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Sacubitril-valsartan therapy in a patient with heart failure due to isolated left ventricular noncompaction: a case report and literature review

Yang, Ya-Wei1; Yuan, Jun2; Xing, Jing-Fen1; Fan, Min1,∗

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doi: 10.1097/CP9.0000000000000003
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Left ventricular noncompaction (LVNC) is characterized by prominent left ventricular trabeculae, deep intertrabecular recesses and thin compacted layer [1]. The most common and clinically significant feature of LVNC is heart failure with reduced ejection fraction (HFrEF), for which there is no specific treatment[1]. Here, we report a case of LVNC that responded favorably to sacubitril-valsartan treatment. Left ventricular ejection fraction (LVEF) based on cardiac magnetic resonance imaging (CMRI) improved by 25% with features suggestive of reverse modeling after 16 months of treatment.

Case presentation

A 58-year-old woman presented to the emergency department with progressively aggravated dyspnea after physical activities for 4 months. Over the past 4 years, she has been receiving various treatments for HFrEF (as low as 27%), including metoprolol 47.5 mg/day, benazepril 10 mg/day, torasemide 20 mg/day, spirolactone 20 mg/day, and digoxin 0.25 mg/day, but her clinical conditions and echocardiographic parameters remained poor. She denied history of smoking, alcohol abuse, hypertension, diabetes, and coronary/valvular heart diseases. Upon presentation, blood pressure was 132/90 mm Hg, heart rate was 106/min, and respiratory rate was 32/min. On physical examination, moist rales were audible in lower lungs in both sides and pitting edema was noted in both feet. Laboratory studies revealed a brain natriuretic peptide level of 1310 pg/mL. Electrocardiogram revealed premature ventricular beats and intraventricular block (Figure 1). She was treated with 40 mg torasemide to reduce the cardiac preload in the emergency room, and then transferred to the Heart Failure Unit.

Figure 1:
An electrocardiogram showing premature ventricular beats and intraventricular block.

A chest computed tomography next day showed no significant lung congestion. Twenty-four hours Holter monitoring recorded a total of 3382 premature ventricular beats. A transthoracic echocardiogram (ECHO) showed a severely enlarged left ventricle (Figure 2A and B) with a reduced LVEF of 26% (Simpson), severe diastolic dysfunction (E/é >15, Class IV) (Figure 3A), and features of LVNC (Figure 3B and C). CMRI confirmed left ventricular noncompaction (Figure 4A and B). The ratio versus compacted myocardium was >2.3 overall, and as high as 3.9 in the inferior lateral wall of the LV at the end-diastolic phase. The LVEF was 24%.

Figure 2:
Echocardiographic findings.A and B, upon presentation. left ventricular (LV) end-diastolic diameter: 68 mm; LV end-diastolic volume: 159 mL; ejection fraction (EF): Simpson 26%. C and D, after 15 months. LV end-diastolic diameter: 53 mm; LV end-diastolic volume: 94 mL; EF: Simpson 51%.
Figure 3:
Diastolic function upon presentation and after 16 months of treatmentA, E/é>15, pulmonary arterial systolic pressure (PASP): 50 mmHg, Class IV; B, 10<E/é<14, PASP: 50 mmHg, Class II. C and D, Three-dimensional and two-dimensional echocardiogram (ECHO) showing hyper-trabeculation of the left ventricular walls and deep recesses.
Figure 4:
Cardiac magnetic resonance imaging in the four-chamber view and short-axis view of the left ventricle showing hyper-trabeculations (white arrows) and left ventricle non-compaction with functional improvement after 16 months of treatment.A and B, ratio of non-compacted to compacted = 3.9, ejection fraction (EF): 24% Intelli Space Portal, Simpson. C and D, ratio of non-compacted to compacted = 2.8, EF: 50% Intelli Space Portal, Simpson.

Considering the poor response to previous treatment, sacubitril-valsartan 50 mg twice a day was added to guideline-recommended treatment (β-blocker, torasemide, spirolactone, digoxin, and isosorbide mononitrate). Symptoms and signs improved rapidly, and the patient was discharged 1 week later. Discharge prescription included spirolactone 20 mg, metoprolol 47.5 mg, and sacubitril-valsartan 50 mg twice a day. A follow-up 4 weeks after discharge indicated unsatisfactory blood pressure control, and sacubitril/valsartan was adjusted to 100 mg twice daily. All other drug treatments remained unchanged. Regular follow-up during the following 12 months showed good control of blood pressure (90–120/50–70 mm Hg) and resting heart rate (45–55/min). An ECHO examination 16 months later demonstrated a significantly smaller cavity of the heart and improved LV systolic (EF 51%) and diastolic (10<E/é<14, Class II) function (Figures 2C and D and 3D). CMRI showed significantly reduced ratio of 2.8 in noncompacted versus compacted myocardium (Figure 4C and D). The details of the patient's process of diagnosis and treatment are shown in Table 1.

Table 1 - Timeline
Time Events
Four years before presentation Symptoms and signs of heart failure, including dyspnea and lower limb edema. No conditions other than LVNC (eg, coronary artery disease) were noted. She received guideline-recommended treatment for HFrEF (27%).
Four months before presentation Progressively aggravated shortness of breath
First day at the emergency department Moist rales were audible over both lower lungs and bilateral pitting edema was noted in both feet. Brain natriuretic peptide level of 1310 pg/mL. She received torasemide to reduce the preload.
First day in Heart Failure Unit. ECHO showed a severely enlarged LV with 26% LVEF and class IV diastolic dysfunction (E/é >15). In CMRI, LVEF was 24%, and the non-compacted to compacted ratio was >2.3 (3.9 in the inferior lateral wall of the LV end-diastolic phase).
First week in Heart Failure Unit. The patient was managed with β-blocker, torasemide, spirolactone, digoxin, isosorbide mononitrate and sacubitril-valsartan. Symptoms improved substantially and she was discharged in 1 week. Discharge prescription included spirolactone 20 mg, metoprolol 47.5 mg and sacubitril-valsartan 50 mg twice a day.
4-weeks follow-up Sacubitril/valsartan was adjusted to 100 mg twice daily,
12-month follow-up Resting heart rate: 45–55/min; blood pressure: 90–120/50–70 mm Hg.
16-month follow-up No symptoms and signs of HF. ECHO demonstrated significantly smaller heart chamber and 51% LVEF and class II diastolic function. CMRI showed significantly reduced ratio of 2.8 in noncompacted versus compacted myocardium
CMRI: cardiac magnetic resonance imaging; HFrEF: heart failure with reduced ejection fraction; LV: left ventricular; LVEF: left ventricular ejection fraction; LVNC: left ventricular noncompaction.

Discussion and conclusions

LVNC is believed to be the result of stagnation of densification caused by myocardial developmental defects[2]. The LV apical myocardium is the last area that undergoes densification and thus is always involved[3]. Clinical manifestations of LVNC typically include HF, conduction abnormalities, tachycardia, and sudden death[1]. The most common presentation at admission is pump failure[4]. Congestive HF of LVNC could appear as either HFrEF, systolic dysfunction or HF with preserved ejection fraction (HFpEF) and diastolic dysfunction[5]. In more recent reports, HFrEF and marked systolic dysfunction are common[4,6].

LVNC is mainly diagnosed by imaging, including ECHO, CMRI, and LV angiography with ventriculography[7]. CMRI could display the trabeculae at the end-diastolic phase with high resolution and accurately assess the extent of trabecular enlargement, which in turn carries important prognostic significance[8]. The ratio of noncompacted versus compacted myocardium in the index cases was >2.3, and as high as 3.9 in the inferior lateral wall of the LV in the end-diastolic phase, meeting the diagnostic criteria proposed by Petersen and colleagues[9].

There is no specific therapy for LVNC. Management is based on complications, including HF, thromboembolic events and arrhythmia. For symptomatic patients with HF, the ACC/AHA guideline recommends the use of diuretics, β-blockers and angiotensin-converting enzyme inhibitors[10]. A small retrospective study reported smaller LV mass in patients taking versus not taking β-blockers, but no improvement in LVEF and ECHO parameters[11]. The lack of clinical response and ECHO improvement in the index case during the 4-year period prior to presenting to us with β-blockers, torasemide, spirolactone, and digoxin is consistent with the previous report.

Both angiotensin receptor antagonism by valsartan and neprilysin inhibition by sacubitril could result in a set of beneficial responses, including vasodilatation, water, and sodium excretion and reverse ventricular remodeling[12]. In the PARADIGM-HF study, sacubitril-valsartan reduced the relative risk of cardiovascular death or hospitalization by 20% in HFrEF patients[13]. Interestingly, subgroup analysis in the PARADIGM-HF study indicated treatment benefit across various disease etiologies. In the PROVE-HF study, 12-month sacubitril-valsartan treatment was associated with 9.4% increase in LVEF as well as significant reductions in LV end-diastolic volume index (LVEDVI) and LV end-systolic volume index (LVESVI)[14]. In the index case, long-term sacubitril-valsartan treatment resulted in robust and sustained increase in LVEF and decrease in LVEDVI and LVESVI. Clinically significant improvement in left atrial volume index and ratio of early transmitral doppler velocity/early diastolic annular velocity (E/é) was also observed.

Sacubitril-valsartan has been shown to alleviate myocardial fibrosis in animal models[15]. In the index patient, the ratio of non-compacted to compacted LV in the short-axis view of the end-diastolic stage at 16 months after treatment was 2.8, which was lower than upon presentation. The result suggested possible reversal of myocardial remodeling, which in turn has been associated with improved long-term outcomes[16].

In conclusion, the robust and sustained hemodynamic improvement and reduced ratio of noncompacted to compacted myocardium in this case suggested possible reverse remodeling in LVNC with sacubitril-valsartan treatment although cause-effect relationship is far from clear.


Cost of MRI and ECHO examinations was provided by the fund of Shanghai Sailing Program (Grant Number: 20YF1450300). Travel expenses for patient follow-up were provided by the fund of the Key Project of Yueyang Hospital (Grant Number: 2019YYZ03).

Author contributions

YWY wrote the manuscript. JY and JFX performed the imaging examination and participated in collecting data. MF revised the manuscript. All authors reviewed and approved the manuscript.

Conflict of interest statement

The authors declare that they have no financial conflict of interest with regard to the content of this report.


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Heart failure; Left ventricular noncompaction; Reverse remodeling; Sacubitril-valsartan

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