EP Lab Digest - January 2008 - (Page 28) 28 PACEMAKER PUZZLE JANUARY 2008 Pacemaker/ICD Puzzle Revealed! Melanie T. Gura, RN, MSN, CNS, CCDS/AP FHRS, FAHA , Director, Pacemaker & Arrhythmia Services Northeast Ohio Cardiovascular Specialists Akron, Ohio Medications • Coreg: 6.25 mg bid • Digoxin: 0.25 mg qd • Lasix: 80 mg bid • Lisinopril: 10 mg qd • Spironolactone: 25 mg, 1/2 tab qd • Warfarin (as directed) • Lipitor: 20 mg qd • Zyrtec: 10 mg qd Physical Examination On examination, there was no JVD, chest sounds were clear to auscultation, heart sounds were regular with a normal S1, S2 without rubs, murmurs or gallops, and no edema. Device evaluation revealed normal ICD function: • No ventricular tachyarrhythmias • No atrial fibrillation • No change in atrial and ventricular stimulation and sensing thresholds • 24-hour Holter revealed this ECG (See Figure 1) I n this month’s installment, we reveal the answer to December’s pacemaker/ICD puzzle. Let us know if you answered correctly! Pacemaker/ICD Puzzle Question: Which of the following is demonstrated in the Holter recording shown in Figure 1? A: Ventricular oversensing B: Loss of ventricular capture C: Concealed conduction D: Crosstalk inhibition E: Normal device function (Correct Answer!) Explanation: Figure 1. Clinical History A 56-year-old female with non-ischemic dilated cardiomyopathy, an ejection fraction of 25%, congestive heart failure, recurrent atrial fibrillation, pulmonary hypertension, and hyperlipidemia, states that she has periodic palpitations associated with shortness of breath. She denies chest pain, orthopnea, dizziness, and syncope. • Normal device function is due to Managed Ventricular Pacing (MVP™); • MVP is designed to provide functional AAI(R) pacing mode while providing the safety of dual chamber ventricular pacing in the presence of persistent or transient loss of conduction; • The key benefit is a reduction in unnecessary RV pacing due to the promotion of AV synchrony; • The potential clinical outcomes are a reduction in cumulative percent of RVpacing, which may result in reduced incidence of AT/AF and slow the progression of heart failure. Device History S/P ICD implantation: • ICD: Medtronic D154ATG EnTrust™ • A Lead: Medtronic 5076 CapSure Fix Novus • V Lead: Medtronic 6949 Sprint Fidelis References 1. Medtronic MVP™ Mode Patient Information Sheet. 2. Medtronic Tip Card: MVP™ Operation. 3. Sweeney M, et al. Medtronic Technical Concept Paper: AV Conduction: Preserving Intrinsic PR Intervals in Implantable Device Patients. November 2004. 4. Sweeney MO, Hellkamp AS, Ellenbogen KA, et al, for the MOde Selection Trial (MOST) Investigators. Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation 2003;107:2932-2937. 5. Wilkoff BL, Cook JR, Epstein AE, et al, on behalf of the DAVID Trial Investigators. Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA 2002;288:3115-3123. Readers, let us know if you have a pacemaker or ICD puzzle that you would like to see featured in this section. Email all submissions to: “jelrod@hmpcommunications.com”
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