Introduction: Valvular heart disease can lead to chronic heart failure, especially when the treatment adherence is low. (1)

Case report: 47-year-old-male, obese, smoker, with previous history of diabetes, hypertension, chronic obstructive pulmonary disease and a myocardial infarction without significant stenosis of coronary arteries 6 years prior, was admitted for the first time in 2012 due to heart failure and paroxysmal atrial fibrillation. The echocardiographic exam showed a dilated left ventricle with a reduced ejection fraction (EF) of 38%, a bicuspid aortic valve without significant stenosis or regurgitation and dilated ascending aorta (4.6 cm). During the next four years he was repeatedly hospitalized due to worsening heart failure (WHF) with a gradual decline in EF (35%) and further dilation of the ascending aorta (5.5 cm). Cardio-surgical repair of the ascending aorta and aortic valve replacement was offered to him in 2016 and again in 2019, but the patient never decided to undergo the surgical procedure and he did not show up for his check-ups regularly. During 2021 he was hospitalized several times because of WHF, even with cardiogenic shock when he admitted that he was drinking excessive amounts of alcohol. Repeated coronary angiographies never showed a sign of atherosclerosis. Finally in 2021 an implantable cardioverter defibrillator was implanted in a primary prevention setting. Heart transplantation was also considered but myocardial scintigraphy showed viability of the myocardium and the Heart Team decided he is not a suitable candidate for transplantation. He finally had a cardio-surgical repair of the ascending aorta (plication) and aortic valve replacement in May 2023, then 58 years old, (the aortic stenosis was severe, ascending aorta was 5.5 cm, EF 22% and systolic function of the right ventricle was severely reduced). Shortly after, in June 2023 he was admitted again because of WHF with an EF of 23% admitting he was not taking his medications regularly and seemingly still consuming alcohol every day.

Conclusion: This is a case report of a patient who would probably have much better outcome if he would have had better treatment adherence.