8. Pacemaker Indication

Published on 02/03/2015 by admin

Filed under Cardiovascular

Last modified 22/04/2025

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History

The patient was a nonsmoker and enjoyed good health in the past. He had a history of new-onset dizziness and one episode of syncope. He was admitted to the hospital, and electrocardiogram (ECG) showed complete heart block with ventricular escape rate about 40 bpm. Clinically, he was not in heart failure, and echocardiography demonstrated normal left ventricular systolic function. Because there was no reversible cause, a dual-chamber pacemaker was implanted. The right ventricular lead was fixed at the right ventricular apex, and the right atrial lead was fixed at the right atrial appendage. The procedure was uneventful, and he was discharged.
One month after discharge, the patient reported a decrease in exercise tolerance and dyspnea.

Current Medications

The patient is on no medications.

Current Symptoms

The patient experienced a decrease in exercise tolerance and dyspnea.

Comments

It is likely new-onset heart failure symptoms occurred after device implantation.

Physical Examination

Laboratory Data

Electrocardiogram

Findings

Atrial sensing and ventricular pacing rhythm, dependent pacing rhythm.

Comments

The ECG showed dependent pacing rhythm.

Chest Radiograph

Findings

The chest radiograph did not show any abnormalities.

Comments

It is necessary to rule out pulmonary disease and see any evidence of congestive heart failure.

Echocardiogram

Findings

Echocardiography revealed decreased systolic function and dyssynchronous contraction (Figures 8-1 and 8-2).

Findings

The echocardiogram also shows improved systolic function and synchronous contraction after upgrade (Figure 8-3).

Magnetic Resonance Imaging

It is contraindicated to proceed to magnetic resonance imaging (MRI) with a history of non–MRI-compatible pacemaker implantation.
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FIGURE 8-1 Short axis view. See expertconsult.com for video.

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FIGURE 8-2 Apical four chamber view. See expertconsult.com for video.

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Catheterization

Catheterization is an appropriate option in this patient.

Hemodynamics

Hemodynamic studies revealed left ventricular end-diastolic pressure of approximately 14 mm H2O.

Findings

The findings on coronary angiogram were normal.

Comments

It is necessary to rule out underlying ischemic heart disease.

Focused Clinical Questions and Discussion Points

Question

What is the clinical diagnosis?

Discussion

Clinically, the patient’s symptoms are compatible with a diagnosis of heart failure. It is necessary to exclude other causes, such as pulmonary disease and undiagnosed ischemic heart disease.

Question

For device interrogation, which pacing parameter is particularly useful to establish the potential diagnosis?
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FIGURE 8-3 Short axis view. See expertconsult.com for video. image

Discussion

Pacing burden is the most important parameter in this case. Pacing burden is directly related to the risk for development of pacing-induced left ventricular systolic dysfunction.

Question

What kinds of investigation are indicated?

Discussion

Echocardiography is essential to establish the diagnosis; in this case it showed evidence of deterioration of systolic function and enabled assessment of the degree of systolic dyssynchrony in this patient. Also, coronary angiogram is indicated in this case and it is important to rule out ischemia-related cardiac dysfunction.

Question

What is the potential treatment for this condition?

Discussion

The cause of systolic dysfunction in this patient is abnormal pacing; therefore upgrading to biventricular pacing was recommended.

Final Diagnosis

The final diagnosis in this case is pacing-induced left ventricular systolic dysfunction with clinical features of heart failure.

Plan of Action

The plan of action for this patient was to correct the underlying dyssynchrony and upgrade to cardiac resynchronization therapy with a pacemaker (CRT-P).

Intervention

The intervention for this patient was to upgrade to biventricular pacing.

Outcome

Postimplantation echocardiography showed improved systolic function, and the degree of dyssynchrony was minimal. Clinically, significant improvement was seen and exercise tolerance was improved.

Comments

This case illustrates the potential risk for pacing-induced left ventricular dysfunction. The risk is particularly high if the patient has an underlying history of systolic dysfunction.4 The cause is mainly pacing-induced mechanical dyssynchrony. Recent studies demontrated that right ventricular pacing causes deterioration of systolic function after 2 years but systolic function was preserved if the patient received biventricular pacing at baseline.1,5 Although baseline systolic function was normal in both groups, the risk for deterioration was related to the degree of pacing burden. As a result, current guidelines recommend implantation of a biventricular pacemaker for those with underlying systolic dysfunction and dependent pacing. Also, guidelines suggest upgrading the device to biventricular pacing on evidence of pacing-induced systolic dysfunction by conventional right ventricular pacing.2,3

Selected References

1. Chan J.Y., Fang F., Zhang Q. et al. Biventricular pacing is superior to right ventricular pacing in bradycardia patients with preserved systolic function: 2-year results of the PACE trial. Eur Heart J. 2011;32:2533–2540.

2. Epstein A.E., DiMarco J.P., Ellenbogen K.A. et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices); American Association for Thoracic Surgery; Society of Thoracic Surgeons. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. J Am Coll Cardiol. 2008;51:e1–e62.

3. Vardas P.E., Auricchio A., Blanc J.J. et al. European Society of Cardiology; European Heart Rhythm Association. Guidelines for cardiac pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association. Eur Heart J. 2007;28:2256–2295.

4. Wilkoff B.L., Cook J.R., Epstein A.E. et al. Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA. 2002;288:3115–3123.

5. Yu C.M., Chan J.Y., Zhang Q. et al. Biventricular pacing in patients with bradycardia and normal ejection fraction. N Engl J Med. 2009;361:2123–2134.

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