Replies

• (No subject)
  November 20, 2017

• I fixed your wording for you!
  November 20, 2015

• I would NOT implant a pacemaker in this patient now, but he is at increased risk of developing complete heart block.  His prognosis is not very good, but a pacemaker has not been demonstrated to improve the prognosis in this population. If he develops the need for a pacemaker with any additional AV block, I would implant an ICD and possibly a CRT if he continues the need for pacing. I explain the resolution of the heart block and then the LBBB by the good fortune of not infarcting his HIS Bundle or Left bundle but acute edema which resolved. It is rare to acutely decide to do a CRT and it is rare to acutely decide to do an ICD, but post MI and post open heart surgery are the two times that our hand gets forced due to AV block, need to implant something and inability to know if LVEF will improve with GDMT. If no pacer/ICD acutely we would consider a wearable ICD for 40 days and if the LVEF still less than 35% would implant an ICD then.
  August 24, 2015

• Hi Faisal, Thanks for the interesting case. I also think the matter is not to pace or not to pace, but ischemic or not ischemic. If you think a coronary angiography is too much, you could consider a coro-CT ( sensibility is high for left main and prox LAD lesions which are mostly responsible of ischemic LBBB). After excluding this watchful waiting is reasonable.
  June 29, 2015

• Location should be dependent on multiple factors. Who is doing the procedure? Fluoroscopy? Where will the rescue be done? The buyin of the team members? If the rescue can be done effectively in the location where the best imaging is available and with the immediate availability of the surgeon, then it does not matter otherwise. However if transfering of the patient is needed to rescue the patient, this is not acceptable.
  February 26, 2015