Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstracts
Cardiovascular, Case Report
Cardiovascular, Commentary
Cardiovascular, Editorial
Cardiovascular, Guest Editorial
Cardiovascular, Images in Cardiology
Cardiovascular, Interventional Round
Cardiovascular, Original Article
Cardiovascular, Perspective Review
Cardiovascular, Preface
Cardiovascular, Review Article
Cardiovascular, Student’s Corner
Case Report
Case Report, Cardiovascular
Case Reports
Case Series, Cardiovascular
Clinical Discussion
Clinical Rounds
CPC
Current Issue
Debate
Dedication
Editorial
Editorial Cardiovascular
Editorial, From the Publisher’s Desk
Expert Comments
Expert's Opinion
Genetic Autopsy
Genetics Autopsy
Guest Editorial, Cardiovascular
Image in Cardiology
Images in Cardiology
Images in Cardiology, Cardiovascular
Interventional Round
Interventional Round, Cardiovascular
Interventional Rounds
Letter to Editor
Letter to the Editor
Media and news
Original Article
Original Article, Cardiovascular
Original Article, Cardiovascular Health
Practice in Medicine
Preface
Review Article
Review Article, Cardiovascular
Scientific Paper
Short Communication
Student's Corner
Supplementary
Supplemetary
WINCARS Activities
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstracts
Cardiovascular, Case Report
Cardiovascular, Commentary
Cardiovascular, Editorial
Cardiovascular, Guest Editorial
Cardiovascular, Images in Cardiology
Cardiovascular, Interventional Round
Cardiovascular, Original Article
Cardiovascular, Perspective Review
Cardiovascular, Preface
Cardiovascular, Review Article
Cardiovascular, Student’s Corner
Case Report
Case Report, Cardiovascular
Case Reports
Case Series, Cardiovascular
Clinical Discussion
Clinical Rounds
CPC
Current Issue
Debate
Dedication
Editorial
Editorial Cardiovascular
Editorial, From the Publisher’s Desk
Expert Comments
Expert's Opinion
Genetic Autopsy
Genetics Autopsy
Guest Editorial, Cardiovascular
Image in Cardiology
Images in Cardiology
Images in Cardiology, Cardiovascular
Interventional Round
Interventional Round, Cardiovascular
Interventional Rounds
Letter to Editor
Letter to the Editor
Media and news
Original Article
Original Article, Cardiovascular
Original Article, Cardiovascular Health
Practice in Medicine
Preface
Review Article
Review Article, Cardiovascular
Scientific Paper
Short Communication
Student's Corner
Supplementary
Supplemetary
WINCARS Activities
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstracts
Cardiovascular, Case Report
Cardiovascular, Commentary
Cardiovascular, Editorial
Cardiovascular, Guest Editorial
Cardiovascular, Images in Cardiology
Cardiovascular, Interventional Round
Cardiovascular, Original Article
Cardiovascular, Perspective Review
Cardiovascular, Preface
Cardiovascular, Review Article
Cardiovascular, Student’s Corner
Case Report
Case Report, Cardiovascular
Case Reports
Case Series, Cardiovascular
Clinical Discussion
Clinical Rounds
CPC
Current Issue
Debate
Dedication
Editorial
Editorial Cardiovascular
Editorial, From the Publisher’s Desk
Expert Comments
Expert's Opinion
Genetic Autopsy
Genetics Autopsy
Guest Editorial, Cardiovascular
Image in Cardiology
Images in Cardiology
Images in Cardiology, Cardiovascular
Interventional Round
Interventional Round, Cardiovascular
Interventional Rounds
Letter to Editor
Letter to the Editor
Media and news
Original Article
Original Article, Cardiovascular
Original Article, Cardiovascular Health
Practice in Medicine
Preface
Review Article
Review Article, Cardiovascular
Scientific Paper
Short Communication
Student's Corner
Supplementary
Supplemetary
WINCARS Activities
View/Download PDF

Translate this page into:

Images in Cardiology
06 (
04
); 250-251
doi:
10.1055/s-0041-1739128

Himalayan Fibrillatory Waves in Juvenile Rheumatic Mitral Stenosis

Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

A. Shaheer Ahmed, MD, DM, DNB Department of Cardiology, 7th Floor, Super Speciality Block, Vardhman Mahavir Medical College and Safdarjung Hospital New Delhi 110029 ahmedshaheer53@gmail.com

Licence
This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Disclaimer:
This article was originally published by Thieme Medical and Scientific Publishers Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

An 18-year-old girl, a known case of rheumatic mitral stenosis, presented with dyspnea and palpitations. Electrocardiogram was done, which revealed atrial fibrillation and a large amplitude atrial fibrillatory wave, which was more than the voltage of R wave V1, a finding which is quite uncommon. Echocardiography revealed a large left atrium which was 80 mm in diameter. The patient was started on oral anticoagulation and referred for mitral valve replacement with maze procedure.

Keywords

atrial fibrillation
juvenile mitral stenosis

Introduction

Juvenile mitral stenosis was first described by Dr. Sujoy B. Roy from India. Juvenile mitral stenosis is characterized by presentation with severe mitral stenosis in those less than 20 years of age. Such patients tend to have less calcific valves, severe pulmonary hypertension, and fairly normal cardiac output. Atrial fibrillation (AF) is relatively uncommon, seen in only around 6% of the cases. We report a case of juvenile mitral stenosis, who presented with Himalayan fibrillatory waves in the electrocardiogram.

Case Presentation

An 18-year-old girl presented with complaints of dyspnea on exertion, New York Heart Association (NYHA) class II for 4 years, which progressed to class III for the past 1 month. She also had history of intermittent palpitations. On examination, she had a pulse rate of 126/min, which was irregularly irregular. Cardiovascular examination revealed S1 of variable intensity and a middiastolic murmur at the apex. Chest X-ray showed left atrial enlargement. Electrocardiogram showed irregularly irregular rhythm with a ventricular rate of approximately 98/min. There was a coarse atrial fibrillatory waveform seen in the electrocardiograph (ECG). The fibrillatory waves were very large, measuring around 6 to 7 mm. The amplitude of the fibrillatory wave was more than the amplitude of QRS complex in lead V1 (Fig. 1A). This feature was suggestive of left atrial enlargement. Echocardiography revealed severe mitral stenosis with mitral valve area of 0.8 cm2 and mild-to-moderate mitral regurgitation. The left atrium was grossly dilated measuring 80 mm in parasternal long axis view (Fig. 1B). There was grade 2+ spontaneous echo contrast in the left atrium. Anticoagulation was initiated with enoxaparin and, subsequently, warfarin. The patient was referred for mitral valve replacement and maze procedure.

Fig. 1 (A) 12-lead electrocardiogram showing large (Himalayan) fibrillatory waves (B) Echocardiography in parasternal long axis view showing left atrial enlargement, spontaneous echo contrast, and thickened mitral valve.

Fig. 1 (A) 12-lead electrocardiogram showing large (Himalayan) fibrillatory waves (B) Echocardiography in parasternal long axis view showing left atrial enlargement, spontaneous echo contrast, and thickened mitral valve.

Discussion

AF has an overall prevalence of 1 to 2% worldwide.1 In elderly population, nonvalvular AF predominates, whereas in younger population, it is predominantly due to valvular heart disease. Among the valvular heart disease, mitral stenosis is the most common lesion associated with AF. The presence of AF in juvenile rheumatic mitral stenosis relatively uncommon, with an incidence of 3 to 10%, which is very less when in comparison with their older counterparts.2 Based on the amplitude of the fibrillatory waves, AF is classified as fine AF if it is less than 1 mm and coarse AF if more than 1 mm. Coarse AF is considered as a marker of left atrial enlargement.3 Coarse AF is associated with hypertrophied atrial myocardium and more organized left atrial contraction in comparison to fine AF.4 Coarse AF has higher propensity for thromboembolic events despite having lesser tendency for clot formation.5 Extensive atrial myocardial hypertrophy without much structural damage in this young patient of rheumatic mitral stenosis is the plausible explanation for Himalayan fibrillatory wave. Systematic examination of this electrocardiogram is vital, as looking only at the lead V1 will give impression of either ventricular tachycardia or artifact.

Conclusion

Juvenile mitral stenosis is less commonly associated with AF. In our case, juvenile mitral stenosis presented AF, that too with coarse large amplitude atrial fibrillatory waves.

Conflict of Interest

None declared.

References

  1. , , , , . Epidemiology of atrial fibrillation in the 21st century: novel methods and new insights. Circ Res. 2020;127(01):4-20.
    [Google Scholar]
  2. , . Proceedings: challenge of juvenile mitral stenosis in India. Jpn Circ J. 1975;39(02):198.
    [Google Scholar]
  3. , , . The diagnostic importance of fibrillatory wave size. Circulation. 1962;25:991-994.
    [Google Scholar]
  4. , , , et al . Fine versus coarse atrial fibrillation in rheumatic mitral stenosis: the impact of aging and the clinical significance. Ann Noninvasive Electrocardiol. 2018;23(04):e12540.
    [Google Scholar]
  5. , , , et al . Fine vs. coarse atrial fibrillation: which one is more risky? Cardiology. 2007;107(03):193-196.
    [Google Scholar]
Show Sections