Optimizing Pacemaker Based Heart Rate in a Patient With Severe Aortic Regurgitation and Mitral Regurgitation

BACKGROUND: Data are limited on the optimal heart rate (HR) in patients with pacemakers and volume loading conditions such as severe aortic regurgitation (AR) or mitral regurgitation (MR) who cannot undergo, or decline, surgical/procedural valve intervention. CASE SUMMARY: A 93-year-old man with remote bioprosthetic aortic valve replacement, mitral regurgitation with a prior mitral clip, sinus node dysfunction, and a dual-chamber pacemaker presented with shortness of breath and was found to have severe AR and moderate MR. A ramp echocardiography-driven HR protocol was used to identify 70 beats/min as his optimal HR to minimize AR and MR and improve cardiac output. DISCUSSION: The optimal HR for patients with volume loading conditions such as severe AR or MR can be determined on an individual basis through serial modulation of the paced HR. It is not necessarily the case that a progressively faster HR results in improved hemodynamic parameters. TAKE-HOME MESSAGES: HR modification in patients with chronotropic incompetence and pacemakers can improve cardiac output, particularly in patients with valvular lesions. An echocardiography-guided HR titration protocol should be considered for patients with volume loading conditions such as severe AR or MR to determine a patient-specific optimal HR.