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

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. 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. Transthoracic Echocardiography a few days after
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5. Etiology
Calcifications of
the aortic-mitral
aponevrosis
highly
suggestive of
post-radiation
valvular heart
disease
Hering American Journal of Cardiology 2003

6. Quantification: Vena Contracta
3 mm
Mild MR
Gray zone
7 mm
Severe MR

7. Quantification: PISA
Aliasing velocity (Va)
R
ERO = 0.17 cm²
RVOL = 37 ml

8. TTE Conclusions
- Post-radiation moderate
organic mitral regurgitation
- Moderate left enlargement
- Normal systolic pulmonary
artery pressure

9. What to do next to explain discrepancies between
outpatient and inpatient echocardiographies
• Nothing
• Transesophageal echocardiography
• Exercise echocardiography
• Other ?

10. What to do next to explain discrepancies between
outpatient and inpatient echocardiographies
• Nothing
• Transesophageal echocardiography
• Exercise echocardiography
• Other ?

11. Transesophageal Echocardiography: beginning
of the examination
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Severe mitral
regurgitation
with complete
lack of
coaptation

12. Transesophageal Echocardiography: Few
minutes later
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Almost disappearance of the mitral regurgitation

13. 3D Transesophageal Echocardiography
Beginning of the examination
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Few minutes later
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3D TEE nicely showing the conformational changes of the
aortic annulus and absence of leaflet coaptation

14. Diagnosis
Severe MR Paroxysmal
Functional called
“eclipsed MR”

15. Coronary Angiography
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Normal coronary angiography

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. 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. Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !
Membership is FREE!