Sinus Tachycardia in Mitral Stenosis

Report:

Sinus tachycardia 114/min

Left atrial abnormality

Comment:

The trace is not really suggestive of mitral stenosis. Apart from the obviously increased PTF in V1, the only clue – a weak one - is small R wave in L1.

Yet he was one of the most interesting cases of MS I treated in ICU. He had severe pulmonary œdema in Casualty and had to be intubated; an echocardiogram showed some “mitral valve thickening”. A Cardiologist missed the physical signs (as did many others) and misread the echocardiogram; he had to be persuaded to come to ICU and repeat the echo, still claiming the initial one was of “good quality”. It was: I merely wanted him to save face. A tact of a Versailles diplomat is required in these situations.

But the real interest lies elsewhere. He could not be extubated: attempts at weaning lead to marked tachycardia (Fig 47a) and oedema welling up the tube. I gave him frequent boluses and eventually an infusion of metoprolol and extubated him in an hour, without diuretics. Something one dreams of doing but rarely has the opportunity.

The patient underwent a mitral valve replacement a few months later.