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TC Yung Paediatric Cardiology Unit Grantham Hospital Hong Kong,Biventricular pacing in a baby with RV pacing induced heart failure,The 10th South China International Congress of Cardiology, Guangzhou, 2008,Male baby Antenatal at 21 week of gestation noted have bradycardia and AV block mother anti Ro, RF + ve LSCS at 35 weeks for progressive fetal heart failure, birth weight 2.36 kg Post-natal Respiratory distress CXR : cardiomegaly, CT ratio 67% Put on nasal CPAP + Isoprenaline infusion,CT ratio 67%,Transfer to TGH on the day of birth Echo showed normal heart structure, LVSF 38.9%, LVEDD 2.78cm LVEF 77.2% HR 50-60/min, systolic BP 55mmHg while on isoprenaline infusion,Epicardial pacemaker insertion the second day after admission RA 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 DDDR Impedance - V lead 589 - A lead 343 A pacing threshold - 1.8V 0.5ms V pacing threshold - 1.6V 0.5ms R wave8.8mv P 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 12 post pacing,Surgical drainage of pericardial fluid (30cc),LVEDD 2.76cm, FS 14.6%, EF 37.8% Dilated LV cavity,3 weeks post pacing Discharge from hospital with diuretics Pacing rate 70-180/min,3.5 months post RV pacing Significant heart failure symptom: tachypnea and fluid retention Echo- dilated LV, LVEDD 3.3 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 pacing Pace mode changed to VVI 130/min Hospitalized for dobutamine infusion,ECHO progressive LV dilatation,Severe LV dysynchrony, LVPW Septal delay 255ms,3 days after admission When 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 deteriorate The baby was intubated for 5 days RV pacing rate was increased to 120/min Plan Biventricular epicardial pacing,LV epicardial pacing LV lead threshold = 1.0 v , 0.4ms RV/LV delay = 4ms (LV first),1 day after biventricular pacing,Post bivent pacing LVPW Septal delay 65ms,DDD RV pacing LVPW Septal delay 255ms,Second day post biventricular pacing LVEDD 3.24cm, LVSF 20.6%, mild mitral incompetence,Second day post biventricular pacing Sense AV intervals VTI of LVOT 50ms8.3 80ms9.1 100ms9.1 120ms8.5 140ms5.8 V-V delay LV first VTI of LVOT (sense AV 100ms) 4 ms7.8 12ms7.5 20ms6.8 40ms7.5,Biventricular pacing QRD duration: 100 ms,Post epicardial DDD (RA RV ) pacing 90 -180 ppm QRS duration 120 ms,DDD RV pacing QRS duration: 120 ms,Biventricular pacing QRD duration: 100 ms,1 week after Bivent pacing Home with diuretics and ACEI LVEDD 3.19cm, LVSF 20.2% LVEF 49.3% Septal-LVPW delay 65ms 10 days after Bivent pacing LVEDD 3.02cm, LVSF 26.7%, LVEF 60.0% 17 days after Bivent pacing LVEDD 2.51cm, LVSF 27.8% ,LVEF 62.5% 4 weeks post Bivent pacing LVEDD 2.4cm, LVSF 33% LVEF 69.9%,3 weeks after Bivent pacing,5 months post Bivent pacing LVEDD 2.5cm, LVSF 44% , LVEF 82% no mitral incompetence Off medication,9 months post biventrcular pacing LVEDD 2.32cm, FS 32.5% LVEF 67.2%,LV size and LV ejection fraction,cm,Bivent pacing,Admission for heart failure,Summary: RV pacing may occasionally induced severe LV dysfunction secondary to LV dysynchrony LV dysfunction may be evident within 2 weeks after RV pacing and progress to dilated cardiomyopathy Biventricular 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 pacing LVEDD 2.5cm, LVSF 44% , LVEF 82% no mitral incompetence Off medication,
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