Abstract
Diastolic mitral regurgitation (DMR) may occur due to an increased left ventricular (LV) cavity pressure compared to the left atrial (LA) pressure. This may occur with bradycardia when diastolic filling time is increased. In our case, the patient was found to have blocked bigeminal premature atrial contractions (PACs) causing bradycardia leading to diastolic mitral regurgitation. N/A N/A A 58-year-old woman presented with one week history of shortness of breath, paroxysmal nocturnal dyspnea, lower extremity edema, and weight gain. Past medical history was remarkable for transient ischemic attack and closure of patent foramen ovale with 30-mm Gore device. Examination was remarkable for bradycardia, elevated JVP and peripheral edema. Electrocardiogram showed bradycardia secondary to blocked bigeminal premature atrial complexes (PAC) [Fig A]. Transthoracic echocardiogram demonstrated diastolic mitral valve regurgitation [Fig B]. Cardiac catheterization showed normal coronary arteries. She was treated with intravenous furosemide for volume management. Bradycardia was paradoxically treated using nadolol 20 mg daily for suppression of PACs after which the patient’s symptoms were stabilized. DMR is usually seen in complete heart block due to reversal in atrioventricular pressure gradients. Interestingly, in our case, non-conducted PACs which caused significant bradycardia were responsible for DMR. PAC morphology was consistent with septal origin. We propose that the likely etiology of septal PACs is the impingement of septal occluder device on the non-coronary sinus and retro-aortic atrial septum.
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