Triple-site pacing: a new supported therapy approach for bridge to recovery with a left ventricular assist system in a patient with idiopathic dilated cardiomyopathy

Left ventricular assist devices (LVAD) are widely used as bridges to cardiac transplantation or for destination therapy. LVAD support may also function as a bridge to ventricular recovery, but a sufficient rate of recovery has not been obtained, even with various adjuvant therapies. Cardiac resynchronization therapy (CRT) is an effective treatment for heart failure, and there is a report of successful weaning off LVAD with CRT. However, some patients with CRT could not improve their cardiac function because of residual dyssynchrony. Herein, we describe a case of a successful bridge to recovery with triple-site pacing for residual dyssynchrony after biventricular pacing. A 34-year-old woman with heart failure due to dilated cardiomyopathy whose condition deteriorated underwent Toyobo LVAD implantation, resulting in improvement of the left ventricular ejection fraction (LVEF) from 12 to 36%. Because of left ventricular dyssynchrony, we performed CRT, but residual dyssynchrony impeded cardiac recovery. We inserted an additional ventricular lead at the right ventricular outlet to achieve triple-site pacing in order to obtain complete synchronization. The LVEF improved to 45%, and the patient was successfully weaned off the LVAD. In LVAD-supported cases of persistent left ventricular dyssynchrony with CRT, implantation of triple-site pacing could potentially accelerate recovery.