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Keywords:

  • mitral valve obstruction;
  • aortic regurgitation

Case Report

  1. Top of page
  2. Case Report
  3. References
  4. Supporting Information

A 43-year-old man referred for routine preoperative ECG (lower back surgery) was found to have asymptomatic atrial fibrillation. His blood pressure was 120/60 mmHg and his pulse 85 bpm. Clinical examination revealed a systolic murmur terminating well before the second heart sound, an early diastolic decrescendo murmur, and a mid-diastolic murmur audible over the cardiac apex (Austin Flint murmur). Subsequent transthoracic echocardiography (iE33 xMATRIX Ultrasound, Philips Medical Systems, Andover, MA, USA) showed a bicuspid aortic valve with eccentric aortic regurgitation. More detailed evaluation with transesophageal echocardiography (TEE) (iE33 xMATRIX Ultrasound) confirmed a bicuspid aortic valve with valve incompetence due to anterior prolapse of the joint right and left coronary cusp (Fig. 1, movie clip S1) resulting in a severe, eccentric, high-velocity jet projected towards the anterior mitral leaflet (AML). As a consequence, diastolic opening of the AML was highly restricted (Fig. 2, movie clip S2), resulting in mitral inflow obstruction and impaired diastolic filling. Real time three-dimensional TEE revealed remarkable distortion and premature diastolic closure of the mitral valve along the A2-P2 scallops, with more moderate obstruction at the A3-P3 section, and a relatively unrestricted opening of A1-P1, resulting in an asymmetric mitral valve inflow orifice (Fig. 3, movie clip S3). Assessment of the diastolic inflow pattern using pulsed-wave Doppler was consistent with these findings, showing absence of early filling in the 144° mid-esophageal view as opposed to presence of a distinct E-wave in the 0° mid-esophageal view (Fig. 4). Mitral inflow orifice, measured by planimetry, was 2.7 cm2, with a mean transmitral gradient of 1.5 mmHg (peak gradient 2.9 mmHg). Although there was a significant diastolic distortion of the mitral leaflets in the A2-P2 section, the hemodynamic significance of the inflow obstruction remained very low. The patient was subsequently referred for valve-sparing aortic root replacement with repair of the native aortic valve.

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Figure 1. Two-dimensional mid-esophageal short-axis TEE view of the aortic valve in systole, depicting the joint left- and right coronary cusp (arrow), thus, confirming the presence of a bicuspid aortic valve. TEE = transesophageal echocardiography.

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image

Figure 2. Two-dimensional mid-esophageal three-chamber TEE view in color-compare mode at mid-diastole showing the severe eccentric aortic regurgitant jet restricting normal anterior mitral leaflet opening. TEE = transesophageal echocardiography.

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image

Figure 3. Real time three-dimensional TEE in mid-diastole (“surgeon's view”), depicting an altered mitral inflow orifice caused by the severe eccentric aortic regurgitant jet. There is an almost complete obstruction of A2 anterior mitral leaflet opening, whereas section A3 is only moderately obstructed and section A1 opens relatively normal. TEE = transesophageal echocardiography.

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image

Figure 4. Two-dimensional pulsed-wave Doppler of mitral valve inflow at the mid-esophageal level with the transducer rotated at 0° (upper right) and 144° (lower right), together with an overview of these respective transducer rotation angles in a real time three-dimensional TEE image (left). Notice the presence of an early filling wave at 0° (with the 2D plane passing through the A1-P1 section), whereas in the 144° mid-esophageal view (i.e. A2-P2 section) no E-wave can be detected. In both sections there is an important atrial contribution to the diastolic filling, as shown by the presence of an end-diastolic A-wave in both views. TEE = transesophageal echocardiography.

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While the cause of the Austin Flint murmur has been subject to debate[1-3] (with one study finding no correlation between the presence of this murmur and mitral valve area[2]), this case seems to endorse the hypothesis that early diastolic closure of the AML induced by the aortic regurgitant jet, even without hemodynamic significance, is pivotal in causing this particular auscultatory finding.

References

  1. Top of page
  2. Case Report
  3. References
  4. Supporting Information
  • 1
    Rahko PS: Doppler and echocardiographic characteristics of patients having an Austin Flint murmur. Circulation 1991;83:19401950.
  • 2
    Landzberg JS, Pflugfelder PW, Cassidy MM, et al: Etiology of the Austin Flint murmur. J Am Coll Cardiol 1992;20:408413.
  • 3
    Emi S, Fukuda N, Oki T, et al: Genesis of the Austin Flint murmur: Relation to mitral inflow and aortic regurgitant flow dynamics. J Am Coll Cardiol 1993;21:13991405.

Supporting Information

  1. Top of page
  2. Case Report
  3. References
  4. Supporting Information
FilenameFormatSizeDescription
echo12271-sup-0001-Movie1.avivideo/avi3014KMovie clip S1. Two-dimensional mid-esophageal short-axis TEE view of the bicuspid aortic valve in color-compare mode, showing a joint left and right coronary cusp, with diastolic anterior prolapse of the joint cusp and secondary severe aortic regurgitation.
echo12271-sup-0002-Movie2.avivideo/avi1131KMovie clip S2. Two-dimensional mid-esophageal three-chamber TEE view in color-compare mode at mid-diastole showing the severe eccentric aortic regurgitant jet restricting normal anterior mitral leaflet opening.
echo12271-sup-0003-Movie3.avivideo/avi963KMovie clip S3. Real-time three-dimensional TEE in mid-diastole ("surgeon's view"), depicting an altered mitral inflow orifice caused by the severe eccentric aortic regurgitant jet. There is an almost complete obstruction of A2 anterior mitral leaflet opening, whereas section A3 is only moderately obstructed and section A1 opens relatively normal.

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