An Unusual Mitral Regurgitation

David Messika-Zeitoun MD, PhD and Claire Cimadevilla MDBichat Hospital, Paris, France

Medical History

• 49 years-old lady• Past medical history

• Hodgkin disease : radiotherapy + chemotherapy in 1993

• Cardiovascular risk factors: none• Symptoms:

• Palpitations• Shortness of breath (NYHA II)

Medical History

• First visit (outpatient clinic) in November 2008• 3/6 systolic murmur• ECG: Sinus rhythm, left bundle block branch • Transthoracic echocardiography

• Severe mitral regurgitation• Systolic pulmonary artery pressure: 50 mm hg

Transthoracic Echocardiography a few days after

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Etiology

Hering American Journal of Cardiology 2003

Calcifications of the aortic-mitral aponevrosis highly suggestive of post-radiation valvular heart disease

Quantification: Vena Contracta

3 mm 7 mm

Mild MR Severe MRGray zone

Quantification: PISA

Aliasing velocity (Va)

R

ERO = 0.17 cm²RVOL = 37 ml

TTE Conclusions

- Post-radiation moderate organic mitral regurgitation- Moderate left enlargement- Normal systolic pulmonary artery pressure

What to do next to explain discrepancies between outpatient and inpatient echocardiographies

• Nothing

• Transesophageal echocardiography

• Exercise echocardiography

• Other ?

What to do next to explain discrepancies between outpatient and inpatient echocardiographies

• Nothing

• Transesophageal echocardiography

• Exercise echocardiography

• Other ?

Transesophageal Echocardiography: beginning of the examination

Severe mitral regurgitation with complete lack of coaptation

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Transesophageal Echocardiography: Few minutes later

Almost disappearance of the mitral regurgitation

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3D Transesophageal Echocardiography

3D TEE nicely showing the conformational changes of the aortic annulus and absence of leaflet coaptation

Beginning of the examination Few minutes later

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Diagnosis

Severe MR ParoxysmalFunctional called “eclipsed MR”

Coronary Angiography

Normal coronary angiography

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Exercise Echocardiography

• Under beta-blocker therapy• 60 W, 82% maximal predicted heart rate• Stop because of fatigue• No change in left ventricular ejection

fraction• No change in the degree and mechanism of

mitral regurgitation• Systolic pulmonary artery pressure:

progressive raise from 30 to 60 mm Hg

At 5 years, our patient remains moderately symptomatic and never experienced any acute complication such as pulmonary edema

We are collecting similar cases. If you are

interested in participating please contact us

david.messika-zeitoun@bch.aphp.fr

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