<HTML><BODY style="word-wrap: break-word; -khtml-nbsp-mode: space; -khtml-line-break: after-white-space; "><DIV>She appears to have a familial cardiomypopathy. Some cohorts of </DIV><DIV>these patients have progressive heart block and LV dysfunciton. In </DIV><DIV>this case HCM may be associated. In other patients with progressive </DIV><DIV>heart block, an ASD may be present.</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>In any case there is a risk of SCD with pacemaker therapy alone. </DIV><DIV>Certainly, in the presence of severe dysfunction and CHB, I would </DIV><DIV>suggest an ICD CRT device with the hope of improving function and </DIV><DIV>protecting aginst the risk of SCD.</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>Alan Kadish</DIV><BR><DIV><DIV><BR class="khtml-block-placeholder"></DIV><BLOCKQUOTE type="cite"><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; min-height: 14px; "><BR></DIV> <DIV>Dear Dr Dubner</DIV><DIV> </DIV><DIV> thank you for this excellent educational site</DIV><DIV> </DIV><DIV> A 38 year old femal referred to our center with new onset dyspnea from a few month ago. She had family history of sudden cardia death. She had CHB with wide ventricular escape rhythm. TT.echocardiography revealed sever LV and RV systolic dysfunction, asymetric septal hyperthrophy, pulmonary hypertention (PAP=65-70mmhg) and without LVOT gradient.patient,s dyspnea improved with low dose diuretics , ACE inhibitor and TPM implantation.</DIV><DIV> Do you recommend DDD pacemaker for this patient?</DIV><DIV> or</DIV><DIV> Do you recommend ICD-DR or ICD-CRT?</DIV><DIV> </DIV><DIV> what is your opinion about clinical course of her disease?</DIV><DIV> </DIV><DIV> does she need further workup before device implantation?</DIV><DIV> </DIV><DIV> sincerely yours</DIV><DIV> </DIV><DIV> Hormoz Alizadeh MD</DIV><DIV> Department of Pacemaker and Electrophysiology</DIV><DIV>Rajaie Cardiovascular Medical and Research Center</DIV><DIV>Tehran, Iran</DIV><BR><DIV> <SPAN class="Apple-style-span" style="border-collapse: separate; border-spacing: 0px 0px; color: rgb(0, 0, 0); font-family: Helvetica; font-size: 12px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; text-align: auto; -khtml-text-decorations-in-effect: none; text-indent: 0px; -apple-text-size-adjust: auto; text-transform: none; orphans: 2; white-space: normal; widows: 2; word-spacing: 0px; "></SPAN></DIV></BLOCKQUOTE></DIV><BR><DIV> <SPAN class="Apple-style-span" style="border-collapse: separate; border-spacing: 0px 0px; color: rgb(0, 0, 0); font-family: Helvetica; font-size: 12px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; text-align: auto; -khtml-text-decorations-in-effect: none; text-indent: 0px; -apple-text-size-adjust: auto; text-transform: none; orphans: 2; white-space: normal; widows: 2; word-spacing: 0px; "><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">--</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Dr.<SPAN class="Apple-converted-space"> </SPAN>Sergio<SPAN class="Apple-converted-space"> </SPAN>Dubner</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">President<SPAN class="Apple-converted-space"> </SPAN>of<SPAN class="Apple-converted-space"> </SPAN>Scientific<SPAN class="Apple-converted-space"> </SPAN>Committee</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal Lucida Grande; min-height: 16px; ; font-family: Lucida Grande; font-size: 13px; "><BR style="font-family: Lucida Grande; font-size: 13px; "></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Dr.<SPAN class="Apple-converted-space"> </SPAN>Edgardo<SPAN class="Apple-converted-space"> </SPAN>Schapachnik</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">President<SPAN class="Apple-converted-space"> </SPAN>of<SPAN class="Apple-converted-space"> </SPAN>Steering<SPAN class="Apple-converted-space"> </SPAN>Committee</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV><BR class="khtml-block-placeholder"></DIV><BR class="Apple-interchange-newline"></SPAN> </DIV><BR></BODY></HTML>