Ghidul privind diagnosticul şi managementul sincopei - Romanian ...

Cornelia Cãlinescu et al
Risk factors for sudden death
cant, was modest and variable between subjects and
symptomatic relief was reported by patients in the presence,
but also in the absence of pacing 1 .
Th us, the European guidelines for the management
of HCM patients recommend this therapeutic alternative
only in elderly patients (older than 65 years), with
obstructive HCM refractory to drug therapy, which can
benefi t from the reduction of outfl ow gradient and improve
exercise capacity (for which alternatives to surgery
are oft en desirable) 3 .
In our patient the eechocardiography performed
one day aft er pacing did not show a reduction of the
LV outfl ow gradient, but the patient is going to be reassessed.
Due to severe concentric LV hypertrophy, septal artery
embolization or septal selective surgical resection,
remain to be re discussed in case no benefi cial eff ects
are observed in a longer term 9 .
Current trends are to believe that benefi cial eff ects of
dual-chamber pacing in hypertrophic cardiomyopathy
are signifi cantly more important in a long term: thus,
although the initial reduction of the gradient in the left
ventricular outfl ow tract may be insignifi cant, in the
long run it may be substantial, because of left ventricular
remodeling due to the dissynchronism achieved
by pacing 10 .
Th e most commonly accepted mechanism of gradient
reduction aft er pacing in HCM remains the inversion
of the ventricular contraction sequence as a
consequence of right ventricular apical activation mimicking
left bundle branch block leading to: widening
of the left ventricular outfl ow tract; a decrease in the
Venturi eff ect; and a decrease in systolic anterior motion
of the mitral valve. Th e AV delays required to produce
complete right ventricular pre-excitation is the
crucial requirement for success of this treatment 11 .
Th us, dual -chamber pacing requires review by randomized
studies, and long-term follow-up should be
considered in patients whose condition does not allow
surgically therapy, septal ablation, patients that have
moderate left ventricular hypertrophy, conventional
Romanian Journal of Cardiology
Vol. 26(21), No. 2, 2011
pacing indications, or increased risk to develop heart
block secondary to surgery or septal ablation 1,12 .
Case Particularities
- signifi cant biventricular myocardial hypertrophy
with dynamic obstruction in the left ventricular
outfl ow tract in the presence of an important family
history of sudden death, required implantation
of an ICD with dual chamber pacing in a
young patient.
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