Winter 2008

A Case of Heart Failure

In July 2007, a 45-year-old, previously healthy man presented at a community hospital in the East Bay with an acute anterior myocardial infarction. Two bare metal stents were placed in the left anterior descending artery. He did well and was subsequently discharged. He was readmitted in mid-August for heart failure with an ejection fraction of 30 percent, was treated medically and was again discharged.

On Sept. 5, he presented at the emergency department of the East Bay hospital with nonspecific symptoms. Shortly after arrival there, he sustained a ventricular tachycardiac arrest, requiring intubation and defibrillation. He developed cardiogenic shock and underwent repeated cardiac catheterization, which revealed patent arteries. An intra-aortic balloon pump was placed and inotropic therapy was initiated.

On Sept. 8, the intra-aortic balloon pump was removed and intravenous therapy was adjusted. The patient also underwent dialysis for renal failure.

Referral to UCSF

In the course of evaluating the patient, a UCSF cardiology fellow working at this community hospital determined that the patient was in profound cardiogenic shock and would require mechanical circulatory support. A referral for transfer was made to the UCSF advanced heart failure and transplant inpatient service.


On Sept. 12, the patient was transferred to intensive cardiac care at UCSF. He was already intubated, and on arrival had incessant ventricular tachycardia and was in profound cardiogenic shock. He was evaluated by a team comprising heart failure specialists, interventional cardiologists, electrophysiologists and cardiothoracic surgeons.


The patient required frequent electrical cardioversion and adjustments of intravenous anti-arrhythmic medications. An intra-aortic balloon pump was placed and intravenous inotropic therapy was adjusted. He was placed on extracorporeal membrane oxygenation and was stabilized. Twenty-four hours later, he underwent placement of a Thoratec biventricular assist device and continuous venous-venous hemofiltration for renal failure.


The patient recovered with full neurological, pulmonary and renal function. Two months after admission to UCSF, he was on the biventricular assist device and ambulating about the hospital. The patient was listed for heart transplantation, and a plan was devised to send him home on mechanical circulatory support while waiting for a new heart.

Related Information

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