A 76-year-old man presented with severe dyspnoea, leading to urgent hospitalization for congestive heart failure. The patient had Parkinson’s disease treated with bromocriptine at a dose of 30 mg/day for more than 7 years (total cumulative dose = 30 × 365 × 7 = 77 g); he did not have cardiovascular risk factors. Transthoracic Doppler echocardiography (TTE) showed a dilated left ventricle with normal ejection fraction and no wall motion abnormalities. Both left heart valves (mitral and aortic) were thickened with a drumstick appearance and restrictive motion of the two mitral leaflets causing severe mitral regurgitation. There was also a restrictive motion of the right and the no coronary aortic cusps leading to significant aortic valve regurgitation. The left atrium was dilated and there was significant tricuspid regurgitation with thickened tricuspid leaflets and a dilated tricuspid annulus; the estimated pulmonary artery systolic pressure was around 65 mmHg. Coronary angiography showed three-vessel disease. However, after multidisciplinary staff consultation and in accordance with his family, the patient did not have cardiac surgery because of his severe Parkinson’s disease and global mediocre status. In fact, the operative risk was felt to be greater than the benefits of undergoing coronary artery bypass graft and double mitral and aortic valve replacement associated with tricuspid annuloplasty.
Previous studies have shown an association between ergot alkaloids, such as pergolide or cabergoline, and the occurrence of toxic drug-induced valvular disease. However, the association between severe valvular heart disease and bromocriptine is extremely rare (one case from Marseille with a similar total cumulative dose of 73 g was described in 2002; the patient had severe multiple valve regurgitation). Although there was no histological proof however, given the time course, cumulative dose, chemical similarity of bromocriptine to other ergo derivatives and typical valve lesions seen on TTE ( Figs. 1–3 ; Videos 1–4 ), we felt that there was a strong and probable association between prolonged bromocriptine treatment and the occurrence of severe multiple valves disease.
