|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 2 | Page : 132-134
Acute heart failure within 10 days of dual-chamber pacemaker implantation: A novel etiology
Joseph G Noto1, Jesse A Johnson1, Santo Longo2, Sudip Nanda3
1 Department of Internal Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
2 Department of Pathology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
3 Department of Cardiac Electrophysiology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
|Date of Submission||04-Mar-2019|
|Date of Decision||05-Mar-2019|
|Date of Acceptance||17-Mar-2019|
|Date of Web Publication||29-Aug-2019|
Dr. Sudip Nanda
Department of Cardiac Electrophysiology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, Pennsylvania 18015
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Noto JG, Johnson JA, Longo S, Nanda S. Acute heart failure within 10 days of dual-chamber pacemaker implantation: A novel etiology. Int J Acad Med 2019;5:132-4
|How to cite this URL:|
Noto JG, Johnson JA, Longo S, Nanda S. Acute heart failure within 10 days of dual-chamber pacemaker implantation: A novel etiology. Int J Acad Med [serial online] 2019 [cited 2019 Sep 23];5:132-4. Available from: http://www.ijam-web.org/text.asp?2019/5/2/132/265676
Permanent cardiac pacemaker (PPM) implantation is the standard treatment for symptomatic bradycardia and irreversible atrioventricular block. Despite the safety and effectiveness of PPM implantation, early complications (<30 days) occur in approximately 5% of cases and late complications in approximately 3% of cases. One such complication, pacing-induced heart failure, usually takes at least several months to develop and tends to occur in patients with a history of symptomatic heart failure or decreased ejection fraction.,, We describe an unusual case of pacing-induced heart failure just 10 days after PPM implantation in a previously asymptomatic patient with normal baseline systolic function.
A 96-year-old male with medical history of hypertension, hyperlipidemia, and hypothyroidism presented to the emergency department with 10 days of intermittent lightheadedness and generalized weakness. Physical examination revealed bradycardia with a heart rate of 33 beats per minute (bpm). An electrocardiogram revealed second-degree atrioventricular block with 2:1 conduction [Figure 1]. An echocardiogram showed a left ventricular ejection fraction (LVEF) of 60% [Figure 2]a. After exclusion of reversible causes (electrolyte abnormalities, hypothyroidism, ischemia, and medication induced), the patient was referred for a PPM. The patient underwent successful implantation of a DDDR (dual-chamber pacing, dual-chamber sensing, dual response, and rate adaptive) PPM. Before discharge, the patient was started on metoprolol succinate 25 mg daily, following an episode of non-sustained ventricular tachycardia. His home dose of levothyroxine 50 mcg daily was continued throughout this timeframe.
|Figure 1: Preprocedure electrocardiogram showing 2:1 atrioventricular block, right bundle branch block, and occasional premature ventricular complexes|
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|Figure 2: End-systolic apical four-chamber view transthoracic echocardiogram showing (a) left ventricular ejection fraction 60% with end systolic volume 51 mL before pacemaker implantation, (b) Left ventricular ejection fraction 30% with end systolic volume 102 mL and severe diffuse hypokinesis 10 days after the procedure, (c) Color flow Doppler across the tricuspid valve showing mild tricuspid regurgitation, and (d) Continuous-wave Doppler of tricuspid regurgitation showing peak pulmonary artery systolic pressure of 51 mmHg|
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Ten days after discharge, the patient again presented to the emergency department with dyspnea and lower-extremity edema. Physical examination revealed bibasilar rales and 1+ pitting lower-extremity edema. Serum troponin was 3.38 ng/mL and N-terminal pro-brain natriuretic peptide (NT-proBNP) was 17,424 pg/mL. Pacemaker interrogation is shown in [Table 1]. An electrocardiogram showed a ventricular paced rhythm with QRS duration 152 ms and no ST segment abnormalities. A new echocardiogram demonstrated LVEF of 30% with severe diffuse hypokinesis, mild tricuspid regurgitation, and pulmonary arterial hypertension [Figure 2]b, [Figure 2]c, [Figure 2]d. The patient was admitted to the hospital for management of type 2 non-ST-elevation myocardial infarction and acute heart failure.
Cardiac catheterization revealed 90% stenosis of the left anterior descending and 85% stenosis of the right coronary artery, which were subsequently revascularized with drug-eluting stents [Figure 3]. The patient was discharged on furosemide 20 mg per day. At 3-month follow-up, the patient reported significant symptomatic improvement and NT-proBNP trended down to 2,247 pg/mL. A repeat echocardiogram at 9 months demonstrated recovery of LVEF to 50%.
|Figure 3: Cardiac catheterization showing (a) mid-left anterior descending artery with 90% stenosis, (b) mid-right coronary artery with 85% stenosis, (c) left anterior descending, and (d) right coronary artery lesions after revascularization|
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This report illustrates an unusual case of pacing-induced heart failure within 10 days of dual-chamber PPM implantation. In the mode selection trial, 10% of patients in the dual-chamber group experienced at least one heart failure related hospitalization through 33-month follow-up. However, pacing-induced heart failure is very unusual in patients with no prior cardiac history and normal baseline systolic function and seldom occurs within 10 days of device implantation.,, After his initial presentation with a heart rate of 33 bpm, artificial pacing at 60–80 bpm likely increased myocardial oxygen demand resulting in an ischemic cardiomyopathy. The patient's clinical, laboratory, and echocardiographic improvement following revascularization further supports this as the etiology of his heart failure. However, this report is limited, as we cannot definitively exclude stress cardiomyopathy from the differential diagnosis on the basis of these findings.
While pacing-induced heart failure is a well-known complication of right ventricular pacing, it rarely occurs in just 10 days. It is also uncommon in patients with normal baseline LVEF and no prior cardiac history. This case emphasizes the need for a thorough diagnostic evaluation in patients presenting with dyspnea after PPM implantation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
This research did not require ethical approval because it did not involve human or animal experimental designs. Applicable EQUATOR Network (http://www.equator-network.org/) guidelines were followed by the authors.
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[Figure 1], [Figure 2], [Figure 3]