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Implan a ion o ICD in a pa ien wi h hea ailu e wi h mildly educed ejec ion
ac ion
Denisla Emilo Bise o 1, * and Ma iana Dimi o a Yonche a-Mihaylo a 2
1 Uni e si y Hospi al Bu gas, Bu gas, Bulga ia.
2 Mili a y Academy, So ia, Bulga ia.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1715-1720
Publica ion his o y: Recei ed on 18 Ma ch 2025; e ised on 26 Ap il 2025; accep ed on 29 Ap il 2025
A icle DOI: h ps://doi.o g/10.30574/wja .2025.26.2.1425
Abs ac
Hea ailu e a ec s app oxima ely 2% o he adul popula ion in de eloped coun ies, wi h p e alence escala ing o
10% among hose aged o e 70 yea s. Pa ien s wi h Hea Failu e wi h Mildly Reduced Ejec ion F ac ion (HFm EF)
exhibi a isk p o ile compa able o hose wi h educed ejec ion ac ion (EF), necessi a ing hei classi ica ion as high-
isk and ailo ing he apeu ic goals acco dingly. The clinical case p esen ed he e o a pa ien wi h HFm EF and ele a ed
a hy hmic isk unde sco es he need o e ining indica ions o p ima y p e en ion o sudden ca diac dea h (SCD).
Fu he mo e, he e is an impe a i e o iden i y and alida e a panel o in es iga ions o guide decision-making o
pa ien s wi h bo de line indica ions o high- ol age de ice implan a ion. This app oach aims o op imize he bene i -
o- isk a io o hese indi iduals.
Keywo ds: Le Ven icula Dys unc ion; Myoca dial Fib osis; Implan able De ib illa o
1. In oduc ion
Hea ailu e (HF) is a clinical synd ome cha ac e ized by a igue and sho ness o b ea h, o en accompanied by
ele a ed jugula enous p essu e, auscul a o y indings o pulmona y conges ion, and pe iphe al edema [1]. Based on
he assessmen o le en icula sys olic unc ion, HF is ca ego ized in o h ee pheno ypes: HF wi h educed ejec ion
ac ion (HF EF), HF wi h p ese ed ejec ion ac ion (HFpEF), and HF wi h mildly educed ejec ion ac ion (HFm EF).
Da a om andomized ials indica e ha pa ien s wi h HFm EF bene i equally om he ecommended HF he apies
as hose wi h HF EF. Addi ionally, pa ien s p esen ing wi h conges i e HF symp oms a e a an inc eased isk o a al
ca dio ascula e en s, including sudden ca diac dea h (SCD). The p ima y cause o ad e se ou comes in HF pa ien s is
disease decompensa ion, wi h he second mos common cause being sudden a hy hmic ca diac dea h, which is no
di ec ly ela ed o he ejec ion ac ion (EF) [2].
These indings sugges he need o eassessmen o isk in pa ien s wi h EF g ea e han 35% o educe ca dio ascula
mo ali y wi hin his pa ien popula ion.
2. Case Desc ip ion
A 50-yea -old woman p esen ed o he ou pa ien clinic wi h symp oms o conges i e hea ailu e (CHF), classi ied as
NYHA unc ional class III, wi h a du a ion o 2–3 weeks. She had no p io his o y o ca diac disease and had no
p e iously sough medical ca e.
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On physical examina ion, mois c ackles we e no ed a he bases o bo h lungs. The hea a e was 70 bpm, wi h a sys olic
mu mu a he ca diac apex adia ing o he axilla. He blood p essu e was 100/60 mmHg. An elec oca diog am (ECG)
e ealed sinus hy hm, le axis de ia ion, and nega i e T wa es in leads I, aVL, and V4–V6 (Figu e 1).
Figu e 1 ECG o he pa ien in he ou pa ien clinic
Echoca diog aphic e alua ion e ealed a non-dila ed le en icle (LV) wi h a mode a ely educed ejec ion ac ion
(EF) o 42% (Figu e 2). The LV showed symme ical wall mo ion wi h di usely dep essed con ac ili y. Mode a e mi al
egu gi a ion was obse ed, along wi h es ic i e dias olic illing pa e ns, e idenced by an E/A a io o 2.01 and an
E/E’ a io o 15. The le a ium was mildly dila ed, wi h an indexed olume o 45 mL/m².
The igh en icle (RV) was non-dila ed, wi h e idence o mode a e icuspid egu gi a ion and an indi ec ly measu ed
sys olic pulmona y a e y p essu e (SPAP) o 30 mmHg.
Figu e 2 Baseline echoca diog aphic examina ion—pa as e nal long-axis iew
To de e mine he unde lying e iology o he sys olic dys unc ion, co ona y angiog aphy was pe o med a e he
s abiliza ion o hea ailu e symp oms (Figu e 3). The esul s showed no e idence o s eno ic co ona y a he oscle osis.
Labo a o y e alua ions, including hy oid-s imula ing ho mone (TSH), we e wi hin e e ence anges. T ea men was
ini ia ed in acco dance wi h cu en guidelines o imp o e symp oms: diu e ics (Class I), Dapagli lozin/Empagli lozin
(Class I), ACE inhibi o s/ARNI/ARB (Class IIb), and be a-blocke s (Class IIb) [1].
The p esc ibed he apy included o asemide 10 mg in he mo ning, bisop olol 2.5 mg in he mo ning wi h dose i a ion
o 5 mg daily, eple enone 25 mg in he mo ning, amip il 2.5 mg in he e ening, and an SGLT2 inhibi o . The apy wi h
an angio ensin ecep o -nep ilysin inhibi o (ARNI) was ini ia ed bu discon inued due o hypo ension and eplaced
wi h amip il a he minimal e ec i e dose.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1715-1720
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A a ollow-up examina ion h ee mon hs la e , he pa ien demons a ed an imp o ed unc ional s a us o NYHA class
I. Howe e , echoca diog aphic assessmen showed no signi ican change in le en icula (LV) sys olic unc ion. A
educ ion in mi al and icuspid egu gi a ion o g ade I was obse ed, along wi h a dec ease in indi ec ly measu ed
sys olic pulmona y a e y p essu e o 20 mmHg.
Figu e 3 In asi e co ona y angiog aphy. Righ an e io oblique (RAO) p ojec ion a 20°, showing no e idence o
s enosis in he le main a e y (LM), le an e io descending a e y (LAD), o le ci cum lex a e y (LCx)
Gi en he p esence o LV sys olic dys unc ion (ejec ion ac ion [EF] below 45%) wi hou LV ca i y dila ion, and in he
absence o p essu e o olume o e load, such as hype ension o al ula pa hology, o ischemic co ona y a e y
disease as unde lying causes, he diagnosis o non-dila ed le en icula ca diomyopa hy was es ablished [3].
To be e e alua e he pa ien ’s p ognosis and isk o a hy hmic e en s, he eam decided o pe o m ca diac magne ic
esonance imaging wi h la e gadolinium enhancemen (CMR-LGE). The esul s e ealed ex ensi e a eas o myoca dial
ib osis p edominan ly a ec ing he subepica dial and in amu al egions o he LV (Figu e 4). Mode a e LV sys olic
dys unc ion wi h an EF o 41% was con i med.
Figu e 4 Ca diac MRI wi h la e gadolinium enhancemen showing a longi udinal sec ion o he le en icle (LV) and a
ou -chambe iew, isualizing he LV, igh en icle (RV), le a ium (LA), and igh a ium (RA). (LV - le en icle,
RV - igh en icle, LA - le a ium, RA - igh a ium)
A gene ic es was discussed wi h he pa ien , bu due o pe sonal conside a ions, i was de e ed o a la e s age. Gi en
he pa ien 's his o y o palpi a ions, 24-hou Hol e ECG moni o ing was pe o med, e ealing polymo phic en icula
ec opy occupying app oxima ely 10% o he day. Long- e m ea men wi h amioda one was deemed unsui able due o
pa ien in ole ance. Elec ophysiological s udy and po en ial abla ion o en icula ec opy we e also conside ed bu
declined by he pa ien .
As he Hol e ECG indings we e eco ded while he pa ien was on he maximum ole a ed dose o bisop olol, he
decision was made o implan a loop eco de o assess he isk o a hy hmogenic e en s in he con ex o signi ican
in amu al myoca dial ib osis de ec ed on ca diac MRI.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1715-1720
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Follow-up eleme y om he implan ed de ice one week la e e ealed se e al episodes o non-sus ained
monomo phic en icula achyca dia (VT), las ing 4–5 seconds wi h a hea a e o 180 bpm.
Gi en hese indings, he pa ien was classi ied as high- isk, and an ICD-DDDR was implan ed o p ima y p e en ion o
sudden ca diac dea h (SCD) (Figu e 5).
Figu e 5 Implan ed wi h a bi en icula de ib illa o wi h an elec ode in he igh a ial appendage and a high-
ol age elec ode in he apex o he le en icle
Figu e 6 Teleme y da a om he implan ed de ib illa o . The i s ow shows he a ial channel eco ding. The
second ow shows he en icula channel, whe e he en icula a e is 270 bpm and he a ial a e is 98 bpm, which
a e among he de e minan s o he de ice's de ec ion o en icula achyca dia (VT). Due o he con i med episode
o high- equency VT alling wi hin he VF zone, a 36J shock was deli e ed, success ully e mina ing he episode
A he 3-mon h ollow-up isi a e implan a ion, se e al episodes o non-sus ained en icula achyca dia (VT) we e
eco ded by he de ice. A he 5-mon h ollow-up, he pa ien p esen ed o he eme gency clinic wi h a his o y o a
syncopal episode.
Teleme y da a e ealed sus ained VT wi h a hea a e o 270 bpm, and because i ell wi hin he en icula ib illa ion
(VF) zone, he de ice success ully de ib illa ed he pa ien wi h a 36J shock (Figu e 6).
3. Discussion
The 12-lead elec oca diog am (ECG) is a undamen al diagnos ic ool o a ange o ca diac diseases. Howe e ,
documen ing a hy hmias associa ed wi h exis ing symp oms o en p o es challenging. Depending on he equency o
he symp oms, bo h he app op ia e eco ding de ice and he du a ion o he eco ding should be selec ed. Hol e ECG
moni o ing o a pe iod o 24 o 48 hou s is applicable when pa ien s p esen wi h daily symp oms [3]. Implan able loop
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1715-1720
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eco de s (ILR) a e conside ed when episodes o pa oxysmal achya hy hmias and a his o y o syncopal symp oms
wi h an unclea e iology a e suspec ed.
In he case o he pa ien p esen ed he e, polymo phic en icula ec opy was eco ded while on he maximum ole a ed
dose o a be a-blocke . We hypo hesized ha he documen ed le en icula dys unc ion migh be a esul o he
obse ed ec opy, bu we lacked da a on he bu den o ec opic bea s p io o ini ia ing pha macological he apy. Gi en
ha he hea ailu e ea men o e a 3-mon h pe iod did no lead o no maliza ion o le en icula pumping
pa ame e s, coupled wi h MRI indings indica ing myoca dial ib osis a ec ing ex ensi e in amu al egions, we
concluded ha he le en icula emodeling p ocess had ad anced, wi h a co esponding loss o con ac ile issue.
O e he pas wo decades, nume ous s udies ha e been conduc ed o assess he necessi y and bene i s o implan able
ca dio e e -de ib illa o s (ICDs). The esul s ha e been mo e han con o e sial. On one hand, da a om an
obse a ional s udy indica e ha mos ic ims o sudden ca diac dea h (SCD) do no ha e se e e le en icula sys olic
dys unc ion and a e gene ally no p o ec ed by ICDs, as hey all ou side he indica ions o p ima y p e en ion wi h
implan able de ices [4]. On he o he hand, da a om he DEFINITE (De ib illa o s in Non-Ischemic Ca diomyopa hy
T ea men E alua ion) ial show a low incidence o shock he apy om implan ed de ib illa o s as p ima y p e en ion
in pa ien s wi h non-ischemic dila ed ca diomyopa hy (DCM) [5]. The esul s o hese and o he s udies highligh he
need o mo e p ecise indica ions o p ima y p e en ion o SCD wi h ICDs, pa icula ly in non-ischemic dila ed
ca diomyopa hy. I is c ucial o iden i y app op ia e imaging s udies ha can dis inguish high- isk indi iduals and
se um ma ke s wi h su icien sensi i i y and speci ici y o be used o isk s a i ica ion.
In a me a-analysis conduc ed by Di Ma co e al. on s udies examining he ela ionship be ween he p esence o
signi ican myoca dial ib osis, de ec ed wi h CMR and LGE, and he isk o sudden ca diac dea h (SCD), in e es ing
indings we e obse ed [6]. In s udies epo ing ib osis abo e 35%, an a hy hmic endpoin was obse ed in 23.9% o
pa ien s wi h LGE on CMR and in 5.6% o pa ien s wi hou LGE. In cases wi h ib osis below 35%, he a hy hmic
endpoin was ound in 19.6% o pa ien s wi h LGE and 4.1% in hose wi hou LGE. A signi ican associa ion was also
no ed be ween he p esence o LGE and he mani es a ion o en icula achyca dia (VT) o SCD, bo h in he g oup wi h
educed le en icula ejec ion ac ion (LVEF) below 35% and in hose wi h LVEF abo e 35%. This me a-analysis
showed ha LGE is signi ican ly associa ed wi h an a hy hmic endpoin (OR 7.8) among s udies ha included only
pa ien s wi h p ima y p e en ion o SCD and no signi ican co ona y a he oscle osis. Pa ien s wi h LGE had a ela i ely
high annual a e o a hy hmic e en s (17.2%), while hose wi hou LGE, who accoun ed o app oxima ely 58% o he
indi iduals included in s udies on p ima y p e en ion o SCD wi h ICD, had a ela i ely low a e o a hy hmic e en s
(2.1% pe yea ). The e o e, inco po a ing he p esence o LGE in o he c i e ia o p ima y p e en ion o SCD wi h ICD
may help guide ea men owa d a subg oup o pa ien s wi h a high- isk p o ile. On he o he hand, ICD implan a ion
in low- isk pa ien s exposes hem o po en ial pe ip ocedu al complica ions om de ice implan a ion, which is unlikely
o imp o e hei p ognosis.
Myoca dial emodeling in he p esence o hea ailu e is associa ed wi h he de elopmen o in e s i ial ib osis and
collagen deposi ion [7]. Bo h eplacemen and di use myoca dial ib osis a e linked o ad e se ou comes, bo h in
pa ien s wi h indica ions o implan a ion o ca diac de ices and in hose unde going ca diac su gical in e en ions [8,
9].
Al hough he e has been an ac i e sea ch o eliable bioma ke s o assess ac i a ed collagen syn hesis in ecen yea s
[10, 11], CMR-LGE has been es ablished as he gold s anda d o e alua ing myoca dial ib osis bu den. This highligh s
ha his imaging echnique is a eliable me hod o de e mining isk and p o ides aluable in o ma ion o pa ien s
wi h hea ailu e symp oms, as well as hose wi h conduc ion abno mali ies, implan ed elec onic de ices, and ischemic
hea disease (IHD) wi h ope a i e e ascula iza ion.
4. Conclusion
Risk assessmen in pa ien s wi h mode a ely educed sys olic unc ion is o en a signi ican clinical challenge. To make
he co ec decision, a comp ehensi e app oach should be employed, u ilizing all a ailable clinical, imaging, and
labo a o y es s. The implan a ion o moni o ing de ices p o ides aluable in o ma ion abou he exis ing hy hm and
conduc ion pa hology in his pa ien g oup, while pe o ming CMR wi h LGE can se e as a powe ul ool o
di e en ia ing high- isk indi iduals. The selec ion o eliable bioma ke s o ac i a ed collagen syn hesis, among he
many known molecules, equi es he conduc ion o ex ensi e andomized ials.
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Compliance wi h e hical s anda ds
Disclosu e o con lic o in e es
No con lic o in e es o be disclosed.
S a emen o in o med consen
In o med consen was ob ained om all indi idual pa icipan s included in he s udy.
Re e ences
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