Introduction: Acute heart failure is defined as a „de novo“ onset syndrome or worsening of a chronic heart failure whose in-hospital and at discharge prognosis is reserved. An important role in management of AHF is the identification of etiology and precipitating factors, which allow the initiation of targeted treatment.

Objective: With this presentation, we want to present the case of a patient 71-year-old patient dyslipidemic, hypertensive, type 2 diabetes mellitus, with history of coronary heart disease (inferior MI, coronary artery bypass graftingx3), carotid endarterectomy and per-manent pacemaker (DDD), with repeated presentati-ons for worsening of heart failure symptoms, whose etiology was different every time, describing the way of diagnosis, treatment and its evolution.

Methods: In Jan 2019: paroxysmal nocturnal dyspnea, marked fatigability. ECG: pacemaker rythm (DDD type). Echocardiography: dilated LV, LVEF: 25-30%, intensive calcified aortic valve, LV-Ao gradient =58/24 mmHg. ETE: AVA <1 cm2. Angiographic: Permeable grafts, 95% ACX stenosis for which angioplasty was performed. For aortic stenosis of the low flow-low gradient type was performed TAVI. After 2 months: marked fatigue and dyspnea with a tendency to ort-hopnea. ECG: pacemaker rythm (VVI! Mode). It is reprogrammed into DDDR mode. Echocardiography: important pulmonary hypertension. ETE: small mobile formations attached to the atrial lead. CT thorax (i.v. contrast) does not exclude peripheral PE.

Results: Post-TAVI echocardiography revealed an improvement in FEVS to 43% with favorable clinical progression. And at the second admission, dilatation of right cavities at ecocardiography, increased D-dimers and thrombus-like atrial lead attached formations suggest the presence of PE, which is why the anticoagu-lant treatment was initiated with the spectacular remis-sion of the symptoms and pulmonary hypertension.

Conclusions: The case presented illustrates the impor-tance of identifying the etiology of heart failure worse-ning in order to obtain optimal results: 1. Myocardial ischemia – angioplasty; 2. Severe aortic stenosis -TAVI; Pacemaker syndrome – programming from VVI mode to DDD mode; 4. PE-anticoagulant treatment.