Successful intervention for decompensated heart failure with complicated pathophysiologies with complex interdependence: a case report

Abstract

Background There is limited evidence regarding the optimal strategy for treating patients with acute decompensated heart failure complicated by severe left ventricular dysfunction, functional mitral regurgitation (FMR), and atrial septal defect that cannot be controlled despite optimal medical treatment. Case summary A 72-year-old man with non-ischemic cardiomyopathy presented with acute heart failure and recurrent atrial fibrillation. An electrocardiogram after electrical cardioversion revealed left bundle block with QRS duration of 152 ms. Transthoracic echocardiography revealed severe left ventricular dysfunction, severe FMR, and a left-to-right shunt through an iatrogenic atrial septal defect (IASD). Despite initial optimal medical therapy for heart failure, the patient's condition was not completely controlled. After a discussion among the heart team, we performed cardiac resynchronization therapy (CRT) as the next strategy. Two weeks after CRT device implantation, heart failure was controlled, with improvement in cardiac function and FMR. The left-to-right shunts through the IASD also improved. Discussion When treating decompensated heart failure with complicated pathophysiologies, it is crucial to prioritize the predominant pathophysiological factor and engage in thorough discussions with the heart team regarding the most appropriate intervention.