Case 2:
A 54-year-old male was admitted with history of exertional dyspnea for
18 months. Clinical examination revealed an irregularly irregular pulse
at rate of 40 bpm with blood pressure 160/70 mmHg and elevated JVP. Mild
cardiomegaly was present with grade 2/6 pan systolic murmur at apex.
ECG (Fig 2A) revealed atrial fibrillation (AF) with ventricular rate of
40 bpm and normal axis. Echocardiography showed dilated RA, obliterated
RV apex, moderate TR and mild mitral regurgitation. A 24-hour Holter
showed evidence of high-grade AV block.
RV angiography (Fig 3, A and B) shows involvement of RV inflow with
calcified and obliterated RV apex, dilated RV outflow and significant
TR. Smooth endocardial border was visualized in the LV angiogram
suggestive of LV involvement. A diagnosis of biventricular EMF with AF
and CHB was made. Electrophysiological study showed high pacing
threshold at RV endocardium along with poor R wave sensing. Coronary
sinus was cannulated and LV lead (Corox ProMRI 0TW-S, Biotronik) was
positioned at the middle cardiac vein distally. Post procedure chest
X-ray (Fig 3 C and D) showed optimal lead position. Lead parameters
remained stable at 4 years of follow up.