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Summer 2008

Heart Failure — A Case Study

The patient, Roberto Estrada, is a 23-year-old male born with coarctation of the aorta and a bicuspid aortic valve. He received a prosthetic patch aortoplasty as a neonate. At age 19, he was admitted to UCSF Medical Center with sinus tachycardia. He subsequently reported that, for a few months prior, he had been experiencing fatigue and shortness of breath with exertion upon lying down and upon waking from sleep. He had developed heart failure due to aortic insufficiency and aortic stenosis leading to dilated cardiomyopathy.

Referral to UCSF Heart Failure Clinic

Estrada was referred for evaluation to Teresa De Marco, M.D., in the UCSF Heart Failure Clinic by UCSF pediatric cardiologist David Teitel, M.D. Beyond addressing the patient's urgent care, the goal was to address Estrada's future cardiac care needs in an adult clinic. At every stage, Teitel, who had been managing Estrada's specialty care for years, was informed of his condition and the treatment he received through the Heart Failure Clinic during clinic visits and hospital admissions. In January 2004, Estrada was listed as UNOS status 2 for heart transplantation.

Interdisciplinary Team Evaluation and Treatment

With aggressive medical therapy requiring frequent visits to the Heart Failure Clinic for medication up-titration and close monitoring by heart failure nurse practitioners, Estrada's NYHA functional class improved from IV to II. His ejection fraction improved from 20 percent to 35 percent. An automatic implantable cardioverter-defibrillator (AICD) was implanted by the UCSF Cardiac Electrophysiology Service as the primary preventive of sudden death.

In July 2004, Estrada's improvement enabled him to be put on hold for transplantation while the Heart Failure Clinic continued to monitor his status. At this point, he was stable enough to undergo valve surgery and was referred to UCSF cardiothoracic surgeon Charles Hoopes, M.D.,; for aortic valve replacement. The patient tolerated the procedure well and, with NYHA functional class I symptoms, was able to return to work on his preoperative medical regimen.

Approximately two years later, however, Estrada's condition deteriorated and he was admitted with acute, decompensated heart failure as a result of medication noncompliance. He was aggressively treated in the hospital and his outpatient medical regimen was reinitiated. However, despite this therapy, he continued to be highly symptomatic, with an ejection fraction of less than 20 percent. He required repeated hospitalization and, eventually, inotropic therapy to maintain stability. Consequently, in June 2007, Estrada was listed as UNOS status 1A (high priority) for orthotopic heart transplantation.

Surgical Intervention

Twenty-one days after Estrada's listing, heart transplantation was performed by Hoopes, assisted by Subashini Daniel, M.D. The patient was extubated the same day and had an uneventful postoperative course. The AICD was removed. He was discharged eight days after the surgery, at which time he received extensive instructions for glucose monitoring, pain management, medications, a rehabilitation plan, and a schedule for follow-up visits and biopsy procedures.

Outcome and Follow-up

Estrada was closely followed after surgery. He did not sustain any episodes of rejection, and allograft function is excellent. Hypertension was easily controlled with an ACE inhibitor. He is currently on Prograf, prednisone and CellCept to prevent rejection. He receives follow-up care in the transplant clinic every three months. The patient reports no symptoms. His exercise tolerance is unlimited, and he is enjoying a full and active life.

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