Heart Failure\Radiofrequency Ablation + Left Atrial Appendage Occlusion\Worsening Symptoms\Heart Valve Replacement

Male, 60 years old (Previous year’s discharge record; all dates in this record refer to the year prior to the atrial fibrillation radiofrequency ablation and left atrial appendage occlusion procedure in this case) Admission date: April 28 Discharge date: May 9 Length of stay: 11 days Admission diagnosis: 1. Atrial fibrillation with heart failure?; 2. Complete right bundle branch block; 3. Chronic gastritis Discharge diagnosis: 1. Hypertrophic cardiomyopathy with enlargement of the left atrium, right atrium, and right ventricle, severe mitral regurgitation, atrial fibrillation, and heart failure; 2. Complete right bundle branch block; 3. Pleural effusion; 4. Ascites; 5. Pulmonary infection; 6. Chronic gastritis Admission status: 1. The patient is a 59-year-old married male. 2. He was admitted because of “palpitations on exertion with abdominal distension for 2 months.” 3. Physical examination: T 36.7℃, P 88 beats/min, R 20 breaths/min, BP 112/71 mmHg. He was alert and in fair spirits, breathing comfortably, with no cyanosis of the lips, no jugular venous distension, and a midline trachea. Breath sounds were clear in both lungs with no dry or moist rales. The precordium showed no abnormal protrusion, the cardiac border was normal, heart rate was 104 beats/min with absolute irregularity, heart sounds were strong, and no murmurs were heard. Peripheral vascular signs were negative. The abdomen was soft with no tenderness or rebound tenderness. There was mild pitting edema on the dorsum of both feet. 4. Ancillary examinations: (April 28) Electrocardiogram: 1. Atrial fibrillation; 2. Complete right bundle branch block. Hospital course: After admission, the patient received isosorbide mononitrate for coronary vasodilation, furosemide and spironolactone for diuresis, rivaroxaban for anticoagulation, and azithromycin for infection control. Laboratory tests and main consultations: (April 28) Complete blood count: White blood cell count 5.6×10⁹/L, neutrophil percentage 53.4%, hemoglobin 141 g/L, red blood cell count 4.28×10¹²/L (↓), platelet count 133×10⁹/L. (April 28) Coagulation profile + D-dimer: Prothrombin time 15.7 seconds (↑), normal plasma prothrombin time 11.0 seconds, prothrombin activity 61%, PT-INR 1.41 (↑), fibrinogen 2.97 g/L, thrombin time 22.6 seconds, TT-R 1.03, activated partial thromboplastin time 37.3 seconds, APTT-R 1.17, D-dimer 798 μg/L (↑). (April 28) Liver, kidney, electrolytes, lipids, cardiac markers (including homocysteine) + CRP: Alanine aminotransferase 17 U/L, aspartate aminotransferase 33 U/L, alkaline phosphatase 114 U/L, γ-glutamyl transferase 204 U/L (↑), albumin 40.6 g/L, total bilirubin 43.6 μmol/L (↑), direct bilirubin 13.8 μmol/L (↑), indirect bilirubin 29.8 μmol/L (↑), prealbumin 145 mg/L (↓), glucose 4.8 mmol/L, urea 4.5 mmol/L, creatinine 88 μmol/L, estimated glomerular filtration rate 83 ml/min, uric acid 380 μmol/L, serum potassium 4.20 mmol/L, sodium 137 mmol/L, chloride 104.3 mmol/L, total calcium 2.25 mmol/L, total cholesterol 3.75 mmol/L, triglycerides 0.58 mmol/L, high-density lipoprotein cholesterol 0.98 mmol/L (↓), C-reactive protein 2.7 mg/L. (April 28) NT-proBNP + 7 tumor markers (male): Alpha-fetoprotein 5.5 μg/L, carcinoembryonic antigen 3.1 μg/L, CA125 273.9 kU/L (↑), CA19-9 <0.8 kU/L, CA15-3 4.9 kU/L, prostate-specific antigen 0.44 μg/L, free PSA 0.24 μg/L, free PSA/total PSA 0.55 (↑), N-terminal pro-B-type natriuretic peptide 2188 ng/L (↑). (April 30) Stool routine + occult blood: Color brown-yellow, consistency soft, white blood cells none/HP, red blood cells none/HP, fungi none, occult blood weakly positive. (April 30) Transfusion panel: Hepatitis B surface antigen negative, surface antibody weakly positive, e antigen negative, e antibody negative, core antibody positive (+), HIV antibody (screen) negative, syphilis antibody (ELISA) negative, hepatitis C virus antibody negative. (April 30) Urinalysis: Urine occult blood +1, urobilinogen +1, microscopy white blood cells none/HP, red blood cells 0-3/HP, epithelial cells none/LP. (May 3) Immunoglobulins + complement C3/C4: IgG 17.90 g/L (↑), IgA 2.78 g/L, IgM 1.24 g/L, C3 0.84 g/L (↓), C4 0.18 g/L. (May 3) Complete blood count: White blood cell count 5.8×10⁹/L, neutrophil percentage 51.5%, hemoglobin 148 g/L, red blood cell count 4.48×10¹²/L (↓), platelet count 137×10⁹/L. (May 3) Liver, kidney, electrolytes + CRP: Alanine aminotransferase 25 U/L, aspartate aminotransferase 41 U/L (↑), alkaline phosphatase 121 U/L, γ-glutamyl transferase 212 U/L (↑), albumin 42.9 g/L, total bilirubin 36.3 μmol/L (↑), prealbumin 160 mg/L (↓), glucose 4.8 mmol/L, urea 4.1 mmol/L, creatinine 94 μmol/L, estimated glomerular filtration rate 76 ml/min, uric acid 392 μmol/L, serum potassium 4.39 mmol/L, sodium 138 mmol/L, chloride 103.5 mmol/L, total calcium 2.35 mmol/L, C-reactive protein 1.4 mg/L. (May 3) Anti-CCP antibody: <7.00 U/mL. (May 3) Thyroid function (5 items): Triiodothyronine 1.47 nmol/L, thyroxine 93.4 nmol/L, free T3 3.91 pmol/L, free T4 11.1 pmol/L, thyroid-stimulating hormone 3.71 mIU/L. On May 5, thoracentesis was performed, yielding approximately 30 ml of light-yellow pleural fluid sent for routine analysis, protein, LDH, ADA, culture, CEA, AFP, acid-fast bacilli, and BNP. (May 3) Pleural fluid routine + protein: Color yellow, transparency slightly turbid, no coagulation, mucoprotein qualitative test negative, nucleated cell count 947×10⁶/L, neutrophil percentage 5%, lymphocyte percentage 48%, mesothelial cell percentage 22%, eosinophil percentage (value missing), monocyte percentage 25%, protein 20.5 g/L. (May 4) ADA (pleural fluid) + LDH (pleural fluid): Lactate dehydrogenase 139 U/L, adenosine deaminase 5.8 U/L. (May 4) Acid-fast bacilli (pleural/ascitic fluid): Negative (−). (May 4) AFP (pleural fluid) + NT-proBNP (pleural fluid) + CEA (pleural fluid): Alpha-fetoprotein 1.4 μg/L, carcinoembryonic antigen 0.8 μg/L, N-terminal pro-B-type natriuretic peptide 1996 ng/L (↑). (May 5) Pleural fluid culture: No bacterial growth after 2 days. Cardiology consultation was requested. The diagnosis was considered hypertrophic cardiomyopathy with biatrial and right ventricular enlargement, severe mitral regurgitation, atrial fibrillation, and heart failure. Recommendations: 1. Continue diuresis and myocardial support; 2. Anticoagulation therapy and elective transfer to cardiology for atrial fibrillation cardioversion. Special examinations during hospitalization: Ultrasound (April 29) liver, gallbladder, spleen: Bilateral pleural effusion and ascites. Ultrasound (April 30) heart and carotid arteries: Left and right atrial enlargement, right ventricular enlargement, ventricular septal thickening, severe mitral regurgitation due to malcoaptation, moderate pulmonary hypertension with moderate tricuspid regurgitation, normal left ventricular systolic function, small pericardial effusion, intimal thickening of the right common carotid artery and bifurcation, intimal thickening and plaque formation at the left common carotid artery bifurcation. (April 30) Chest and cardiac CT: Mild infection in both lower lobes (suggest recheck after treatment), mild fibrotic foci in both lungs, cardiomegaly, small calcified plaques in coronary arteries, small pericardial effusion, bilateral pleural effusions (right greater), compressive atelectasis of right lower lobe. (April 30) Abdominal CT: Small amount of ascites; suggestive of chronic liver disease—recommend contrast-enhanced scan. (April 30) Repeat chest and cardiac CT: Same findings as above. Ultrasound (May 3) bilateral pleural effusion localization: Bilateral pleural effusions. Comorbidities: 1. Hypertrophic cardiomyopathy with left and right atrial and right ventricular enlargement and severe mitral regurgitation; 2. Pleural effusion; 3. Ascites; 4. Pulmonary infection. Discharge status: The patient was in good general condition with no cough, sputum, fever, chest tightness, or chest pain. Physical examination: Alert and in fair spirits, breathing comfortably, no cyanosis of lips, no jugular venous distension, midline trachea, clear breath sounds in both lungs without dry or moist rales, normal precordium and cardiac border, absolutely irregular rhythm, strong heart sounds, no murmurs, negative peripheral vascular signs, soft abdomen without tenderness or rebound, no obvious lower limb edema. Treatment outcome: Improved Discharge medications: Isosorbide mononitrate tablets 20 mg, 48 tablets/1 box: 1 tablet twice daily orally; Rivaroxaban tablets 10 mg, 5 tablets/1 box: 1 tablet once daily orally; Metoprolol tartrate tablets 47.5 mg, 1 box: ½ tablet once daily orally; Furosemide tablets 20 mg, 100 tablets: ½ tablet once daily orally; Spironolactone tablets 20 mg, 100 tablets: 1 tablet once daily orally; Azithromycin tablets 0.25 g, 6 tablets/1 box: 2 tablets once daily orally.

Admission record Department: Cardiovascular Medicine First admission record Admission date: March 6, 16:29:24 History provided by: Patient Chief complaint: Recurrent chest tightness for 10 months. History of present illness: Ten months ago, after drinking liquor, the patient developed chest tightness, shortness of breath, and mild palpitations, mainly triggered by climbing three flights of stairs or similar activity. Symptoms improved after resting for about 10 minutes. He also had bilateral lower limb edema up to the knees and reduced urine output. There was no chest pain, headache, dizziness, blurred vision, or cough with sputum. He sought care at an outside hospital and was diagnosed with 1. Atrial fibrillation with possible heart failure; 2. Complete right bundle branch block; 3. Chronic gastritis. His condition improved with treatment, and radiofrequency ablation for atrial fibrillation was recommended, which the patient and family declined. He then presented to our outpatient clinic. Holter monitoring showed atrial fibrillation with aberrant conduction, occasional multifocal ventricular premature beats, short runs of ventricular tachycardia, ST-T changes, and complete right bundle branch block. The impression was atrial fibrillation, cardiomyopathy, complete right bundle branch block, and heart failure. Echocardiography suggested asymmetric left ventricular wall thickening, most consistent with hypertrophic cardiomyopathy; CMR was recommended for further clarification. There was marked left and right atrial enlargement, right ventricular enlargement, and a small pericardial effusion. Radiofrequency ablation for atrial fibrillation was again recommended. He was admitted for further evaluation and treatment with the diagnosis of atrial fibrillation, cardiomyopathy, complete right bundle branch block, and heart failure. Record date: March 6, 18:00 Discharge record Department: Cardiovascular Medicine Length of hospital stay: 5 days Admission date: March 6 Discharge date: March 10 Admission diagnosis: Atrial fibrillation; heart failure Discharge diagnosis: Persistent atrial fibrillation; radiofrequency ablation for atrial fibrillation; left atrial appendage occlusion; heart failure; lacunar cerebral infarction Admission status: T 36.6°C, P 95 beats/min, BP 99/71 mmHg, R 18 breaths/min. No jaundice of skin or sclera. Supple neck, midline trachea, no thyroid enlargement. No cyanosis, no jugular venous distension, no abnormal neck vessel pulsations. No palpable superficial lymph nodes. Clear breath sounds in both lungs without rales or pleural rub. Soft abdomen, no tenderness or rebound, liver and spleen not palpable below costal margin. Neurologic examination normal. Cardiac examination: No precordial bulge or abnormal pulsations. Apical impulse in the left 5th intercostal space, 0.5 cm inside the midclavicular line, strong, without heave, friction, or thrill. Normal cardiac dullness borders. Normal heart sounds, rate 95 beats/min, regular rhythm, no murmurs or pericardial rub. No pulsus alternans, water-hammer pulse, or Duroziez sign. No lower limb edema; dorsalis pedis pulses intact. Prior-year Holter: Atrial fibrillation with aberrant conduction, occasional multifocal ventricular premature beats, short runs of ventricular tachycardia, ST-T changes, complete right bundle branch block. Echocardiogram from the previous May 11: Asymmetric left ventricular wall thickening, most consistent with hypertrophic cardiomyopathy; recommend CMR. Marked left and right atrial enlargement, right ventricular enlargement, small pericardial effusion. 1. Male, 60 years old 2. Admitted for recurrent chest tightness for 10 months 3. Physical examination and ancillary tests as above Hospital course: Laboratory and special investigations: March 7 Blood type: A, Rh positive Thyroid function: T3 1.48 nmol/L, T4 102.15 nmol/L, TSH 4.39 mIU/L, free T3 5.60 pmol/L, free T4 10.89 pmol/L CA125 35.7 U/ml (↑), AFP 5.07 ng/ml, CEA 2.9 μg/L, CA153 4.5 U/ml, CA19-9 <0.8 U/ml HIV antibody negative, anti-HCV negative, syphilis antibody negative Hepatitis B markers: HBsAg negative, HBsAb positive, others negative as expected High-sensitivity troponin 0.018 μg/L, myoglobin 48.0 ng/mL, BNP 833 pg/mL (↑) Prothrombin time 18.3 seconds (↑), aPTT 54.0 seconds (↑) WBC 5.69×10⁹/L, neutrophils 60.4%, RBC 4.12×10¹²/L (↓), platelets 126×10⁹/L, hemoglobin 133 g/L Total bilirubin 24 μmol/L (↑), indirect bilirubin 12 μmol/L, direct bilirubin 12 μmol/L (↑), ALT 21 U/L, GGT 131 U/L (↑), AST 36 U/L, urea 6.2 mmol/L, eGFR 93.3, potassium 4.48 mmol/L, creatinine 79 μmol/L March 8 echocardiogram: Moderate to severe left atrial enlargement with mitral regurgitation, right atrial and ventricular enlargement with severe tricuspid regurgitation. LVEDD 52 mm, LVESD 32 mm, LA 54 mm, IVS 11 mm, LVPW 11 mm, LVEF 68.3%. Brain MRI: Scattered lacunar infarcts. Intraoperative transesophageal echocardiography for left atrial appendage occlusion. March 9 ALT 34 U/L, CRP <5.0 mg/L, urea 8.1 mmol/L (↑), glucose 5.8 mmol/L (↑), creatinine 78 μmol/L, potassium 4.46 mmol/L, lactate 2.5 mmol/L (↑) WBC 8.74×10⁹/L (neutrophils 78.5% ↑), RBC 3.91×10¹²/L (↓), platelets 121×10⁹/L (↓), hemoglobin 128 g/L (↓) PT 17.8 seconds (↑), aPTT 106.3 seconds (↑) Arterial blood gas: pH 7.375, PCO2 31.7 mmHg (↓), PO2 100.9 mmHg (↑) BNP 631 pg/mL (↑) The patient completed relevant investigations after admission. Treatment included rivaroxaban for anticoagulation, furosemide plus spironolactone for diuresis and potassium sparing, and metoprolol extended-release for ventricular rate control. Preoperative transesophageal echocardiography ruled out left atrial thrombus. On March 8, under local anesthesia, he underwent radiofrequency ablation for atrial fibrillation plus left atrial appendage occlusion. Intraoperative findings: Bilateral femoral vein access, coronary sinus catheter placement. Transseptal puncture under CARTOSOUND guidance (pre-procedure left atrial pressure 24 mmHg). Left atrial geometry created, pulmonary vein isolation performed guided by angiography and mapping, followed by 200J biphasic cardioversion to sinus rhythm. Lasso catheter confirmed successful bilateral pulmonary vein isolation. Large areas of low voltage in the left atrium were noted; substrate modification was performed at fragmented potentials lateral to the left atrial appendage. The procedure was successful. Post-ablation left atrial pressure was 30 mmHg. Left atrial appendage angiography showed ostium 30 mm and landing zone 29 mm; a 34/38 mm Lambre device was deployed. No residual leak on TEE. The procedure went smoothly and the patient remained stable afterward. Post-procedure medications included mosapride for gastrointestinal motility, esomeprazole for gastric protection, amiodarone for rhythm control, and torasemide for diuresis. The patient was stable and was discharged. Discharge status: The patient was in generally satisfactory condition without specific complaints. Physical examination: Stable vital signs. Clear breath sounds in both lungs without significant moist rales. Regular heart rhythm without significant pathologic murmurs. Soft abdomen without tenderness or rebound. Liver and spleen not palpable. No lower limb edema. Dorsalis pedis pulses intact. No hematoma at puncture sites with good pulsation. Treatment outcome: Improved. Discharge medications: Metoprolol extended-release 47.5 mg: 23.75 mg orally once daily. Torasemide 5 mg orally once daily. Amiodarone 200 mg orally once daily. Mosapride 5 mg orally three times daily. Esomeprazole 20 mg orally once daily. Spironolactone 20 mg orally twice daily. Rivaroxaban 10 mg orally once daily. No pathology performed. Electrocardiogram report (March 12) Sinus rhythm, PtfV1 < -0.03 mm·s, first-degree atrioventricular block, complete right bundle branch block, ST-T changes, atrial premature beats, extreme right axis deviation, low voltage in limb and left precordial leads. Laboratory report (June 12) B-type natriuretic peptide: 1660 pg/mL (↑) (reference 0–100 pg/mL) Electrocardiogram (June 12) Atrial fibrillation, complete right bundle branch block, ST-T changes, low voltage in limb leads, left axis deviation. Echocardiogram (June 12) Left atrial enlargement, left atrial appendage occluder visible. Normal left ventricular dimensions with apical thickening 11–12 mm. Moderate eccentric mitral regurgitation. Moderate tricuspid regurgitation. Small pericardial effusion. LVEF 76%. Echocardiogram (June 19) Marked left atrial enlargement, asymmetric left ventricular hypertrophy (maximum 18 mm) with ground-glass appearance. Moderate to severe mitral regurgitation with possible commissural prolapse. Severe tricuspid regurgitation with prolapse of septal and posterior leaflets. Apical aneurysm. Pericardial effusion. LVEF 55%. Left atrial appendage occlusion status. Recommend transesophageal echocardiography for further evaluation. Cardiac MRI (June 22–28) Post radiofrequency ablation and left atrial appendage occlusion. Asymmetric hypertrophy of the interventricular septum and anterior left ventricular wall (septal thickness up to 18–23 mm) with patchy late gadolinium enhancement. Apical aneurysm. Pericardial effusion. Mitral and tricuspid regurgitation. Biatrial enlargement. Impression: Consistent with hypertrophic cardiomyopathy. According to family reports, the patient’s condition worsened after the March 8 procedure (radiofrequency ablation and left atrial appendage occlusion). He then went to another hospital for heart valve surgery. Details are unknown.