European Heart Journal Supplements (2002) 4 (Supplement D), D132-D133
Case study: a patient with dilated cardiomyopathy, left
bundle branch block, recurrent syncope and heart
failure
D. B6cker and G. Breithardt
Miinster University Hospital, Miinster, Germany
Case presentation
A 61-year-old male patient was admitted to our hospital for
syncope that was not preceded by symptoms. The status of
the patient had already improved by the time the ambulance
arrived. He had a regular heart rate and was perfectly
orientated. Before this event he had been in New York Heart
Association functional class III (dyspnoea after climbing
one floor, no dyspnoea at rest and no angina).
Over the past 3 years, he had experienced recurrent
episodes of pre-syncope. Dilated cardiomyopathy had been
diagnosed in 1993, with a left ventricular ejection fraction of
20%. He was on the following medications: captopril 25 mg
three times daily; carvedilol 6.25 mg twice daily; furosemide
40 mg twice daily; and oral anticoagulation therapy.
On arrival at our hospital his blood pressure was
100/60 mmHg, with a heart rate of 76 beats, min- 1. ECG
demonstrated a complete left bundle branch block (LBBB)
morphology, with a PR interval of 0-23 s and a QRS
duration of 0.18 s. There was no ST-segment elevation.
During the hospital stay 24-h Holter monitoring was
conducted, demonstrating a normal sinus rhythm with rates
between 48 and 99 beats, min- ~, with no pauses and no
ventricular arrhythmia (<1% premature ventricular
contractions), and no symptoms. The chest radiograph
demonstrated a normal pulmonary interstitial structure, with
the pulmonary bases clear of any interstitial effusion. The
cardiothoracic index was 55%, Left heart catheterization
showed normal coronary arteries.
Questions
Is an electrophysiology study
warranted in this patient?
Because of the recurrent syncopes in the presence of dilated
cardiomyopathy and LBBB, either intermittent high-degree
Correspondence:Prof. Dr. Giinter Breithardt, Medizinische Klinik und
Poliklinik C (Kardiologie/Angiologie),Universitfitsklinikum Miinster,
D-48129 Miinster, Germany.
1520-765X/02/0D0132 + 02 $35.00/0
atrioventricular block or recurrent tachyarrhythmia was
suspected. Therefore, after other causes were excluded as
far as possible, an electrophysiology study was carried out.
Ventricular tachycardia was inducible with only two extra-
stimuli (270 and 200 ms) and a basic drive from the right
ventricular apex of 430 ms.
Which therapeutic options
should be considered?
The therapeutic options that were considered include the
following:
Pacemaker implantation
Initiation of amiodarone (and beta-blocker) therapy
Pacemaker implantation and amiodarone administration
Implantable cardioverter-defibrillator (ICD) with pacing
backup (VVI-ICD)
Dual chamber ICD with pacing backup (DDD-ICD) and
with atrial defibrillator capability
Dual chamber ICD with pacing backup (DDD-ICD),
including biventricular pacing capability
The therapy chosen for this patient was the latter one
from the above list- dual chamber ICD with pacing backup,
including biventricular pacing capability.
Follow-up of the patient
After several months, the patient returned to our institution
for a regular follow-up appointment. He was in New York
Heart Association functional class II, and had not suffered
any syncope since the implant of his DDD-ICD with
biventricular pacing capability. When the implanted
ventricular resynchronization device was interrogated, one
episode ofventricular tachycardias was found in the memory
of the device. The ventricular tachycardia had occurred
3 months after implantation, and was associated with pre-
syncope. The arrhythmia had a rate of 230 beats, min 1 and
was appropriately detected and terminated, with the first
shock administered automatically by the device.
This case study demonstrates diagnostic procedures and
considerations in such patients. It is presented to show the
2002 The European Society of Cardiology
 Case study: dilated cardiomyopathy, LBBB, recurrent syncope and heart failure D133

efficacy and significance of this new mode of therapy for diminished left ventricular function, LBBB and a prolonged
patients presenting with heart failure symptoms due to QRS width.

Eur Heart J Supplements, Vol. 4 (Suppl D) April 2002