<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; ">Dear Dr Alizadeh:</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">What an interesting case! A difficult one too.</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">It sounds like familial dilated cardiomyopathy versus final dilated phase of hypertrophic cardiomyopathy, but I would like to have more information. What exactly is her LV ejection fraction? Were there any LV wall motion abnormalities in her Echo? Has she ever had typical chest pain? What about her cholesterol levels? (a familial dyslipemia could explain an early onset of ischaemic heart disease in this patient).</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Does she have a history of hypertension? I mean, even though LV hypertrophy secondary to hypertension is usually concentric, sometimes severe hypertension could lead to asymetric LV hypertrophy.</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Assuming there is no any significant left sided valvular disease, the presence of severe RV dysfunction and moderate to severe pulmonary hypertension (PAPS 65-70 mm Hg) implies long standing severe LV dysfunction in this patient and usually poor prognosis (and lack of response to CRT). Moreover, if this patient has severe mitral regurgitation secondary to severe LV dilatation CRT is unlikely to benefit her.</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Regarding her medical treatment, I assume she is on low dose diuretics and ACEI but she is off beta blockers and anti-aldosterone drugs. After pacemaker implantation, an optimize medical treatment including appropriate dose of ACEI, beta-blockers and anti-aldosterone drugs will probably improve her LVsystolic function rendering unnecessary ICD/CRT therapy.</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Finally, There is a clear indication for permanent pacemaker implantation (complete AV block with a wide QRS complex escape suggesting infra-hisian block). RV apical pacing will induce, LV dyssynchony that, in turn, will probably lead to worsening of both LV systolic function and CHF symptoms, but high septal RV pacing is less likely to cause severe LV dyssynchrony.</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">In summary, If her LVEF is over 30% I will go for a DDD pacemaker with an active fixation lead in the high RV septum plus optimization of medical treatment (ACEI, BB, anti-aldost). However, if her LVEF is clearly below 30% (by nuclear ventriculography ideally) I will implant either a CRT-ICD in the case of lack of severe mitral regurgitation or DDD-ICD (usually as a bridge to cardiac transplantation) when severe MR is present. The lack of response to CRT will make this young patient a good candidate to cardiac transplantation.</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Thank you all.</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Congratulations to the organizers.</DIV><P style="margin: 0.0px 0.0px 0.0px 0.0px"> </P><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Aldo Alberto Furlani MD</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Cardiac Electrophysilogist</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Consultant Cardiologist</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Heart Institute of the Caribbean</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><A href="mailto:afurlani@caribbeanheart.com">afurlani@caribbeanheart.com</A></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><A href="http://www.caribbeanheart.com/">www.caribbeanheart.com</A></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><DIV><DIV>El 12/10/2006, a las 23:12, SCD Symposium escribió:</DIV><BR class="Apple-interchange-newline"><BLOCKQUOTE type="cite"><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Forum of the ISHNE Sudden Cardiac Death World-Wide Internet Symposium</DIV><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; min-height: 14px; "><BR></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Medtronic's free physician resource center:</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><A href="http://www.medtronicconnect.com">http://www.medtronicconnect.com</A></DIV><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; 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; "><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><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; ">Scd-forum mailing list</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><A href="mailto:Scd-forum@scd-symposium.org">Scd-forum@scd-symposium.org</A></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><A href="http://www.grupoakros.com.ar/mailman/listinfo/scd-forum">http://www.grupoakros.com.ar/mailman/listinfo/scd-forum</A></DIV> </BLOCKQUOTE></DIV><BR></BODY></HTML>