Palliative care for a patient with heart failure

Abstract

Background. Despite growing need for palliative care for patients with advanced heart failure, many challenges exist to making effective palliative care interventions available. Little data exists on heart failure patients who receive palliative care, and there are only a handful of studies examining which palliative care interventions are effective in heart failure. Case report. We present a case of 50 years old man admitted at our department with signs of advanced heart failure. Physical examination attested a severe peripheral edema, a tensionate abdomen with an enlarged liver with a 75 heart beats/min with a arterial tension about 85/55 mmHg. His cardiac problems started at his 34 years old when multiple paroxysmal attacks of atrial fibrillation were detected, sinus rhythm were assessed by multiple electrical cardioversions (2002-2004). In 2004 was made a procedure of ablation near the paradisiac region of right atrium. Next years (2011-2012) due to the progressive signs of heart failure and atrial asystole detected at ECG-Holter monitoring accompanied by severe bradycardia, a permanent pacemaker was implanted in VVIR pacing mode. In parallel his echocardiogram showed normal dimensions of left and right ventricles, but a progressive severe enlargement of both atrial chambers with a progressive worsening of mitral and tricuspid regurgitation, ejection fraction of left ventricle was about 30-35%, severe pulmonary hypertension. In 2013 was made an annuloplasty of mitral and tricuspid valves. Also due to instability of heart rhythm and uncontrolled heart rate, the pacing mode was switched to AAIR mode, then to DDDR, and then again to VVIR pacing modes. At the moment of presentation his echocardiogram showed a severe dilatation of right and left atrial chambers, right ventricle, a mild enlargement of left ventricle, with a severe diffuse reduction in ejection fraction (12%), a mild to moderate mitral and tricuspid regurgitation and a severe pulmonary hypertension. Coronary angiogram showed non-obstructive coronary lesions. His medical treatment consisted of standard medication of heart failure, intensive diuresis, medication of pain and antidepressants. Interventional treatment included a few sessions of thoracocentesis, decompression of thoracic lymphatic duct, drainage of ascetic fluid and peritoneal lavage. Conclusions. In the setting of echocardiographic data of the presented patient and arrhythmic events it’s hard to make a differential diagnosis between tachycardia-mediated cardiomyopathy and dilated cardiomyopathy. Prognosis of such case is uncertain and the difference between curative and palliative treatment is not well defined. But, still, the emerging role of palliative care is drived from improving quality of life for patients with end-stage congestive heart failure.