CONGRESS ABSTRACT

We describe the case of a 62-yo female patient with permanent atrial fibrillation, who underwent aortic, mitral and tricuspid valve replacement with mechanical prostheses (during surgery an epicardial bipolar lead was placed for potential future use). In August 2024 she had a syncope and was admitted to Cardiology Unit as an echocardiogram showed severe LV dysfunction. Holter ECG found AF with phases of bradycardia and t achycardia. She was on digoxin, metoprolol, furosemide and warfarin therapy. Coronarography showed no coronary lesions. Spironolactone and empagliflozin were added before discharge. In November 2024 she was admitted to our Department for further evaluation, reporting dyspnea with minimal exertion (NYHA III). ECG showed high ventricular rate AF with LBBB (QRSd 140 ms). Echocardiogram confirmed severe LVEF reduction. We decided to implant a Pacemaker with CSP aiming LVEF improvement. Crossing the tricuspid mechanical prosthesis with leads was excluded, due to high risk of damage and/or rupture in the short-medium term. The only way for CSP was HBP by the atrial side. In the operating room we made a skin incision at left subclavian level and isolated the connector pin of the epicardial lead. After left subclavian vein cannulation, through a deflectable catheter and a lead for CSP, we found a low voltage His signal on the polygraph, but unfortunately pacing output threshold was very high, likely due to post-surgical fibrosis. So we decided to shift to CRT via coronary sinus. The CS angiography showed an optimal target vein in the LV lateral wall. A quadripolar lead was successfully placed. A CRT-P device was implanted, connecting the epicardial lead to the RV port and the CS lead to the LV port, while the atrial port was capped . Post-procedural ECG showed significant QRS narrowing. Given the severe LVEF reduction the patient was discharged with a wearable cardioverter-defibrillator and the same OMT. At 1-month follow-up LVEF showed initial improvement and at 3 months it reached 50%, with marked reduction in patient’s dyspnea. The WCD was subsequently removed. In the comparison between conventional CRT and CSP there isn’t a clear winner and they should be considered as backups for each other, as both are valid alternatives that can bring significant benefits to the patient. We have shown how using this type of hybrid stimulation could lead to satisfactory results in terms of QRSd, LVEF recovery and consequently improvement in patient’s symptoms.