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Postoperative chest-X-ray showing CRT-D device.
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We present the case of a 46-year old male with end-stage heart failure due to ethyltoxic cardiomyopathy. The patient did not
meet the criteria for heart transplantation and declined left ventricular assist device implantation. We decided to conduct
cardiac resynchronization therapy defibrillator (CRT-D) implantation. Under general anaesthesia for C...
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... of the patient stabilized and he could be transferred to the intensive care unit (ICU). During the following 5 days, repeated attempts to wean the patient from ECMO failed due to deteriorating haemodynamics. We decided to proceed with CRT-D implantation while still on ECMO support. A Medtronic ® Maximo II CRT-D device was successfully implanted (Fig. 1). Stimulation threshold showed good results with 0.5 V/0.5 ms for the right atrium, 0.5 V/0.5 ms for the right and 1.0 V/0.5 ms for the left ventricle. Programmed atrio-ventricular (AV) delay was 180 ms and programmed ventricular stimulation time was RV-LV 0 ms. Under biventricular stimulation with 80 bpm, cardiac function improved ...
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Objectives:
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Citations
... To our knowledge, there are no published studies on refractory cardiogenic shock (defined by clinical, biological and echography spectrum) in ACM treated with VA-ECMO. Only 1 case of ACM treated by VA-ECMO has been reported, and the authors focused only on the interest of resynchronization therapy for the weaning of VA-ECMO [4]. ...
Even though alcoholism is a major health concern, alcoholic cardiomyopathy is a little-known pathology. The exact prevalence remains elusive (20-40% of dilated cardiomyopathy). However, it can lead to dilated cardiomyopathy, heart failure and refractory cardiogenic shock. The literature on cardiogenic shock in alcoholic cardiomyopathy is limited. We report 4 cases of patients with refractory cardiogenic shock due to heavy alcohol consumption, who were treated with venoarterial extracorporeal membrane oxygenation. The evolution was favourable with recovery in 3 patients and the need for heart transplantation in 1 patient. After 3-5 years, all patients are alive, 2 of 4 are sober, all of them are on cardiac follow-up and none of them have presented with a cardiac relapse.
... There have been few selective studies and case reports investigating the usefulness of "rescue" CRT in patients with non-ambulatory New York Heart Association (NYHA) functional class IV HF or cardiogenic shock. [3][4][5][6][7] Most attempts, however, have been unsuccessful. For example, in a retrospective study by Mantziari et al 3) 24 patients underwent CRT implantation during hospitalization in the cardiac critical care unit. ...
65-year-old woman was admitted to our hospital with acute decompensated heart failure with reduced left ventricular ejection fraction and severe mitral regurgitation. Electrocardiography revealed a typical left bundle branch block and atrial fibrillation. Her condition deteriorated despite administering high-doses of inotropes and vasopressors. Pending a decision to therapy, venoarterial extracorporeal membrane oxygenation (ECMO) was performed when the patient underwent a cardiogenic shock. Although the hemodynamic status stabilized with ECMO support, weaning the patient from ECMO was not possible. Thus, we decided to perform cardiac resynchronization with defibrillator implantation as a “rescue” therapy. Five days post-implantation, the patient was successfully weaned from ECMO.
... Although several large cohort studies regarding CRT in pediatric patients have been reported [4,5], most reports are case series that focus on heart failure after surgery for congenital heart diseases, right ventricular pacing-induced cardiomyopathy, and heart failure in patients with a functional single ventricle. In our case, DCMP is a rare disease entity for CRT in the pediatric population, and it is extremely rare that CRT is performed during ECMO in infants despite several reports for adults [6,7]. It is challenging to perform CRT in a small infant during ECMO. ...
Although heart transplantation is a final therapeutic option in pediatric patients with dilated cardiomyopathy (DCMP),
the shortage of pediatric heart donors is a major obstacle. In adults with DCMP characterized by cardiac dyssynchrony,
cardiac resynchronization therapy (CRT) is known to be an effective treatment option. However, there is a
lack of evidence on the effectiveness of CRT in infants with DCMP. Several studies have reported improvement in
hemodynamics and cardiac performance following CRT in infants with DCMP. Here, we report CRT in an infant
with DCMP during extracorporeal membrane oxygenation with 5 months of follow-up.
Bradyarrhythmias represent a common pathology in the intensive care unit (ICU) with etiologies of varying severity. Treatment has often been focused on correcting underlying causes and may require pacing for urgent hemodynamic support. In recent years, there has been interest in physiologic pacing modalities which avoid the dyssynchrony from right ventricular (RV) only pacing. Cardiac resynchronization therapy (CRT) through biventricular pacing is a well-established device-based electrical therapy in patients with wide QRS and heart failure. Recently, it has been shown that biventricular pacing may also be pursued for hemodynamic rescue in the ICU setting. Efforts to re-engage the conduction system with His bundle pacing or further downstream have also emerged as alternative means to deliver resynchronization, with early applications in the ICU now being reported. The goal of the review is to examine bradyarrhythmia causes and management in the ICU as well as investigate new approaches in physiologic pacing and their potential roles in critically ill patients.
Extracorporeal membrane oxygenation provides effective circulatory support while waiting for cardiac recovery in patients with potentially reversible heart disease, or for heart transplantation, or for implantation of a ventricular assist device (VAD) in patients with terminal heart disease [1–4].
Pecha et al. [1] report the interesting case of a 46-year old patient with end-stage heart failure and ventricular dys-synchrony who underwent successful implantation of a cardiac resynchronization therapy device while on extracorporeal membrane oxygenation support. This proved to have tremendous beneficial effect on the haemodynamic status of the patient who was able to be weaned from ECMO support a few hours after implantation. We would like to add a brief comment regarding the use of temporary biventricular pacing after cardiac surgery. According to the literature, little is known about cardiac resynchronization therapy in acute heart failure or in the immediate period after cardiac surgery.
Cannesson et al. [2] were the first to publish the successful use of cardiac resynchronization therapy in the early period after cardiac surgery. A 68-year-old patient with congestive heart failure and cardiac dys-synchrony underwent mitral valve annuloplasty; weaning from catecholamines was achievable after implantation of a biventricular pacing system on postoperative day 10.
Biventricular pacing is an established therapy for patients with advanced heart failure associated with left ventricular dysfunction and intraventricular conduction delay [3]. Moreover, in patients with left ventricular dysfunction and cardiac dys-synchrony undergoing coronary artery bypass grafting, the postoperative outcome is influenced by cardiac dys-synchrony. Maruskova et al. [4] showed that patients with the most severe dys-synchrony had the worst outcome, and they concluded that cardiac dys-synchrony is an important determinant of postoperative outcomes in this patient population.
Permanent biventricular pacing is currently the standard of care for patients with advanced heart failure and intraventricular conduction delay [3]. Although the long-term benefits of biventricular pacing are appreciated several months after implantation, the haemodynamic effects of changes to pacing parameters are reflected acutely by metrics such as stroke volume and ventricular dys-synchrony. This prompt haemodynamic amelioration was shown in a recent randomized trial. The BiPACS trial [5] (Biventricular Pacing after Cardiac Surgery) is the first randomized study to assess the role of temporary biventricular optimization at multiple time points in the perioperative cardiac surgical setting. Temporary biventricular pacing increases intraoperative cardiac output by up to 14% in patients with left ventricular dysfunction undergoing cardiac surgery.
Patients with prior ventricular dysfunction and large QRS complexes are among the highest-risk cardiac surgical patients and are an appropriate group in which to assess the benefit of temporary biventricular pacing. The postoperative mechanisms by which biventricular pacing acutely reduces dys-synchrony and improves haemodynamic status are still an area of ongoing investigation.
Conflict of interest: none declared
