Advanced Heart Failure Exacerbated by Discreet Left Ventricular Lead Non-Capture

Jon Krathen*, John Costello, Mark Moshiyakhov, Raphael Corbisiero and Kulpreet Barn

Advanced Heart Failure Exacerbated by Discreet Left Ventricular Lead Non-Capture.

This case report illustrates a challenging case of worsening heart failure in a previously well-compensated patient with unclear etiology. Further workup revealed the patient’s cardiac resynchronization therapy-defibrillator (CRT-D) left ventricle (LV) lead was losing capture during positional changes. This case demonstrates the importance of device optimization, as well as electrocardiogram (ECG) monitoring to elucidate possible causes of acute systolic heart failure.

This case outlines a 74-year-old male with ischemic cardiomyopathy with a left ventricular ejection fraction of 35% with history of cardiac resynchronization therapy-defibrillator (CRT-D) implantation. He presented with a new drop in functional New York Heart Association (NYHA) heart failure classification, which continued to worsen despite attempts at coronary revascularization and initiation of milrinone therapy. Later hospitalization revealed a change in QRS morphology. Further device interrogation revealed that the patient was losing left ventricle (LV) capture with deep inspiration in a supine position. After replacement of the patient’s
LV lead, the patient had significant improvement in NYHA functional status, and was transitioned to oral heart failure medications.

The most recent echocardiogram prior to his visit the clinic revealed an ejection fraction of 35%, moderate mitral regurgitation, and grossly normal appearing aortic, pulmonic and tricuspid valves. There was no evidence of elevated pulmonary artery systolic pressures. Nuclear viability testing with thalium-201 revealed a large area of inferior infarction with evidence of viability in the inferolateral wall. The patient presented 1/2017 to the cardiology clinic with significant symptoms of dyspnea on exertion. His NYHA functional class dropped from class I to IV.

Heart Res Open J. 2020;7(1): 3-6. doi: 10.17140/HROJ-7-153