Reactions Weekly | 2021
Multiple drugs
Abstract
Lack of efficacy: case report A woman in her late 50s [exact age not stated] exhibited lack of efficacy during treatment with carperitide, milrinone, dobutamine and furosemide for recurrent and refractory heart failure (HF). The woman, who had a history of congestive heart failure with second-degree atrioventricular block and left bundle branch block, was admitted for recurrent and refractory right HF. At the age of 50 years, her left ventricular (LV) function decreased with dyssynchrony and biventricular pacemaker cardiac resynchronisation therapy (CRT) was attempted, which failed due to no suitable coronary vein in the posterolateral area was available. Therefore, a DDD pacemaker was implanted, and unspecified diuretics, betablocker and angiotensin receptor blocker were initiated. Despite the treatment, HF worsened with progressive LV dysfunction and was complicated with significant mitral regurgitation (MR) and tricuspid regurgitation (TR) due to secondary pulmonary hypertension (PH). She had previously undergone tricuspid and mitral valve plasty and surgical placement of an epicardial LV pacing lead in the posterolateral wall for CRT. She was diagnosed with isolated cardiac sarcoidosis and was treated with unspecified steroid therapy; however, she developed steroid-induced osteoporosis and diabetes mellitus, and no improvement in the ventricular function was noted. At 55 years of age, she developed ventricular tachycardia and fibrillation, which required resuscitation. The CRT was upgraded to cardiac resynchronisation with defibrillator. At 57 years of age, the HF aggravated due to progressive LV dysfunction as well as recurrent severe MR and TR, and she had undergone mitral and tricuspid valve replacement. Postoperatively, she frequently developed HF. She received IV therapy with dobutamine, milrinone, carperitide and furosemide for HF [dosages not stated]. She experienced catheter-related sepsis. Echocardiography, performed 26 months postoperatively, revealed severe LV dysfunction, prosthetic tricuspid stenosis and normal bioprosthetic mitral valve. At the age 60 years, she was hospitalised for refractory right HF, which required prolonged IV infusions of dobutamine and carperitide with intermittent IV furosemide for multiple times over several weeks. Peripherally inserted central venous catheter was placed for prolonged infusion of these drugs. However, she experienced 3 episodes of bacteraemia with Citrobacter species, Staphylococcus caprae and Achrmonobacter xylosoidans. She started receiving treatment with unspecified antibiotic therapy. Despite the treatment, she gradually developed multiple organ failure and died due to refractory right heart failure at hospital day 322. The explanted tricuspid bioprosthesis on autopsy demonstrated marked pannus formation, which resulted in stiff and immobile cusps. The same mitral bioprosthesis, which was implanted on the same day, was noted to be normal.