Left Atrial and Right Ventricular Pacing as a Treatment for Symptomatic Congestive Heart Failure

Despite significant advances in medical therapy of congestive heart failure (CHF), patients with class III and IV CHF suffer from a poor quality of life and a grave prognosis.^1,2 Currently, there is ample evidence that atrial synchronized sequential pacing in left or both ventricles improves some electrical abnormalities and provides symptomatic relief for selected patients with stage III or IV CHF.^3-7 Left atrial (LA) pacing remains unexplored as a treatment modality in these patients. Case Report. A 72-year-old man with stage III CHF due to ischemic cardiomyopathy and past medical history of myocardial infarction, hypertension, hypercholesterolemia, atrial fibrillation, and pacemaker for complete heart block, was admitted to have an upgrade from a VVIR to a biventricular pacemaker for further treatment of his persistent CHF symptoms (despite optimal medical therapy with lisinopril, digoxin, and carvedilol). He was found to have atypical atrial flutter on ECG and continuous monitoring (Figure 1). During the procedure, multiple attempts to advance the lead intended for left ventricular pacing via the coronary sinus to a stable position failed. The lead was left in the coronary sinus, and was used to rapidly pace the left atrium to terminate atrial flutter and re-establish sinus rhythm. This lead was stable at the left atrial pacing site (Figure 2) and was attached along with the right ventricular lead to a dual chamber pacemaker. The lead was tested with excellent sensing and pacing parameters. Both two-week and two-month follow-up visits showed significant clinical improvement of CHF symptoms (to class II), exertion capacity, and quality of life. He continued to have appropriate left atrial and right ventricular pacing without evidence of atrial flutter or fibrillation (Figure 3). Conclusion. Biventricular pacing has become an accepted therapeutic modality in the treatment of symptomatic CHF, despite optimal medical therapy. In the event of failure of successful implantation of a lead at a LV site via the coronary sinus, a stable LA pacing site may be beneficial in advanced CHF. Especially in patients with atrial dysrhythmias, LA pacing may be as good an option as biventricular pacing for optimizing cardiac output and symptomatic relief. Some of the benefit may derive from left atrio-ventricular resynchronization. Further studies are needed to determine the appropriate candidates, as well as optimal LA pacing sites.