Images in cardiovascular medicine

Diastolic mitral regurgitation in a patient with 2:1 atrioventricular block

DOI: https://doi.org/10.4414/cvm.2020.02132
Publication Date: 16.11.2020
Cardiovasc Med. 2020;23:w02132

Beeler Remo, Gujer Samuel, Kaeslin Thomas

Department of Cardiology, Kantonsspital Obwalden, Switzerland

A 93-year-old woman was referred to our emergency department with New York Heart Association class III heart failure and weight gain. She had a prior history of arterial hypertension with hypertensive cardiomyopathy, diagnosed in 2008.

The ECG revealed a 2:1 atrioventricular (AV) block, which was assumed to be the reason for the patient’s symptoms.

The subsequent echocardiography work up revealed (in addition to a commonly seen systolic mitral regurgitation) diastolic mitral regurgitation, typically seen during long AV delays. Furthermore, a mitral inflow signal could be seen after the P wave, corresponding to an A wave, independent from the conduction to the ventricle.

For diastolic mitral regurgitation to occur, diastolic left ventricular (LV) pressure must exceed the left atrial pressure. In our case, this was due to isolated atrial contraction, not followed by a ventricular systole. In this context, the long LV filling time leads to an increased LV pressure towards the late phase of diastole. In addition to this, our patient was earlier described as having elevated LV filling pressures due to diastolic dysfunction because of hypertensive cardiomyopathy. The same phenomenon can occur within the right heart chambers. In our patient, diastolic tricuspid regurgitation was also noted.

Figures 1–5 show the echocardiographic and ECG findings.

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Figure 1
Colour M Mode of the mitral inflow in the apical four-chamber view. The ECG shows the 2:1 atrioventricular block, and the corresponding atrial filling (A) and early diastolic filling (E). The (typical) systolic mitral regurgitation (**) and the diastolic mitral regurgitation (*) can be observed.
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Figure 2
Pulsed wave Doppler of the mitral inflow in the apical four-chamber view. The ECG shows the 2:1 atrioventricular block, and the corresponding atrial filling (A) and early diastolic filling (E). The inflow speed of the A wave after the E wave is higher, than the A wave without prior E wave, due to summation effects.
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Figure 3
Continuous wave Doppler of the mitral inflow in the apical-four chamber view. The ECG shows the 2:1 atrioventricular block, and the corresponding atrial filling (A) and early diastolic filling (E). The (typical) systolic mitral regurgitation (**) and the diastolic mitral regurgitation (*) can be observed.
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Figure 4
A resting ECG showing the 2:1 atrioventricular block and right bundle branch block with left anterior fascicle block.
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Figure 5
Repeat echocardiography after implantation of a pacemaker (during intrinsic atrioventricular conduction): Colour M mode and corresponding continuous wave Doppler of the mitral inflow. Only the (typical) systolic mitral regurgitation (**) can be seen, with no diastolic mitral regurgitation.

Disclosure statement

No financial support and no other potential conflict of interest relevant to this article was reported.

Correspondence

Dr Remo Beeler, MD, Kantonsspital Obwalden, Medizin/Kardiologie, Brünigstrasse 181, CH-6060 Sarnen, remo.beeler[at]ksow.ch

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