Abstract
A 61-year-old man with dilated cardiomyopathy presented with progressive biventricular decompensation. Two years before admission, the patient had a dual-chamber pacemaker implanted in another hospital because of “sick-sinus-syndrome.” Physical examination showed a heart rate of 110 bpm, with a blood pressure of 150/100 mm Hg, inspiratory crepitant rales over both lung fields, and moderate jugular venous distension. Additional findings included a mitral insufficiency murmur and a tender enlarged liver. The 12-lead ECG showed atrial flutter with negative p-waves in II, III, and aVF (cycle length 270 ms), with 2:1-AV-conduction and wide QRS-complex (165 ms) with left-bundle-branch-block-morphology (Figure 1). An echocardiogram demonstrated that the left ventricle was markedly dilated (72.5 mm end-diastolic …
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