21
Management strategies Key points
• Management options discussed included
use of further noninvasive and invasive
diagnostic strategies versus empiric
arrhythmia therapies as follows:
▶ Prolonged ambulatory monitoring or
loop recorder insertion
▶ Empiric pacemaker implantation given
evidence of conduction system disease
▶ EP testing to assess AV conduction
and evaluate the inducibility of VAs,
followed by CIED insertion
• Values elicited in discussion included
likelihood of recurrence with further
injuries, potential for life-threatening
brady- and tachyarrhythmias as causative
etiolog y, and favorable functional status
with reasonable expected longevity.
• Given age, high functional status, and
potentially serious causative arrhythmias,
EP testing was performed. Pacemaker
implantation was planned with possible
ICD insertion if clinically relevant VAs
were induced.
• Age, high functional status,
and serious nature of syncope
with injury prompted aggressive
evaluation.
• Empiric pacemaker implantation
without further testing could be
considered given existing RBBB.
• Normal LVEF suggests absence of
significant myocardial involvement.
• Clinical benefit of empiric ICD
implantation in this situation
remains uncertain.
• EP study was primarily utilized
to determine the suitability of
ICD implantation, as pacemaker
implantation was appropriate with
clinical features at presentation.
• Management options discussed included
implantation of dual-chamber pacemaker,
biventricular pacemaker (CRT-P), and
biventricular ICD (CRT-D) implantation.
• Values elicited in discussion included desire
for improved functional capacity, reduction
of symptoms attributed to bradycardia and
left ventricular dysfunction, and prevention
of sudden death due to malignant brady-
and tachyarrythmias.
• The decision was made to proceed with
biventricular ICD (CRT-D) implantation,
as this would address all the relevant
cardiovascular issues described.
• Restoration of AV synchrony with
alleviation of related symptoms was
accomplished by permanent pacing.
• Anticipated RV pacing ≥40%
coupled with moderate preexisting
left ventricular dysfunction warrants
implantation of CRT device.
• ICD implantation may be
considered in DM1 patients who
require pacing due to ongoing risk of
sudden death, possibly due to VAs.
• Moderate left ventricular
dysfunction indicates myocardial
involvement/infiltration due to
DM1.
• Beta-adrenergic blockade for
left ventricular dysfunction may
be safely used following device
insertion without concern for
aggravating bradycardia.
