Severe mitral regurgitation due to atrial tachyarrhythmia: cure by DC cardioversion

in Echo Research and Practice
Authors: Jack Parnell BSc BMBS1, Mehak Tahir MD1, and Benoy N Shah MD MRCP FESC1
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  • 1 Wessex Cardiac Centre, University Hospital Southampton, Southampton, UK

Correspondence should be addressed to B N Shah: benoy.shah@uhs.nhs.uk
Open access

Summary

A 62-year-old man admitted with palpitations had a 12-lead ECG that revealed atrial flutter with 2:1 AV block (rate 150 bpm). Transthoracic echocardiography (TTE) revealed normal left ventricular size with impaired systolic function and severe MR (Fig. 1, panels A, B and Videos 1, 2). No MV prolapse was seen. The admitting doctor informed the patient that mitral valve surgery was the likely outcome. However, after senior review, the patient was commenced on rate-control, diuretic and anticoagulant medications. He was discharged and returned 6 weeks later for direct current cardioversion, which successfully restored sinus rhythm. TTE 2 months later showed normal LV function and trivial MR (Fig. 1, panel C and Video 3). This case highlights the importance of understanding the mechanism underlying MV dysfunction. The mitral annulus is a thin fibrofatty ring that geometrically resembles a parabola; its sphincteric contraction reduces MV annular area by ~25% during the cardiac cycle, facilitating normal leaflet coaptation (1). Consequently, the onset of atrial flutter – and loss of annular contraction – resulted in MR, and this was exacerbated by the rapid heart rate, which reduces the normal ventricular closing forces on the valve leading to incomplete mitral leaflet coaptation. Clinicians are reminded that atrial arrhythmias with high heart rates can disrupt normal MV function, producing MR which can be resolved by treating the underlying abnormality (i.e. atrial arrhythmia) (2, 3) and thus avoiding unnecessary cardiac surgery.

Figure 1
Figure 1

Incomplete mitral valve closure (white arrow) seen in the apical four-chamber view (panel A), which resulted in severe MR on colour Doppler imaging (panel B). Repeat echocardiography 2 months after successful restoration of sinus rhythm, there was only trivial residual MR (panel C).

Citation: Echo Research and Practice 6, 2; 10.1530/ERP-19-0007

Apical four-chamber view, demonstrating incomplete leaflet coaptation between the anterior mitral valve leaflet (AMVL) and posterior mitral valve leaflet (PMVL). L, lateral wall; LA, left atrium; LV, left ventricle; S, septum. View Video 1 at http://movie-usa.glencoesoftware.com/video/10.1530/ERP-19-0007/video-1.

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Apical four-chamber view demonstrating severe mitral regurgitation on colour Doppler imaging (arrows). View Video 2 at http://movie-usa.glencoesoftware.com/video/10.1530/ERP-19-0007/video-2.

Download Video 2

Apical four-chamber view demonstrating trivial mitral regurgitation on colour Doppler imaging (arrows) after restoration of sinus rhythm. View Video 3 at http://movie-usa.glencoesoftware.com/video/10.1530/ERP-19-0007/video-3.

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Declaration of interest

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding

This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Patient consent

Written informed consent was obtained from the patient.

Author contribution statement

J P and M T wrote the first draft, which was revised by B N S. B N S is the guarantor for the article.

References

  • 1

    Levine RA, Hagége AA, Judge DP, Padala M, Dal-Bianco JP, Aikawa E, Beaudoin J, Bischoff J, Bouatia-Naji N, Bruneval P, et al. Mitral valve disease – morphology and mechanisms. Nature Reviews Cardiology 2015 12 689710. (https://doi.org/10.1038/nrcardio.2015.161)

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  • 2

    Gertz ZM, Raina A, Saghy L, Zado ES, Callans DJ, Marchlinski FE, Keane MG & Silvestry FE. Evidence of atrial functional mitral regurgitation due to atrial fibrillation: reversal with arrhythmia control. Journal of the American College of Cardiology 2011 58 14741481. (https://doi.org/10.1016/j.jacc.2011.06.032)

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  • 3

    Kihara T, Gillinov AM, Takasaki K, Fukuda S, Song JM, Shiota M & Shiota T. Mitral regurgitation associated with mitral annular dilation in patients with lone atrial fibrillation: an echocardiographic study. Echocardiography 2009 26 885889. (https://doi.org/10.1111/j.1540-8175.2009.00904.x)

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    Incomplete mitral valve closure (white arrow) seen in the apical four-chamber view (panel A), which resulted in severe MR on colour Doppler imaging (panel B). Repeat echocardiography 2 months after successful restoration of sinus rhythm, there was only trivial residual MR (panel C).

  • 1

    Levine RA, Hagége AA, Judge DP, Padala M, Dal-Bianco JP, Aikawa E, Beaudoin J, Bischoff J, Bouatia-Naji N, Bruneval P, et al. Mitral valve disease – morphology and mechanisms. Nature Reviews Cardiology 2015 12 689710. (https://doi.org/10.1038/nrcardio.2015.161)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Gertz ZM, Raina A, Saghy L, Zado ES, Callans DJ, Marchlinski FE, Keane MG & Silvestry FE. Evidence of atrial functional mitral regurgitation due to atrial fibrillation: reversal with arrhythmia control. Journal of the American College of Cardiology 2011 58 14741481. (https://doi.org/10.1016/j.jacc.2011.06.032)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Kihara T, Gillinov AM, Takasaki K, Fukuda S, Song JM, Shiota M & Shiota T. Mitral regurgitation associated with mitral annular dilation in patients with lone atrial fibrillation: an echocardiographic study. Echocardiography 2009 26 885889. (https://doi.org/10.1111/j.1540-8175.2009.00904.x)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation