'Ablation before Pacemaker' in a patient with bradycardia: a case report

Symptomatic sinus bradycardia is a common clinical condition encountered by clinicians. The current guidelines recommend treatment of symptomatic sinus bradycardia with a pacemaker implantation. However it is important to be cognizant of some potential confounding factors and recognizing these can sometimes be difficult. We report a case of symptomatic bradycardia that was treated with ablation due to the presence of underlying dual Atrio-Ventricular (AV) nodal pathways. A 77-year-old male with a past medical history of hypertension and dyslipidemia presented to the emergency department with complaints of episodic dizziness. He was feeling well until the day of presentation when he experienced ‘severe dizziness’ which was worse with exertion and partly improved with rest. He denied chest pain or palpitations. On physical examination the patient was afebrile with a pulse of 39 beats per minute, an oxygen saturation of 98% on room air and a blood pressure of 141/66 in the seated position without postural changes. Initial laboratory data including troponins were within normal limits. Serial ECGs showed evidence of dual AV nodal pathways (Figures 1 and 2).