Cardiac resynchronisation therapy versus dual site right ventricular pacing in a patient with permanent pacemaker and congestive heart failure

EP Europace, Jan 2005

A 46-year-old male patient who had long-term right ventricular (RV) pacing for symptomatic complete heart block, initially by an epicardial, later with an endocardial pacing lead at the RV apex, developed congestive heart failure (CHF) and chronic atrial fibrillation 7 years following the pacemaker implantation and was medically treated. During follow-up, his pacemaker was upgraded to a cardiac resynchronisation therapy (CRT) device, because of uncontrolled CHF symptoms, New York Heart Association (NYHA) functional class IV, while on drugs. The patient's symptomatic status improved to NYHA functional class II with CRT. After 17 months of CRT, the battery became depleted, because of the high capture threshold of the left ventricular lead. The patient was then given dual site RV pacing (RV outflow tract + RV apex) in place of CRT, which showed similar efficacy at 12 weeks follow-up.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://academic.oup.com/europace/article-pdf/7/4/380/7537219/380.pdf

Cardiac resynchronisation therapy versus dual site right ventricular pacing in a patient with permanent pacemaker and congestive heart failure

Abstract A 46-year-old male patient who had long-term right ventricular (RV) pacing for symptomatic complete heart block, initially by an epicardial, later with an endocardial pacing lead at the RV apex, developed congestive heart failure (CHF) and chronic atrial fibrillation 7 years following the pacemaker implantation and was medically treated. During follow-up, his pacemaker was upgraded to a cardiac resynchronisation therapy (CRT) device, because of uncontrolled CHF symptoms, New York Heart Association (NYHA) functional class IV, while on drugs. The patient's symptomatic status improved to NYHA functional class II with CRT. After 17 months of CRT, the battery became depleted, because of the high capture threshold of the left ventricular lead. The patient was then given dual site RV pacing (RV outflow tract + RV apex) in place of CRT, which showed similar efficacy at 12 weeks follow-up. cardiac resynchronisation therapy, heart failure, complete heart block, pacemaker, atrial fibrillation Introduction Cardiac resynchronisation therapy (CRT), a novel pacing therapy for severely symptomatic congestive heart failure (CHF) patients with ventricular conduction delay, is indicated in patients with preserved sinus rhythm [1] . Few data are available concerning the benefit of CRT in CHF patients with chronic atrial fibrillation (AF) and complete heart block. We report here the benefits and problems associated with CRT in a patient with a permanent pacemaker implantation (PPI) for complete heart block (CHB), who developed chronic AF and CHF during follow-up. The effect of dual site right ventricular pacing in place of CRT, which the patient has subsequently undergone, is also discussed. Case report A 46-year-old male patient underwent PPI (VVI, Medtronic Inc, Minneapolis, MN, USA) with an epicardial pacing lead on the right ventricle (RV) ( Fig. 2B ) at the age of 30 years for symptomatic CHB. The electrophysiological study at that time showed the conduction block to be below the His bundle. Seven years following the PPI, the patient developed symptoms of CHF, New York Heart Association (NYHA) functional class III, and chronic AF. The echocardiographic examination showed dilated cardiac chambers with concentric left ventricular hypertrophy and left ventricular ejection fraction (LVEF) of 27% ( Fig. 1A ). The patient was managed with diuretics, digoxin, enalapril, amiodarone and oral anticoagulants. Nine years following the initial PPI, the pulse generator (PG) showed impending battery depletion. The patient underwent PPI with an endocardial pacing lead (CapSure Z 5034, Medtronic Inc.,) placed at the right ventricular apex ( Fig. 2B ) through the right cephalic vein and PG (VVIR, VIGOR 1130, Guidant Inc, St. Paul, MN, USA) positioned in the subcutaneous pocket in the right pectoral region. Figure 1 View largeDownload slide M-mode echocardiographic images of the LV showing- chamber dimensions and LVEF before initiation of CRT (A), after initiation of CRT (B) and with dual site RV pacing (C). LV – left ventricle, RV – right ventricle, CRT – cardiac resynchronisation therapy, LVEDD/ESD mm – left ventricular end diastolic dimension/left ventricular end systolic dimension in millimetres, LVEF% – left ventricular ejection fraction percentage. Figure 1 View largeDownload slide M-mode echocardiographic images of the LV showing- chamber dimensions and LVEF before initiation of CRT (A), after initiation of CRT (B) and with dual site RV pacing (C). LV – left ventricle, RV – right ventricle, CRT – cardiac resynchronisation therapy, LVEDD/ESD mm – left ventricular end diastolic dimension/left ventricular end systolic dimension in millimetres, LVEF% – left ventricular ejection fraction percentage. Figure 2 View largeDownload slide (A) Coronary sinus venogram showing posterolateral cardiac vein (thick arrow) and other branches (thin arrows) of CS, which are small in caliber, CS – coronary sinus. (B) Fluoroscopic cardiac image in anteroposterior view – depicting position of LV lead (thick arrow) during CRT; RV leads in RVOT (arrow head), RV apex (thin arrow) during dual site RV pacing and RV epicardial pacing lead (curved arrow) implanted during first permanent pacemaker surgery (see text for details). Figure 2 View largeDownload slide (A) Coronary sinus venogram showing posterolateral cardiac vein (thick arrow) and other branches (thin arrows) of CS, which are small in caliber, CS – coronary sinus. (B) Fluoroscopic cardiac image in anteroposterior view – depicting position of LV lead (thick arrow) during CRT; RV leads in RVOT (arrow head), RV apex (thin arrow) during dual site RV pacing and RV epicardial pacing lead (curved arrow) implanted during first permanent pacemaker surgery (see text for details). The patient's symptoms of heart failure worsened (NYHA functional class IV), despite adequate medical therapy, requiring repeated hospital admissions. When the second PG s (...truncated)


This is a preview of a remote PDF: https://academic.oup.com/europace/article-pdf/7/4/380/7537219/380.pdf

Satish, Oruganti Sai, Yeh, Kuan-Hung, Wen, Ming-Shien, Wang, Chun-Chieh. Cardiac resynchronisation therapy versus dual site right ventricular pacing in a patient with permanent pacemaker and congestive heart failure, EP Europace, 2005, pp. 380-384, Volume 7, Issue 4, DOI: 10.1016/j.eupc.2005.01.008