Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Endocardial Left Ventricular Lead: High Approach


Age Gender Occupation Working Diagnosis
65 Years Male Retired Heart Failure

History

The patient was a 65-year-old retired man seeking treatment for dilated cardiomyopathy with normal coronary arteries for about 10 years. Risk factors are dyslipidemia and obesity (91 kg, 173 cm). Two procedures of ablation for atrial fibrillation and atrial tachycardia were performed 6 and 2 years earlier. One year previously, a new episode of atrial fibrillation was treated with direct current shock and amiodarone. The patient is currently in sinus rhythm and remains in New York Heart Association (NYHA) class III under medical therapy. The patient has no pulmonary disease, and respiratory tests are normal.

Comments

This is a long history of heart failure in a patient being followed adequately and benefiting from currently available therapeutic techniques. The cardiomyopathy is considered idiopathic, and atrial arrhythmias are events that do not fully explain the current heart failure status of the patient.

Medications

The patient was taking bisoprolol 2.5 mg daily, ramipril 5 mg daily, rosuvastatin 20 mg daily, furosemide 40 mg daily, warfarin with international normalized ratio (INR) between 2 and 3, amiodarone 200 mg daily.

Comments

The patient could not tolerate the recommended dosages of beta blockers and angiotensin-converting enzyme (ACE) inhibitors because of symptomatic hypotension. The spironolactone that was given previously had to be stopped for occurrence of hyperkalemia. Thus medical treatment is not optimal, because patient ideally should require 10 mg daily each of bisoprolol and ramipril. The statin is given for the hypercholesterolemia. Amiodarone and warfarin are for rhythm control and prevention of thromboembolism, respectively. The furosemide dosage is sufficient for controlling the heart failure symptoms.

Current Symptoms

The patient is in NYHA class III, with predominant dyspnea on exertion, accompanied with palpitations, fatigue, and mild peripheral edema.

Comments

The patient never experienced symptoms of acute heart failure even during the occurrence of atrial tachyarrhythmias. Increasing the dosage of furosemide did not minimize symptoms.

Physical Examination

  • BP/HR : 98/71 mm Hg/95 bpm at rest

  • Height/weight: 173 cm/91 kg

  • Neck veins: Not dilated

  • Lungs/chest: No crackle at auscultation

  • Heart: No murmur, no abnormal heart sound

  • Abdomen: No ascites

  • Extremities: Mild limb edema

Comments

Although the patient had symptoms of heart failure, no objective sign can be observed except from sinus tachycardia and hypotension. This may occur in patients with chronic heart failure.

Laboratory Data

  • Hemoglobin: 12.7 g%

  • Hematocrit/packed cell volume: 37.6%

  • Platelet count: 184 g/L

  • Sodium: 139 mmol/L

  • Potassium: 4.2 mmol/L

  • Creatinine: 109 mmol/L

  • Urea nitrogen: 8.4 mmol/L

  • B-type natriuretic peptide: 1287 pg/mL

Comments

The patient has mild impairment of renal function, and B-type natriuretic peptide (BNP) is elevated.

Electrocardiogram

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