A patient with four artificial heart valves after ergotamine therapy.

A 67-year-old female was evaluated in the out-patient clinic because of shortness of breath on exertion and regular spells of fever. She had been taking ergotamine tartrate to treat migraine for more than 30 years. The patient had undergone aortic-valve replacement for aortic insufficiency three years before. On echocardiographic evaluation, severe retraction and insufficiency of the remaining native heart valves was demonstrated. Endocarditis and carcinoid syndrome were excluded. The mitral, tricuspid and pulmonary valves were all replaced by a mechanical valvular prosthesis. Pathological-anatomical evaluation of the three replaced valves and the aortic valve replaced three years earlier disclosed identical findings, compatible with long-term ergotamine use. Nine months after surgery, a sick sinus syndrome developed necessitating implantation of a DDDR pacemaker with a right atrial and a coronary sinus lead. Functional class according to the New York Heart Association improved from class III to I. After stopping the ergotamine, the fever disappeared. However, the migraine spells reoccurred which are now being treated with paracetamol.