A 76-year-old woman with a 10-year history of idiopathic cardiomyopathy.
In 1998, the patient presented with rapid deterioration of her capacity, associated with episodes of paroxysmal episodes of ventricular response and sinus bradycardia disease, which led to the right implantation of the atrial fibrillation secondary to symptomatic atrial fibrillation.
It was maintained in relative good general conditions, in functional capacity I-II, in medical treatment with: carvedilol, loartan, isosorbide, digoxin, furosemide and oral anticoagulation.
His echocardiogram in 2001 showed left ventricular dilation (systolic diameter 59 mm and diastolic diameter 68 mm) and ventricular dysfunction (fraction of consolidation 13%).
Despite optimization of the doses of his medications, he presented deterioration of his functional capacity, reaching dyspnea on minimal exertion and chronic atrial fibrillation with good frequency control.
In 2003, the patient was submitted to upgrade a biventricular installation (Saint Jude®, Frontier 5510).
An attempt was made to implant the left ventricular pacing lead, which was confirmed by ventricular pacing because the coronary sinus was located. In the same lead, a new electrode was placed on the right ventricle, which was damaged by pacing in the anterior ventricle.
During this hospitalization, bipolar epicardial lead of left ventricular stimulation (Medtronic® 4968) was implanted by left minithoracotomy.
The patient was not cardioverted and was discharged in good condition 48 h after surgery.
VVT was programmed and the patient recovered with clear symptomatic improvement and functional capacity II.
He remained stable until the end of 2004, when his functional capacity reappeared with minimal exertion and lower limb edema, despite the presence of pharmacological treatment at maximum doses 2, his maximum deterioration of consciousness, his adequate anticoagulant treatment at 10 mg, 12.5 mg
Intercurrent illness was not detected.
The patient was hospitalized for reassessment, her echocardiogram showed dilatation and ventricular dysfunction (diameter/59 mm, left ventricular fraction between the lateral wall of 64 and 7%), mitral insufficiency and moderate tricuspid septum without stenosis.
She was discouraged from attempting electrical cardioversion and, before attempting infusion of intravenous inotropes, she was offered as an alternative of exception to test whether the implant of a second electrode of right ventricular stimulation could help.
For this purpose, a third bipolar pacing lead was implanted in the septoinfundibular region of the right ventricle (Saint Jude® 1688T), by puncture with left subclavian vein technique.
The biventricular pacing device Saint Jude® Frontier 5510 was maintained.
The left ventricular epicardial pacing lead and the new right septoinfundibular ventricular pacing lead were connected through an Y-shaped adapter (Oscor 2x.Bis/Bis ventricular apical connection).
The electrocardiogram before and after the procedure is shown in Figure 2.
The patient was discharged maintaining her pharmacological therapy, with symptomatic improvement, with functional capacity II-III, without symptoms or edema at two months of follow-up.
