Small Circumscribed Aortic Dissection Complicating Annuloaortic Ectasia in a Non-Marfanoid Patient

Annuloaortic ectasia, cystic medial degeneration of the afflicted aortic wall leading to progressive dilatation, is often accompanied by Marfan's syndrome. Some portions of intimal flap is commonly demonstrated along the aorta in the noninvasive diagnosis of aortic dissection. We report the first case of circumscribed aortic dissection developed in a 28 year old obese non-Marfanoid patient. He was transferred after thrombolytic therapy at a community hospital because of severe chest pain and ST segment elevation. Transthoracic echocardiography showed markedly dilated aortic root, moderate amount of pericardial effusion, mild aortic regurgitation in spite of normal regional wall motion of left ventricle. Intimal flap, characteristic of aortic dissection, was not seen with computed tomography. Intimal tear was demonstrated just above aortic valve only by transesophageal echocardiography. Two parallel intimal tear and small circumscribed dissection was demonstrated by autopsy.

Severe Cholestatic Jaundice and Subsequent Pancytopenia Associated with Ticlopidine

No abstract available.

Outpatient Cardiac Catheterization and Angiography: Safety and Experience with Transradial Approach

BACKGROUND AND OBJECTIVES: The safety and efficacy of outpatient cardiac catheterization was established. We evaluated our patient population and complications selected for outpatient procedures and our experience with transradial approach. MATERIALS AND METHODS: A total of 346 outpatient cardiac catheterization (31% of all diagnosticprocedures),performed with transradial approach, was compared with 788 in patient diagnostic procedures in terms of patient population, clinical and angiographic features, complications of examinations. RESULTS: 1) Indications of outpatient coronary angiography were as follows: follow-up of coronary interventions or bypass surgery (41.6%), recent-onset or aggravated angina (31.2%), atypical chest pain (19.4%), stable angina (3.8%), recent myocardial infarction (2.9%), variant angina (0.9%), preoperative evaluation of valvular or congenital heart disease (0.3%). 2) Significant coronary lesions were found in 216 (62.5%) patients and left main disease in 1 2 (3.5%). Coronary spasm test, internal mammary artery or saphenous vein graft angiography, aorto-ileofemoral angiography, and bilateral carotid angiography were safely performed as indicated. 3) Success rate of examination by primary approach was 94.5%, similar to 94.9% of inpatients. Alternative brachial or femoral approaches were needed in 19 (5.5%) patients. 4) No death, cerebral thromboembolism or myocardial infarction were observed and one-day admission was required in 13 (3.7%) patients. Initial 254 patients (33%) showed good radial pulse (94%), weak or absent radial pulse (6%), abnormal reverse Allen test (6%) up to 61+/-25 days. However, no claudication was observed. CONCLUSION: Cardiac catheterization and angiography was safely performed in the outpatient population selected using much extended inclusion criteria. Transradial approach is useful to set up outpatient procedures with less facilities and personnels and makes it available in the daytime with low readmission rate.

Evaluation of Left Internal Mammary Artery during Right Transradial Coronary Angiography: A New, Fast and Reliable Technique

BACKGROUND: The technique to evaluate left internal mammary artery (LIMA) is not well established during right transradial coronary angiography. MATERIALS AND METHODS: Following coronary angiography via right radial artery, LIMA angiography was performed using 5 French (F) Judkins JL-3.5 catheter in 110 patients (56+/-9 years [range: 46-81], 77 males). Eleven (10%) patients had grafted LIMAs. Subclavian and innominate arteries were moderately tortuous in 14 (13%) patients and aortic arches elongated and more vertically oriented in 16 (15%). The catheter, standing in the ascending aorta with its natural curve, was withdrawn slowly while being rotated clockwise to engage its tip in the proximal left subclavian artery. After the tip portion was adjusted, contrast material was injected while sphyngomanometer cuff inflation applied to the left upper arm. RESULTS: Nonselective LIMA angiography was successfully performed in 108 (98%) patients. The catheter was engaged in the subclavian artery in a mean of 11+/-8 seconds (range: 3-136) from the time when the catheter was withdrawn from the ascending aorta. The image quality of LIMA was satisfactory in 103 (95%) patients and not satisfactory in 5 (5%) in whom the catheter tip was not placed near the origin of LIMA. In ten (91%) of the 11 patients with grafted LIMA, the anastomosis site and distal coronary vessels were well visualized. There were no complications, including arterial dissection and thromboembolism. CONCLUSION: Nonselective technique using 5 F Judkins JL-3.5 catheter is easy, fast, safe and reliable for evaluating LIMA during right transradial coronary angiography.

Outpatient Cardiac Catheterization and Angiography: Safety and Experience with Transradial Approach

BACKGROUND AND OBJECTIVES: The safety and efficacy of outpatient cardiac catheterization was established. We evaluated our patient population and complications selected for outpatient procedures and our experience with transradial approach. MATERIALS AND METHODS: A total of 346 outpatient cardiac catheterization (31% of all diagnosticprocedures),performed with transradial approach, was compared with 788 in patient diagnostic procedures in terms of patient population, clinical and angiographic features, complications of examinations. RESULTS: 1) Indications of outpatient coronary angiography were as follows: follow-up of coronary interventions or bypass surgery (41.6%), recent-onset or aggravated angina (31.2%), atypical chest pain (19.4%), stable angina (3.8%), recent myocardial infarction (2.9%), variant angina (0.9%), preoperative evaluation of valvular or congenital heart disease (0.3%). 2) Significant coronary lesions were found in 216 (62.5%) patients and left main disease in 1 2 (3.5%). Coronary spasm test, internal mammary artery or saphenous vein graft angiography, aorto-ileofemoral angiography, and bilateral carotid angiography were safely performed as indicated. 3) Success rate of examination by primary approach was 94.5%, similar to 94.9% of inpatients. Alternative brachial or femoral approaches were needed in 19 (5.5%) patients. 4) No death, cerebral thromboembolism or myocardial infarction were observed and one-day admission was required in 13 (3.7%) patients. Initial 254 patients (33%) showed good radial pulse (94%), weak or absent radial pulse (6%), abnormal reverse Allen test (6%) up to 61+/-25 days. However, no claudication was observed. CONCLUSION: Cardiac catheterization and angiography was safely performed in the outpatient population selected using much extended inclusion criteria. Transradial approach is useful to set up outpatient procedures with less facilities and personnels and makes it available in the daytime with low readmission rate.

Evaluation of Left Internal Mammary Artery during Right Transradial Coronary Angiography: A New, Fast and Reliable Technique

BACKGROUND: The technique to evaluate left internal mammary artery (LIMA) is not well established during right transradial coronary angiography. MATERIALS AND METHODS: Following coronary angiography via right radial artery, LIMA angiography was performed using 5 French (F) Judkins JL-3.5 catheter in 110 patients (56+/-9 years [range: 46-81], 77 males). Eleven (10%) patients had grafted LIMAs. Subclavian and innominate arteries were moderately tortuous in 14 (13%) patients and aortic arches elongated and more vertically oriented in 16 (15%). The catheter, standing in the ascending aorta with its natural curve, was withdrawn slowly while being rotated clockwise to engage its tip in the proximal left subclavian artery. After the tip portion was adjusted, contrast material was injected while sphyngomanometer cuff inflation applied to the left upper arm. RESULTS: Nonselective LIMA angiography was successfully performed in 108 (98%) patients. The catheter was engaged in the subclavian artery in a mean of 11+/-8 seconds (range: 3-136) from the time when the catheter was withdrawn from the ascending aorta. The image quality of LIMA was satisfactory in 103 (95%) patients and not satisfactory in 5 (5%) in whom the catheter tip was not placed near the origin of LIMA. In ten (91%) of the 11 patients with grafted LIMA, the anastomosis site and distal coronary vessels were well visualized. There were no complications, including arterial dissection and thromboembolism. CONCLUSION: Nonselective technique using 5 F Judkins JL-3.5 catheter is easy, fast, safe and reliable for evaluating LIMA during right transradial coronary angiography.

Early Outcomes of Coronary Stenting in Thrombus-Containing Lesions

BACKGROUND: Thrombus-containing lesions (TCL) are associated with lower initial success rates and higher restenosis rates after balloon dilation. Furthermore, it has been considered as an absolute contraindication of coronary stenting. With advances in antithrombotic regimens and implantation techniques, coronary stenting has been widened to lesions with adverse morphologic features or to patients with acute coronary syndrome. Here we report the early clinical and angiographic results of coronary stenting in TCL. METHODS: We studied 24 consecutive patients (58+/-8 years, 18 males) undergoing coronary stenting in TCL. Fifteen patients (63%) were treated for acute myocardial infarction (AMI) and 9 (37%) for unstable angina. Stenting was performed as the primary therapy in 23 patients (96%) and secondary after angioplasty failure in I patient (4%). RESULTS: 1) Twenty-five stents were deployed successfully in all 24 patients with TCL. Distal flow with TIMI grade 3 was obtained immediately in 21 patients (88%). Ventricular fibrillation occurred in 3 patients (13%) during the procedure-related death or emergency bypass surgery did not occur. Marked CK elevation (over 5000U/L) was observed in 5 patients (21%) with AMI who underwent primary stenting. Two of these 5 patients (8%) had distal flow with TIMI grade 2 consistent with distal embolization, and one (4%) had distal flow with TIMI grade 0, suggesting acute stent occlusion. All 24 patients (100%) were event-free and showed clinical improvement at the last follow-up visit (71+/-15 days). 2) Quantitative angiography demonstrated excellent angiographic results after stenting (minimal luminal diameter 0.3+/-0.3 vs. 3.4+/-0.3mm, diameter stenosis 90.1+/-10.7 vs. -13.3+/-8.1%, p<0.005 respectively). Acute gain was 3.1+/-0.3mm (p<0.005). CONCLUSIONS: With low incidents of complications, coronary stenting could be used successfully for select patients with TCL as a primary therapeutic option under aggressive antithrombotic therapy. Although early clinical results were excellent, the long-term benefits remain to be established.

False Tendones - Echocardiographic Features and Clinical Implications

BACKGROUND: False tendons(FT), also referred to as pseudotendons or bands, are fibrous strings that pass from two papillary muscles and insert elsewhere except mitral valve leaflets. They can be classified into six types according to sites of attachment to the left ventricular wall and thickness. FT have been generally considered to be common normal structural variants with no clinical significance. But, these may be misinterpreted echocardiographically as left ventricular endocardium of the ventricular septum or mural thrornbus, since the echo from the tendon might mimic these structures. Moreover they have been reported to be a cause of functional ejection murmur. Some investigators have suggested that FT rnight be an etiologic factor in the genesis of ventricular arrhythmias in the autopsy and the clinical studies. METHODS: We evaluated the prevalence of the false tendons in consecutive 263 patients for 2 month period in routine echocardiographic method. In cases with FT, we examined their attachment and thickness accurately by tilting and rotating the echo probe, and classified them. In possible 9 cases, 24 hour ambulatory ECG monitoring was performed and evaluated the existence of ventricular arrhythmias. RESULTS: FT were found in routine echocardiographic views in 15 patients(male 11, female 4) out of 263 patients(prevalence 5.7%). The pye of FT were longitudinal type 7 cases(thin 3 cases, thick 4 cases) most commonly, diagonal type 3 cases(thin 2 cases, thick 1 cases), transverse thin type 4 cases and apical thin type 1 case. In 24 hour ambulatory ECG monitoring, ventricular premature contractions were detected in all 9 patients. Interestingly in one patient(case 5) visited with dyspnea and repetitive long period of palpitation, suggestive ILVT(idiopathic left ventricular tachycardia) and FT(longitudinal thick type) were coexisted. CONCLUSION: FT are common normal variants, but may be confused with other normal structures. Clinically in apparently healthy subjects with symptomatic idiopathic ventricular arrhythmias(ventricular premature contractions, ILVT and so on), the echocardiography would be performed carefully for the existence of FT and could be helpful for the evaluation of etiologies.

Role of Transesophageal Echocardiography in Identifying Anomalous Origin and Course of Coronary Arteries

BACKGROUND: Anomalous origin of a coronary artery is rare, but it can lead to angina pectoris, acute myocardial infarction, or even sudden death in the absence of atherosclerosis. Even when an anomalous vessel is identified angiographically, it may be difficult to delineate its true course on the basis of angiography alone. We attempted to determine whether transesophageal echocardiography (TEE) is of value in making the diagnosis and outlining the course of anomalous left circumflex (LCx) or right coronary arteries (RCA). METHOD: Eight adult patients with anomalous origin of LCx or RCA documented by selective coronary angiography were studied by transthoracic echocardiography (TTE) and multiplane TEE. RESULTS: Anomalous coronary ostia were visualized in all eight patients by TEE, but in only one with anomalous RCA out of eight patients by TTE. The proximal segments of anomalous coronary vessels were delineated in all eight patients by TEE and in only three with anomalous LCx out of eight patients by TTE. CONCLUSION: TEE is a valuable adjunctive diagnostic tool for the identification of anomalous coronary origin and course and is superior to TTE in adult patients.

Torsade de Pointes in Advanced Atrioventricular Block: A Cause of Syncope

Advanced or complete atrioventricular (AV) block is frequently regarded as a cause of informed syncopal attacks even though escape rhythm is maintained. Torsades de pointes (TdP) may be a significant complication of AV block associated with QT prolongation. Maintaining ventricular rate over 70 beats/min is known to be important to normalize QT interval and to reduce the possibility of bradycardia-related TdP recurrence after pacemaker implantation. We report one case of syncopal attacks associated with TdP in a 70 year old female patient with advanced AV block and prolonged QT interval. She was referred to evaluate palpitation and syncope. Advanced AV block and QT interval prolongation were seen with electrocardiography, but junctional escape rhythm was maintained. Syncopal attacks occurred during temporary pacemaker insertion. Multiple episodes of nonsustained polymorphic ventricular tachycardia and TdP related to syncopal attacks were demonstrated by 24-hour Holter monitoring. A permanent pacemaker was implanted and ventricular rate was set over 70 beats/min resulting in no recurrence of TdP and syncope.

Usefulness of the Initial Electrocardiogram for Predicting the Infarct-Related Artery in Acute Inferior Myocardial Infarction

BACKGROUND AND OBJECTIVES: Eectrocardiogram (ECG) may provide valuable informations regarding the infarct-related artery (IRA), which may be of guidance in selecting the therapeutic modality. ST segment elevation in inferior leads usually indicates occlusion of right coronary artery, less often left circumflex coronary artery or rarely occlusion of left anterior descending coronary artery may be the cause. We are to determine whether the initial ECG can differentiate the right coronary artery (RCA) or left circumflex artery (LCx) occlusion in acute inferior myocardial infarction (IMI). MATERIALS AND METHOD: We compared retrospectively the ECG recorded within 12 hours from the onset of chest pain with coronary angiographic findings in 85 patients (34% of all 250 patients) having electrocardiographic criteria for IMI. RESULTS: 1) Angiographic characteristics. Of the 85 patients, IRA was RCA in 65 (76%) (38[58%] proximal, 27[42%] distal to first right ventricular branch), and LCx in 20 (24%) (nine[45%] proximal to first obtuse marginal branch or involving a high first marginal branch, eleven[55%] distal obstruction). RCA dominance was more common in RCA occlusion group (100% vs 80%, p=0.001), and LCx dominance in LCx occlusion group (15% vs 0%, p=0.001). No significant difference was noted between two groups regarding vessels diseased, involvement of left anterior descending coronary artery and contralateral artery (RCA or LCx), location of the lesion. 2) Electrocardio-graphic characteritics. Lateral limb leads (I, aVL) :ST segment depression (> or = 1 mm) was more common in RCA occlusion group (82% vs 45%, p=0.001). Isoelectric ST segment in I was more common in LCx occlusion group (100% vs 15%, p=0.001). Left precordial leads (V(5,6)) :ST segment elevation (> or = 1 mm) was more common in LCx occlusion group (60% vs 15%, p=0.001). Isoelectric ST segment was more common in RCA occlusion group (57% vs 20%, p=0.004). ST segment depression (> or = 1 mm) was not different between two groups. Right precordial leads (V(1-4)) :ST segment changes were not different between two groups. Lead I and left precordial leads (V(5,6)) :Isoelectric ST segment in lead I and ST segment elevation (> or = 1 mm) in V(5) or V(6) was more common in LCx occlusion group (60% vs 5%, p<0.05, sensitivity 60% specificity 95% positive/negative predictive value 80%/89%, test accuracy 87%). Amplitude of R wave in V(1) :Amplitude of R wave in V was greater in LCx occlusion group (3.60+/-1.42 mm vs 2.20+/-1.42 mm, p<0.05). CONCLUSION: The initial electrocardiogram was useful in differentiating LCx occlusion from RCA occlusion in patients with IMI. Absence of ST segment depression in I and aVL, and ST segment elevation in V(5,6), isoelectric ST segment in I, tall R wave in V(1) were significantly more common in LCx occlusion.

Persistent Left Superior Vena Cava Combined with Sick Sinus Syndrome

Persistent left superior vena cava (PLSVC) is a rare but one of the most common venous anomalies. Its incidence is reported as 0.3 - 0.5% in the general population, but in those with congenital heart disease, its incidence may range as high as 3 - 10%. PLSVC draining into coronary sinus is usually of little hemodynamic consequences, but it may become significant during cardiac catheterization, transvenous pacemaker insertion and cardiac surgery. Some investigators suggested that this anomaly is related with cardiac electrical instability due to anomalous development of AV nodal tissue with venous draining anomaly, and others suggested that the predisposing anomaly is in the sinus node and the dysrrhythmia is part of sick sinus syndrome. We report a 48 year-old female who had intermittent palpitation and near syncope, was diagnosed as sick sinus syndrome and underwent to implant permanent dual pacemaker implantation. Before implantation, we suspected PLSVC in 2-dimensional and contrast echocardiogram and confirmed it by cardiac catheterization. So, we successfully performed pacemaker implantation via right subclavian approach.

Plaque Morphology in Acute Coronary Syndrome: An Intravascular Ultrasound Study

BACKGROUND: Plaque rupture of the atherosclerotic plaque is an important pathophysiologic mechanism of acute coronary syndrorne(acute myocardial infarction or unstable angina). Plaque rupture and resulting thrombus formation could be identified by intravascular ultrasound (IVUS), even though the sensitivity was variable in previous reports. We sought to know the morphologic characteristics, incidence of plaque rupture and thrombus formation by ultrasound in patients with acute coronary syndrome. METHOD: Between April and Septernber 1997, 23 admitted patients who was diagnosed as unstable angina or acute rnyocardial infarction was included. We performed coronary angiography with IVUS examination within 2 weeks. Atherosclerotic plaque was classified into soft, fibrous, calcific, and mixed plaque, and plaque rupture was defined as rupture of fibrous cap with discontinuity and / or backflow into plaque. Thrombus was defined as a scintillating, movable mass or layering materials that could be distinguished from underlying plaque. RESULTS: Most of the plaques were soft and mixed types(14 and 6, out of 23 cases). Plaque rupture could be identified only in small portion(6 cases, 26%) of the cases. Thrombus was noted in 12 cases(52%). 4 cases showed both plaque rupture and thrombus. CONCLUSION: Soft plaque is the most frequent plaque pye in acute coronary syndrome. IVUS is a useful tool to identify the morphologic features of the plaque such as rupture and thrombus formation.

A Case of Nonfamilial Benign Recurrent Intrahepatic Cholestasis / 대한간학회지

Benign recurrent intrahepatic cholestasis (BRIC) is a rare desease, which usually manifests between the age of 10 and 20. Its main clinical feature is multiple recurrent episodes of cholestasis without extrahepatic bile duct obstruction. We report here a case of nonfamilial benign recurrent intrahepatic cholestasis. The patient has experienced recurrent jaundice with pruritus since childhood. Main bile duct obstrution was excluded by abdominal CT and endoscopic retrograde cholangiopancreatography. Other causes of cholestasis were not found. Hepatic histology revealed bile plug which were mainly concentrated in the centrilobular region, and increased number of mononuclear cells in the portal triad, but hepatic parenchyma showed no inflammation and necrosis. In the last anicteric period, she was healthy and the liver function test and biopsy specimen were normal.

A Case of Nonfamilial Benign Recurrent Intrahepatic Cholestasis / 대한간학회지

Benign recurrent intrahepatic cholestasis (BRIC) is a rare desease, which usually manifests between the age of 10 and 20. Its main clinical feature is multiple recurrent episodes of cholestasis without extrahepatic bile duct obstruction. We report here a case of nonfamilial benign recurrent intrahepatic cholestasis. The patient has experienced recurrent jaundice with pruritus since childhood. Main bile duct obstrution was excluded by abdominal CT and endoscopic retrograde cholangiopancreatography. Other causes of cholestasis were not found. Hepatic histology revealed bile plug which were mainly concentrated in the centrilobular region, and increased number of mononuclear cells in the portal triad, but hepatic parenchyma showed no inflammation and necrosis. In the last anicteric period, she was healthy and the liver function test and biopsy specimen were normal.

Isolated Ostial left Main Stenosis Diagnosed by Transesophageal Doppler Echocardiography

The therapeutic strategy of the left main disease is quite different frorn usual coronary artery disease. Therefore, the diagnostic evaluation should be done carefully. Eventhough coronary angiography has been considered as a gold standard for the diagnosis of left main disease, its diagnosis is not possible in all cases. In questionable situation, direct visualization of the left main coronary artery and Doppler measurements of coronary blood flow by transesophageal echocardiography may give some diagnostic aids. We report a case of suspected isolated ostial left main stenosis, which was helped diagnotically by perfoming transesophageal Doppler echocardiography.

Clinical Applications of Three-Dimensional Echocardiography

BACKGROUND: Three-dimensional echocardiography has good feasibility and real image display in dynamic and spatial cardiac structures. So we designed this study to assess both the feasibility and potential role of three-dimensional echocardiography for the evaluation of cardiac structures and adjacent relationships. METHOD: We studied 25 patients with various heart structures. Cross-sectional images of specific interesting region were acquired from multiplane transesophageal echocardiography and reconstructed to three-dimensional images by TomTec image processing system. These images were presented in volume-rendered dynamic display for assessing of additonal informations. RESULTS: Three-dimensional reconstructions of usual viewpoints and interesting cut planes were possible in all patients. When compared with standard two dimensional images, additional informations were provided in all reconstructed cases. Among these images, mitral valve morphology, aortoseptal continuity and interatrial septum were the structures for which three-dimensional echocardiography were most useful. CONCLUSION: Although it was preliminary datas which needs large-scale randonmized prospective studies, three-dimensional echocardiograpy may be most potent and promising methods in evaluating anatomic and functional assessment of heart structures.

Anomalous Origin of the Left Circumflex Coronary Artery: A Report of 2 Cases and Echocardiographic Features

Anomalous origin of the left circumflex coronary artery(LCx) from the right sinus of Valsalva is the most common coronary anomaly and, generally, is considered to be benign. Nevertheless, myocardial infarction or sudden death in young patients with this coronary anomaly has infrequently been described. The LCx arises from the right sinus of Valsalva or proximal right coronary artery, courses posterior to the aorta to enter the left atrioventricular groove, and provide branches to the left lateral wall of heart. Transthoracic or transesophageal echocardiography may provide a useful diagnostic clue although coronary angiography is the standard diagnostic method. We report 2 cases of anomalous origin of the LCx from right aortic sinus with typical echocardiographic images.

Anterior Mitral Leaflat Perforation in Patients with Bicuspid Aortic Valve Endocarditis

Mitral valve perforation is a rare cause of severe mitral regurgitation, which occurs most commonly as a secondary involvement of aortic valve endocarditis. The probable mechanisrns are direct extension of the infection from the aortic valve, infected aortic regurgitant jet striking the ventricular surfaces of the mitral-aortic intervalvular fibrosa(MAIVF) and the anterior mitral leaflet(AML). Early recognition of these subaortic complications in patients with aortic valve endocarditis is important because (1) these complications may produce severe mitral regurgitation and hemodynamic collapse, (2) the presence of severe mitral valve involvement may present as primary mitral valve disease, (3) these complications can be overlooked during aortic valve replacement, and (4) cause difficulty in valve replacement and high mortality. We report two cases of AML perforation observed in patients with bicuspid aortic valve endocarditis.

A Case of Pacemaker Syndrome

Although ventricular pacing alone initially had deemed adequate for most clinical situations, some patients did not do well after ventricular pacing was initiated, and developed various symptoms attributed to this mode of pacing. The pacemaker syndrome is complex of clinical signs and symptoms related to the adverse hemodynamic and electrophysiologic consequences of ventricular pacing in the absence of other causes. Neurologic symptoms or those congestive heart failure predominated. We recently experienced a case of pacemaker syndrome in a 44-year-old female who had suffered sick sinus syndrome and was implanted with dual chamber pacing system being programmed to VVI pacing. She complained of chest discomfort, dyspnea, and near-fainting in a day after being programmed to VVI. Blood pressure was decreased to 9/60mmHg. Electrocardiography showed toPwave onT wave, representing retrograde ventriculoatrial conduction. The symptoms and signs were disappeared immediately after the pacing system was programmed to DDD pacing.