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1、TC YungPaediatric Cardiology UnitGrantham HospitalHong Kong,Biventricular pacing in a baby with RV pacing induced heart failure,The 10th South China International Congress of Cardiology,Guangzhou,2008,Male babyAntenatalat 21 week of gestation noted have bradycardia and AV blockmother anti Ro,RF+ve L
2、SCS at 35 weeks for progressive fetal heart failure,birth weight 2.36 kgPost-natal Respiratory distressCXR:cardiomegaly,CT ratio 67%Put on nasal CPAP+Isoprenaline infusion,CT ratio 67%,Transfer to TGH on the day of birthEcho showed normal heart structure,LVSF 38.9%,LVEDD 2.78cm LVEF 77.2%HR 50-60/mi
3、n,systolic BP 55mmHg while on isoprenaline infusion,Epicardial pacemaker insertion the second day after admissionRA RV(inferior wall)pacing DDD(90-180/min),Post epicardial DDD pacing:CT ratio 67.9%,Measurement at Operation Leads 4965 steroid-eluted leads for both RA and RV Generator-Sensia SE DR 01
4、DDDRImpedance-V lead 589-A lead 343 A pacing threshold-1.8V 0.5msV pacing threshold-1.6V 0.5ms R wave8.8mvP wave3.4mv,Paradoxical septal motion,LVEDD 2.1cm,FS 25.3%,LVEF 58%,3 days after RV pacing,ECHO post DDD pacing:,ECHO before DDD pacing:,Pericardial effusion,Short axis view,Long axis view,Day 1
5、2 post pacing,Surgical drainage of pericardial fluid(30cc),LVEDD 2.76cm,FS 14.6%,EF 37.8%Dilated LV cavity,3 weeks post pacingDischarge from hospital with diuretics Pacing rate 70-180/min,3.5 months post RV pacingSignificant heart failure symptom:tachypnea and fluid retentionEcho-dilated LV,LVEDD 3.
6、3 cm-Moderate tricuspid and mitral incompetence Poor LV contraction,LVFS 5%LVEF 14.3%ECG showed irregular rhythm,Wenckebach phenomenon due to rapid atrial rate while on DDD pacingPace mode changed to VVI 130/minHospitalized for dobutamine infusion,ECHO progressive LV dilatation,Severe LV dysynchrony
7、,LVPW Septal delay 255ms,3 days after admissionWhen VVI turned off intrinsic escape rhythm,synchronized LV contraction pacing rate to 55/min and started isoprenaline to promote synchronized contraction,But heart failure continued to deteriorateThe baby was intubated for 5 daysRV pacing rate was incr
8、eased to 120/minPlan Biventricular epicardial pacing,LV epicardial pacing LV lead threshold=1.0 v,0.4msRV/LV delay=4ms(LV first),1 day after biventricular pacing,Post bivent pacingLVPW Septal delay 65ms,DDD RV pacing LVPW Septal delay 255ms,Second day post biventricular pacingLVEDD 3.24cm,LVSF 20.6%
9、,mild mitral incompetence,Second day post biventricular pacing Sense AV intervals VTI of LVOT50ms8.380ms9.1100ms9.1120ms8.5140ms5.8 V-V delay LV first VTI of LVOT(sense AV 100ms)4 ms7.812ms7.520ms6.8 40ms7.5,Biventricular pacing QRD duration:100 ms,Post epicardial DDD(RA RV)pacing 90-180 ppm QRS dur
10、ation 120 ms,DDD RV pacing QRS duration:120 ms,Biventricular pacing QRD duration:100 ms,1 week after Bivent pacing Home with diuretics and ACEILVEDD 3.19cm,LVSF 20.2%LVEF 49.3%Septal-LVPW delay 65ms10 days after Bivent pacing LVEDD 3.02cm,LVSF 26.7%,LVEF 60.0%17 days after Bivent pacing LVEDD 2.51cm
11、,LVSF 27.8%,LVEF 62.5%4 weeks post Bivent pacingLVEDD 2.4cm,LVSF 33%LVEF 69.9%,3 weeks after Bivent pacing,5 months post Bivent pacingLVEDD 2.5cm,LVSF 44%,LVEF 82%no mitral incompetenceOff medication,9 months post biventrcular pacing LVEDD 2.32cm,FS 32.5%LVEF 67.2%,LV size and LV ejection fraction,c
12、m,Bivent pacing,Admission for heart failure,Summary:RV pacing may occasionally induced severe LV dysfunction secondary to LV dysynchronyLV dysfunction may be evident within 2 weeks after RV pacing and progress to dilated cardiomyopathyBiventricular pacing(CRT)can correct the LV dysynchrony and the dilated cardiomyopathy,Post epicardial DDD(RA RV)pacing 90-180 ppm QRS duration 120 ms,5 months post Bivent pacingLVEDD 2.5cm,LVSF 44%,LVEF 82%no mitral incompetenceOff medication,
