HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

History
No known drug allergies. Cardiovascular risk factors (CVRF): dyslipidaemia, type 2 diabetes mellitus, arterial hypertension. Non-ischemic dilated cardiomyopathy, with coronary angiography in 2019 without significant lesions. At last check-up, patient stable in NYHA II. In last echocardiographic control: left ventricle (LV) with slightly increased volumes and moderate depression of global systolic function (LVEF 37%) with abnormal septoapical movement and akinesia of all mid-apical segments. Moderate mitral regurgitation. Mild aortic insufficiency. Right ventricle (RV) with increased diameters and preserved global systolic function. Moderate tricuspid insufficiency allowing an estimated PAPS of approximately 45 mmHg (mild PH). Paroxysmal atrial fibrillation (AF). Other antecedents: mild chronic obstructive pulmonary disease (COPD). Subclinical hypothyroidism. Surgical interventions: appendectomy and tonsillectomy. Treatment: eutirox 50 mcg/24 hours, atorvastatin 40 mg/24 hours, pantoprazole 40 mg/24 hours, salbutamol on demand, zolpidem 10 mg/24 hours, nebivolol 2.5 mg/12 hours, apixaban 5 mg (1 tablet every 12 hours), eplerenone 50 mg/24 hours, seguril 40 mg/24 hours, dapagliflozin 10 mg/24 hours, sacubitril/valsartan 49/51 mg/12 hours.


Present illness
A 76-year-old man with the above-described history presented to the emergency department of our hospital with decompensated heart failure. He presented with a picture of approximately one month's evolution consisting of worsening functional class with progressive dyspnoea until he became resting, accompanied by orthopnoea on 3 pillows and paroxysmal nocturnal dyspnoea. No decrease in the diuresis rhythm. He reported swelling of the lower limbs and increased abdominal perimeter. No chest pain or palpitations. No fever or infectious semiology by apparatus. He attended the hospital out of appointment for outpatient cardiology consultations, from where he was referred for admission.

Physical examination
Blood pressure (BP) 145/76, heart rate (HR) 77 bpm, oxygen saturation 97% room air, temperature 36.3 oC. Good general condition. Conscious and oriented. Normohydrated and normal colour. Eupneic at rest. Abdomen: distended, matt on percussion with moderate ascites, pain on palpation in the left hypochondrium, no masses or megaliths. Cardiac auscultation: arrhythmic heart sounds, no murmurs. Pulmonary auscultation: preserved vesicular murmur with bibasal crackles. Lower limbs: tibiomalleolar oedema +++/++++, increased jugular venous pressure, no signs of deep vein thrombosis (DVT).

COMPLEMENTARY TESTS
Electrocardiogram (ECG): On admission: sinus bradycardia at 50 bpm. Elongated PR 360 ms. Wide QRS 160 ms, with morphology of non-specific intraventricular conduction disorder. On discharge: paced rhythm with CRT at 60 bpm. PR 160ms. Wide QRS 130 ms with morphology of complete right bundle branch block. Chest X-ray (admission): centred cardiomediastinal silhouette, cardiomegaly, vascular redistribution, bilateral pleural effusion. Laboratory tests (admission): CBC: red cells 4.4 10*12/l, haemoglobin 12.3 g/dl, haematocrit 37.6%, MCV 85.5 fl, MCH 28 pg, MCHC 32.8 g/dl, RDW 15.5%. Leukocytes 6.8 10*9/l, neutrophils 62.8%, lymphocytes 23%, monocytes 11.1%, eosinophils 2.1%, basophils 1%, neutrophils 4,310*9/l. Lymphocytes 1.6 10*9/l, monocytes 0.8 10*9/l, eosinophils 0.1 10*9/l, basophils 0.1 10*9/l, platelets 90 10*9/l, PWV 10.9 fl. Coagulation: prothrombin time (PT) 21.7 s, Quick's index 40%, INR 1.86, aPTT 34.2 s, ratio (aPTT) 1.15, derived fibrinogen 386 mg/dl. Biochemistry: glucose 91 mg/dl, sodium 141 mEq/l, potassium 3.9 mEq/l, chlorine 104 mEq/l, total bilirubin 2.2 mg/dl, alanine aminotransferase GPT 63 U/l, creatinine 1.06 mg/dl, estimated GFR CKD-EPI 67.83 ml/min/1.73 m2, uric acid 9.3 mg/dl, protein 5.8 g/dl, C-reactive protein 1.1 mg/dl, thyrotropin (TSH) 4.00 uIU/ml. Ferric Met: ferritin 25 μg/l, iron 48 μg/dl, total Fe fixation capacity 428 ug/dl, transferrin saturation index 11.2%. Carbohydrate 125 (CA125) 262 IU/ml, NT-proBNP 17963.0 pg/ml. PCR SARS-CoV2 negative.
Echocardiogram: Admission: LV with increased diameters with anomalous septo-apical movement and global hypokinesia, leading to severe ventricular dysfunction (LVEF 33%). Aortic root of normal diameter, with preserved opening sigmoids. Moderate mitral insufficiency with ORE by PISA of 0.25 cm2, sclerosed valve, dilatation of the annulus (46 x 36 mm). Mild aortic insufficiency. RV with increased diameters and moderately depressed global systolic function. Moderate tricuspid regurgitation, dilatation of the annulus, systolic pulmonary artery pressure approximately 45-50 mm Hg. IVC of 24 mm, without inspiratory collapse. Follow-up at 4 months: LV of slightly increased diameters and volumes with mild depression of LVEF (50%). Mild mitral and aortic insufficiency. Mitral filling pattern with single E wave. No signs of increased LV end-diastolic pressures. Moderately dilated left atrium. RV with increased diameters and slightly depressed systolic function. Tricuspid insufficiency allowing an estimated PAPS of 25 mmHg. Inferior vena cava (IVC) not dilated, with adequate inspiratory collapse.

CLINICAL EVOLUTION
The patient was admitted to cardiology for decompensated heart failure. Intensive diuretic treatment was started with adequate depletion and the patient tolerated oral furosemide on discharge. An echocardiogram was performed on admission showing severe ventricular dysfunction (25%), with interventricular asynchrony and moderate mitral and tricuspid regurgitation. Given the indication for ICD-CRT, the case was discussed with the arrhythmia unit, and the device was implanted prior to discharge. In successive check-ups, the patient reported a marked improvement in functional class (currently in NYHA I), which remained stable. A control echocardiogram showed a marked improvement in function, with correction of asynchrony and a reduction in the degree of regurgitations.


DIAGNOSIS
Non-ischaemic dilated cardiomyopathy, with severe LV dysfunction.
Interventricular asynchrony due to non-LBBB conduction disorder.
Implantation of ICD-CRT.
