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