[Early warning system for pulmonary fluid status monitoring in terminal heart failure].
METHODS
A 38-year-old man was admitted for increasing dyspnea, nausea and emesis during the preceding year. Clinically he was in heart failure NYHA stage III. He had not been on any regular medication and had no other medical complaints. Physical examination revealed a pulse of 100/min., hypotension (100/60 mmHg) and jugular vein distension. Bilateral pulmonary rales were noted on auscultation. A slight edema of both lower legs was noted.


METHODS
A 12-lead electrocardiogram showed complete left bundle branch block with a QRS duration of 160 ms. Chest x-ray revealed cardiomegaly with pulmonary vascular congestion. Transthoracic echocardiography demonstrated reduced left ventricular function with an ejection fraction of 10-15%. Left heart catheterization excluded coronary heart disease and confirmed the decreased left ventricular function.


METHODS
Medical treatment for heart failure secondary to dilated cardiomyopathy was initiated without significant improvement in clinical status. Cardiac resynchronization therapy (CRT) was therefore performed with implantation of a biventricular pacer with defibrillator (CRT-D) and a fluid status monitoring system (OptiVol). Subsequently the patient was able to increase his physical activity to NYHA class II and was followed in our outpatient clinic. Since initial treatment the patient has been seen twice for clinical signs of pulmonary edema. Both times the fluid monitoring system of the CRT-D gave an alarm signal early enough to allow cardiac re-compensation by expanding the current medication. Both times hospital admission was avoided.


CONCLUSIONS
Cardiac resynchronization therapy has been established as an adjunct to optimal pharmacological therapy in eligible patients with severe heart failure. A fluid status monitoring system integrated into the device measures intrathoracic impedance, allowing patients to be alerted before the onset of symptoms of fluid overload. Thus, treatment can be adjusted and hospitalization is avoidable.
Wedekind
H
H
Medizinische Klinik I (Kardiologie und Intensivmedizin), Hamm. horst.wedekind@marienhospital-hamm.de
Möller
K
K
D000328:Adult; D002037:Bundle-Branch Block / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D002304:Cardiac Pacing, Artificial; D002311:Cardiomyopathy, Dilated / Q000150:complications; D017147:Defibrillators, Implantable; D004452:Echocardiography; D004554:Electric Countershock / Q000379:methods; D017097:Electric Impedance; D004562:Electrocardiography; D006333:Heart Failure / Q000150:complications* / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D008297:Male; D008991:Monitoring, Physiologic / Q000295:instrumentation / Q000379:methods*; D010138:Pacemaker, Artificial; D011654:Pulmonary Edema / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D013902:Radiography, Thoracic; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy