Image challenge
Heart failure in a patient with a pacemaker CLINICAL INTRODUCTION A 76-year-old woman was admitted for progressive dyspnoea. Physical examination revealed basal pulmonary crepitations and peripheral oedema. Blood pressure was 135/75 mm Hg and heart rate 60 bpm. B-type natriuretic peptide (BNP) was 600 pg/mL; blood tests were otherwise unremarkable. The ECG showed continuous ventricular pacing and the echocardiogram revealed mild LV hypertrophy with a normal EF. Colour and continuous wave Doppler (CD, CWD) at different phases of the cardiac cycle are presented (figure 1).
Medical history included hypertension and a prior admission for symptomatic complete atrioventricular (AV) block 5 months earlier for which the patient received a single-chamber ventricular pacemaker due to technical problems with the atrial lead implantation.
QUESTION What is the best treatment option at this point? A. Diuretics B. Mitral annuloplasty C. Dual chamber pacemaker D. Cardiac resynchronisation For the answer see page 496
Figure 1 2D transthoracic echocardiogram. Upper panel: continuous-wave Doppler recordings of the mitral flow. Lower panels: Colour flow Doppler at different phases of the cardiac cycle (red lines). VC, vena contracta.
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Moya-Mur JL, et al. Heart March 2015 Vol 101 No 6
Image challenge
Heart failure in a patient with a pacemaker From the question on page 484
atrium, resulting in DMR, especially at high late-diastolic LV pressures.1–3 This mechanism is demonstrated by speckle tracking echocardiography in online supplementary figure. José Luis Moya-Mur, Rocio Hinojar, José Luis Zamorano Cardiology Department, Ramón y Cajal University Hospital, Madrid, Spain
ANSWER: C The correct answer is (C), dual chamber pacemaker. CWD showed atrial contraction and atrioventricular dissociation (figure 2). CWD and CD showed retrograde flow into the left atrium during the last part of atrial contraction indicating diastolic mitral regurgitation (DMR). The remarkably large regurgitant vena contracta (VC) was suggestive of significant mitral regurgitation (MR), but this was seen in late diastole. The patient had only mild, early-systolic MR with a small VC (figure 1; see online supplementary video 1). With a definitive diagnosis of pacemaker syndrome, a DDD pacemaker was implanted. The patient clinically improved, and the BNP normalised. Although diuretics might provide symptomatic relief, it would not solve the cause of the decompensation. Second, the mitral annulus was not involved in the mechanism of DMR, hence annuloplasty would not be appropriate. Finally, LV function was normal and DMR was not induced by V-V dyssynchrony, therefore cardiac resynchronisation is not indicated. Pacemaker syndrome is a clinical consequence of AV dissociation due to the loss of atrial contribution to ventricular filling decreasing cardiac output and atrial contraction against a closed valve increasing atrial pressure. DMR can complicate, and also contribute, to this syndrome. In healthy subjects, simultaneous ventricular contraction and atrial relaxation result in mitral valve closure. In AV dissociation, atrial relaxation may occur in the absence of ventricular contraction, causing the mitral valve to remain open. Reverse diastolic AV gradients force blood to flow from the ventricle to the
Correspondence to Dr Rocio Hinojar, Cardiology Department, Ramón y Cajal University Hospital, Carretera de Colmenar Km 9.100, Madrid 28034, Spain; [email protected] Contributors JLM-M contributed to the acquisition of the images. JLM-M, RH and JLZ contributed to the planning, conduct and reporting of the work. JLZ is responsible for the overall content as guarantor. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/heartjnl-2014-306604).
To cite Moya-Mur JL, Hinojar R, Zamorano JL. Heart 2015;101:496. Received 10 September 2014 Revised 9 November 2014 Accepted 13 November 2014 Heart 2015;101:496. doi:10.1136/heartjnl-2014-306604
REFERENCES 1 2 3
Sisu RC, Vinereanu D. Different mechanisms for diastolic mitral regurgitation illustrated by three comparative cases. Echocardiography 2011;28:476–9. Agmon Y, Freeman WK, Oh JK, et al. Diastolic mitral regurgitation. Circulation 1999;99:e13. Schnittger I, Appleton CP, Hatle LK, et al. Diastolic mitral and tricuspid regurgitation by Doppler echocardiography in patients with atrioventricular block: new insight into the mechanism of atrioventricular valve closure. J Am Coll Cardiol 1988;11:83–8.
Figure 2 Despite poor quality of ECG tracing, continuous-wave Doppler recordings of the mitral flow show atrioventricular dissociation, the atrial (a) contraction component (red arrow) and the diastolic mitral regurgitation (DMR). Although, DMR can be appreciated in the first colour wave Doppler (CWD) cycle, atrial contraction is fused with the atrial E wave. The second CWD cycle is the most representative showing DMR just after the atrial contraction component.
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Moya-Mur JL, et al. Heart March 2015 Vol 101 No 6
Heart failure in a patient with a pacemaker CLINICAL INTRODUCTION A 76-year-old woman was admitted for progressive dyspnoea. Physical examination revealed basal pulmonary crepitations and peripheral oedema. Blood pressure was 135/75 mm Hg and heart rate 60 bpm. B-type natriuretic peptide (BNP) was 600 pg/mL; blood tests were otherwise unremarkable. The ECG showed continuous ventricular pacing and the echocardiogram revealed mild LV hypertrophy with a normal EF. Colour and continuous wave Doppler (CD, CWD) at different phases of the cardiac cycle are presented (figure 1).
Medical history included hypertension and a prior admission for symptomatic complete atrioventricular (AV) block 5 months earlier for which the patient received a single-chamber ventricular pacemaker due to technical problems with the atrial lead implantation.
QUESTION What is the best treatment option at this point? A. Diuretics B. Mitral annuloplasty C. Dual chamber pacemaker D. Cardiac resynchronisation For the answer see page 496
Figure 1 2D transthoracic echocardiogram. Upper panel: continuous-wave Doppler recordings of the mitral flow. Lower panels: Colour flow Doppler at different phases of the cardiac cycle (red lines). VC, vena contracta.
484
Moya-Mur JL, et al. Heart March 2015 Vol 101 No 6
Image challenge
Heart failure in a patient with a pacemaker From the question on page 484
atrium, resulting in DMR, especially at high late-diastolic LV pressures.1–3 This mechanism is demonstrated by speckle tracking echocardiography in online supplementary figure. José Luis Moya-Mur, Rocio Hinojar, José Luis Zamorano Cardiology Department, Ramón y Cajal University Hospital, Madrid, Spain
ANSWER: C The correct answer is (C), dual chamber pacemaker. CWD showed atrial contraction and atrioventricular dissociation (figure 2). CWD and CD showed retrograde flow into the left atrium during the last part of atrial contraction indicating diastolic mitral regurgitation (DMR). The remarkably large regurgitant vena contracta (VC) was suggestive of significant mitral regurgitation (MR), but this was seen in late diastole. The patient had only mild, early-systolic MR with a small VC (figure 1; see online supplementary video 1). With a definitive diagnosis of pacemaker syndrome, a DDD pacemaker was implanted. The patient clinically improved, and the BNP normalised. Although diuretics might provide symptomatic relief, it would not solve the cause of the decompensation. Second, the mitral annulus was not involved in the mechanism of DMR, hence annuloplasty would not be appropriate. Finally, LV function was normal and DMR was not induced by V-V dyssynchrony, therefore cardiac resynchronisation is not indicated. Pacemaker syndrome is a clinical consequence of AV dissociation due to the loss of atrial contribution to ventricular filling decreasing cardiac output and atrial contraction against a closed valve increasing atrial pressure. DMR can complicate, and also contribute, to this syndrome. In healthy subjects, simultaneous ventricular contraction and atrial relaxation result in mitral valve closure. In AV dissociation, atrial relaxation may occur in the absence of ventricular contraction, causing the mitral valve to remain open. Reverse diastolic AV gradients force blood to flow from the ventricle to the
Correspondence to Dr Rocio Hinojar, Cardiology Department, Ramón y Cajal University Hospital, Carretera de Colmenar Km 9.100, Madrid 28034, Spain; [email protected] Contributors JLM-M contributed to the acquisition of the images. JLM-M, RH and JLZ contributed to the planning, conduct and reporting of the work. JLZ is responsible for the overall content as guarantor. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/heartjnl-2014-306604).
To cite Moya-Mur JL, Hinojar R, Zamorano JL. Heart 2015;101:496. Received 10 September 2014 Revised 9 November 2014 Accepted 13 November 2014 Heart 2015;101:496. doi:10.1136/heartjnl-2014-306604
REFERENCES 1 2 3
Sisu RC, Vinereanu D. Different mechanisms for diastolic mitral regurgitation illustrated by three comparative cases. Echocardiography 2011;28:476–9. Agmon Y, Freeman WK, Oh JK, et al. Diastolic mitral regurgitation. Circulation 1999;99:e13. Schnittger I, Appleton CP, Hatle LK, et al. Diastolic mitral and tricuspid regurgitation by Doppler echocardiography in patients with atrioventricular block: new insight into the mechanism of atrioventricular valve closure. J Am Coll Cardiol 1988;11:83–8.
Figure 2 Despite poor quality of ECG tracing, continuous-wave Doppler recordings of the mitral flow show atrioventricular dissociation, the atrial (a) contraction component (red arrow) and the diastolic mitral regurgitation (DMR). Although, DMR can be appreciated in the first colour wave Doppler (CWD) cycle, atrial contraction is fused with the atrial E wave. The second CWD cycle is the most representative showing DMR just after the atrial contraction component.
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Moya-Mur JL, et al. Heart March 2015 Vol 101 No 6
