Presentation

• 70 year old male
• Dyspnea on exertion since a year
• Increased since 2 weeks, NYHA III

Clinical findings

• Pulse - 95 bpm, irregular
• Apex displaced inferior and lateral
• S3
• Bilateral crepitations

Echo

• Global hypokinesia with LVEF 15%
• LV - 69mm/61mm. LA - 57mmx70mm
• Severe MR, severe TR
• RVSP = RAP + 49 mm Hg

ECG

Diagnosis

• Dilated Cardiomyopathy
• Heart failure
• Persistent Atrial fibrillation
• Wide QRS - Left bundle branch block

What next ?

• Evaluate for Coronary ischemia and treat if required
• Atrial fibrillation
  • AF induced cardiomyopathy ?
  • Rate or rhythm control ?
  • Anticoagulation ?
• Wide QRS with heart failure - CRT ?

Coronary evaluation

Atrial fibrillation

• Rhythm control
  • Better in heart failure
  • Difficult to achieve with LA enlargement
• Rate control
  • Beta blockers
  • Digoxin

Atrial fibrillation - Anticoagulation

• CHA2DS2-VASc score = 2
• Started on OAC

Cardiac resynchronization therapy

• LBBB morphology
• QRS d > 150 ms
• Non ischemic cardiomyopathy
• Male
• Atrial fibrillation

Cardiac resynchronization therapy

• Biventricular pacing
• His bundle pacing
• Left bundle area pacing
• HOT-CRT / LOT-CRT

DDD pacemaker with left bundle pacing

ECG on pacing

AVJ ablation

Final ECG

Outcome

• Improvement in EF
• Stable NYHA II failure