Rheumatic Severe Mitral Stenosis With Complete Heart Block
Pravin K. Goel, Nagaraja Moorthy & Tanuj Bhatia
Pediatric Cardiology ISSN 0172-0643 Pediatr Cardiol DOI 10.1007/s00246-013-0629-0
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Author's personal copy Pediatr Cardiol DOI 10.1007/s00246-013-0629-0
IMAGES IN PEDIATRIC CARDIOLOGY
Rheumatic Severe Mitral Stenosis With Complete Heart Block Pravin K. Goel • Nagaraja Moorthy Tanuj Bhatia
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Received: 19 October 2012 / Accepted: 1 January 2013 Ó Springer Science+Business Media New York 2013
Abstract Rheumatic fever presenting with complete heart block is very rare and usually transient. We describe a child with chronic severe rheumatic mitral stenosis with persistent complete heart block with interesting echocardiographic findings. Keywords Complete heart block Mitral stenosis Rheumatic heart disease
A-16-year-old female child was admitted with a history of progressive dyspnoea associated with paroxysmal nocturnal dyspnea. There was no history of syncope or presyncope. Pulse rate was 39 bpm and regular. Jugular venous pulse showed intermittent cannon a wave. Cardiovascular examination was suggestive of severe mitral stenosis with pulmonary hypertension. Electrocardiogram showed left atrial enlargement and complete heart block with a ventricular rate of 39 bpm. Transthoracic echocardiography showed features of rheumatic severe mitral stenosis (Fig. 1) with severe
pulmonary hypertension (right-ventricular systolic pressure = 74 mm Hg). The gradient across mitral valve was 24/14 mm Hg, and the mitral valve orifice area by planimetry was 0.9 cm2. Doppler color wave examination showed unusual pattern of mitral inflow signals of varying shapes (Fig. 2). Correlating with the electrocardiograph, the multiple sharp peaks represented the atrial contractions (A signal [arrows in Fig. 2]) falling on E signals at varying intervals. Rheumatic fever presenting as complete heart block is very rare, usually transient, and represents involvement of the conduction pathways in a reversible fashion [1, 3]. The complete heart block may persist B12 months [2]. However, our patient had chronic rheumatic heart disease with severe mitral stenosis and pulmonary hypertension. Hence, the onset of complete heart block could not be confirmed, and co-occurrence of congenital complete heart block could be ruled out. Rheumatic mitral stenosis with complete heart block may be accompanied with interesting echocardiographic findings of A-V dissociation on Doppler examination as seen in our patient.
P. K. Goel N. Moorthy (&) T. Bhatia Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India e-mail:
[email protected]
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Author's personal copy Pediatr Cardiol Fig. 1 Transthoracic echocardiogram showing features of rheumatic severe mitral stenosis. Note the electrocardiographic strip showing complete heart block
Fig. 2 Continuous Doppler imaging across mitral inflow showing features of severe mitral stenosis with irregular pattern of inflow signal with multiple sharp peaks. Note the electrocardiographic strip showing complete heart block and arrows representing atrial contraction (a)
References 1. Barold SS, Sischy D, Punzi J, Kaplan EL (1998) Advanced atrioventricular block in 39-year-old man with acute rheumatic fever. Pacing Clin Electrophysiol 21:2025–2028
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2. Shah CK, Gupta R (1993) Persistent complete heart block following acute rheumatic fever in a 12 year old girl. J Assoc Physicians India 41(6):389–390 3. Zalzstein E, Maor R, Zucker N, Katz A (2003) Advanced atrioventricular conduction block in acute rheumatic fever. Cardiol Young 13:506–508
