Objective: The aim of this paper is to present a chronic heart failure patient who associates many cardiac and noncardiac severe comorbidities. Multimodality ima-ging helps the clinician to put the diagnosis, but taking a therapeutic decision is sometimes difficult. The new therapeutic interventions are not feasible due to prohi-bitive surgical risk. Thus, the clinician has to manage heart failure symptoms, prevent decompensating and in hospital admission. Due to multiple severe cardi-ac pathologies we were stuck in a situation similar to a draw in a chess game. We were forced to limit our treatment options in order to keep the patient stable.

Methods: A 72 year old man came at our out-patient clinic 3 years ago for severe pulmonary edema. He was diagnosed with class IV NYHA, biventricular dilata-tion, severe secondary mitral regurgitation but also important pericardial fluid and severe ascending aor-tic dilatation with important aortic regurgitation. He associates hypertension, diabetes mellitus, pulmonary chronic obstructive disease, lower limb venous insuf-ficiency, sleep apnoea and obesity, too. He is doing quite well with 4 times per year in hospital admission, medically optimal treated but no invasive intervention despite guidelines recommendations because of high operative risk. Follow-up was done by assessing clini-cal congestion score, echocardiographic and by NT-pro BNP.

Results: Electrocardiogram showed atrial fibrillation, secondary ST-T changes. Echocardiography revealed dilated LV (184/81 ml), ejection fraction 44%, severe mitral insufficiency, huge left atria (800ml), severe as-cending aorta dilatation (58 mm) and important cir-cumferential pericardial fluid (24 mm) without echo-cardiographic or clinical signs for cardiac tamponade. The angio-CT confirmed the echocardiographic data, showing the recalibration of the cross and descending aorta. He was evaluated for the eligibility for the coro-nary angiogram, surgical or interventional correction of severe mitral insufficiency, severe ascending aortic dilatation and pericardiocentesis. The risk was EuroS-CORE 28%, STS Risk Score 15%. The risk-benefit ratio lead us for a conservative medical treatment.

Conclusions: Multimodal imaging helps the ambula-tory clinician to put the etiological diagnosis of heart failure. Cardiac and non cardiac severe comorbidi-ties of the chronic heart failure patient may limit the treatment recommended by the latest guidelines. The follow-up should include: biological (NT-pro BNP) and echocardiographic parameters which may antici-pate clinical congestion and lead to therapeutic action before decompensation. The latest combination sacu-bitril / valsartan in a maximum dose made a great di-fference in the patients quality of life, reduced the de-compensations and the need for in hospital admission.