DDD pacemaker for severe heart failure-alternate to CRT
The following case report appears in the Indian Heart Journal.

A 77-yr old diabetic diagnosed as dilated cardiomyopathy since about 2years presented to the emergency department with sudden onset severe breathlessness and was in a circulatory collapsed state. He was immediately put on ventillatory support and initial high doses of parenteral Inotropes.

His ECG showed sinus tachycardia and LBBB with QRS duration of 160 ms. Echocardiography showed dilated LV with global hypokinesia and left ventricular ejection fraction [LVEF] of 15%–18%. Later he could be weaned off the ventilator but was dependent on inotropic support. The biochemical parameters stabilized. He demonstrated no atrial or ventricular arrhythmias. His earlier echocardiography showed dilated left ventricular and LVEF of 20% and coronary angiography revealed normal coronaries.

He had been on full medical treatment and the need for CRT device was strongly explained to the patient but the financial constraints prevented it to be implanted. After explaining the pros and cons a Dual Chamber Pacemeker [DDD] was implanted with Right Atrial [RA] – isolated Left Ventricular [LV] pacing, using J curve atrial [isoflex 52 cm is1] lead for right atrum and S curve LV bipolar [isoflex 86 cm is 1] lead for LV pacing via Coronary sinus and into the left postero-lateral coronary vein. AV synchrony and LV pacing were tested.

The lead parameters were atrial capture 0.5 V and impedence 473 ohm and the Left Ventricular capture was 0.7 V and impedence 648 ohm. The ECG revealed change from LBBB to RBBB. Using Echo-Doppler guidance Pacemaker AV interval was set at 90 msec. His hemodynamics showed an encouraging immediate increase in the central pressures and showed a change in the contours of the pressure waves from a bifid to sharp upstroke.

The inotropic support was immediately withdrawn. Patient showed remarkable clinical improvement and the Echocardiography post implantation showed disappearance of IVS jerky movement and LVEF of 30% −35%. Patient was discharged in 2 days and in the followed up regularly at two weeks interval.

At the end of four months patient is completely asymptomatic,and ECG repeatedly showed RA sense and LV pacing. Echocardiography showed at four months a decrease in LV dimensions and global LVEF of 50%–55%. Patient is not only has now a good exercise tolerance but also has a normal social life.

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