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.
Follow-Up:
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.
Conclusions:
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.