Severe Cardiorenometabolic Remodeling as a Substrate for Persistent Atrial Fibrillation and Heart Failure Progression Despite Effective CRT-D: A Case Report

Abstract

We present the case of a 67-year-old male patient with ischemic dilated cardiomyopathy, heart failure with reduced ejection fraction (HFrEF), permanent atrial fibrillation (AF), and stage 3b chronic kidney disease (CKD) in the setting of a pronounced cardiorenometabolic phenotype including class III obesity and type 2 diabetes mellitus. Despite prior implantation of cardiac resynchronization therapy with defibrillator (CRT-D) and 99% biventricular pacing, the patient remained heart failure in New York Heart Association (NYHA) functional class III–IV and demonstrated progressive renal dysfunction.

The patient was admitted due to acute decompensation of chronic heart failure with features consistent with type 2 cardiorenal syndrome. Comprehensive optimization of guideline-directed medical therapy, including initiation of an SGLT2 inhibitor, rate control strategy, oral anticoagulation, metabolic correction, and nephrology monitoring, resulted in clinical stabilization without the need for renal replacement therapy.

This case illustrates the potential role of advanced structural and metabolic remodeling as a determinant of persistent AF and relative clinical non-response to CRT-D within the cardiorenometabolic continuum.