For specialists

Patient P with HFrEF

03.06.2020 The patient (1957 y.) was admitted to one of the private clinics with shortness of breath and reduced oxygen saturation up to 85%. In the Covid-19 era, after CT of the lungs, the patient was diagnosed with:

“Diagnosis: Non-hospital bilateral polysegmental pneumonia, III class group. Respiratory failure of the 2nd degree. Bilateral minimal hydrothorax. Ischemic heart disease. Postinfarction cardiosclerosis (1992, 1997, 2005). Exertional angina, functional class 4. CABG 1997. Permanent form of atrial fibrillation. NYHA III. Left ventricular systolic dysfunction (EF 20% -30%). Hypertensive disease, grade III, the risk is very high. Diabetes mellitus, type 2, art. compensation. Cholecystectomy. Chronic viral hepatitis C.

CT scan of the patient on admission.

Could such a picture on CT scan explain the decrease in oxygenation to 84%?

CT scan of the patient on admission, part 2

Transthoracic echocardiography with vector analysis revealed heart failure with a reduced ejection fraction and a significant decrease in the global longitudinal strain.

parasternal long axis view
four-chamber view with spectral analysis
two-chamber view with spectral analysis
three-chamber view with spectral analysis
Bulls-eye. Loss of several sectors of the poor ultrasound window

Global longitudinal strain 5,95% – severe heart failure with reduced ejection fraction 37%, LVEDV 260 ml, LVESV 160 ml.

Obviously, the patient had symptoms of an exacerbated heart failure. Moreover, several tests for covid were negative.

Mitral valve peak pressure gradient 4.2 mm Hg
Mitral valve mean pressure gradient 3.5 mm Hg
MV regurgitation 2 – 3 ст.
V regurgitation 65 ml
MR PISA 6,01
E lat 0.127 m/s
E/E’ lat. 10.2
left atrial pressure 17 мм.рт.ст.
Pulmonary valve Pressure gradient 1.6 mm Hg
regurgitation 1 grade.
PAP: (sist.) 69 mm Hg (mean) 50mm Hg
Pulmonary trunk 30 mm
Right pulmonary artey 20 mm
Left pulmonary artery 17 mm
coronary angiography: LAD occlusion and critical OS stenosis

LAD occlusion and critical OS stenosis

coronary angiography: occlusion of the right coronary artery
aortography with no bypasses in it

The patient was discharged from the clinic with improvement and full confidence that he had pneumonia.

Nevertheless, despite the therapy prescribed by the cardiologist and pulmonologist, the patient returned to the clinic with complaints of shortness of breath and decreased blood oxygenation.

The patient was referred to a cardiac surgeon to resolve the issue of a re-CABG.

The cardiac surgeon offered the patient a re CABG in the absence of the effect of the best medical therapy. The fact is that patients after coronary artery bypass grafting have very low compliance with drug intake, which means they can be a beneficiary of high-quality drug therapy.
the patient has already taken all these drugs

Best medical therapy is not only drugs, but also their targeted dosages.

we were able to achieve target doses

Due to the presence of arterial hypertension in the patient, we were able to quickly reach the target dosages of the drugs. But that’s not all! One of the SGLT 2 receptor blockers “off label” was prescribed to the patient. Indications for the treatment of HFrEF for this drug have not yet been prescribed in the instructions. This decision was made based on the results of the EMPEROR-Reduced Trial.

We repeated the EchoCG with spectral analysis a few months later:

two-chamber view with spectral analysis a few months after treatment
three-chamber view with spectral analysis a few months after treatment
four-chamber view with spectral analysis a few months after treatment
mitral regurgitation up to 2 stage plus aortic regurgitation 1 st
decrease in lateral E/e’ by 2 times tells us about a decrease in pressure in the left atrium ~ 8,5 mm Hg
“bulls eye” view. Speckle tracking analisis a few months after treatment

We get the improvement of global contractility by 2 times with an increase in GLS up to 11.8

The conclusions of the ISCHEMIA trial are fully confirmed by our case: the guidelines guided conservative therapy has the same power as the endovascular coronary intervention. The main thing is that the patient have to be compliant.