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Irregular cardiac rhythm with combined rheumatic mitral stenosis and aortic stenosis.

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An electrocardiogram in a 56-year-old man revealed coarse atrial fibrillation with a controlled ventricular response, a single ventricular premature complex, left ventricular hypertrophy, and digitalis effect (Figure). The fibrillatory waves are large and superficially resemble atrial flutter, but unlike flutter waves, the waves are not uniform in voltage or timing. Coarse atrial fibrillatory waves, i.e., those with an amplitude >1 mm (0.1 mV), are more often associated with rheumatic valvular disease (1), congenital heart disease (2), or hypertrophic cardiomyopathy, whereas fine fibrillatory waves are more often associated with atherosclerotic cardiac disease (1). Although any atrial fibrillation is a marker for left atrial enlargement, coarse atrial fibrillation appears to be a more specific marker (1, 3).

This patient had longstanding rheumatic heart disease with more severe mitral stenosis than regurgitation and significant aortic stenosis and regurgitation. The mitral disease was the major cause of his left atrial enlargement and atrial fibrillation. The aortic valve disease was the main reason for his left ventricular hypertrophy, manifested in the electrocardiogram by [RV.sub.5] > 26 mm (2.6 mV), [RV.sub.6] > 20 mm, [SV.sub.1] [greater than or equal to] 30 mm, [SV.sub.1] + [RV.sub.5] or [RV.sub.6] > 35 mm, and [SV.sub.2] + [RV.sub.5] or [RV.sub.6] > 45 mm (4). The repolarization changes in leads [V.sub.4] to [V.sub.6] could be due to left ventricular hypertrophy, but the essentially isoelectric J points, rounded sagging of the ST segments, and small but upright T waves also suggest the effects of digoxin, a drug he was taking.

Because of symptomatic congestive heart failure, the patient underwent mitral and aortic valve replacement. He had an uneventful postoperative course.

D. Luke Glancy, MD, and T. Griffin Gaines, MD

From the Sections of Cardiology, Departments of Medicine, Louisiana State University Health Sciences Center and the Interim Louisiana State University Public Hospital, New Orleans.

Corresponding author: D. Luke Glancy, MD, 7300 Lakeshore Drive, #30, New Orleans, LA 70124 (e-mail: dglanc@lsuhsc.edu).

(1.) Thurmann M, Janney JG Jr. The diagnostic importance of fibrillatory wave size. Circulation 1962;25:991-994.

(2.) Thurmann M. Coarse atrial fibrillation in congenital heart disease. Circulation 1965;32:290-292.

(3.) Peter RH, Morris JJ Jr, Mcintosh HD. Relationship of fibrillatory waves and P waves in the electrocardiogram. Circulation 1966;33:599-606.

(4.) Milliken JA, Macfarlane PW, Lawrie TDV. Enlargement and hypertrophy. In Macfarlane PW, Lawrie TDV, eds. Comprehensive Electrocardiology. Theory and Practice in Health and Disease, vol. 1. New York: Pergamon Press, 1989:631-670.

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Title Annotation:Electrocardiographic Report
Author:Glancy, D. Luke; Gaines, T. Griffin
Publication:Baylor University Medical Center Proceedings
Article Type:Clinical report
Geographic Code:1USA
Date:Jan 1, 2014
Words:426
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