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A 71 year old woman presented with severe shortness of breath (New York Heart Association (NYHA) functional class IV) despite optimised medical treatment (angiotensin converting enzyme inhibitor, β blocker, spironolactone, and digoxin). ECG revealed first degree atrioventricular (AV) block (PR interval 256 ms) and left bundle branch block (QRS duration 190 ms). Two dimensional echocardiography showed severe systolic dysfunction (biplane left ventricular ejection fraction 27%) and moderate to severe mitral regurgitation (upper panel, centre). Coronary artery disease was ruled out by coronary angiography. Cardiac resynchronisation therapy (CRT) was initiated with implantation of a biventricular pacemaker (Contak TR1241, Guidant, St Paul, Minnesota, USA), a right ventricular apical lead, and a left ventricular pacing lead (Guidant 4512) positioned in a posterolateral epicardial vein through the coronary sinus. The AV delay was programmed to 120 ms.
At the three months follow up, echocardiography demonstrated reduced severity of mitral regurgitation (lower panel, centre) Three dimensional transoesophageal echocardiographic reconstruction of the regurgitant jet by colour Doppler during atrial pacing (upper panel, right, and video sequence 1) and during CRT with atriobiventricular pacing (lower panel, right, and video sequence 2) documented immediate reduction in severity of mitral regurgitation by CRT.
After an additional three months (six months follow up), the patient improved to NYHA functional class II. Maximal Vo2 increased from 729 ml/min (12.1 Vo2/kg) be fore implantation to 1161 ml/min (16.6 Vo2/kg), plasma noradrenaline (norepinephrine) concentrations decreased from 524 ng/l to355 ng/l, and end diastolic volume decreased from 222 ml to 163 ml.
This case highlights the potential of CRT to reduce functional mitral regurgitation in dilated cardiomyopathy. The effect is immediate and may contribute to improved exercise capacity and left ventricular reverse remodelling.
Acute effects of resynchronisation treatment on functional mitral regurgitation in dilated
OA Breithardt, HP Kühl, C Stellbrink
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Sequence 1 Three dimensional TOE reconstruction of the regurgitated jet by colour Doppler during atrial pacing
File size: 391 KB
Sequence 2 Three dimensional TOE reconstruction of the regurgitated jet by colour Doppler during CRT with atriobiventricular pacing
File size: 391 KB