Abstract
Introduction: Bradycardia is a frequent cause of morbidity and mortality in spinal cord injury (SCI) patients and optimal timing of permanent pacemaker implant is unclear. Case Summary: A 67-year-old female with no cardiac history was admitted for fall of uncertain etiology complicated by severe cervical SCI and neurogenic shock. Despite emergent surgical decompression, the injury resulted in quadriplegia. Post-operatively, bradycardic arrest occurred requiring resuscitation and dependence on dopamine infusion. Rhythm strip from showed p-p slowing followed by high grade atrioventricular block with multiple blocked p waves. A decision was made for early intervention with implantation of a Micra leadless pacemaker (LPM) (Medtronic, Minneapolis, MN) for both hemodynamically significant bradycardia and backup to prevent bradycardic arrest. A LPM was successfully implanted without complication on hospital day 8. The pacemaker was set to VVI 60. Post operatively, the patient required intermittent pacing and tolerated dopamine weaning. Discussion: Bradycardia in SCI patients, especially those with high cervical and complete SCI, occurs due to unopposed parasympathetic activity, resulting in baseline sinus bradycardia. Even more concerning is the risk for sudden and unpredictable sinus arrest and/or AV block, which is a leading cause of mortality in the first year after SCI. While initial management of bradyarrhythmia in SCI patients may respond to pharmacologic intervention, temporary and/or permanent pacing may be indicated. Acute SCI patients may not be ideal candidates for traditional pacemakers since ICU and infectious complications are common in this cohort, but LPMs have extremely low risk of implant site and infectious complications and can be utilized earlier in the hospital course. Our case showcases this strategy of early leadless pacemaker implantation. Further study is needed to better evaluate the safety and efficacy of this strategy.
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