An Unusual Mitral
Regurgitation
David Messika-Zeitoun MD, PhD and
Claire Cimadevilla MD
Bichat Hospital, Paris, France
Medical History

• 49 years-old lady
• Past medical history
• Hodgkin disease : radiotherapy + chemotherapy in 1993

• Car...
Medical History

• First visit (outpatient clinic) in November 2008
• 3/6 systolic murmur
• ECG: Sinus rhythm, left bundle...
Transthoracic Echocardiography a few days after
Watch video

Watch video

Watch video

Watch video
Etiology

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

Heri...
Quantification: Vena Contracta

3 mm
Mild MR

Gray zone

7 mm
Severe MR
Quantification: PISA

Aliasing velocity (Va)

R

ERO = 0.17 cm²
RVOL = 37 ml
TTE Conclusions
- Post-radiation moderate

organic mitral regurgitation
- Moderate left enlargement
- Normal systolic pulm...
What to do next to explain discrepancies between
outpatient and inpatient echocardiographies

• Nothing
• Transesophageal ...
What to do next to explain discrepancies between
outpatient and inpatient echocardiographies

• Nothing
• Transesophageal ...
Transesophageal Echocardiography: beginning
of the examination
Watch video

Watch video

Watch video

Severe mitral
regurg...
Transesophageal Echocardiography: Few
minutes later
Watch video

Watch video

Almost disappearance of the mitral regurgita...
3D Transesophageal Echocardiography
Beginning of the examination
Watch video

Few minutes later
Watch video

3D TEE nicely...
Diagnosis
Severe MR Paroxysmal
Functional called
“eclipsed MR”
Coronary Angiography
Watch video

Watch video

Normal coronary angiography
Exercise Echocardiography

Under beta-blocker therapy
60 W, 82% maximal predicted heart rate
Stop because of fatigue
No ch...
At 5 years, our patient
remains moderately
symptomatic and never
experienced any acute
complication such as
pulmonary edem...
Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !

Membership is FREE!
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An unusual-mitral-regurgitation

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An unusual-mitral-regurgitation

  1. 1. An Unusual Mitral Regurgitation David Messika-Zeitoun MD, PhD and Claire Cimadevilla MD Bichat Hospital, Paris, France
  2. 2. 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)
  3. 3. 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
  4. 4. Transthoracic Echocardiography a few days after Watch video Watch video Watch video Watch video
  5. 5. Etiology Calcifications of the aortic-mitral aponevrosis highly suggestive of post-radiation valvular heart disease Hering American Journal of Cardiology 2003
  6. 6. Quantification: Vena Contracta 3 mm Mild MR Gray zone 7 mm Severe MR
  7. 7. Quantification: PISA Aliasing velocity (Va) R ERO = 0.17 cm² RVOL = 37 ml
  8. 8. TTE Conclusions - Post-radiation moderate organic mitral regurgitation - Moderate left enlargement - Normal systolic pulmonary artery pressure
  9. 9. What to do next to explain discrepancies between outpatient and inpatient echocardiographies • Nothing • Transesophageal echocardiography • Exercise echocardiography • Other ?
  10. 10. What to do next to explain discrepancies between outpatient and inpatient echocardiographies • Nothing • Transesophageal echocardiography • Exercise echocardiography • Other ?
  11. 11. Transesophageal Echocardiography: beginning of the examination Watch video Watch video Watch video Severe mitral regurgitation with complete lack of coaptation
  12. 12. Transesophageal Echocardiography: Few minutes later Watch video Watch video Almost disappearance of the mitral regurgitation
  13. 13. 3D Transesophageal Echocardiography Beginning of the examination Watch video Few minutes later Watch video 3D TEE nicely showing the conformational changes of the aortic annulus and absence of leaflet coaptation
  14. 14. Diagnosis Severe MR Paroxysmal Functional called “eclipsed MR”
  15. 15. Coronary Angiography Watch video Watch video Normal coronary angiography
  16. 16. 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 • • • •
  17. 17. 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
  18. 18. Join the ESC Working Group on Valvular Heart Disease and take part in its activities ! Membership is FREE!

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