Imaging Case Study: What is Causing the Mitral Regurgitation (MR)?
Dr. James Thomas
Director of Cardiovascular Imaging Section, Department of Cardiovascular Medicine
- 22 year old woman with neurofibromatosis and a (reportedly) recent murmur
- PMHx:
No evidence for infection
- Referred for transthoracic echo
Parasternal Long Axis View
Severe MR of Unclear Etiology
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Echo 1- click on the small arrow on the bottom left of the player to start & stop tape
Possible causes of MR :
A. Prolapse
B. Restriction
C. Cleft
D. Perforation
E. Papillary muscle elongation/rupture
F. Ventricular dilatation
G. SAM
H. Something weird
Parasternal Long Axis View
Abnormal structure in left atrium
Echo 2- click on the small arrow on the bottom left of the player to start & stop tape
What is this?
Looks like a string in the LA attached to anterior mitral leaflet
Apical Four-Chamber View
Massive dilation of left ventricle and atrium
Echo 3- click on the small arrow on the bottom left of the player to start & stop tape
Apical Four-Chamber View
Severe MR
Echo 4- click on the small arrow on the bottom left of the player to start & stop tape
Mitral Inflow
Elevated E-wave consistent with severe MR
Pulmonary Venous Flow
Marked systolic flow reversal c/w severe MR
Tricuspid Regurgitation CW Velocity
Subcostal View
String tethers anterior mitral leaflet to mid-atrial septum
Echo 5- click on the small arrow on the bottom left of the player to start & stop tape
What is the cause of MR :
A. Prolapse
B. Restriction
C. Cleft
D. Perforation
E. Papillary muscle elongation/rupture
F. Ventricular dilatation
G. SAM
H. Something weird
String from the interatrial septum to the AML tip restricts closure, allowing AML to slide behind PML, resulting in 4+ posteriorly directed MR
Into the operating room with Gosta Petterson, M.D.
Preop TEE Basal Long-Axis View
String prevents anterior leaflet from reaching the posterior
Echo 6- click on the small arrow on the bottom left of the player to start & stop tape
Preop TEE Basal Long-Axis View
Torential regurgitation
Echo 7- click on the small arrow on the bottom left of the player to start & stop tape
Proximal Convergence Zone
Regurgitant orifice area ~ 0.7 cm2
Pulmonary Venous Flow
Marked systolic flow reversal c/w severe MR
The Pathology
Fibrous band from the interatrial septum to the tip of the anterior mitral leaflet
The Operation
Postop TEE Basal 4-Chamber View
Trivial mitral regurgitation
Echo 8- click on the small arrow on the bottom left of the player to start & stop tape
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