Case 1:
A 75-year-old male presented with frequent syncopal episodes in the last 4 years, last episode being 20 days prior to the admission in our hospital. There was no history of angina or dyspnea on exertion. There was no history suggestive of any familial cardiac illness and sudden cardiac death.
On clinical examination, he was found to have a pulse rate of 40 bpm with blood pressure of 112/70 mmHg. Cardiomegaly was present with grade 2/6 pansystolic murmur at apex. ECG showed features of atrial flutter with CHB, narrow QRS escape with rate of 35-40 bpm, and incomplete right bundle branch block (Fig 1A). Chest- X- ray showed cardiomegaly. Transthoracic echocardiography (TTE) showed dilated right atrium (RA), apical obliteration of right ventricle (RV), moderate tricuspid regurgitation (TR) with good left ventricular (LV) function. RV angiogram (Figure 1C) in the RAO view shows bipartite RV, calcified and obliterated RV apex, partially obliterated RV body with normal RV inflow and outflow, mildly dilated RV outflow tract, irregularly shaped LV cavity and moderate diastolic mitral regurgitation.
A diagnosis of biventricular EMF with atrial flutter and CHB was made. The patient was planned for permanent pacemaker implantation. Lead parameters at multiple RV positions were suboptimal due to the obliterated RV body apex and body. Hence, coronary sinus was cannulated and LV active fixation lead (Attain Stability®, Model 4796-88 cm, Medtronic, Minneapolis, MN, USA) was positioned at the lateral tributary of coronary sinus. Lead parameters (bipolar threshold 1.3 V @ 0.5 ms, impedance 662 Ohms, R wave 17 mV) were found to be satisfactory. Post procedure fluoroscopy shows good lead position (Fig 1,D-G). Patient is symptom-free with no worsening of lead parameters at 4 years of follow up.