Vasovagal syncope is not a benign condition in the elderly population. In patients not responsive to conservative therapy and whose abrupt faints are associated with serious injuries and seriously affected quality of life, pacemaker therapy was suggested. However, the usefulness of cardiac pacing for the prevention of recurrences of vasovagal syncope remains controversial because of the dominant role of the vasodepressor component during the episode. In the Medical Center Alkmaar, the Head-Up Tilt Test (HUTT) has been used since 1996 during the work-up of patients who present with vasovagal syncope. The HUTT showed a dominant cardioinhibitory response in 4.5% of our patients; in elderly patients with vasovagal syncope without prodromal symptoms and refractory on conservative therapy, pacemaker therapy was very effective in preventing syncope during long-term follow-up. (Neth Heart J 2008;16(Suppl1):S15-S19.)
vasovagal; syncope; cardiac; pacing
A 41-year-old man with no relevant cardiac history presented for evaluation of episodic syncope. Electrocardiography showed sinus rhythm with right bundle-branch block and Q waves in leads II, III, and aVF. Subsequent exercise treadmill testing and technetium 99m sestamibi study revealed a reversible posterior defect. Coronary angiography later showed a right coronary artery that arose from the left coronary sinus—an anomaly that has been associated with angina, myocardial infarction, and sudden cardiac death.
After being informed of the potential risks and options associated with this anomaly, the patient chose long-term β-blocker medical therapy. At follow-up, this treatment appeared to have resolved his episodic syncope. (Tex Heart Inst J 2002;29:37–9)
Coronary vessel anomalies/diagnosis/complications/pathology/therapy; heart catheterization; risk assessment
The facts collected in the third part of this paper justify the following conclusions: (1) All of the cardinal symptoms of Stokes-Adams disease may be duplicated by heart-block resulting from a lesion in or near the auriculo-ventricular bundle of His, and by this alone. (2) No typical case of Stokes-Adams disease has been described in which heart-block might not have been the cause of the trouble. (3) It can be shown that all cases of Stokes-Adams disease which have been studied by sufficiently accurate methods were cases of heart-block. (4) It would appear that heart-block without and with syncopal attacks are two stages of the same disease process.
Although patients with syncope and bundle branch block (BBB) are at high risk of developing atrio-ventricular block, syncope may be due to other aetiologies. We performed a prospective, observational study of the clinical outcomes of patients with syncope and BBB following a systematic diagnostic approach.
Methods and results
Patients with ≥1 syncope in the last 6 months, with QRS duration ≥120 ms, were prospectively studied following a three-phase diagnostic strategy: Phase I, initial evaluation; Phase II, electrophysiological study (EPS); and Phase III, insertion of an implantable loop recorder (ILR). Overall, 323 patients (left ventricular ejection fraction 56 ± 12%) were studied. The aetiological diagnosis was established in 267 (82.7%) patients (102 at initial evaluation, 113 upon EPS, and 52 upon ILR) with the following aetiologies: bradyarrhythmia (202), carotid sinus syndrome (20), ventricular tachycardia (18), neurally mediated (9), orthostatic hypotension (4), drug-induced (3), secondary to cardiopulmonary disease (2), supraventricular tachycardia (1), bradycardia–tachycardia (1), and non-arrhythmic (7). A pacemaker was implanted in 220 (68.1%), an implantable cardioverter defibrillator in 19 (5.8%), and radiofrequency catheter ablation was performed in 3 patients. Twenty patients (6%) had died at an average follow-up of 19.2 ± 8.2 months.
In patients with syncope, BBB, and mean left ventricular ejection fraction of 56 ± 12%, a systematic diagnostic approach achieves a high rate of aetiological diagnosis and allows to select specific treatment.
Syncope; Bundle branch block; Electrocardiography; Pacemakers
Swallow syncope (also known as deglutition syncope) is a relatively rare type of syncope that is treatable if diagnosed correctly. We report a case of a 39-year-old man with recurrent swallow syncope. The patient did not have structural heart disease. He developed a complete atrioventricular block upon drinking a cold beverage (Chilsung cider) while undergoing a repeated head-up tilt test. The patient was advised to avoid cold beverages and has been symptom free for 5 months.
Syncope; Deglutition; Atrioventricular block
The syncopal attacks of complete heart block may be due either to ventricular standstill or to ventricular acceleration including fibrillation. As treatment may be harmful unless the underlying mechanism in each case is determined, it is important to apply the available methods for differentiation.
Epinephrine and certain related compounds (sympathomimetic amines) are the only effective substances in the therapy of ventricular arrest.
Isopropyl nor-epinephrine is a most potent drug in the prevention and treatment of ventricular arrest and has the advantage that it does not dispose to fibrillation.
Quinidine is unreliable and probably hazardous in the control of ventricular fibrillation in heart block as it appears to precipitate this arrhythmia.
Preliminary observations indicate that ectopic ventricular rhythms are also induced by procaine amide in complete heart block.
Isuprel® may be of value in the therapy of ventricular acceleration, by preventing the ventricular arrest which frequently follows the initial acceleration.
Extensive clinical experience has demonstrated that implantable cardiac pacemakers are safe and effective mechanisms for controlling symptoms and preventing the hazards of third degree heart block with Stokes-Adams syncope. Medical management of this disease does not provide reliable protection and life expectancy averages about two years after diagnosis. Hence the negligible surgical morbidity and mortality associated with pacemaker implantation justifies broad indications to implant one of the four commercially available battery-powered units.
Elective implantation of a pacemaker should be considered in patients with persistent third degree heart block who have had: One or more episodes of Stokes-Adams syncope; surgical injury to the conduction system, regardless of syncopal attacks; evidence of low cardiac output with cardiomegaly secondary to bradycardia. Few if any other cardiac arrythmias are satisfactorily controlled by an electrical pacemaker.
Emergency pacemaker control is obviously necessary for patients developing intractable or recurrent bouts of asystole. During the interval until an implantable unit can be obtained and sterilized, the patient may be controlled by intravenous isoproterenol or by an external pacemaker attached to a transvenous catheter electrode, a precordial skin electrode or a percutaneous myocardial wire electrode.
The mechanisms underlying syncope remain unknown in about 20% of patients with recurrent syncope. The implantable loop recorder (ILR) has been shown to be a useful diagnostic tool in patients with unexplained syncope even after negative initial evaluations. Nevertheless, ILR has rarely been used in clinical practice.
Materials and Methods
This study included 18 consecutive patients who had an ILR implanted at our center because of recurrent unexplained syncope after extensive diagnostic tests between February 2006 and June 2011.
Diagnosis was confirmed in 10 (55.6%) of the 18 enrolled patients (13 males, 61±15 years). The confirmed diagnoses included sick sinus syndrome (n=6, 60%), advanced atrioventricular block (n=2, 20%) and ventricular tachyarrhythmia (n=2, 20%). The mean follow-up durations of the total study subjects and the diagnosed patients were 11.3±10.6 months and 5.6±9.2 months, respectively. Of the 10 diagnosed patients, 8 (80%) were diagnosed within 6 months of loop recorder implantation.
ILR may be a valuable and effective diagnostic tool for patients with unexplained syncope.
Implantable loop recorder; syncope
Atrial and ventricular pacemaker function was studied in 20 patients with idiopathic chronic complete heart block using the rate response to an intravenous bolus dose of isoprenaline (5 mug/70 kg bodyweight). Pacemaker responses were compared with those of 16 normal control subjects. None of the patients was having syncopal attacks at the time of admission and they were therefore selected in that none required immediate pacing. Ten of the patients had His bundle electrograms; all were shown to have a pre-His type of atrioventricular block. Two major groups emerge from the responses to isoprenaline. (a) High risk group: 11 of the 14 patients with reduced ventricular pacemaker responses had frequent syncopal attacks; 8 of the patients with Adams-Stokes syncope had a bundle-branch block pattern, while 3 had a narrow QRS. These patients require pacing. (b) Low risk group: a low risk asymptomatic group (5 patients) was identified with atrial and ventricular responses to isoprenaline within normal range. One of these patients had a bundle-branch block pattern, while 4 had a narrow QRS. These patients might be managed without pacing. The atrial response to isoprenaline was reduced in 12 of the 20 cases, 10 of whom also had reduced ventricular responses. All 9 patients with bundle-branch block had reduced ventricular responses, while 7 had reduced atrial responses. This evidence indicates that cardiac conducting tissue pathophysiology is widespread in complete heart bolck. The present work suggests that consideration of the ventricular pacemaker function is important in assessing liability to syncope in complete heart block. While patients with Adams-Stokes attacks require pacing it is suggested that all asymptomatic patients with complete heart block and those with minor symptoms are assessed using studies of both ventricular pacemaker function and site. A low risk group not requiring a pacemaker may emerge after sufficient follow-up assessment.
OBJECTIVE--To evaluate the effect of permanent pacing in cardioinhibitory malignant vasovagal syndrome. PATIENTS AND METHODS--37 patients with permanent pacemakers for cardioinhibitory malignant vasovagal syndrome. All presented with syncope (median six episodes, median frequency two episodes a year) and after conventional investigation and invasive electrophysiological assessment they remained undiagnosed, and without a generally accepted indication for pacemaker implantation. In all vasovagal syncope with cardioinhibition (heart rate at syncope < 60 beats/min) developed during tilt tests performed according to the Westminster protocol (head up tilt at 60 degrees with a footplate support for 45 minutes or until syncope intervenes). Dual chamber pacemakers were implanted in 35 (95%) and VVI pacemakers in the remaining two (5%). RESULTS--Over a mean (SD) follow up since implantation of 50.2 (23.9) months symptomatic improvement occurred in 89%: 62% remained free of syncope and 27% were completely symptom free. The collective syncopal burden of these 37 patients was reduced from 136 to 11 episodes each year. During follow up three patients died from unrelated causes. Patients who become asystolic during the tilt test (sinus pause of at least four seconds) experienced no greater benefit from pacing than those with less extreme cardioinhibition. Patients who remained free of syncope since implantation were younger than those who continued to experience syncope. Patients who remained completely symptom free after implantation were younger, more likely to be male, and had had fewer syncopal episodes before implantation than those who continued to experience syncope or presyncope. No other demographic, clinical, investigative, or pacing variable suggested a more favourable outcome after implant. CONCLUSIONS--This retrospective and uncontrolled experience suggests a possible role for permanent pacing in selected patients with cardioinhibitory malignant vasovagal syndrome. Improved acquisition of tilt test data may enable better selection of patients who are suitable for permanent pacing. A randomised prospective study to compare permanent pacing with no treatment or with medical treatment in cardioinhibitory malignant vasovagal syndrome is indicated.
OBJECTIVE--To study the value of intravenous disopyramide as part of an invasive electrophysiological study in predicting impending high degree atrioventricular block in patients with bifascicular block. DESIGN--An invasive electrophysiological study was performed in the basal state and after the infusion of disopyramide (2 mg/kg body weight). The progression to high degree atrioventricular block was assessed by bradycardia-detecting pacemakers or repeated 12-lead electrocardiogram recordings, or both. PATIENTS--73 patients with bifascicular block were included, of whom 25 had a history of unexplained syncope. The remaining 48 patients had no arrhythmia related symptoms and were included as controls. All patients had an ejection fraction of > 35%. RESULTS--After a mean follow up of 23 months, seven patients in the syncope group and three in the non-syncope group had a documented high degree atrioventricular block or pacemaker-detected bradycardia of < or = 30 beats/min for > or = 6 s. The sensitivity of the disopyramide test was 71% and the specificity 98%. The corresponding figures for an abnormal electrophysiological study in the basal state were 14% and 91%, respectively. CONCLUSIONS--The sensitivity of an invasive electrophysiological study in patients with bifascicular block and syncope can be markedly increased by the use of intravenous disopyramide. A positive test is a highly specific finding and warrants pacemaker implantation.
Ten patients, between the ages of 39 and 75 years, underwent subcutaneous implantation of an electrode pacemaker for relief of recurrent syncopal episodes of Stokes-Adams disease. Their prolonged course of severe disability on medical therapy is in marked contrast to their new life, free of syncopal attacks, on pacemaker therapy. Experience in the management of these patients has shown that the electrode catheter, introduced intravenously to stimulate the right ventricular endocardium, is the best temporary therapy in a patient with uncontrollable syncopal attacks, and it should be used in all patients undergoing the surgical procedure of implantation. Pacemaker therapy is applicable to patients in sinus rhythm as well as to those in complete heart block. Observations on the effect of heart rate on cardiac output have shown the need of a faster rate in the presence of congestive failure for the maintenance of an adequate cardiac output. The favourable course of patients after implantation of a pacemaker indicates that this is the treatment of choice in Stokes-Adams disease.
A 32-year-old Spanish man presented to hospital after a second episode of syncope immediately following exercise. On admission, his vitals signs were stable and he had a regular heart rate of 60 bpm. ECG and transthoracic echocardiogram were normal. He completed 15 min of a BRUCE protocol exercise test. One minute and ten seconds into recovery, he lost consciousness. His ECG demonstrated sinus arrest with pauses of up to 5 s and subsequently junctional ectopy. After 38 s, his heart returned to sinus rhythm at a rate of 140 bpm and he regained consciousness. Vasovagal syncope following exercise in the absence of structural heart disease is uncommonly reported. When cases of exercise-related syncope in patients with structurally normal hearts have been reported, the typical patient is a young male who engages in physical training. Treatment strategies in patients suffering with vasovagal asystole are necessarily empirical, and careful judgement based on the specific features of the individual cases needs to be employed.
Severe aortic valve stenosis (AVS) can cause an exercise-induced reflex syncope (RS). The precise mechanism of this syncope is not known. The changes in hemodynamics are variable, including arrhythmias and myocardial ischemia, and one of the few consistent changes is a sudden fall in systemic and pulmonary arterial pressures (suggesting a reduced vascular resistance) followed by a decline in heart rate. The contribution of the cardioinhibitory and vasodepressor components of the RS to hemodynamics was evaluated by a computer model. This lumped-parameter computer simulation was based on equivalent electronic circuits (EECs) that reflect the hemodynamic conditions of a heart with severe AVS and a concomitantly decreased contractility as a long-term detrimental consequence of compensatory left ventricular hypertrophy. In addition, the EECs model simulated the resetting of the sympathetic nervous tone in the heart and systemic circuit during exercise and exercise-induced syncope, the fluctuating intra-thoracic pressure during respiration, and the passive relaxation of ventricle during diastole. The results of this simulation were consistent with the published case reports of exertional syncope in patients with AVS. The value of the EEC model is its ability to quantify the effect of a selective and gradable change in heart rate, ventricular contractility, or systemic vascular resistance on the hemodynamics during an exertional syncope in patients with severe AVS.
Sinus node dysfunction (SND) following orthotopic heart transplantation may lead to bradycardia, atrioventricular block, sick sinus syndrome, syncope, and death, with 6%-23% of patients requiring pacemakers.
Permanent pacemakers were placed in 5% of orthotopic heart transplants conducted at our institution from January 2002 to October 2008.
Three different implant techniques were used over this time: (1) dual-chamber pacing in the donor atrium and ventricle (AD-VD) (62.5%); (2) single lead in the donor atrium (AD) (12.5%); and (3) dual leads placed in both donor and recipient atrium (AR-AD) (25%). Using the percentage of paced histograms recorded in the device, heart rate variability for the types of lead placements were 14% for AD-VD, 35% for AD, and 97% for AR-AD.
The transplanted heart is characterized physiologically by autonomic denervation and chronotropic incompetence. Restoration of chronotropic competence by atrial pacing increases exercise duration and peak VO2. Rate responsiveness can be achieved in this patient population with the placement of one lead in the remnant right atrium and one lead in the transplanted donor right atrium.
Chronotropic incompetence; dual-atrial pacing; orthotopic heart transplantation; permanent pacemaker; sinus node dysfunction
We report our experience of 20 patients who have had permanent pacemakers implanted for the first time after the age of 90. The main indications were syncope or presyncope which occurred in 15 patients. Complete heart block was present in 14 patients. Syncopal and presyncopal symptoms were cured in 73%. Nonagenarians paced for complete heart block can expect to survive for as long as others of the same age without heart block. Permanent pacing is an effective and appropriate treatment in the very old.
A 29-year-old man was referred to the emergency department with a complaint of abdominal pain and dizziness. He had experienced two previous syncopal episodes. His family history revealed that his mother and his two uncles had received permanent pacemaker implantation. His initial heart rate was 49 beats per minute. The electrocardiography (ECG) showed atrial flutter and right bundle branch block (RBBB) with left anterior fascicular block (LAFB). On admission, 24-hour Holter showed ventricular pause up to 16 seconds during syncope. Radio frequency catheter ablation (RFCA) of atrial flutter was performed. The ECG revealed bifascicular block (RBBB and LAFB) and first-degree atrioventricular block. He received a permanent pacemaker implantation. His brother's and his sister's ECGs also showed trifascicular block and the pedigree showed autosomal dominant inheritance. This patient was diagnosed with a progressive familial heart block (PFHB) type I. This would be the first report of a PFHB type I case documented in Korea.
Hereditary bundle branch system defect; Atrial flutter
The effect of permanent pacing on chronic complete atrioventricular block complicated by cardiac failure was studied in 6 patients by measurement of indirect left atrial pressure 15 minutes after institution of pacing and again 3 to 12 months later. In addition, 21 patients with complete heart block and clinical plus radiological evidence of cardiac failure at the time of pacing 3 to 6 years earlier were also reviewed. Only 1 of 6 patients studied haemodynamically improved and 1 died in cardiac failure. Of 21 patients assessed clinically, 10 had improved and 8 had died after a mean follow-up of 53 months. In the absence of syncope, pacing was of little symptomatic benefit but still may be justified to prolong survival. Both studies indicated a particularly poor prognosis for patients known to have coronary artery disease. No reliable means were found of determining the prognosis in the individual patient with cardiac failure before pacing.
Pulmonary embolism may escape prompt diagnosis since clinical symptoms and signs are nonspecific. The occurrence of syncope as the sole initial symptom in a previously healthy patient with no predisposing factors to embolism and no hemodynamic instability is extremely rare, which may have been a factor in the delayed diagnosis. We describe a case of agnogenic massive pulmonary embolism with syncope as the initial symptom. A 41-year-old previously healthy female was admitted to the Department of Neurology, Taizhou People’s Hospital in March 2012, for two transitory episodes of syncope during a 5-h period. Following admission, chest computed tomography demonstrated embolism in the right main pulmonary and left inferior pulmonary arteries. Color ultrasonography revealed a dilated right ventricle and right heart overload, severe tricuspid regurgitation and severe pulmonary hypertension. Following the final diagnosis, the patient was successfully treated with interventional mechanical thrombectomy combined with thrombolytic therapy with local and systemic low-dose urokinase. We consider that raised awareness and early diagnosis and treatment were key factors in ensuring a satisfactory prognosis.
pulmonary embolism; interventional therapy; syncope
Syncope following permanent pacemaker (PM) implantation is a nightmare for electrophysiologists. We describe a case of daily recurrent syncope in an 84-year-old man having a dual-chamber pacemaker implanted for complete atrio-ventricular block occurred 4 years before the admission to our department. He had a history of arterial hypertension, parossistic atrial fibrillation, chronic obstructive pulmonary disease, stage-III chronic renal failure, mild vascular cognitive impairment and glaucoma. The initial work-up including electrocardiogram (ECG), repeated PM interrogations, Holter electrocardiogram, blood pressure measurement in orthostatic position, complete blood count, serum glycaemia, electrolytes and thyroid function tests showed normal findings. Syncope occurred in lying position and during 90° left clockwise neck rotation and was associated to pallor, sweating, tonic-clonic seizures and transient self-limited loss of consciousness lasting a few seconds. Electroencephalogram was normal. During continuous ECG monitoring, the right rotation of the head determined a ventricular asystolic pause lasting 9 seconds associated with loss of consciousness. Restoration of sinus rhythm was observed after bringing back the head in axis. The PM interrogation, performed during pacing failure, recorded low impedance of bipolar ventricular lead, suggesting a damage in lead insulation. It is likely that lead movements during clockwise neck rotation produced an intermittent short circuit that prevented sufficient energy delivery to the myocardium with a consequence of sudden loss of capture.
synsope; neurology; hypertension; pacemaker.
Deglutition syncope has been demonstrated in isolated case reports, the first being described over 50 years ago. It is thought to be caused by a hypersensitive vagotonic reflex in response to esophageal dilation after swallowing. It can cause syncope due to complete atrioventricular (AV) block and acute reduction of cardiac output. Although rare, its lethality is worthy of discussion, as early recognition can offer complete treatment with placement of a pacemaker. A 54-year-old man presented with 30 years of lightheadedness and syncope, followed by disorientation and tremors, after eating sandwiches or drinking carbonated beverages. He initially was evaluated by a neurologist. Work-up included cardiac 2D transthoracic echocardiogram, electroencephalogram, swallow stud, pulmonary function tests, electrocardiogram, and cardiac stress testing. All tests were within normal limits, and it was determined that he was suffering from convulsive syncope and deglutition syncope. Referral to the cardiac electrophysiology department with tilt-table testing accompanied by swallow evaluation was then recommended. The tests demonstrated marked vagal response resulting in sinus bradycardia with second-degree AV block and pauses up to 3.5 seconds. Patient experienced near syncope. A rate-responsive, dual-chamber Boston Scientific pacemaker with DDDR programming was implanted. Patient has remained asymptomatic at follow-up.
AV block; deglutition syncope; vagotonic hypersensitivity; dual chamber pacemaker; tilt-table; electophysiologic testing
A 21 year old man presented with multiple, recurrent episodes of complete atrioventricular (AV) block associated with swallowing. Electrophysiological study revealed an AV block with swallowing of carbonated beverages and balloon inflation in the lower oesophagus. Evaluation did not demonstrate any underlying oesophageal or cardiac disease, and the AV block was not induced after intravenous atropine administration. The AV block was probably caused by a hypersensitive vagotonic reflex triggered by mechanical receptors in the lower oesophagus, resulting in suppression of the AV node. Head up tilt test revealed an increase in the high frequency spectrum of heart rate variability before the onset of the syncope. These findings suggest that the amplitude of the continual fluctuations in response to a variety of stimuli and derangement from both intrinsic and extrinsic environments was greater in this patient than in normal subjects. Swallow syncope is an unusual but treatable disorder. These reflexes that become exaggerated to the point of causing illness are poorly understood.
Keywords: swallow syncope; AV block; electrophysiological study; head up tilt test
Syncope is a common presentation to the Emergency Department (ED); however, appropriate management and indications for hospitalization remain an ongoing challenge. The objective of this study was to determine if a predefined decision rule could accurately identify patients with syncope likely to have an adverse outcome or critical intervention. A prospective, observational, cohort study was conducted of consecutive ED patients aged 18 years or older presenting with syncope. A clinical decision rule was developed a priori to identify patients at risk if they met any of the following 8 criteria: 1) Signs and symptoms of acute coronary syndrome; 2) Signs of conduction disease; 3) Worrisome cardiac history; 4) Valvular heart disease by history or physical examination; 5) Family history of sudden death; 6) Persistent abnormal vital signs in the ED; 7) Volume depletion; 8) Primary central nervous system event. The primary outcome was either a critical intervention or an adverse outcome within 30 days. Among 362 patients enrolled with syncope, 293 (81%) patients completed their 30-day follow-up. Of these, 201 (69%) were admitted. There were 68 patients (23%) who had either a critical intervention or adverse outcome. The rule identified 66/68 patients who met the outcome for a sensitivity of 97% (95% confidence interval 93–100%) and specificity of 62% (56 – 69%). This pathway may be useful in identifying patients with syncope who are likely to have adverse outcome or critical interventions. Implementation and multicenter validation is needed before widespread application.
syncope; outcomes; decision; rule
The differential diagnosis of syncope versus seizures represents a daily challenge for cardiologists and neurologists. Long Q-T syndrome and hypertrophic cardiomyopathy (HCM) are two hereditary arrhythmogenic heart conditions causing syncope in early adulthood. We report the cases of two patients who were reassessed for transient loss of consciousness (TLOC) with convulsions despite treatment. The first patient, a 40-year-old woman, had been diagnosed with epilepsy and was given phenytoin. Her episodes took place while swimming or when in emotional distress and were not followed by post-ictal confusion. An electrocardiogram showed a very prolonged Q-Tc interval. The second patient, a 30-year-old man with HCM in whom a defibrillator had been implanted on the assumption that he was having cardiogenic syncopes, was actually found to have epilepsy. Adequate treatment rendered both patients asymptomatic. In conclusion, the clinical history and 12-lead electrocardiography remain crucial in the management of TLOC, ideally involving both cardiologists and neurologists.
Acute rheumatic fever (ARF) is a well-characterized illness. However, syncope in ARF due to advanced heart block is very rare. A 10-year-old boy was admitted with recurrent syncope for 12 h. The patient was diagnosed as ARF because of arthritis, elevated acute phase reactants, advanced heart block, high antistreptolysin O titer, and echocardiographic evidence of mitral regurgitation. On the 9th day of hospitalization, the electrocardiogram revealed normal sinus rhythm.
Advanced heart block; rheumatic fever; syncope