Goreisan as a successful adjuvant therapy of heart failure with preserved ejection fraction and advanced chronic kidney disease: a case report

Abstract

Atrial functional mitral and tricuspid regurgitation due to atrial fibrillation (AF) are common causes of heart failure with preserved ejection fraction, but standard treatment with conventional diuretics can often lead to renal dysfunction. Kampo Goreisan, a traditional Eastern-Asian herbal medicine that regulates body water balance via the aquaporin-incorporated water reabsorption system can be used as an alternative therapy without causing renal burden. In this report, we describe a case of successful treatment with Goreisan of heart failure with preserved ejection fraction (HFpEF) due to atrial functional mitral and tricuspid regurgitation (AFMR/TR) receiving guideline-directed medical-therapy. Goreisan could afford amelioration of regurgitation and improvement bilateral systolic ventricular function without renal dysfunction. Thus, Goreisan may be a promising therapeutic option for patients refractory to conventional diuretics.

Figure 1

Examinations before Goreisan treatment. (a) Electrocardiogram shows atrial fibrillation with left anterior hemiblock. (b) Chest radiograph shows mild bilateral pulmonary congestion, moderate pleural effusion, and enlargement of the right ventricle and bilateral atrium. (c) Echocardiography shows dilation of left atrium (upper left panel), small diameter and D-shape of the left ventricle (lower left panel), severe tricuspid regurgitation (upper right panel), and moderate mitral regurgitation (lower right panel).

Figure 2

Clinical time course of this patient. Goreisan was administered in addition to tolvaptan, azosemide, and furosemide. BNP; B-type natriuretic peptide, eGFR; estimated glomerular filtration rate.

Figure 3

Examinations after Goreisan treatment. (a) Chest radiograph shows significant reduction in cardiac enlargement and pleural effusion. (b) Echocardiography shows decreased left atrial enlargement (upper left panel), disappearance of left ventricular D-shape (lower left panel), residual severe tricuspid regurgitation (upper right panel), and reduction in mitral regurgitation (lower right panel).

Figure 4

Schematic illustration of diuretic-related drugs used in this patient. In the proximal tubule, empagliflozin inhibits the sodium (Na⁺)-glucose (Glu) co-transporter 2 to reduce glucose reabsorption, resulting in increased urinary sodium and glucose excretion. In the thick ascending limb of Henle’s loop, azosemide and furosemide inhibit the sodium-potassium (K⁺)-chloride (Cl⁻) co-transporter, which can lead to significant diuresis. In the medullary collecting duct, tolvaptan blocks the V2 receptor (V2R) and reduces the effect of arginine/vasopressin (AVP) in the renal water reabsorption channel, aquaporin-2 (AQP2). Goreisan can inhibit the expression level of both V2R and AQP2 in the medullary collecting duct. This illustration of nephron was adapted from a design by BioRender.com.