HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

History
Cardiovascular risk factors (CVRF): diabetes mellitus, ex-smoker, dyslipidaemia. Diffuse large B-cell lymphoma, treated with chemotherapy 10 years ago, in complete remission. Chronic heart failure: non-ischemic dilated cardiomyopathy (DCM), LVEF 33%, generalised hypokinesia.

Current disease
A 63 year-old male under follow-up by the heart failure unit of our hospital for dilated cardiomyopathy of non-ischaemic aetiology. The patient is in NYHA II, with no signs of peripheral congestion.

In the successive analytical controls since the consultation, absolute iron deficiency (ferritin 84 ng/ml and STAT 13%) and Hb of 13 g/dl were observed. Normal renal function: creatinine 0.84 mg/dl, GFR 85.94 ml/min/1.73 m2, and Nt-proBNP 3,657 pg/ml. The patient was included in the protocol for the study of iron deficiency in patients with HF and reduced LVEF.

Chronic treatment: insulin Toujeo 50 IU/day, metformin/empagliflozin 1000/12.5 mg/12 h, sacubitril/valsartan 49/51 mg/12 h, bisoprolol 5 mg/day, furosemide 40 mg/day and eplerenone 12.5 mg/day.

COMPLEMENTARY TESTS
As part of the study protocol, the following tests were performed: Baseline echocardiogram: left ventricle of normal diameters (LVEDD 48 mm), without hypertrophy of its walls and with severe depression of global systolic function (EF 35%) secondary to generalised hypokinesia. Aortic root of normal diameter with sigmoids of normal thickness and opening. There is no evidence of valve dysfunction. Mitral valve with leaflets of normal thickness and mobility. Trivial mitral insufficiency. LV diastolic pattern suggestive of impaired relaxation (E/A 0.7) with normal estimated filling pressures (E/e' 9). Normal sized atria. Non-dilated right ventricle with slightly depressed systolic function. No tricuspid insufficiency (TI). Absence of pericardial effusion. Global longitudinal strain (GLS) of -12.2%. Baseline cardiac magnetic resonance (CMR): left ventricle with preserved wall thickness, slightly increased diastolic volume (IVTDVI 97 ml/m2; IVTSVI 64 ml/m2) and severely depressed global systolic function (LVEF 34%), secondary to generalised hypokinesia. Right ventricle with preserved morphology and volumes (IVTDVD 75 ml/m2; IVTSVD 38 ml/m2) and slightly depressed systolic function (LVEF 49%). Left atrium of size at the upper limit: 39 mm, 26 cm2, 15 cm2/m2. Aorta and great vessels of normal diameter and morphology. Bilateral pleural effusion. T1 myocardium: 1082 ms. T2* myocardium: 35 ms. Electrocardiogram (ECG): sinus rhythm at 95 bpm, PR 160 ms, narrow QRS, normal axis. Atrial extrasystoles.

CLINICAL EVOLUTION
According to protocol, 1,000 mg of intravenous iron carboxymaltose (Ferinject ®) was administered weekly for 2 weeks, and after confirming normalisation of the iron profile with analytical tests, a new structural assessment was performed. CMR after 4 weeks of iron treatment: left ventricle with preserved wall thickness and diastolic volume (IVTDVI 84 ml/m2; IVTSVI 48 ml/m2). Moderately depressed global systolic function (LVEF 43%), secondary to generalised hypokinesia. Right ventricle of preserved morphology and volumes (IVTDVD 65 ml/m2; IVTSVD 30 ml/m2) and borderline systolic function (LVEF 54%). Left atrium of normal size: 34 mm, 23 cm2, 13 cm2/m2. Aorta and great vessels of normal diameter and morphology. T1 myocardium: 1037 ms T2* myocardium: 38 ms. There was significant improvement in LV ejection fraction estimated by CMR (LVEF 43% at 30 days), with a decrease in T1 mapping to 1037 ms, indicating myocardial iron repletion.

In addition, there was evidence of an increase in GLS to -19.1%. These changes were accompanied by improvement in quality of life, 6-minute test and other surrogates of heart failure.

DIAGNOSIS
Dilated cardiomyopathy with severely depressed LVEF.
Absolute iron deficiency.
Myocardial iron repletion after treatment with iron carboxymaltose (Ferinject).
