Mile-High Heart: Transoceanic Flight with a Wearable Cardioverter Defibrillator as Sudden Cardiac Death Prevention - A Clinical Case Study

Veronica Buia (Fürth)1, F. Ciotola (Fürth)1, D. Stangl (Fürth)1, H. Rittger (Fürth)1, L. Vitali-Serdoz (Fürth)1

1Klinikum Fürth Med. Klinik I - Kardiologie Fürth, Deutschland


Patient Presentation:

A 73-year-old Brazilian patient arrived at our emergency department with complaints of dyspnea, which he stated had started during his 13-hour flight journey from Brazil three days prior. The patient reported undergoing a recent comprehensive cardiac evaluation, which had not revealed any cardiac issues. He had several cardiovascular risk factors, including diabetes and arterial hypertension.

Diagnostic evaluation and work up:

Initial assessments included an electrocardiogram (ECG), which revealed a sinus rhythm with a complete left bundle branch block and borderline positive Sgarbossa criteria. Laboratory tests exhibited signs of cardiac decompensation (nt-proBNP 23,900 pg/ml) , elevated markers of ischemia (high-sensitive troponin T 1.29 ng/ml, CK 232 U/l, CKMB 38 U/l) and positive D-dimers (1,25 mg/l). Given the symptoms, the prolonged flight history and the positive D-dimers, pulmonary embolism was initially considered and subsequently ruled out through a spiral computed tomography (CT) scan, following the current 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism . 

An emergency coronary angiography was then planned. However, the patient repeatedly declined the procedure even with the assistance of a translator. After two days, the patient's daughter arrived from Brazil, and on the third day, a coronary angiography could be successfully performed. It revealed a thrombotic occlusion of the right coronary artery, requiring implantation of three drug-eluting stents, and a subtotal stenosis of the left descending artery/left main, necessitating one drug-eluting stent. The patient was recompensated and remained stable over the following days,  showing no arrhythmias other than monomorphic ventricular extrasystoles. 



Following initiation of heart failure therapy, an echocardiogram showed a persistently severely reduced ejection fraction resulting from the subacute myocardial infarction. The ECG demonstrated improvement, including a reduction in the bundle branch block to a left posterior hemiblock. The patient expressed a strong desire to continue treatment and follow-up at home, in Brazil. After a multidisciplinary discussion, it was determined that the patient could return to Brazil with an accompanying cardiologist, aided by a wearable cardioverter defibrillator (WCD) for the flight. The device would be sent back to Germany afterward since Brazil lacks the support for the WCD proper follow-up. The WCD showed no irregularities during the 14 days in which the patient wore and during the whole flight home. 


To our knowledge this is the first described case oft he utilization oft he WCD on a long haul flight as additional safety measure for a patient at high risk for life-threatening arrhythmias. The successful use of a wearable cardioverter defibrillator during a long flight provides a novel approach to ensure the safety of high-risk patients during travel, even when returning to a country without necessary medical support. 

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