Salvage CRT-D Implantation In A Patient With Advanced Biventricular Congestive Heart Failure Complicated With Cardiogenic Shock - Pace It Out

Abstract

<h3>Background</h3> CRT-D therapy, when indicated, improves quality of life and reduces mortality and CHF readmission rates. It is unknown if CRT-D can be beneficial in certain advanced CHF patients presenting repeatedly with cardiogenic shock (CS). <h3>Case</h3> A 64 year old female with a history of CAD post CABG, CHF (EF 5-10% with severe RV dysfunction <b>Figure 1</b>, EF was 40-45% 1.5 years ago), presented with shortness of breath. BP 108/91 mmHg. Exam: Cool extremities. Lactic acid 3.85. EKG: Old LBBB with QRS of 158 msec. She was diagnosed with CS. She had recurrent readmissions for CHF and CS before: First at a local hospital in June 2020, second at our hospital in July 2020 with medical therapy optimization (MTO), and third at our hospital in July 2020 (this time). <h3>Decision-making</h3> The patient was admitted to CCU for milrinone and Lasix. LHC: Patent LIMA to LAD, occluded SVG to RI, and 70-80% RI disease <b>Figure 1</b>. After 2 days, she improved and was transferred to the floor. The big EF drop was out of proportion to CAD burden. She had recurrent readmissions with MTO failure. Due to lack of insurance, she was not able to get home inotropes or work up for LVAD or transplant. Thus, the decision was to proceed with salvage CRT-D implantation <b>Figure 1</b>. She was discharged after 11 days. Since discharge 3.5 months ago, she continued to do well without any admission. <h3>Conclusion</h3> Salvage CRT-D can be considered in patients with advanced CHF with recurrent inotrope reversible CS on a case-by-case basis. Further studies are needed to validate this consideration.