Recurrent acute pulmonary oedema and cardiac arrest secondary to intermittent electrical dyssynchrony: a role for cardiac resynchronization despite preserved left ventricular function

Abstract

Recurrent pulmonary oedema with no obvious precipitant can prove difficult to treat in patients with preserved left ventricular (LV) systolic function. This report describes the novel use of cardiac resynchronization therapy (CRT) in the prevention of acute pulmonary oedema precipitated by intermittent electrical dyssynchrony in a patient with preserved LV systolic function.Acute pulmonary oedema remains a common presentation to emergency departments. The aetiology of the pulmonary oedema is not always apparent. In patients with preserved systolic function but evidence of diastolic dysfunction, it is unclear what triggers the acute deterioration or what treatments will prevent recurrence. We present a case in which electrical dyssynchrony [left bundle branch block (LBBB)] was noted to precipitate acute pulmonary oedema in a patient with preserved systolic function. Cardiac resynchronization therapy (CRT) was used to eliminate LBBB successfully and has thus prevented further acute pulmonary oedema. Case reportA 75-year-old Caucasian woman with no history of cardiac disease, hypertension, or diabetes presented with recurrent acute pulmonary oedema ( Figure 1A). On two occasions she suffered respiratory arrest followed by circulatory arrest (pulseless electrical activity) and required ventilation. Either side of these events she was asymptomatic with good exercise tolerance and no cardiac symptoms.Extensive investigations were performed to identify the aetiology of the acute pulmonary oedema. Angiography was repeated with intravascular ultrasound (IVUS) assessment and acetylcholine provocation. IVUS suggested more significant stenoses than suggested previously. The operator felt the severity of each acute presentation justified deployement of stents in both the LAD and RCA. Despite patent stents, pulmonary

Recurrent flash pulmonary edema due to rate-dependent left bundle branch block

“…An electrophysiologic study confirmed the development of LBBB only with pacing greater than 140 BPM. In another case report, a 75-year-old woman experienced 2 episodes of respiratory arrest and pulseless electrical activity in the setting of “flash” pulmonary edema 8 . Imaging studies revealed preserved systolic function; exercise testing eventually induced sinus tachycardia with LBBB and recurrent pulmonary edema.…”

Heart failure highlights in 2012–2013

“…The term atrial resynchronization therapy can be coined for this therapy and might be new in the arsenal of treatments for HFPEF and to prevent AF . In addition to atrial resynchronization, ventricular resynchronization can also be effective in patients with HFPEF . Biventricular pacing might be the preferred strategy in any patient that needs continuous ventricular pacing .…”

“…89 In addition to atrial resynchronization, ventricular resynchronization can also be effective in patients with HFPEF. 90 Biventricular pacing might be the preferred strategy in any patient that needs continuous ventricular pacing. 7 Whether this is true for all patients remains unknown.…”