CASE REPORT
Apaient wit four artifcial heart valves after ergotamine therapy
M. Bijl, T.W. Galema, L.A. van Herwerden, M.J.M. Kofflard, P.N.W.M. Breuls, R.B.A. van de Brink
A 67-year-old female was evaluated in the outpatient clinic because of shortness of breath on exertion and regular spells of fever. She had been taking ergotamine tartrate to treat migraine for more than 30 years. The patient had undergone aortic-valve replacement for aortic insufficiency three years before. On echocardiographic evaluation, severe retraction and insuffiency of the remaining native heart valves was demonstrated. Endocarditis and carcinoid syndrome were exduded. The mitral, tricuspid and pulmonary valves were all replaced by a mechanical valvular prosthesis. Pathologicalanatomical evaluation of the three replaced valves and the aortic valve replaced three years earlier disclosed identical findings, compatible with long-term ergotamine use. Nine months after surgery, a sick sinus syndrome developed necessitating implantation of a DDDRpacmaker with a right atrial and a coronary sinus lead. Functional class according to the New York Heart Association improved from class m to I. After stopping the ergotamine, the fever disappeared. However, the migraine spells reoccurred which are now being treated with paracetamol. (NethHeartJ2006;14:431-3.)
Keywords: valves, aortic, mitral, pulmonary, tricuspid, ergotamine tartrate M. BiJI MJ.M. Koffiard P.N.W.M. Breuls Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, the Netherlands T.W. Galema LA. van Herwerden Department of Cardiology and Thoracic Surgery, Thoraxcentre, Erasmus Medical Centre, Rotterdam, the Netherlands R.B.A. van de Brink Department of Cardiology, Academic Medical Centre, Amsterdam, the Netherlands
Correspondence to: M. Biji Department of Cardiology, Albert Schweitzer Hospital, PO Box 404, 3300 AK Dordrecht, the Netherlands E-mail:
[email protected]
Netherlands Heart Journal, Volume 14, Number 12, December 2006
A 67-year-old female was evaluated in the outpatient clinic because offatigue and progressive symptoms of breathlessness on exertion. The patient's medical history reported recurrent cystitis and migraine for which she had been taking ergotamine tartrate 2 mg daily for almost 30 years. She had undergone aortic valve replacement with a St Jude mechanical valve no. 23 because of severe aortic insufficiency three years before presentation. Transoesophageal echocardiography at that time had shown a severely insufficient aortic valve with normal anatomy and no other valvular abnormalities. In the last months before presentation she had suffered from regular spells offever, and the symptoms of breathlessness had worsened, despite addition of furosemide 40 mg and digoxin 0.25 mg to the standard coumadin treatment. She was estimated to be in functional class III according to the NewYork Heart Association. On physical examination her height was 1.68 m and weight 60 kg. Blood pressure was 170/95 mmHg, the jugular venous pressure was elevated, valvular clicks were well audible and normal, a II/VI systolic and II/VI diastolic murmur could be heard along the right sternal border suggestive of a combined tricuspid valvular dysfunction. There was a marked hepatomegaly, peripheral oedema was absent. The ECG showed sinus rhythm without signs of left or right ventricular hypertrophy and atypical repolarisation disturbances could be appreciated in all leads. Laboratory tests demonstrated mild liver function abnormalities (y-glutamyltransferase 216 E/l, normal
