Europace Advance Access originally published online on May 17, 2007
Europace 2007 9(9):768-769; doi:10.1093/europace/eum069
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CARDIAC RESYNCHRONISATION THERAPY
Regression of mitral regurgitation after cardiac resynchronization therapy in an adult with preserved left ventricular function and right ventricular pacing
1 Hospital Haut Leveque, Service Pr Clementy, University Victor Segalen, Avenue Magellan, Pessac, 33000 Bordeaux, France
Manuscript submitted 8 February 2007. Accepted after revision 21 March 2007.
* Corresponding author. Tel: +11 33 5 57 65 65 65; fax: +11 33 5 57 65 65 43. E-mail address: bordacharp{at}hotmail.com
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We report the case of a 60-year-old patient with preserved ventricular function and no organic mitral leaflet disease implanted with a dual-chamber pacemaker. Right ventricular pacing induced a major ventricular dyssynchrony, a severe mitral regurgitation, and symptoms of congestive heart failure. Upgrading to a biventricular device was associated with a decrease in the symptoms, the ventricular dyssynchrony, and the mitral regurgitation.
Key Words: Biventricular pacing, Mitral regurgitation, Ventricular dyssynchrony
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Cardiac resynchronization therapy (CRT) is a rapidly evolving therapeutic option for patients with severe heart failure and ventricular conduction delay. Large clinical trials have reported the sustained benefit of CRT in patients with severe heart failure (NYHA class III or IV), impaired left ventricular ejection fraction (
35%), and a wide QRS complex (>120 ms). The potential impact of CRT in the subset of patients with ventricular dyssynchrony but preserved left ventricular function has been poorly documented. We report the case of a 60-year-old man who was referred to our centre for syncope with complete atrioventricular block. The echocardiography demonstrated a normal left ventricular function (64%), a left ventricular end-diastolic diameter (LVED) of 45 mm, and the absence of significant valvulopathy. He underwent the implantation of a transvenous dual-chamber pacemaker. Three months after, this patient was hospitalized for symptoms of right- and left-ventricular dysfunction. An echocardiography showed the presence of a severe mitral regurgitation, a major ventricular dyssynchrony (98 ms between septal and lateral electromechanical delays) measured with tissue Doppler imaging, an LVED of 48 mm, and a slightly depressed ejection fraction (54%). Despite instauration of an optimal medical therapy, the patient remained NYHA functional class III. The patient was upgraded to a CRT-device with implantation of a lateral left ventricular lead. After 1 month of CRT, symptoms and exercise tolerance improved markedly from NYHA class III to class I with a maximal oxygen uptake on exercise testing increased by 27%. The echocardiography showed an absence of ventricular dysynchrony (28 ms between septal and lateral electromechanical delays). The picture demonstrates the favourable impact of biventricular pacing vs. right ventricular pacing (RVP) with a reduction of mitral regurgitation from severe to mild. The effective regurgitant orifice area decreased from 29 to 6 mm2. This case report shows the potential impact of CRT in patients with subnormal left ventricular function and dyssynchrony induced by RVP. The effect of CRT on mitral regurgitation is probably related to the improvement in ventricular dyssynchrony.
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