Torrential mitral regurgitation following right ventricular apical pacing in rheumatic mitral valve disease: a case report
File(s)
Published version
Author(s)
Okafor, Joseph
Vazir, Ali
Haldar, Shouvik
Khattar, Rajdeep
Type
Journal Article
Abstract
Background
Mitral regurgitation may develop or worsen following right ventricular apical pacing due to dyssynchronous left ventricular contraction. Pre-existing secondary mitral annular dilation is a well-recognized and important contributing factor. This description of pacing-induced torrential mitral regurgitation in the setting of rheumatic mitral valve disease is a rare case in which a primary mitral valve lesion was the antecedent mechanism.
Case summary
A 60-year-old man was admitted with dizziness and pre-syncope. Twelve-lead electrocardiogram showed complete heart block. A dual-chamber pacemaker was implanted and programmed in DDD mode. Transthoracic echocardiography performed a day later demonstrated a left ventricular ejection fraction (LVEF) of 63% and moderate mitral regurgitation. The patient presented 4 months later with breathlessness and orthopnoea. Pacemaker interrogation demonstrated a 98% right ventricular pacing burden. Echocardiography revealed torrential mitral regurgitation secondary to left ventricular dyssynchrony and complete loss of leaflet coaptation with preserved systolic function. Post-capillary pulmonary hypertension was diagnosed following right heart catheterization. The patient underwent metallic mitral valve replacement, tricuspid annuloplasty, and left internal mammary artery grafting to the left anterior descending artery for a severe proximal stenosis. On inspection, the native mitral valve was notably rheumatic in appearance, and this was confirmed histologically.
Discussion
It is important to closely monitor the progression of mitral regurgitation in those with primary mitral valve disease undergoing right ventricular pacing. Early follow-up may prevent the adverse haemodynamic consequences of worsening mitral regurgitation, with a greater chance of recovery of left ventricular function following surgery.
Mitral regurgitation may develop or worsen following right ventricular apical pacing due to dyssynchronous left ventricular contraction. Pre-existing secondary mitral annular dilation is a well-recognized and important contributing factor. This description of pacing-induced torrential mitral regurgitation in the setting of rheumatic mitral valve disease is a rare case in which a primary mitral valve lesion was the antecedent mechanism.
Case summary
A 60-year-old man was admitted with dizziness and pre-syncope. Twelve-lead electrocardiogram showed complete heart block. A dual-chamber pacemaker was implanted and programmed in DDD mode. Transthoracic echocardiography performed a day later demonstrated a left ventricular ejection fraction (LVEF) of 63% and moderate mitral regurgitation. The patient presented 4 months later with breathlessness and orthopnoea. Pacemaker interrogation demonstrated a 98% right ventricular pacing burden. Echocardiography revealed torrential mitral regurgitation secondary to left ventricular dyssynchrony and complete loss of leaflet coaptation with preserved systolic function. Post-capillary pulmonary hypertension was diagnosed following right heart catheterization. The patient underwent metallic mitral valve replacement, tricuspid annuloplasty, and left internal mammary artery grafting to the left anterior descending artery for a severe proximal stenosis. On inspection, the native mitral valve was notably rheumatic in appearance, and this was confirmed histologically.
Discussion
It is important to closely monitor the progression of mitral regurgitation in those with primary mitral valve disease undergoing right ventricular pacing. Early follow-up may prevent the adverse haemodynamic consequences of worsening mitral regurgitation, with a greater chance of recovery of left ventricular function following surgery.
Editor(s)
Cvijic, Marta
Mandoli, Giulia Elena
Date Issued
2023-08-09
Date Acceptance
2023-08-08
Citation
European Heart Journal: Case Reports, 2023, 7 (8), pp.1-5
ISSN
2514-2119
Publisher
Oxford University Press
Start Page
1
End Page
5
Journal / Book Title
European Heart Journal: Case Reports
Volume
7
Issue
8
Copyright Statement
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
License URL
Identifier
http://dx.doi.org/10.1093/ehjcr/ytad380
Publication Status
Published
Date Publish Online
2023-08-09