Outcome of Patient with Refractory Nonischemic Dilated Cardiomyopathy Treated with the First Biventricular Pacemaker in Cambodia

Thu, 1/22/09 - 3:33pm
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$Outcome of Patient with Refractory Nonischemic Dilated Cardiomyopathy Treated with the First Biventricular Pacemaker in Cambodia$

Author(s):

Mam Chandara, MD, William Choe, MD, and *Jeffery Terrell Centre de Cardiologie de Phnom Penh *Field Clinical Specialist, Biotronik USA Phnom Penh, Cambodia

Acute improvement in left ventricular function and mitral insufficiency has been reported using a biventricular pacemaker. In this article, we report on Cambodia’s first biventricular pacemaker implantation.

Case Report

The patient was a 45-year-old Cambodian male with one month of progressive dyspnea on exertion. He presented to Centre de Cardiologie de Phnom Penh in New York Heart Association Class IV congestive heart failure and cardiac cachexia on February 13, 2008. Initial physical examination revealed a blood pressure of 97/63, heart rate of 80 bpm, and elevated jugular venous pressure. Cardiac examination revealed a regular sinus rhythm, enlarged and laterally displaced cardiac point of maximal impulse, S4, S1, S2, and S3 gallop. A mitral systolic murmur with intensity of 4/6 was noted. Pulmonary examination revealed bilateral pulmonary rales. He also had hepatomegaly and 4+ peripheral edema.

Initial electrocardiogram showed sinus rhythm, first-degree AV block, left branch block and left ventricular hypertrophy. Chest X-ray confirmed cardiomegaly and bilateral pulmonary edema. Echocardiography was performed demonstrating enlarged left ventricular dimensions (LVD = 83 mm, LA = 43 mm), severe left ventricular dysfunction with an estimated ejection fraction of less than 10% with left ventricular dysynchrony, and severe mitral regurgitation with elevation of pulmonary pressure at 50 mmHg. The patient was placed on furosemide 80 mg IV, carvediolol 6.25 mg, and dobutamine infusion. After several days of medical therapy, he continued to have NYHA Class IV heart failure. He also developed atrial fibrillation with a ventricular rate of 80-90 bpm. Due to his refractory congestive heart failure status, a biventricular pacemaker was recommended. However, a current generation biventricular device was not available at that time. A dual-chamber pacemaker and standard pacing leads, a “Y” adapter, and a coronary sinus lead were available. We decided to proceed and “Y” adapt the leads into a dual-chamber pacemaker on February 22, 2008.

Procedure

References:

1. Ypenburg C, Lancellotti P, Tops L, et al. Acute effects of initiation and withdrawal of cardiac resynchronization therapy on papillary muscle dyssynchrony and mitral regurgitation. J Am Coll Cardiol 2007;50:2071-2077.
2. Ypenburg C, Lancellotti P, Tops L, et al. Mechanism of improvement in mitral regurgitation after cardiac resynchronization therapy. Eur Heart J 2008;29:757–765.
3. Bulava A, Lukl J, Skvarilova M. Dramatically improved left ventricular function after biventricular pacemaker implantation — A case report. Eur J Heart Failure 2005;7:231-233.