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.