commonly due to ventricular arrest or ilbrillation complicating heart block (Johansson). Prolonged ventri~ cular asystote is particularly likely to occur in two types of cases; those where incomplete heart block is in process of changing Co the complete variety, and where heart block (either complete or incomplete) has acutely developed during the evolution of a myocardial infarction. In either case the pacemaker may be used to preserve the life of the patient until a stable or sinus rhythm has returned, or until a permanent transistorised pacemaker is implanted in the patient's body (Chardack et al.).

The following report concerns the use of the pacemaker in two patients who developed SCokes-'Adams syndrome soon after an acute myocardi~al infarction had taken place.

CASE 1 : A sixty-six year old female was admit ted unconscious hav ing complained of severe chest pain some sever hours previously. On examinat ion the respiratory rate was 12, the pa t ien t was cold and cyanotic, the B.P. was unreeordable. The femora pulse could just be felt at a rate varying between 12 and 16. An ECG showed acute posterolateral myocardial infarction with complete hear t block and a slow varying ventricular rate. I t was decided to employ the pacemaker at once.

Technique : After sterflising the skin overlying the apex beat, pereutaneous left ventricular puncture was performed with a shor~ number 18 gauge needle using the technique of Brock. The sti lette was withdrawn and a nylon insulated wire su ture was fed th rough the needle. The needle was then withdrawn leaving mos t of the length o f the suture in the cavi ty of the left ventricle. The wire was then connected to the ou tpu t terminal of a transistorised pacemaker (constructed in our workshops by Mr. C. O'Neill). The indifferent electrode was sewn through the skin into the pectoralis major, us ing a second nylon insulated wire suture. With the ECG running, the pace- maker was started, using a s t imulus of 6 volts lasting 0.002 sec.

The first deflections showed tha t the electrode was not in contact with the myocar- ,dium. The suture electrode was withdrawn slowly at the cardiac apex unt i l a satisfactory response was obtained. There was no improvement in the pa t ien t ' s blood p.r.essure, a l t hough the cardiac rate was now controlled by the pacemaker, l~or-adrenalm also fai led to produce any response, and the pat ient died.

At pos t -mor tem there was a massive fresh myocardial infarction involving mos t of t he free wall of the left ventricle. A few mls. of blood were found in the perieardial sac near the site of the ventricular puncture.

Discussion

The heart in this case was probably too extensively infarcted to respond satisfactorily to artificial pacemaking. In addition prolonged periods of asystole prior to admission may have caused irreversible cerebral damage.

CASE 2 : A seventy-four year old diabetic woman was admit ted, having been unconscious for 3 hours. During the three previous nights she had complained of heaviness in the chest. Diabetes had been controlled for some years with oral anti-

~liabetic agents. 31

32 IRISH JOURNAL OF MEDICAL SCIENCE

On examir~ation the patient was deeply unconscious with Cheyne---Stokes respiration. The temperature was 96~ The pulse rate was twelve to twenty, the B.P. being un- recordable. An ECG showed acute anterior infaretign, complete heart block and periods of ventricular asystole lasting as long as twelve seconds (A & B).

Using the technique described above, a wire suture-electrode was placed in the myoeardium. The pacemaker was started, during a long period of ventricular arrest (B) and satisfactory deflections were obtained at once using stimuli of 6 volts • 0"002 sec. The patient rapidly recovered consciousness and the B.P. rose to 120/70 without the help of pressor drugs. Antibiotics were commenced. The ECG showed that a t t imes the intrinsic pacemaker of the heart was interfering with the artificial one (C). The pacemaker was stopped and sinus rhythm was maintained for the next two hours (D).

CASE 2 (lead 2). A : Complete Block : Atrial rate 75 ventricular rate 23. B : Pro- longed ventricular arrest. Pacemaker started (arrow). C: Interference. D : sinus

rhythm, pacemaker off. E : Pacemaker alone.

There was a sudden reversion to heart block followed by total arrest. The pacemaker was restarted and the patient remained on it for the next 12 hours, during which she used a bedpan, ate and talked to her family (E). Twenty hours after admission she had another myocardial infarct and died.

At post-mortem a few mls. of blood were found in the perleardial sac. The hear t showed extensive old and recent infarction.

Comment

T h e idea l o u t c o m e o f t h e c a r d i a c e m e r g e n c i e s j u s t d e s c r i b e d is, o f

cou r se , a l ive p a t i e n t i n a s t ab l e , o r s i n u s r h y t h m , o r a l t e r n a t i v e l y w i t h a n i m p l a n t e d a r t i f i c i a l p a c e m a k e r . T h e t e c h n i q u e d e s c r i b e d a b o v e c a n s e r v e to b r i d g e t h e g a p b e f o r e s u r g e r y a n d i n t e r n a l p a c e m a k e r i m p l a n -

t a t i o n . N e i t h e r o f t h e ca ses d e s c r i b e d ~vas s u i t a b l e f o r t h i s p r o c e d u r e ,

STOKES-ADAMS SYNDROME 33

the first was virtually moribund, the second too advanced in years and in disease.

The artificial pacemaker may of course ,be used externally, i.e., the active electrode is placed on the body surface rather than in the heart itsel~f. The voltages employed for this purpose must ,be greater and generally give rise to skeletal muscular spasm in the region of the active electrode. This is highly unsettling, particularly when the pace- maker is set at rates of 60 and above. Other techniques of electrode insertion have been described ,by Furman and Sch~vedel.

The insertion into the heart of the pacemaker electrode by needle puncture is attended by a number of dangers, immediate and remote. The most important of these are haemopericardium, dislodglnent of the electrode and infection. For this reason it is suggested that this method should be used only while preparations are made for the surgical implantation of an internal pacemaker. An~i,biotics should always be given and the procedure should be performed using aseptic technique.

Conclusion

An artificial pacemaker was used in two cases of Stokes-Adams syn- drome. The technique of inserting a myocardial electrode by per- cutaneous left ventricular puncture is described. I t is suggested that this procedure should only be used to bridge the gap before surgical implantation of a permanent transistorised pacemaker.

Bibliography.

Zoll, P. Resuscitation of the heart in ventricular standstill by external stimulation. New England J. Med., 247 : 768, 1952.

Zoll, P. M., Linenthal, A. J . and Norman, L. R. Treatment of Stokes-Adams disease by external electric stimulation of the heart. Circulation, 9 : 482, 1954.

Johansson. B. W. Adams-Stokes Syndrome. A review and follow-up study of forty-two cases. Am. J. Card., 8 : 76, 1961.

Chardack, W. M., Gage, A. A., Greatbatch, W. The t reatment of complete heart block with an implantable pacemaker. Bull. de la Societe 1Vationale de Chirurgie, 21: 411, 1962.

Furman, S. and Schwedel, J. B. An intracardiae pacemaker for Stokes-Adams seizures. New England J. Med., 261 : 943, 1959.

Brock, R. C., Milstein, B. B., and Ross, D. N. (1956) Thorax, 11, 163.