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Role of Remote Monitoring in Managing a Patient on Cardiac Resynchronization Therapy : Atrial Fibrillation

Age Gender Occupation Working Diagnosis 69 Years Male Retired Accountant Persistent Atrial Fibrillation After Cardiac Surgery History In March 2012 this 68-year-old male patient sought treatment for chest pain. Non–ST segment elevation myocardial infarction (NSTEMI) was diagnosed, and, on catheterization, the patient was found to have severe three-vessel disease. This was unsuitable for percutaneous coronary intervention. He was therefore treated with bypass grafting and mitral valve…

Role of Remote Monitoring in Managing a Patient on Cardiac Resynchronization Therapy: Medical Therapy and Device Optimization

Age Gender Occupation Working Diagnosis 54 Years Male Business Entrepreneur Non-ischemic idiopathic cardiomyopathy History This 54-year-old man first sought treatment in 2005 with symptoms of progressive dyspnea on exertion, pedal edema accompanied by paroxysmal nocturnal dyspnea, and orthopnea. He had initially been treated in the community for upper respiratory tract infection with oral antibiotics but then developed symptoms of shortness of breath and fatigue. On further…

Role of Left Atrial Pressure Monitoring in the Management of Heart Failure

Age Gender Occupation Working Diagnosis 60 Years Male Teacher Congestive Heart Failure, Stage C, New York Heart Association Class III History This 60-year-old man had coronary atherosclerosis, left bundle branch block (LBBB) with a QRS duration of 154 ms, peripheral vascular disease, and cardiomyopathy. He sought an opinion regarding management of his cardiomyopathy, which was diagnosed 10 years previously after he went to a local emergency…

Pulmonary Hypertension and Cardiac Resynchronization Therapy: Evaluation Prior to Implantation and Response to Therapy

Age Gender Occupation Working Diagnosis 58 Years Male Sales Representative Systolic Heart Failure with Severe Pulmonary Hypertension History The patient was referred from another center for consideration of cardiac resynchronization therapy (CRT) for long-standing ischemic cardiomyopathy and progressive heart failure symptoms. At time of referral he described New York Heart Association (NYHA) class III symptoms despite optimal medical therapy. The patient’s history included ischemic heart disease,…

Intrathoracic Impedance (Dietary Incompliance)

Age Gender Occupation Working Diagnosis 65 Years Male Businessman OptiVol Alert for Fluid Overload History In August 2008 the patient received a biventricular implantable cardioverter-defibrillator (ICD; Concerto, Medtronic, Minneapolis, Minn.) due to dilated cardiomyopathy with symptomatic heart failure (New York Heart Association [NYHA] class III) despite optimal pharmacologic treatment. Before implantation, his left ventricular ejection fraction (LVEF) was 20%, with a pattern of global hypokinesia. He…

Significant Residual or Worsening Mitral Regurgitation (MitraClip)

Age Gender Occupation Working Diagnosis 76 Years Female Retired Cardiac Resynchronization Therapy Nonresponder with Persistent Severe Mitral Regurgitation History This 76-year-old female patient was referred to us for persistent heart failure symptoms in New York Heart Association [NYHA] class III to IV and severe functional mitral regurgitation (FMR) despite optimal therapeutic management combining medication, previous biventricular implantable cardioverter-defibrillator (ICD) (cardiac resynchronization therapy defibrillator [CRT-D]) implant, and…

Recognition of Anodal Stimulation

Age Gender Occupation Working Diagnosis 68 Years Male Retired Businessman Ischemic Cardiomyopathy History This 68-year-old man had a history of non-ST elevation myocardial infarction in 2008 and percutaneous coronary intervention with incomplete revascularization to triple-vessel disease. He developed atrial fibrillation and congestive heart failure in 2010. An echocardiogram showed a left ventricular ejection fraction (LVEF) of 19%, left ventricular end-diastolic volume of 146 mL, and left…

Nonresponders to Cardiac Resynchronization Therapy: Switch-Off If Worsening

Age Gender Occupation Working Diagnosis 79 Years Male Retired Golf Professional Ischemic Cardiomyopathy, Remote Cardiac Arrest, Congestive Heart Failure, and Left Bundle Branch Block History This 79-year-old man with type II diabetes, hypertension, 2.5 pack per day smoking history for 46 years, and a strong family history of premature coronary disease (father died at 61 years of age of myocardial infarction) suffered a myocardial infarction in…

Cardiac Contractility Modulation in a Nonresponder to Cardiac Resynchronization Therapy

Age Gender Occupation Working Diagnosis 53 Years Male Retired Dilated and Ischemic Cardiomyopathy with New York Heart Association Heart Failure Class III to IV Symptoms History A 53-year-old man of Greek origin was diagnosed with dilated cardiomyopathy in 1996, at which time his left ventricular ejection fraction (LVEF) was described as moderatelely to severely reduced and coronary artery disease was initially excluded by angiography. The patient…

Management of Frequent Ventricular Extrasystoles

Age Gender Occupation Working Diagnosis 83 Years Male Retired Veterinarian Nonresponder to Cardiac Resynchronization Therapy History An 83-year-old man had undergone implantation of a dual-chamber pacemaker 12 years previously for intermittent high-grade atrioventricular block. He did well for several years, but at age 79 experienced symptoms of congestive heart failure. During the initial hospitalization he was found to have significantly reduced left ventricular systolic function, with…

Difficulties in Prediction of Response to Cardiac Resynchronization Therapy

Age Gender Occupation Working Diagnosis 46 Years Male Engineer Dilated Cardiomyopathy History The patient was diagnosed with myasthenia gravis at the age of 40 years. He reported no cardiologic symptoms until January 2009, when he started experiencing dyspnea on effort. In May 2009 he patient was hospitalized because of congestive heart failure; the echocardiographic examination revealed severe left ventricular dilation and dysfunction. Diuretics and angiotensin-converting enzyme…

Role of Scar Burden Versus Distribution Assessment by Cardiovascular Magnetic Resynchronization in Ischemia

Case 1 Age Gender Occupation Working Diagnosis 63 Years Male Businessman Acute Coronary Syndrome History A 63-year-old man presented to the emergency room with recent-onset episodic chest discomfort described as “muscle ache.” The chest discomfort was radiating to the upper neck and both arms, associated with a tingling sensation. It was not reproducible or worsened on deep inspiration. He recently noticed dyspnea with minimal effort without…

Use of Cardiovascular Magnetic Resonance to Guide Left Ventricular Lead Deployment in Cardiac Resynchronization Therapy

Age Gender Occupation Working Diagnosis 82 Years Female Retired Factory Worker Heart Failure Caused by Ischemic Cardiomyopathy History An 82-year-old woman who had a myocardial infarction and a coronary artery bypass graft (CABG) in 1997 developed progressive dyspnea and limitation of exercise tolerance to 200 yards (New York Heart Association [NYHA] class III) in 2010. After the diagnosis of systolic heart failure, she was started on…

Cardiac Resynchronization Therapy in Non–Left Bundle Branch Block Morphology

Age Gender Occupation Working Diagnosis 62 Years Female Retail Sales Agent Nonischemic Cardiomyopathy History A 62-year-old woman was seen at the cardiology outpatient clinic. Her medical history was significant for the onset of mild heart failure symptoms 2 years previously. She had a past left ventricular ejection fraction (LVEF) of 32% and a diagnosis of nonischemic cardiomyopathy because no significant coronary artery disease was seen on…

Complications of Cardiac Resynchronization Therapy: Infection

Age Gender Occupation Working Diagnosis 86 Years Male Retired Farmer Infection Related to Cardiac Resynchronization Therapy History An 86-year-old gentleman was seen in the clinic for concerns regarding drainage at the site of his cardiac device on the left chest wall. His history was significant for ischemic heart disease and sinus node dysfunction, for which he had undergone pacemaker placement 2 years previously. At that time,…

Extraction of a Biventricular Defibrillator with a Starfix 4195 Coronary Venous Lead

Age Gender Occupation Working Diagnosis 58 Years Male Retired Cardiac Resynchronization Therapy Defibrillator System Infection History A 58-year-old man with ischemic cardiomyopathy with an ejection fraction of 20%, a history of coronary artery bypass graft surgery in 1993, and placement of a biventricular defibrillator (Medtronic Concerto; Guidant 0185 RV ICD lead; Attain Starfix 4195 coronary venous lead) on October 25, 2007 for primary prevention, a history…

A Difficult Case of Diaphragmatic Stimulation

Age Gender Occupation Working Diagnosis 70 Years Female Retired Phrenic Nerve Stimulation After Cardiac Resynchronization Therapy Implant History A 70-year-old woman with nonischemic cardiomyopathy, with New York Heart Association (NYHA) class III symptoms, a left ventricular ejection fraction (LVEF) of 22%, left ventricular end-diastolic dimension of 72 mm, QRS duration of 170 ms, and a left bundle branch block pattern ( Figure 33-1 ) was referred…

Guide Wire Fracture During Cardiac Resynchronization Therapy Implantation and Subsequent Management

Age Gender Occupation Working Diagnosis 65 Years Male Ex-banker, Retired for 2 Years Guide Wire Fracture During Implantation of Cardiac Resynchronization Therapy Device History A 65-year-old man with ischemic dilated cardiomyopathy, already treated by stenting of the anterior interventricular coronary artery and then by coronary artery bypass graft surgery, received a dual-chamber implantable cardioverter-defibrillator (ICD) 4 years previously for primary prevention of sudden cardiac death. At…

Resumption to Sinus Rhythm After Cardiac Resynchronization Therapy in a Patient with Long-Lasting Persistent Atrial Fibrillation

Age Gender Occupation Working Diagnosis 81 Years Male Retired Ischemic Dilatative Cardiomyopathy with Long-Lasting Persistent Atrial Fibrillation History An 81-year-old patient with type 2 diabetes and hypertension as cardiovascular risk factors sought treatment because of effort-related dyspnea (New York Heart Association [NYHA] class III) and presyncopal episodes. A complete cardiologic assessment was performed. On the baseline electrogram (ECG), atrial fibrillation with incomplete left bundle branch block…

Up and Down in Device Therapy

Age Gender Occupation Working Diagnosis 79 Years Male Retired Right Ventricular Pacing–Induced Impaired Ejection Fraction History The patient underwent bypass surgery (left internal mammary artery to left anterior descending artery and saphenous vein graft to distal right coronary artery) 13 years previously. Three months later, routine Holter electrocardiogram (ECG) monitoring revealed asymptomatic episodes of second-degree and third-degree atrioventricular block. The patient refused pacemaker implantation because of…