An 80-year-old woman with previous posterior myocardial infarction was referred to us for exertional dyspnoea. Transthoracic echocardiography at rest revealed a mildly reduced left ventricular ejection fraction of 48% with posterior asynergy and moderate functional mitral regurgitation (MR) most likely due to the tethering of posterior mitral valve leaflet caused by the regional wall motion abnormality. Coronary angiography showed significant stenosis of the right coronary artery and left ventriculography showed Sellers II degree MR. Right heart catheterization at rest demonstrated normal pulmonary capillary wedge pressure (PCWP) and pulmonary artery pressure (PAP) (). After an isometric handgrip exercise (Video 1) at her maximum level for 2 min, her blood pressure increased from 145/66 mmHg to 157/81 mmHg and both PCWP and PAP markedly increased (). On the following day, we performed echocardiography while the patient was grasping a handgrip and observed that functional moderate MR (vena contracta width = 4.3 mm and jet area = 28%) deteriorated to severe grade (7.2 mm and 51%) (Supplementary material online, Figures S1 and S2 and Videos 2 and 3). Thereafter, she underwent a 6-min walk test and complained of exertional dyspnoea as usual. Echocardiography performed immediately after the 6-min walk test confirmed the significant deterioration of MR and elevation of estimated systolic PAP. These results indicated that her exertional dyspnoea was caused by dynamic severe MR.Pulmonary capillary wedge pressure at rest.Pulmonary capillary wedge pressure during handgrip exercise.In this case, a handgrip stress test on right heart catheterization and echocardiography gave important clues for elucidating the cause of dyspnoea. The handgrip stress test imposes pressure loads on the left ventricle and is reportedly useful on diagnosing myocardial ischaemia; however, little is known regarding its utility in patients with MR. This case highlights the importance of the handgrip stress test, a simple manoeuvre that is readily applicable in routine practice, for evaluating exertional dyspnoea in MR patients.
Supplementary material
Supplementary material is available at European Heart Journal - Case Reports online.Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.Conflict of interest: none declared.Click here for additional data file.