Advanced Heart Failure Symptoms Research Articles

Mitral valve surgery in elderly patients with mitral regurgitation

The fastest growing demographic in North America is the elderly. Significant mitral regurgitation is present in more than 10% of this population. There are sparse clinical data to inform decisions regarding the optimal timing of operation and the appropriate operative intervention for this large population of patients with severe mitral regurgitation. Mitral valve surgery can be safely performed in most elderly patients with severe mitral regurgitation. The best outcomes occur when operative intervention is performed early, before advanced symptoms of heart failure develop. In elderly patients with mitral regurgitation, mitral valve repair is associated with superior early and late results compared with replacement. Survival after mitral valve repair among elderly patients is equivalent to a normal age-matched population. Elderly patients with severe mitral regurgitation should be referred for operation before significant symptoms develop. Mitral valve repair is favoured over replacement whenever feasible and is associated with satisfactory early and long-term results. If repair is impossible or the likelihood of durable repair seems low, valve replacement with a bioprosthetic valve should be performed. Further prospective clinical trials are essential to define the role of screening for this prevalent condition and to identify which subgroups of elderly patients will benefit most from early surgical intervention.

Atrial fibrillation ablation in patients with heart failure review

Atrial fibrillation and heart failure often coexist in patients with advanced heart failure symptoms. The result, in addition to a significant impact on quality of life, is an increase in the risk of a adverse clinical outcomes including stroke, hospitalization and overall mortality. Pharmacological therapy for atrial fibrillation in the heart failure population remains limited due to sub-optimal drug efficacy and a likely increased mortality due to pro-arrhythmia. Atrial fibrillation ablation, since it allows for therapy without the need for toxic medication, has the potential to become mainstream treatment in patients with drug refractory, symptomatic atrial fibrillation and heart failure. Randomized studies and observational data suggest that atrial fibrillation ablation provides superior rhythm control to anti-arrhythmic drugs. Atrial fibrilla- tion ablation is relatively safe and may result in improvement of left ventricular function and quality of life. Ongoing studies are attempting to assess a number of outcome measures to help define its role in the heart failure patient population. This review focuses on atrial fibrillation ablation in patients with congestive heart failure, and summarizes the results of available literature.

Mitral Valve Repair for Medically Refractory Functional Mitral Regurgitation in Patients with End-stage Renal Disease and Advanced Heart Failure

Background—Information regarding patient selection for mitral valve repair for chronic kidney disease or end-stage renal disease (ESRD) with severe heart failure (HF) as well as outcome is limited. Methods and Results—We classified 208 patients with advanced HF symptoms (Stage C/D) undergoing mitral valve repair for functional mitral regurgitation into 3 groups: estimated glomerular filtration rate ≥30 mL/min/1.73 m2 (control group, n=144); estimated glomerular filtration rate <30 mL/min/1.73 m2, not dependent on hemodialysis (late chronic kidney disease group, n=45), and ESRD on hemodialysis (ESRD group, n=19; preoperative hemodialysis duration 83±92 months). Follow-up was completed with a mean duration of 49±25 months. Postoperative (1-month) cardiac catheterization showed that left ventricular end-systolic volume index decreased from 109±38 to 79±41, 103±31 to 81±31, and 123±40 to 76±34 mL/m2, in the control, late chronic kidney disease, and ESRD groups, respectively. Left ventricular end-diastolic pre...

Mitral Valve Repair for Medically Refractory Functional Mitral Regurgitation in Patients With End-Stage Renal Disease and Advanced Heart Failure

Information regarding patient selection for mitral valve repair for chronic kidney disease or end-stage renal disease (ESRD) with severe heart failure (HF) as well as outcome is limited. We classified 208 patients with advanced HF symptoms (Stage C/D) undergoing mitral valve repair for functional mitral regurgitation into 3 groups: estimated glomerular filtration rate ≥30 mL/min/1.73 m(2) (control group, n=144); estimated glomerular filtration rate <30 mL/min/1.73 m(2), not dependent on hemodialysis (late chronic kidney disease group, n=45), and ESRD on hemodialysis (ESRD group, n=19; preoperative hemodialysis duration 83 ± 92 months). Follow-up was completed with a mean duration of 49 ± 25 months. Postoperative (1-month) cardiac catheterization showed that left ventricular end-systolic volume index decreased from 109 ± 38 to 79 ± 41, 103 ± 31 to 81 ± 31, and 123 ± 40 to 76 ± 34 mL/m(2), in the control, late chronic kidney disease, and ESRD groups, respectively. Left ventricular end-diastolic pressure decreased, whereas cardiac index increased in all groups with no intergroup differences for those postoperative values. Freedom from mortality and HF readmission at 5 years was 18% ± 7% in late chronic kidney disease (P<0.0001 versus control, P=0.01 versus ESRD), and 64% ± 12% in ESRD (P=1 versus control) as compared with 52% ± 5% in the control group (median event-free survival, 26, 67, and 63 months, respectively). Mitral valve repair for medically refractory functional mitral regurgitation in patients with advanced HF yielded improvements in left ventricular function and hemodynamics irrespective of preoperative renal function status. Patients with ESRD showed favorable late outcome in terms of freedom from mortality and readmission for HF as compared with those with late chronic kidney disease. Further studies are needed to assess the survival benefits of mitral valve repair in patients with ESRD and advanced HF.

The Atria Are Fibrillating

Cardiac resynchronization therapy (CRT) has become an integral treatment modality for patients with heart failure (HF), diminished left ventricular ejection fraction, and a wide QRS complex, conferring symptomatic relief, functional improvement, and survival benefit to the majority of recipients.1–4 CRT indications5 were initially restricted to patients in sinus rhythm, yet as atrial fibrillation (AF) is the most common sustained arrhythmia in patients with HF, with a prevalence that increases with more advanced HF symptoms,6 much attention has focused on expanding the CRT indications to patients with permanent AF. Article see p 566 Despite the fact that approximately a quarter of patients with HF eligible for CRT therapy have permanent AF,6 the overwhelming majority of multicenter, randomized CRT trials have only included patients in sinus rhythm.1–4 The majority of our knowledge regarding the role of CRT in patients with permanent AF is, therefore, based on nonrandomized, observational data. There are special considerations that are pertinent to CRT patients with permanent AF. First, in the absence of large, randomized, prospective trials of CRT versus no CRT in the AF population, it is not firmly established whether patients with AF derive survival, symptomatic, and structural benefits from CRT and if these benefits do occur, whether they are comparable in magnitude to those seen in patients with sinus rhythm. Second, it is not completely established how best to ensure a high burden of biventricular pacing in CRT recipients who also have AF, although the role of atrioventricular nodal ablation in this context seems to be widely accepted.7,8 From a survival perspective, there are no randomized, prospective trials examining the effect of CRT on mortality in patients with AF. Early prospective, nonrandomized, observational data,9 however, showed no difference in total mortality after …

Ventricular Assist Devices

Heart failure is the final common pathway for many chronic heart diseases. With the aging of the population and advances in the treatment of cardiac disease, the number of patients with heart failure continues to increase. Although the majority of patients will remain stable for several years with standard medicines and surgery, a growing number will develop symptoms of advanced heart failure and may be referred for evaluation for heart transplant. For selected patients who are too ill to wait for a heart donor or who are not eligible for a heart transplant because of age or other medical problems, ventricular assist devices (VADs) offer life-saving therapy. Initially designed as temporary support to bridge patients to heart transplant, these devices are now available and increasingly being used as lifetime support or destination therapy. Improvements in device design, along with advances in surgical and medical management, have allowed VAD patients to return home, to work, and to their communities, with excellent quality of life. At the same time, however, unique challenges have been encountered. This Cardiology Patient Page will discuss the fundamentals of VADs, including patient selection, pump design, surgical and medical treatment, expected benefits and long-term risks, and the team approach to care. Heart failure is a common cardiac condition in which the heart is unable to pump blood at a sufficient rate to meet the demands of the body. There are 2 major types of heart failure: one is associated with abnormal heart filling (sometimes called diastolic heart failure or heart failure with preserved ejection fraction), and the other is associated with abnormal heart emptying (also called systolic heart failure or heart failure with reduced ejection fraction). Most patients who develop heart failure have had a prior injury or stress on the heart that caused the heart to weaken. …

Can we predict, prevent, and minimize defibrillator shocks? Lessons learned from “remote monitoring”

s I o f 9 f Beyond their principal role of successfully detecting and treating ventricular tachycardia (VT) and ventricular fibrillation (VF) with overdrive antitachycardia pacing and defibrillation shocks, modern implantable cardioverter-defibrillators (ICDs) are capable of providing sophisticated pacing and resynchronization therapy. They store enormous amounts of technical and patient-related data, such as arrhythmia burden and heart failure status. Device manufacturers recently introduced “remote monitoring” technology, which allows home transmitters to interrogate devices and to download and transmit collected and stored data via the Internet to a protected network. Remote monitoring not only has rapidly shifted the paradigm in device follow-up but has heightened interest in exploring the wealth of available information to better understand device functionality and disease substrates. Irrespective of the indications for ICD placement, given the associated risk factors and comorbidities, the majority of recipients also would be prone, if they have not already experienced, to develop atrial fibrillation (AF). The presence of AF, with its 5% to 30% incidence in the ICD population, is not merely a “nuisance” because it has many detrimental effects. Paroxysmal, persistent, and permanent AF have hazard ratios (HRs) (95% confidence interval] of 1.3 (0.7–2.5), 1.2 (0.6–2.2), and 1.7 (1.0–2.7), respectively, for mortality and 1.2 (0.6–2.2), 1.1 (0.5–2.4), and 2.4 (1.5–4.0), respectively, for appropriate ICD shocks. A ewly detected AF within the first 3 months of ICD placeent carries a significant risk for death with HR of 2.86 1.02–8.05). In patients with left ventricular dysfunction, persistent AF has been shown to cause appropriate ICD shocks and deterioration of heart failure. Furthermore, AF ay be proarrhythmic. In the Jewel AF trial, 8.6% of all T/VF episodes were found to have AF as a preceding or oncomitant rhythm. Interestingly, for consecutive episodes of VT/VF, time to next episode of VT/VF was longer when AF terminated than when it persisted.

Preoperative Factors Associated With Adverse Outcome After Tricuspid Valve Replacement

Preoperative factors associated with increased mortality and worse outcome after tricuspid valve replacement in patients with severe tricuspid regurgitation are poorly understood. We retrospectively analyzed 189 patients (37% men; age, 67.5±11.3 years) who underwent tricuspid valve replacement for severe tricuspid regurgitation. Operative mortality rate was 10%, and was associated with intra-aortic balloon pump (odds ratio, 3.2; 95% confidence interval, 1.9 to 5.6; P<0.0001) or the presence of severe symptoms (New York Heart Association class IV relative to classes II and/or III) at the time of surgery (1.7; 95% confidence interval, 1.05 to 2.8; P=0.02). At the end of follow-up (29.3±27.1 months), 70 patients (37%) died, 6 (3%) needed tricuspid reoperation, and 41 (21.7%) were readmitted for heart failure. Seventy-eight patients (41.3%) were free from cardiovascular events (death, tricuspid reoperation, or heart failure admissions). The only echocardiographic parameter independently associated with adverse outcomes was a decrease in the right index of myocardial performance ratio. All-cause mortality was independently associated with a higher Charlson index (hazard ratio, 1.18; 95% confidence interval, 1.01 to 1.36; P=0.03), shorter right index of myocardial performance ratio (0.91; 95% confidence interval, 0.87 to 0.96; P=0.005), and preoperative New York Heart Association IV class (1.71; 95% confidence interval, 1.3 to 2.2; P<0.0001). In 68 patients with isolated tricuspid valve replacement, the associations between short right index of myocardial performance ratio, high Charlson index, New York Heart Association class IV, and increased mortality remained significant. Tricuspid valve replacement for severe tricuspid regurgitation can be performed with an acceptable operative mortality if patients undergo surgery before the onset of advanced heart failure symptoms. Late mortality is associated with a high preoperative Charlson index, short right index of myocardial performance ratio, and advanced New York Heart Association class.

Risk Assessment in Critically Ill Patients Awaiting Transplantation: a Step Forward

Despite the advent of mechanical circulatory support, orthotopic heart transplantation (OHT) is still the long-term therapy of choice in selected patients with refractory heart failure. Most centers have experienced a change in ‘‘referral epidemiology’’ as increasingly sicker patients are being encountered with advanced heart failure symptoms refractory to inotropic therapy and with concomitant end-organ dysfunction. The reasons for this dramatic shift are elusive but are undoubtedly in part due to the lack of recognition among general clinicians that symptom control does not often translate into improved long-term prognosis in the contemporary cohort of late-stage heart failure patients. Importantly, the long endorsed classification of functional capacity using the New York Heart Association system is no longer optimal since pharmacological and device-based therapy have broadened the phenotypic presentation of late-stage heart failure. Clinicians now face a spectrum of phenotypes within the ‘‘advanced heart failure’’ group ranging from cardiogenic shock to impending shock, inotropic dependency with end-organ failure to intropic dependency without end-organ dysfunction, intermittently stable symptomatic states with recurrent and frequent decompensation, or chronic persistent symptoms resulting in substantial morbidity. The INTERMACS scale was a clinical attempt to further refine and stratify these myriad presentations of patients with late-stage heart failure undergoing left ventricular assist device (LVAD) implantation. The primary intent of this endeavor was to help stratify the appropriate population most likely to benefit from LVAD therapy but also to allow the community of clinicians to develop a communication strategy to convey disease severity. Using a linear scale from 1-7, the INTERMACS scale differentiates patients in a stepwise fashion from the sickest patients with shock (1) and organ hypoperfusion, requiring inotropic therapy, percutaneous mechanical circulatory support, and invasive hemodynamic monitoring, to those patients who suffer significant

Screening for Cognitive Deficits Using the Montreal Cognitive Assessment Tool in Outpatients ≥65 Years of Age With Heart Failure

There is strong evidence to suggest that heart failure (HF) is an independent risk factor for cognitive impairment (CI). The combination of CI and HF is associated with increased mortality, repeat hospitalization, and poor quality of life. The purpose of this pilot study was to determine the presence of CI in older patients with HF using the Montreal Cognitive Assessment (MoCA), a brief screening instrument for CI. We conducted a cross-sectional descriptive study using the MoCA in outpatients with HF who were ≥ 65 years of age. Forty-four patients (mean ± SD 76 ± 6.6 years of age) completed the MoCA. More than 70% of patients scored below the MoCA cutoff score of 26, suggesting the presence of CI. However, 91% of patients with New York Heart Association classes III to IV versus 52% of patients with classes I to II had a MoCA score < 26 (p = 0.004). Patients with a recent hospital admission were more likely to have a MoCA score < 26 versus patients without a recent hospital admission (89% vs 62%, respectively, p < 0.045). Cognitive domain subscores showing significant differences (p <0.01) were short-term memory, visuospatial function, executive function, and language. In conclusion, this study sample represented a group of older patients with HF and no suspected or documented CI, but screening with the MoCA detected CI in >70% of the sample. The presence of CI was significantly more common in patients with advanced HF symptoms or a recent hospitalization. Future studies need to determine if the MoCA can identify the presence of CI that is predictive of adverse clinical outcomes in the HF population.

Improvements in 25 Years of Implantable Cardioverter Defibrillator Therapy

In 1980, Dr. Michel Mirowski and his team inserted the first implantable cardioverter defibrillator (ICD) in a patient. Initially, ICD therapy was not widely accepted, and many physicians actually considered this therapy unethical. Large secondary and primary prevention trials, demonstrating a beneficial effect of ICD therapy in selected patients not only on arrhythmic death but also on all-cause mortality, stimulated a rapid growth in the number of implants and increased patient’s and physician’s acceptance. Improvements in size and weight, arrhythmia discrimination capabilities, battery technology, shock waveform and output, monitoring capabilities and defibrillator electrode technology eventually resulted in the current large number of yearly implants. Today, almost 40 years after the conception of the ICD and 25 years after the first human implant, ICD therapy is the treatment of choice for patients at risk for life-threatening arrhythmias either as secondary or primary prevention. Furthermore, with the more recent addition of resynchronisation therapy to standard ICD therapy, it became possible to treat selected patients with advanced symptoms of heart failure and to lower the risk of sudden death.

Anemia and Iron Deficiency — New Therapeutic Targets in Heart Failure?

Anemia ranges in prevalence from below 10% among patients with mild heart failure symptoms to over 40% for patients with advanced disease.1 Its prevalence is similar among patients who have systolic dysfunction and among patients who have heart failure with preserved systolic function.2,3 Anemia has been associated with older age, diabetes mellitus, chronic renal dysfunction, more advanced heart failure symptoms, lower peak exercise capacity, and worse health-related quality-of-life metrics.3 Anemia has also been shown to be a powerful predictor of rehospitalization rates and survival in chronic heart failure.A complex interaction between impaired cardiac performance, activation of neurohormonal and . . .

Monitoring Is Key to Heart Failure in Elders

Monitoring Is Key to Heart Failure in Elders

Insights From a Cardiac Resynchronization Optimization Clinic as Part of a Heart Failure Disease Management Program

Our aim was to determine the feasibility and value of a protocol-driven approach to patients with cardiac resynchronization therapy (CRT) who did not exhibit a positive response long after implant. Up to one-third of patients with advanced heart failure do not exhibit a positive response to CRT. A total of 75 consecutive ambulatory patients with persistent advanced heart failure symptoms and/or adverse reverse remodeling and CRT implanted >6 months underwent a comprehensive protocol-driven evaluation to determine the potential reasons for a suboptimal response. Recommendations were made to maximize the potential of CRT, and adverse events were documented. All patients (mean left ventricular [LV] ejection fraction 23 +/- 9%, LV end-diastolic volume 275 +/- 127 ml) underwent evaluation. Eighty-eight percent of patients had significantly better echocardiographic indexes of LV filling and LV ejection with optimal setting of their CRT compared with a temporary VVI back-up setting. Most patients had identifiable reasons for suboptimal response, including inadequate device settings (47%), suboptimal medical treatment (32%), arrhythmias (32%), inappropriate lead position (21%), or lack of baseline dyssynchrony (9%). Multidisciplinary recommendations led to changes in device settings and/or other therapy modifications in 74% of patients and were associated with fewer adverse events (13% vs. 50%, odds ratio: 0.2 [95% confidence interval: 0.07 to 0.56], p = 0.002) compared with those in which no recommendation could be made. Routine protocol-driven approach to evaluate ambulatory CRT patients who did not exhibit a positive response is feasible, and changes in device settings and/or other therapies after multidisciplinary evaluation may be associated with fewer adverse events.

Changing Preferences for Survival After Hospitalization With Advanced Heart Failure

This study was designed to analyze how patient preferences for survival versus quality-of-life change after hospitalization with advanced heart failure (HF). Although patient-centered care is a priority, little is known about preferences to trade length of life for quality among hospitalized patients with advanced HF, and it is not known how those preferences change after hospitalization. The time trade-off utility, symptom scores, and 6-min walk distance were measured in 287 patients in the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheter Effectiveness) trial at hospitalization and again during 6 months after therapy to relieve congestion. Willingness to trade was bimodal. At baseline, the median trade for better quality was 3 months' survival time, with a modest relation to symptom severity. Preference for survival time was stable for most patients, but increase after discharge occurred in 98 of 145 (68%) patients initially willing to trade survival time, and was more common with symptom improvement and after therapy guided by pulmonary artery catheters (p = 0.034). Adjusting days alive after hospital discharge for patients' survival preference reduced overall days by 24%, with the largest reduction among patients dying early after discharge (p = 0.0015). Preferences remain in favor of survival for many patients despite advanced HF symptoms, but increase further after hospitalization. The bimodal distribution and the stability of patient preference limit utility as a trial end point, but support its relevance in design of care for an individual patient.

Impact of Cardiac Resynchronization Therapy on Exercise Performance, Functional Capacity, and Quality of Life in Systolic Heart Failure With QRS Prolongation: COMPANION Trial Sub-Study

Background A total of 405 participants in the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure trial were prospectively enrolled in an exercise sub-study designed to study the influence of cardiac resynchronization therapy (CRT) on measures of exercise capacity, functional capacity, and quality of life (QOL). Methods and Results Substudy eligibility included New York Heart Association (NYHA) functional Class III or IV heart failure, left ventricular ejection fraction ≤0.35, QRS interval of ≥120 ms, normal sinus rhythm, a heart failure hospitalization (or equivalent) within 1 year, a peak VO 2 ≤22 mL ·kg ·min, the ability to walk 150 to 425 meters in 6 minutes, forced expiratory volume in 1 second/forced vital capacity ≥50%, and no clinical indication for a pacemaker or implantable cardioverter-defibrillator. Patients were randomized in a 1:4 ratio to optimal medical therapy (OPT) or to OPT plus CRT. Cardiopulmonary exercise testing (peak VO 2 and 6-minute walk distance [6MWD]) and assessment of NYHA functional class and QOL were assessed at baseline and at 3 and 6 months of assigned therapy. There was no significant improvement in peak VO 2 at 6 months in the CRT group compared with the OPT group (+0.63 mL ·kg ·min) by unadjusted analysis ( P = .05) or by analyses adjusted for missing data. Thus the primary end point of the study was not met. There was significantly greater improvement in the 6MWD in the CRT group compared with the OPT group at both 3 and 6 months by both statistical methods ( P ≤ .045). Likewise, a greater proportion of CRT patients improved by 1 or more NYHA functional classes ( P < .01) at 3 months and had better QOL scores ( P < .01) at 3 and 6 months compared with the OPT patients. Baseline peak VO 2 predicted clinical events (time to death, time to death or first hospitalization, or time to death and first heart failure hospitalization: P < .05) in CRT participants. Conclusion CRT patients with moderate to advanced symptoms of systolic heart failure and prolonged QRS intervals benefit from the addition of CRT to OPT in terms of exercise capacity, functional status, and QOL. CRT should be considered standard therapy in this select group of heart failure patients.

Recovery of Left Ventricular Systolic Longitudinal Strain After Valve Replacement in Aortic Stenosis and Relation to Natriuretic Peptides

We sought to examine left ventricular (LV) longitudinal systolic myocardial contractility in isolated valvular aortic stenosis (AS) before and after valve replacement and relation to natriuretic peptides. In all, 45 patients with symptomatic AS without significant coronary artery disease were studied by serial tissue Doppler echocardiography and analysis of plasma atrial and brain natriuretic peptide (Nt-pro-BNP). LV myocardial systolic strain was significantly reduced in AS with preserved ejection fraction and most pronounced in patients with advanced heart failure symptoms. Nt-pro-BNP was significantly related to LV mass index and mean LV strain (r = 0.63, P < .001; and r = 0.61, P < .001, respectively). Mean myocardial systolic strain increased after valve replacement (baseline -9 +/- 4% vs -14 +/- 4% at 12 months, P < .001). The increase of systolic strain and the observed regression of LV mass index were independently related to changes of Nt-pro-BNP (r = -0.67, P < .001; and r = -0.71, P < .001, respectively) during 12 months of follow-up after valve replacement. A significant association was found between changes of plasma atrial natriuretic peptide and echocardiographic markers of LV diastolic function. LV longitudinal systolic strain is severely depressed despite preserved LV ejection fraction and fractional shortening in AS. A significant association exists among natriuretic peptides, myocardial longitudinal contractility, and the degree of symptoms. Reverse LV remodeling after aortic valve replacement with regression of myocardial hypertrophy results in improvement of LV longitudinal myocardial strain and decrease of Nt-pro-BNP plasma levels. LV strain analysis might have the potential to identify patients with asymptomatic AS who might benefit from earlier surgical intervention to preserve overall LV function.

A grateful heart

A 72-year-old man presented with advanced symptoms of heart failure due to an idiopathic dilated cardiomyopathy was diagnosed. He presented with sinus rhythm and a left bundle branch block pattern on the electrocardiogram. The echocardiogram showed a severely depressed left ventricular …

Managing beyond an uncertain illness trajectory: palliative care in advanced heart failure

A lack of comprehensive and effective palliative care is clearly evident in a number of studies describing the end of life for patients with advanced heart failure. These patients have been portrayed as experiencing a wide array of poorly managed symptoms. The primary rationale for the lack of care has been the uncertain illness trajectory that characterizes living with advanced heart failure. Nurses must manage care beyond the illness trajectory from an emphasis of palliative care as each of these patients may face significant illness burden and even sudden death. The purpose of this paper is to: discuss the current status of palliative care for patients with advanced heart failure; explain the basic pathophysiology and resulting signs and symptoms of advanced heart failure; describe pharmacological and non-pharmacological symptom management strategies for patients with advanced heart failure.

Symptoms of advanced heart failure—A case for radiofrequency catheter ablation?

A sixty-year-old man with previous history of coronary artery disease was admitted due to progressive worsening of dyspnoea at exertion (NYHA III functional class) and no angina. Coronary angiography confirmed occlusion of the right coronary artery which was naturally bypassed by homocollaterals with TIMI 3 flow to the peripheral branches. The lesion was not technically suitable for percutaneous angioplasty. The left coronary artery was without stenosis. On echocardiography, both the left ventricle and the left atrium were dilated and hemodynamically significant mitral regurgitation was present. Surface ECG showed a left bundle branch block with repeated runs of monomorphic ventricular ectopic beats (PVC). Radiofrequency catheter ablation of the focus in the posteroseptal region of the left ventricle underneath the mitral valve was performed using electroanatomical mapping system. After the procedure, mitral regurgitation decreased and reverse remodeling of the left ventricle and the left atrium occurred with concomitant significant clinical improvement of the patient. The authors discuss several treatment strategies: mitral valve repair surgery combined with revascularization, implantation of a biventricular ICD system or elimination of the focus of monomorphic VT runs by radiofrequency catheter ablation as a possible causal approach in the treatment of PVC-induced cardiomyopathy.