Critical Care |

Phasic REM Related Sinus Arrest Requiring Permanent Pacemaker Placement FREE TO VIEW

Madhuri Kamatham, MBBS; Sivaraman Sivaswami, MBBS; Alicia Liendo; David McCarty, MD; Cesar Liendo, MD
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Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA

Chest. 2014;146(4_MeetingAbstracts):345A. doi:10.1378/chest.1991937
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SESSION TITLE: Miscellaneous Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: We present a case of sinus arrest related to phasic REM sleep that persisted despite good apnea control.

CASE PRESENTATION: This is a 60 year old African American hypertensive male with severe untreated obstructive sleep apnea initially admitted at another hospital because of new onset CHF, systolic ejection fraction was 40%. Telemetry showed prolonged sinus pauses. Patient was transferred to our facility for possible pacemaker placement. Initially all AV nodal blocking medications were stopped without resolution of sinus pauses. Examination showed BMI 45, Epworth Sleepiness scale 18/24, Mallampati IV and clinical findings of CHF. Patient was admitted to ICU on Bipap 18/12 with partial improvement of oxygenation and fatigue without resolution of the prolonged sinus pauses. Due to a lack of openings in the sleep lab, patient underwent auto Vpap titration in the ICU with the following settings: IPAP maximum 24, EPAP 10 and PS of 5 cm, which resulted in a residual AHI of 25. 95th percentile IPAP was 17 cm H2O. Residual events were suspected to be central in origin and again sinus pauses were not resolved. The patient was then switched to a VPAP ST 17/13 cm with a back up rate of 10 with complete resolution of sleep apnea but without of resolution of sinus pauses. Further review of telemetry revealed that the sinus pauses were aggregated in some periods of the night, raising the possibility of REM related sinus pauses. Additionally, an inverted T wave and down-sloping of the ST segment was noted upon resumption of cardiac electrically activity. Patient underwent a polysomnographic titration in the sleep lab with initial settings of Vpap 17/13 and back up rate of 10. Later, further correction of the respiratory events and snoring was achieved with minor modifications. Patient developed increased REM density and immediately after an eye movement, he developed prolonged sinus pauses. Patient underwent a pacemaker placement and continues with Vpap without difficulties.

DISCUSSION: REM sleep is associated with sympathetic activation. However in phasic REM, there is a sympathetic deactivation, leading to dominance of the parasympathetic system at times resulting in profound bradyarrhythmias.

CONCLUSIONS: Significant sinus pauses in REM sleep may not respond to positive pressure therapy and may require cardiac pacing therapy.

Reference #1: Holty JC, Guilleminault C. REM-related bradyarrhythmia syndrome. Sleep Med Rev 2011;15:143

Reference #2: Janssens W et al REM sleep-related bradyarrhythmia syndrome. Sleep Breath 2007 Sep;11(3):195

DISCLOSURE: The following authors have nothing to disclose: Madhuri Kamatham, Sivaraman Sivaswami, Alicia Liendo, David McCarty, Cesar Liendo

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