<HTML><BODY style="word-wrap: break-word; -khtml-nbsp-mode: space; -khtml-line-break: after-white-space; "><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Dear Hormoz Alizadeh </FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">If your patient has complete AV block with wide ventricular escape, surely she needs electrical stimulation. If there is atrial activity, a dual chamber is indicated.</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">You do not mention any risk factor to think about an ICD, unless you assume this is a cardiomyopathy with severe LV and RV dysfunction, and on the other hand, to indicate a CRT device it should be interesting to know if she has LBBB, if the systolic dysfunction you mention implies ventricular dyssynchrony, or if you can perform tissue Doppler or any other diagnostic method that shows dysynchrony.</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">If there is no dyssynchrony, I should go on with a DDDR pacemaker or think about a dual chamber ICD in case you confirm a cardiomyopathy.</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Best regards,</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Sergio Dubner</FONT></DIV><FONT class="Apple-style-span" face="Arial"><BR></FONT><DIV><BLOCKQUOTE type="cite"><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; min-height: 14px; "><FONT class="Apple-style-span" face="Arial"><BR></FONT></DIV> <DIV><FONT class="Apple-style-span" face="Arial">Dear Dr Dubner</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> thank you for this excellent educational site</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> 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.</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> Do you recommend DDD pacemaker for this patient?</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> or</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> Do you recommend ICD-DR or ICD-CRT?</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> what is your opinion about clinical course of her disease?</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> does she need further workup before device implantation?</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> sincerely yours</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> </FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> Hormoz Alizadeh MD</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"> Department of Pacemaker and Electrophysiology</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">Rajaie Cardiovascular Medical and Research Center</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial">Tehran, Iran</FONT></DIV><DIV><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><FONT class="Apple-style-span" face="Arial"><BR></FONT></BLOCKQUOTE></DIV><FONT class="Apple-style-span" face="Arial"><BR></FONT><BR><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>