History
The patient is a 71-year-old man who has been followed for 20 years. He is a former smoker, having smoked from the age of 20, with 50 years of smoking at one pack per day. He formerly had hypertension. His mother had a myocardial infarction at the age of 60 years; no other family members had known premature vascular disease. He initially sought treatment at the age of 52 years with an anterior myocardial infarction. Thrombolysis was performed at that time, and he was placed on aspirin 325 mg daily.
The patient returned to medical attention 9 years ago with worsening angina (Canadian Cardiovascular Society [CCS] III). An exercise methoxyisobutylisonitrile (MIBI) test demonstrated ST depression in the anterior leads starting 6 minutes into exercise. He was able to exercise for 9 minutes. The maximal ST depression was 0.2 mV in amplitude and persisted 3 minutes into recovery. The nuclear images showed a large reversible defect occupying most of the anterior wall and anterior septum. A subsequent angiogram showed 90% stenosis in the proximal left anterior descending (LAD) artery, 40% stenosis of the left mainstem artery, 50% stenosis of the proximal and mid–right coronary artery, and 60% stenosis of the circumflex artery. Angioplasty was performed, and a bare metal stent was placed in the proximal LAD. He was then started on an angiotensin-converting enzyme (ACE) inhibitor, a statin, and a thienopyridine in addition to his aspirin and was enrolled in a cardiac rehabilitation program.
His echocardiogram at that time showed an ejection fraction of 50%, normal right ventricular function, mild-to-moderate mitral regurgitation, mild tricuspid regurgitation (no other valvulopathy), and right ventricular systolic pressure of 25 mm Hg.
One year ago the patient returned to medical attention with an acute inferior myocardial infarction. He had been on holiday camping and sought treatment 30 hours after the onset of pain. He underwent an angiogram, which revealed an occlusion of the proximal right coronary artery. Collaterals from the circumflex artery filled the distal right coronary artery. The stenosis of the circumflex artery was 75%. The stenosis of the left mainstem artery was 60%. The LAD artery now had a 70% stenosis in its midportion. The left ventricular angiogram showed an ejection fraction of 45% with severe mitral regurgitation.
A subsequent echocardiogram confirmed an ejection fraction of 45% and demonstrated severe mitral regurgitation. Akinesis of the inferior wall and hypokinesis of the anterior wall were noted. The mitral valve appeared morphologically normal. The mitral regurgitation jet was directed posteriorly, thought to be due to a tethered posterior leaflet resulting from the inferior wall motion abnormality.
Coronary artery bypass surgery and mitral valve repair or replacement was recommended. This was undertaken before discharge. He received the following grafts: left internal thoracic artery to mid-LAD with a skip graft to the second diagonal artery; saphenous vein graft from the aorta to a large first obtuse marginal artery with a skip graft to the second obtuse marginal artery; and saphenous vein graft from the aorta to the distal right coronary artery. On examining the mitral valve, the surgeon thought the best result would be obtained with a mechanical mitral valve replacement, which was implanted simultaneously.
The patient’s immediate postprocedure echocardiogram showed no mitral regurgitation and an ejection fraction of 20%. Despite this, his hospital stay was complicated by pulmonary and peripheral edema. He was discharged to home 10 days after surgery on aspirin, an ACE inhibitor, a statin, a diuretic, and a low-dose beta blocker.
He has been attending the heart function and heart failure clinic weekly; his medications have been slowly increased to his target doses. He has had no hospital admissions for heart failure.
He is referred to a cardiac electrophysiologist 3 months after surgery for an opinion regarding device therapy.
Comments
In summary, this patient is a 71-year-old retired electrician with ischemic heart disease and persistently reduced ejection fraction despite revascularization and maximal medical therapy.
Current Medications
The patient’s medications are ramipril 10 mg, aspirin 81 mg, and coumadin (dose titrated to achieve an international normalized ratio of 2.5-3.5) every morning and bisoprolol 10 mg, spironolactone 25 mg, and atorvastatin 80 mg every evening.
Comments
The patient appears to be on optimal medical therapy.
Current Symptoms
The patient currently denies orthopnea and paroxysmal nocturnal dyspnea. He is able to walk one block on a flat surface and has to stop because of shortness of breath.
Comments
He has New York Heart Association class III heart failure symptoms despite being revascularized and on optimal medical therapy.
Physical Examination
Comments
The patient appears mildly volume overloaded.
Laboratory Data
Comments
The patient’s renal insufficiency is long-standing. He has had three previous episodes of acute renal insufficiency resulting from prerenal azotemia. His creatinine has been at this level over the last 12 months.
Electrocardiogram
Findings
The 12-lead electrocardiogram (ECG) shows sinus bradycardia at a rate of 60 bpm, right bundle branch block (RBBB), and left and anterior hemiblock (Figure 3-1).
Comments
The important finding on ECG is that the RBBB is very wide, with a QRS duration of 220 msec.
Echocardiogram
Findings
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