The power of optimal medical therapy using Angiotensin
Receptor-Neprilysin inhibitor (ARNI) in acute decompensated heart
failure, sparing a critical patient open-heart surgery with a device
Timely use of Sacubitril/Valsartan has the potential to significantly
improve cardiac function and dramatically reduce secondary mitral
regurgitation (MR) severity even in patients presenting with acute
decompensated heart failure (HF), not only in compensated chronic HF
patients. The outstanding impact of echocardiography is obvious in
monitoring improvement of cardiac function and MR severity in patients
with heart failure with reduced ejection fraction (HFrEF). We report a
relevant case of an elderly patient who presented with acute
decompensated HF with severe bi-ventricular dysfunction and severe MR.
He was previously on optimal medical therapy (OMT), however still
symptomatic. Coronary angiogram (CAG) depicted three vessel coronary
artery disease (CAD). Patient advised to undergo coronary artery bypass
graft surgery (CABG) with mitral valve repair, then followed by
implantation of a cardiac resynchronization therapy defibrillator device
(CRT-D) if no LV function improvement observed after revascularization.
Patient’s ECG showed a QRSd ≥ 125 ms, hence a good candidate for CRT.
Two weeks after starting Sacubitril/Valsartan the LV EF improved from
15% to 40%. Severe MR reduced to grade II and there was dramatic
improvement of patient’s symptoms from NYHA class IV to NYHA class I.
NT-proBNP reduced from 9,000 pg/ml to 800 pg/ml. Following an elective
percutaneous coronary intervention (PCI), LV EF further improved to
50%. The patient was symptoms-free with preserved LV EF on follow up
for 18 months later. This case report documents the swift
echocardiographic and symptom improvement in an elderly patient with
decompensated end-stage HF when Sacubitril/Valsartan started during the