SYNCOPE DUE TO PRESSURE ON AV NODE DURING HEMODIALYSIS

Abstract

TYPE: Case Report TOPIC: Cardiovascular Disease INTRODUCTION: Syncope in patients undergoing hemodialysis may happen due to many factors and is usually associated with an increased risk of cardiovascular disease and mortality. CASE PRESENTATION: A 79 y/o M with history of hypertension, hyperlipidemia, cerebrovascular disease, chronic kidney disease stage V not on RRT, was admitted due to painless hematuria and hyponatremia. Creatinine progressively worsened from 5.4 to 6.6 and BUN rose from 57 to 86, despite removal of clots from the bladder. A permacath was placed for hemodialysis (HD). During his first HD, within 10 minutes, the patient complained of dizziness and syncopized with tonic rigidity. Troponin was negative 2 hours later, and he was transferred to ICU. He tolerated the second session with a low blood flow rate. On his third HD, the patient had a similar episode, and telemetry showed an atrioventricular (AV) second degree Mobitz I block with bradycardia (HR 40-44) and a dropped beat. He denied chest pain in the peri-event period on both occasions. Troponins were negative 2 and 6 hours after the event, EKG was unremarkable. This was not consistent with acute coronary events. On chest X-ray the permacath tip was within the right atrium nearing the tricuspid valve. DISCUSSION: To the best of our knowledge there are no reported cases of syncope related to HD with a catheter placed close to the AV node. Higher blood flow rates produced elevated pressures on the AV node, which may have altered conduction contributing to our patient’s syncope. CONCLUSIONS: This case indicates the importance of proper permacath placement. DISCLOSURE: Nothing to declare. KEYWORD: syncope av node hemodialysis