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Severe Acute Coronary Syndrome After Left Bundle Branch Area Pacing: Multidisciplinary Team-Guided Management of
Ngoc Dung Kieu1, Quoc-Hoang Nguyen1, Thai Duy Vo1
1Department of Arrhythmology, Cho Ray Hospital, Ho Chi Minh City, Vietnam.
Insights
Left bundle branch area pacing (LBBAP) can rarely cause interventricular septal hematoma (IVSH), mimicking myocardial infarction. Conservative management guided by a multidisciplinary team is safe for selected patients.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Surgery
Background:
- Left bundle branch area pacing (LBBAP) is a physiologic pacing method for bradyarrhythmia and heart failure.
- Interventricular septal hematoma (IVSH) is a rare LBBAP complication that can mimic acute myocardial infarction by compressing collateral circulation.
Background:
Left bundle branch area pacing (LBBAP) is a physiologic pacing technique increasingly used for bradyarrhythmia and heart failure indications. Rare complications include interventricular septal hematoma (IVSH), which may compress collateral flow and present as acute myocardial infarction.
Case Summary:
A 79-year-old woman with chronic total occlusion of the left anterior descending artery and prior stenting of the right coronary artery underwent dual-chamber pacemaker implantation with LBBAP. Twelve hours later, she developed chest pain, pulmonary edema, new anterior ST-segment elevation, and a drop in left ventricular ejection fraction from 54% to 33%. Echocardiography revealed a septal hematoma (14 × 24 mm) surrounding the pacing lead.
Discussion:
A multidisciplinary team including electrophysiology, interventional cardiology, heart failure, and cardiac surgery considered lead revision, percutaneous coronary intervention, coronary artery bypass grafting, and conservative care. Given stable pacing parameters, collateral-dependent chronic total occlusion of the left anterior descending artery, and regression of hematoma on surveillance, conservative management was chosen with staged antithrombotic reintroduction and surgical standby.
Conclusions:
IVSH can precipitate Killip class III ST-segment elevation myocardial infarction after LBBAP without new coronary occlusion. Multidisciplinary team-guided conservative therapy with close surveillance can be safe in selected cases.
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