Patient with Paced Rhythm in Severe Cardiomyopathy Presents with SOB due to Acute Decompensated Heart Failure

This is a middle-aged male with h/o with a history ofheart failure with severely reducedejection fraction due to dilated ischemic cardiomyopathy (EF 5-10%), probably with some component of non-ischemic cardiomyopathy, with h/o CABG, who is status post ICD placement (and previous appropriate shocks for VT) and biventricular pacer ( " cardiac resynchronization therapy " ), who is on amiodarone for VT suppression, and has h/o LV thrombus and is on chronicanticoagulation with warfarin.He presented forparoxysmal nocturnal dyspnea that didn't resolve with use of his home prn diuretics.  He was hypoxic and required oxygen in the ED.He had no chest pain.Prior coronary angiography/revascularization: LAD 40% proximal, 80% mid and 90% distal stenosis; circumflex 70% proximal circumflex; ramus 100% occluded; RCA 90% occluded.Prior echocardiographic study:(1/9/2017) LVEF is 10%, regional WMAs: distal septum anterior and apex, inferior and anterolateral; left ventricular enlargement and concentric hypertrophy; Severe decreased right ventricular systolic performance; no significant change compared to previous.Upon arrival to the ED, he was hypoxic, but readily responded to oxygen.  An ECG was recorded:Biventricular Paced Rhythm, rate 60QRS = 265 ms, QT = 587, QTc = 610(See two spikes approximately 40 ms apart, with large R-wave in V1 confirming LV pacing in addition to RV -- LV pacing results in RBBB configuration with large R-wave in V1)The...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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Source: Hand Surgery - Category: Surgery Authors: Tags: Plast Reconstr Surg Source Type: research
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Source: Respiratory Medicine Case Reports - Category: Respiratory Medicine Source Type: research
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Source: European Journal of Radiology Open - Category: Radiology Source Type: research
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Source: European Journal of Radiology Open - Category: Radiology Source Type: research
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