Novel method of biventricular pacemaker optimization by radial artery tonometr: A case report

Echocardiographic guided pacemaker optimization leads to significant improvement in cardiac function among nonresponders to cardiac resynchronization treatment (CRT). Simpler, noninvasive determination of cardiac function during biventricular pacemaker programming may simplify this procedure. In this report we describe a 73 year old male patient who presented with recent onset NYHA class III symptoms 7 months post-CRT for ischemic cardiomyopathy. During pacemaker optimization using A-pacing at 60 bpm, optimal atrioventricular (AV) delay was found to be 290 ms by both pulsed wave (PW) echo Doppler as well as by the simultaneously measured radial artery pulse waveform analysis by tonometry. No discernable atrial mechanical activity was visible despite presence of sinus rhythm up to an AV delay of 190 ms. Further improvement in cardiac function and decrease in mechanical dyssynchrony was shown with VV optimization by tissue Doppler imaging (TDI). Our report emphasizes the need for individualized biventricular pacemaker optimization post-CRT and that concomitant assessment via radial artery pulse waveform analysis by tonometry along with PW and TDI may provide additional information during pacemaker programming to assist in pacemaker optimization.