Complete heart block presenting with de Musset’s sign

A 71-year-old woman presented with shortness of breath and involuntary head shaking. Physical examination showed nodding of the head with each heart beat (Video 1). Her pulse rate and blood pressure were 40 bpm and 125/55 mm Hg, respectively. ECG revealed complete atrioventricular block with a ventricular rate of 40 and atrial rate of 75 (Fig. 1a). Transthoracic echocardiography displayed moderate aortic regurgitation (AR) and diastolic and systolic mitral regurgitation (MR) (Video 2). Long ventricular diastole caused an increase in the severity of AR, which was perceived to be moderate initially. Increased LVEDP due to relatively acute and severe AR causes early and severe systolic MR (Fig. 1b). Diastolic MR occurred when P waves came in early or mid-diastole but not in systole (Fig. 1c–e). Symptoms relieved after DDDR pacemaker implantation (Video 3). Diastolic and severe systolic MR disappeared (Fig. 1f, Video 4). Moderate AR was aggravated by long diastole in addition to diastolic MR, which increased the diastolic aortoventricular gradient. de Musset’s sign is nodding of head due to increased pulse pressure in severe aortic regurgitation.