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case_images: Electrocardiogram in the emergency department showed a junctional rhythm of 32 bpm without P waves.
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case_images: On arrival to the hospital, the patient was hypotensive and electrocardiogram (ECG) showed a junctional rhythm with sinus arrest (SA; Figure 1).
case_images: Coronary angiography reveals an isolated occlusion of the sinus node artery branching from the proximal right coronary artery (A, C, D, E). A wire successfully crossed the sinus node artery, and the lesion was bougied with a microcatheter (B). The final coronary angiography showed good blood flow in the sinus node artery. Coronary angiography revealed no significant stenosis in left coronary artery. LAD, left anterior descending artery; LCX: left circumflex artery.
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case_images: A transvenous temporary pacemaker was inserted, and CAG revealed a lone occlusion of the SN artery originating from the proximal right coronary artery (RCA; Figure 2A). In left coronary artery, there was no significant stenosis and no branch to perfuse into SN area (Figure 2D and E). The wire successfully passed through the SN artery using a bougie technique with a microcatheter (Figure 2B and C).
case_images: On day 4 after admission, an atrial escape rhythm with negative P waves in V1 started to appear (A). Sinus rhythm recovered on day 10 (B).
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case_images: On day 4 after reperfusion, ectopic atrial rhythm appeared, and the temporary pacemaker was removed (Figure 3A). A sinus rhythm was finally recovered and stabilized on day 10 (Figure 3B).
case_images: Three-dimensional electroanatomical mapping revealed a local low-voltage area on the high lateral side of the right atrium, which coincided with the sinus node (A). (B) The multielectrode catheter was located at the low-voltage area of the sinus node, during which coronary angiography was performed. Triangles showed the tracking of the sinus nodeartery that branched from the right coronary artery. The low-voltage area comprised the perfusion area of the sinus node artery.
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case_images: Three-dimensional electroanatomical mapping revealed a low-voltage area (LVA) in the high lateral side of the right atrium (RA), which coincided with the SN (Figure 4A). Coronary angiography revealed that the SN artery perfused the myocardium around the LVA in the higher RA (Figure 4B).