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Volume 10, Issue 1, Pages 46-52 (January 2013) Temporary left ventricular stimulation in patients with refractory cardiogenic shock and asynchronous left ventricular contraction: A safety and feasibility study Charlotte Eitel, MD, Thomas Gaspar, MD, Kerstin Bode, MD, Bruno Andrea, MD, Philipp Sommer, MD, Carsten Stoepel, MD, Thomas Sarwas, MD, Eigk Grebe, MD, Holger Thiele, MD, Gerhard Hindricks, MD, Christopher Piorkowski, MD Heart Rhythm Volume 10, Issue 1, Pages 46-52 (January 2013) DOI: 10.1016/j.hrthm.2012.09.007 Copyright © 2013 Heart Rhythm Society Terms and Conditions

Figure 1 Mean arterial blood pressure (MAP) and serum lactate before and after left ventricular (LV) lead placement. Hemodynamic and metabolic measurements 1–4 hours before and 24 hours after temporary LV lead placement. Corresponding parameters of the same patient are connected by a black line. A: Invasively assessed MAP. Individual nonresponders are highlighted in red. B: Level of serum lactate. Heart Rhythm 2013 10, 46-52DOI: (10.1016/j.hrthm.2012.09.007) Copyright © 2013 Heart Rhythm Society Terms and Conditions

Figure 2 Implantation result and hemodynamic course in patient 6. A 57-year-old woman presented to an external hospital with sudden onset of progressive heart failure due to acute myocarditis. In refractory cardiogenic shock, the patient was referred to cardiac surgery for implantation of a cardiac assist device. That was refused owing to a perforated gastric ulcer. Temporary left ventricular (LV) stimulation was considered for rescue stabilization. Before implantation, the patient was in sinus tachycardia (heart rate 150 beats/min), with a blood pressure (BP) of 70/30 mm Hg under 0.4 mg/h noradrenaline. Electrocardiogram showed nonspecific intraventricular conduction delay with left bundle branch block appearance (QRS duration 110 ms); aortic and pulmonary pre-ejection period measured 80 and 40 ms, respectively. After 56 hours, the patient was free from inotropic support and abdominal surgery could be performed. The figure displays the course of hemodynamics (BP), catecholamines, and serum lactate values before and after temporary LV stimulation. Heart Rhythm 2013 10, 46-52DOI: (10.1016/j.hrthm.2012.09.007) Copyright © 2013 Heart Rhythm Society Terms and Conditions

Figure 3 Hemodynamic course of patient 3. A 64-year-old man with preexisting ischemic cardiomyopathy was admitted mechanically ventilated and in cardiogenic shock. Electrocardiogram showed sinus rhythm with left bundle branch block (QRS duration 140 ms); aortic and pulmonary pre-ejection periods measured 155 and 110 ms, respectively. The figure displays the course of hemodynamics (blood pressure [BP]), catecholamines, and serum lactate values before and after temporary left ventricular (LV) stimulation. Directly after LV lead placement, stimulation was performed in VVI mode. Consecutively, the patient deteriorated hemodynamically. Reprogramming of the external pacemaker into a VVT mode ensured atrioventricular synchronous LV stimulation, resulting in hemodynamic stabilization. Heart Rhythm 2013 10, 46-52DOI: (10.1016/j.hrthm.2012.09.007) Copyright © 2013 Heart Rhythm Society Terms and Conditions