This 34-year-old man, known to to have mitral valve prolapse with mild regurgitation, developed sudden cough and severe dyspnea. He is brought to the Emergency Department in acute pulmonary edema and has to be intubated and ventilated. Severe mitral regurgitation is noted and the patient undergoes urgent mitral valve replacement. At surgery, vegetations are seen on both mitral valve leaflets and there is rupture of the chordae of the posterior leaflet. A large quantity of fluid is found in the pericardium. The blood cultures are negative. The following ECG is recorded 3 days after surgery:

• Sinus tachycardia, 107/min
• Complete heart block with escape accelerated junctional rhythm – ventricular rate 88/min
• Diffuse ST elevation compatible with acute pericarditis

This ECG is recorded 5 days after surgery:

• Sinus rhythm 70/min
• Complete heart block
• Junctional escape rhythm, 55/min
• Diffuse ST elevation compatible with pericarditis 

A pacemaker is implanted:

• Electronic ventricular pacemaker (VVI)
• Underlying sinus rhythm with complete heart block
• Ventricular pacing – rate 65/min