History
The patient had recurrent hospital admissions for heart failure despite optimal tolerable medical therapy. He had a left ventricular ejection fraction of 25% and mechanical dyssynchrony on tissue Doppler echocardiogram. He also had documented nonsustained ventricular tachycardia and paroxysmal atrial fibrillation on Holter monitoring.
Current Medications
The patient was taking warfarin 0.125 mcg/daily, furosemide 40 mg twice daily, carvedilol 12.5 mg twice daily, aldactone 25 mg daily, digoxin 0.125 mg daily, simvastatin 20 mg daily, and valsartan 80 mg daily.
Current Symptoms
Recurrent admissions for heart failure. Significantly breathless at mild exertion (New York Heart Association class III).
Physical Examination
Laboratory Data
Focused Clinical Questions and Discussion Points
Question
How frequently is a left ventricular lead with an active fixation mechanism required to pace the left ventricle?
Discussion
A left ventricular lead with some form of active fixation mechanism is required to overcome anatomic peculiarity, unstable lead position, and a circumscribed area of optimal pacing threshold without phrenic nerve stimulation in 12% of patients.3
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