4-CHAMBER PACING IN DILATED CARDIOMYOPATHY

A 54-year-old man received a four chamber pacing system for severe con gestive heart failure (NYHA functional Class IV). His ECG showed a lef t bundle branch block (200-msec QRS duration) with 200-msec PR interva l, normal QRS axis, and 90-msec interatrial interval. An acute hemodyn amic study with insertion of four temporary leads was performed prior to the implant, which demonstrated a significant increase in cardiac o utput and decrease of pulmonary capillary wedge pressure. A permanent pacemaker was implanted based on the encouraging results of the acute study. The right chamber leads were introduced by cephalic and subclav ian approaches. The left atrium was paced with a coronary sinus lead, Medtronic SP 2188-58 model. An epicardial Medtronic 5071 lead was plac ed on the LV free wall. The four leads were connected to a standard bi polar DDD pacemaker, Chorus 6234. The two atrial leads were connected via a Y-connector to the atrial channel of the pacemaker with a bipola r pacing configuration. The two ventricular leads were connected in a similar fashion to the ventricular channel of the device. The right ch amber leads were connected to the distal poles. The left chamber leads were connected to the proximal poles of the pacemaker. Six weeks late r, the patient's clinical status improved markedly with a weight loss of 17 kg and disappearance of peripheral edema. His functional class w as reduced to NYHA II, Four chamber pacing is technically feasible. In patients with evidence of interventricular dyssynchrony, this origina l pacing mode probably provides a mechanical activation sequence close r to the natural one. We doubt that this technique will have an impact on long-term survival, but it could be of major importance to improve the patient's well-being and control heart failure.