A Case of Cardiomyopathy with Apparent Interventricular Dyssynchrony Due to Severe Transseptal Conduction Disturbance

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<B>Case:</B> A 60’s man suffered from ventricular tachycardia with cardiomyopathy, and ICD was implanted in 2008. According to the spread low voltage area across ventricular septum, the ventricular lead was fixed on high right ventricular (RV) septum. The patient had lapsed into orthopnea since January, 2011. He suffered second degree atrio-ventricular block with atrium-only pacing, so the pacing mode was changed to DDDR. However, his electrocardiogram showed dissociated biphasic QRS wave, which supposed that the first component reflected RV contraction and second component left ventricular (LV). In echocardiogram, the timing of LV ejection was 150 ms latter than that of RV. In activation map by CARTO system with his own QRS wave, the ventricular conduction started at basal septum and both LV and RV excitation ended simultaneously within 160 ms. While in activation map with RV high-septal pacing, the RV conduction started at pacing-site and ended at RV basal inferior site at 83 ms after the pacing. Subsequently after a 10 ms interval, LV conduction started at LV posteroseptum and ended at LV lateral wall at 226 ms after the pacing. This interventricular dyssynchrony was improved after upgrade to CRTD. <B>Conclusions:</B> We experienced a rare case that showed completely separated RV and LV contraction with RV pacing, due to severe transseptal conduction disturbance.