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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 medical therapy, but developed bronchoconstriction with beta blockers and a cough on angiotensin-converting enzyme (ACE) inhibitors, and she could tolerate only low doses of an angiotensin receptor blocker. Her medical history included permanent atrial fibrillation and peripheral vascular disease.

Comments

The patient was symptomatic from systolic heart failure and intolerant to medical therapy.

Current Medications

The patient was taking clopidogrel 75 mg daily, furosemide 40 mg daily, losartan 50 mg daily, rosuvastatin 10 mg daily, and isosorbide mononitrate XL 60 mg daily.

Comments

The patient experienced bronchoconstriction while on beta blockers, developed a cough on ACE inhibitors, and was intolerant of doses of losartan higher than 50 mg daily.

Current Symptoms

The patient was in NYHA class III. Her exercise capacity was limited at 200 yards by dyspnea, and she had no angina.

Comments

Dyspnea is the main symptom. The patient rarely experienced intermittent claudication.

Physical Examination

  • BP/HR: 98/52 mm Hg/64 bpm (in atrial fibrillation)

  • Neck veins: Jugular venous pressure not elevated

  • Lungs/chest: Clear

  • Heart: First heart sound (S 1 ) and second heart sound (S 2 ) of normal intensity, apex beat displaced laterally, soft ejection systolic murmur

  • Abdomen: Soft, nontender, no organomegaly

  • Extremities: No pitting edema, weak peripheral pulses

Comments

The patient had cardiomegaly, no evidence of pulmonary edema, and a murmur of mitral regurgitation.

Electrocardiogram

Findings

The electrocardiogram showed atrial fibrillation with a ventricular response of 97 bpm and a QRS duration of 134 ms ( Figure 37-1 ). There was fragmentation of the QRS complex in leads II, III, aV F and V 3 , with no evidence of a bundle branch block.

FIGURE 37-1, Pre-implant electrocardiogram.

Comments

The patient had a high ventricular rate at rest, in the background of intolerance to beta blockers. The QRS duration is in keeping with electrical dyssynchrony. The high ventricular rate raises the possibility of tachyarrhythmia-related left ventricular dysfunction.

Chest Radiograph

Findings

The chest radiograph revealed an increased cardiothoracic ratio, no evidence of pulmonary edema, and sternotomy wires ( Figure 37-2 ).

FIGURE 37-2, Pre-implant chest radiograph.

Comments

The findings on chest radiography were in keeping with heart failure without pulmonary edema.

Echocardiogram

Findings

The echocardiogram showed global left ventricular hypokinesia, inferior akinesis, myocardial thinning at the apex, a pseudospherical left ventricle with severely impaired left ventricular function (LVEF of 29% using Simpson’s method), and biatrial dilation ( Figure 37-3 , A ).

FIGURE 37-3, Pre-implant transthoracic echocardiogram showing an apical. A, Apical four-chamber view. B, Continuous wave Doppler image through aortic valve. C, Color Doppler image through mitral valve.

Comments

The findings on echocardiography were in keeping with ischemic cardiomyopathy.

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