Altered Mitral Inflow Orifice in Severe Aortic Regurgitation: Real Time Three-Dimensional Echocardiographic Findings
Article first published online: 6 JUN 2013
© 2013, Wiley Periodicals, Inc.
Volume 31, Issue 1, pages E30–E32, January 2014
How to Cite
- Issue published online: 3 JAN 2014
- Article first published online: 6 JUN 2013
- mitral valve obstruction;
- aortic regurgitation
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.
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), 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.
|echo12271-sup-0001-Movie1.avi||video/avi||3014K||Movie 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.avi||video/avi||1131K||Movie 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.avi||video/avi||963K||Movie 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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