Cardiac Case: 79-year-old Man with Pacemaker and Recent Dental Procedure

00:00 A 79-year- old man comes for him scheduled six month visit.

00:04 Three years ago he had a pacemaker implanted for complete heart block which resulted in a syncopal episode.

00:11 He tells us that he feels poorly for the last two weeks following a dental procedure to remove several badly infected teeth.

00:19 He says specifically he feels tired, sweaty, loss of appetite and he’s had recently several shaking chills.

00:27 Blood pressure a little elevated but not bad for a man his age, heart rate slightly elevated, temperature definitely elevated, normal would be 37 and he has signs of an infection.

00:39 His complete blood count shows that his white cell count is 14,000 with 85% polymorphonuclear cells, normal should be less than 10.000 with about 60% to 70% polys so this is clearly there’s an infection somewhere.

00:55 So again, the critical factors - he's had 3rd degree heart block, he was appropriately treated with a pacemaker and there’s a history of a recent infectious process where he had badly infected teeth removed and of course he has symptoms that suggest a fibrile syndrome probably an infection and he’s blood pressure is a little bit elevated but that’s not so worrisome, this is much more worrisome, his fever.

01:20 And again of course the white count with the polys tells us that there’s an active infectious process.

01:27 Here's his pre-pacemaker EKG which shows complete heart block.

01:33 There’s no relationship between the P waves and the QRSs.

01:37 You should take a moment just to look at it to notice that there’s not a P in front of each QRS and of course the heart rate is markedly slow, there’s a wide QRS because that’s a ventricular pacemaker that takes over and again as mentioned no regular relationship between P waves and QRSs and the diagnosis was appropriate, 3rd degree AV block and of course he had a pacemaker implanted.

02:02 This is a little diagram showing you a DDD pacemaker that is it is paces and senses in both the atrium and the ventricle and is inhibited if the heart rate itself is adequate.

02:16 Here’s a chest x-ray from a patient with a single lead VVI pacemaker that is it senses and paces only in the right ventricle not in the right atrium and you can see very easily on this chest x-ray of the pacemaker box implanted.

02:32 Here we see again his 3rd degree heart block, he gets some blood cultures, they grow staph aureus.

02:40 We do an echocardiogram that shows possible vegetation on the pacemaker wire.

02:45 So what do we do? We have to remove both the wire and the pacemaker.

02:49 The patients gets a course of intravenous vancomycin for a long time.

02:53 He gets a permanent pacemaker implantation and then next time he goes to the dentist he needs prophylactic oral antibiotics.

03:02 Now, what happens when we take out the pacer wire? We’ll he’s gonna go back to 3rd degree heart block so very often we have to implant a temporary pacemaker, once we’ve given a few days of intravenous vancomycin.