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A man in his 70s with a left bundle branch block and advanced valvular systolic heart failure (HF) presented with a subacute HF and low cardiac output (CO) (peripheral hypoperfusion, high lactic levels, symptomatic hypotension). Echocardiography confirmed severe reduction in left ventricular ejection fraction, global longitudinal strain and stroke volume, as assessed by outflow tract pulse Doppler. Acute HF therapy with dobutamine and levosimendan was started, leading to progressive haemodynamic improvement.
After suspension of inotropes, under conditions of haemodynamic stability, a cardiopulmonary ramp-protocol maximal exercise test (CPET) was performed, showing a peculiar breathing during the exercise (figure 1).
Contributors MM, ES and PA have all contributed substantially to this work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.