Flash Pulmonary Edema From Brief Loss of Biventricular Pacing During CRT-D Generator Exchange

Acute cardiogenic pulmonary edema results from abrupt cardiopulmonary derangements, including arrhythmia or acute valvular dysfunction.

An 88-year-old man with nonischemic cardiomyopathy, NYHA functional class III heart failure, left bundle branch block, and severe mitral regurgitation underwent biventricular implantable cardioverter-defibrillator generator replacement. During the procedure, biventricular pacing was interrupted. Within minutes, he developed acute dyspnea, agitation, and hypoxia consistent with flash pulmonary edema.

Loss of biventricular pacing likely caused ventricular dyssynchrony, worsening mitral regurgitation, and rapidly increasing pulmonary venous pressure. Restoration of pacing improved symptoms.

Interruption of biventricular pacing during generator exchange can precipitate flash pulmonary edema, especially in patients with significant mitral regurgitation. Ventricular dyssynchrony from pacing cessation may acutely worsen mitral regurgitation, leading to rapid pulmonary congestion.