History
A 65-year-old man with ischemic dilated cardiomyopathy, already treated by stenting of the anterior interventricular coronary artery and then by coronary artery bypass graft surgery, received a dual-chamber implantable cardioverter-defibrillator (ICD) 4 years previously for primary prevention of sudden cardiac death. At that moment the electrocardiogram (ECG) showed an incomplete left bundle branch block (LBBB) with a QRS duration of less than 120 ms. The patient was later admitted to the hospital because of acute heart failure decompensation. During the last 6 months his functional capacity progressively declined (currently New York Heart Association [NYHA] class III) despite medical therapy optimization.
Comments
This patient showed progressive worsening of his clinical condition likely atributable to the underlying heart disease (coronary artery disease) and progression of ventricular conduction delay (LBBB on surface ECG).
Current Medications
The patient was taking torasemide 10 mg daily, bisoprolol 5 mg daily, spironolactone 25 mg daily, enalapril 10 mg twice daily, aspirin 100 mg daily, and insulin.
Current Symptoms
The patient was experiencing dyspnea at rest, orthopnea, and edema of the inferior extremities.
Physical Examination
Laboratory Data
Electrocardiogram
Findings
The ECG revealed a heart rate of 76 bpm, a sinus rhythm with a PR interval of 190 ms, and a complete LBBB with a QRS duration of 136 ms (Figure 32-1).
FIGURE 32-1
Echocardiography
Findings
The echocardiogram documented a dilated left ventricle (end-diastolic volume 210 mL) with a severe reduction of the ejection fraction (18%); moderate mitral and tricuspid regurgitation; restrictive mitral flow pattern; left atrium dilation (59 mm); moderate pulmonary arterial hypertension (60 mm Hg); and right ventricle with normal dimensions and function.
Catheterization
A coronary angiography was performed showing three-vessel disease with patency of all the coronary grafts (left internal mammary artery on anterior interventricular coronary artery, right internal mammary artery on right coronary artery, double venous grafts on circumflex artery).
Focused Clinical Questions and Discussion Points
Question
What would be the next step for the treatment of the heart failure in this patient?
Discussion
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