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An Unusual Mitral Regurgitation

An unusual case presented by the Working group on Valvular Heart Disease

Topics: Valvular Heart Diseases
Authors: David Messika-Zeitoun, Claire Cimadevilla

Additional contents from webparts:

Case Presentation:

Medical History

49 years-old lady
Past medical history
Hodgkin disease : radiotherapy + chemotherapy in 1993
Cardiovascular risk factors: none
Shortness of breath (NYHA II)
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


Transthoracic Echocardiography



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

Fig. 3 -  Hering American Journal of Cardiology 2003

Quantification: Vena Contracta

Quantification: PISA

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

Transesophageal echocardiography
Exercise echocardiography
Other ?


Transesophageal Echocardiography: beginning of the examination

Severe mitral regurgitation with complete lack of coaptation


Transesophageal Echocardiography: Few minutes later

Almost disappearance of the mitral regurgitation

3D Transesophageal Echocardiography

Beginning of the examination

few minutes later

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

Diagnosis : Severe MR Paroxysmal Functional called “eclipsed MR”

Coronary Angiography

Normal coronary angiography

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 

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

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