An unusual case of ventricular resynchronization from endocardial right ventricular apex

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Congenital heart disease with postoperative complete atrioventricular block and severe left ventricular dysfunction (n=1). Intervention: Dual-chamber pacemaker implantation with endocardial right ventricular apical septal lead placement. Primary outcome: Left ventricular systolic function (LVEF and global longitudinal strain).

Q: What does this research mean for the field?

Endocardial right ventricular apical pacing closely adjacent to the left ventricular apex can achieve ventricular resynchronization and significantly improve left ventricular systolic function in specific anatomical configurations. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Carla Favoccia; Massimo Stefano Silvetti; Gabriele Rinelli; Aurelio Secinaro; Sonia Albanese; Fabrizio Drago

doi:10.1016/j.hrcr.2024.08.018

August 23, 2024HeartRhythm Case ReportsOpen Access

An unusual case of ventricular resynchronization from endocardial right ventricular apex

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Key result

Targeted endocardial RVA pacing improves LVEF by ~30 percentage points at 8 months.

n=1

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Why the study?

Right ventricular apical pacing or left bundle branch block may cause left ventricular dyssynchrony and dysfunction.

Key Points

To report a case of unexpected left ventricular resynchronization and systolic recovery achieved via right ventricular apical lead placement in a patient with complex congenital heart disease.
Evaluated a 27-year-old patient with congenital heart disease who developed left bundle branch block and intermittent complete atrioventricular block after multiple cardiac surgeries.
Performed transvenous dual-chamber pacemaker implantation, positioning the ventricular lead at the right ventricular apex after pacing demonstrated a right bundle branch block morphology.
Assessed lead location and cardiac mechanics using fluoroscopy, intraoperative echocardiography, postoperative computed tomography, and electrocardiography during an 8-month follow-up.
Pacing from the right ventricular apex unexpectedly produced a right bundle branch block pattern with left axis deviation rather than the typical left bundle branch block pattern.
Left ventricular ejection fraction improved from 30% pre-procedure to 60%, and global longitudinal strain improved from -10% to -18%, remaining stable at 8-month follow-up.
Computed tomography confirmed the lead tip resided in the right ventricular apical endocardium directly adjacent to the external left ventricular apical wall.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 male patient (age 27) with complex congenital heart disease, left persistent superior vena cava, postoperative complete AV block, LBBB, and severe LV dysfunction (LVEF 30%), followed for 8 months.

I

Intervention

Dual-chamber pacemaker implantation (DDD 60–170 beats/min) via right-sided access with a stylet-driven transvenous ventricular lead positioned in the endocardial right ventricular apex (RVA) in septal position, close to the LV most external apical wall, followed for 8 months.

O

Outcome

Left ventricular electromechanical resynchronization and systolic function (LVEF and global longitudinal strain) on echocardiography at 8-month follow-up.surrogate

Limitations

Single case report
Result could be rarely reproducible due to the peculiar postsurgical anatomy of this patient
Single patient case report
Results are rarely reproducible and dependent on the peculiar postsurgical anatomic relationship of the right and left ventricular apices

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Implication

Demonstrates that in patients with complex postsurgical congenital heart anatomy where the right ventricular apex lies beneath the left ventricular apex, endocardial RV apical pacing can fortuitously achieve ventricular resynchronization and normalize LV systolic function.

Abstract

Right ventricular apical pacing or left bundle branch block (LBBB) may cause left ventricular (LV) dyssynchrony and dysfunction. Alternative pacing sites, including conduction system pacing, have been proposed to prevent or reduce LV dysfunction in young patients with complete atrioventricular block.

Discussion

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Cite This Study

Favoccia et al. (2024) conducted a case report in Congenital heart disease with postoperative complete atrioventricular block and severe left ventricular dysfunction (n=1). Dual-chamber pacemaker implantation with endocardial right ventricular apical septal lead placement was evaluated on Left ventricular systolic function (LVEF and global longitudinal strain). Endocardial right ventricular apical pacing near the left ventricular apex improved LVEF from 30% to 60% and global longitudinal strain from -10% to -18% at 8 months.

synapsesocial.com/papers/6a7c5ed199c6d6845826ba7d https://doi.org/10.1016/j.hrcr.2024.08.018

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An unusual case of ventricular resynchronization from endocardial right ventricular apex

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

An unusual case of ventricular resynchronization from endocardial right ventricular apex

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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