We describe a case of a permanent pacemaker lead placement via the left pericardiophrenic vein for the treatment of tachy-brady syndrome due to a primary cardiac angiosarcoma. (Level of Difficulty: Advanced.)

Background Implantable Cardiac Hemodynamic Monitors (ICHM) provide real time measurements of PADP (Pulmonary Artery Diastolic Pressures). Implanted pacemakers / defibrillators (CRM) sense thoracic impedance as a subacute and chronic measurement of pulmonary vascular congestion. CRM devices have programmable pacemaker timing intervals that adjust in a closed loop system based on intracardiac electrical signals. No closed loop systems based on mechanical indices of cardiopulmonary status are available. Real time monitoring of PADP has potential to automatically direct optimal CRM timing intervals as part of a closed loop system (CLS). We chose to look at events within cases. Events are defined as specific iterations in timing of base rate, variation in paced chamber, and/or AV interval timing. Hypothesis Changes in CRM timing will affect acute measurements of PADP in patients with HF that will impact venous congestion. Methods 19 patients with ICHM, PPMs / ICDs, history of HFpEF (n = 8) or HFrEF (n=11), and baseline HR = 3 mm Hg change from baseline PAD during any reprogramming (Y); from those that did not (N). Results 5 of 7 cases had > 3 mm change (mean =16) in PADP from intrinsic conduction to RV pacing. 3 of these patients were in sinus rhythm and 2 in permanent atrial fibrillation. 3 of 22 cases with changes in AV timing had > 3 mmHg increase in PAD from baseline settings.1 of 5 cases CRT settings had > 3 mmHg increase when RV pacing alone. Discussion Acute changes in PADP were noted in a majority of cases with RV pacing rather than intrinsic conduction. Changes in AV delays infrequently affected PADP. Further work is needed to determine if chronic changes in PADP occur as a result of changes in pacing timing in order to determine if CLS could improve implantable cardiac hemodynamic measurements.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) placement is often indicated in severe cardiogenic shock and those undergoing prolonged resuscitation for cardiac arrest. However, the initiation of VA-ECMO may be associated with severe left ventricular (LV) afterload with all of its