Acute Mitral Regurgitation due to Spontaneous Chordal Rupture in a Patient With Obstructive Hypertrophic Cardiomyopathy

Mitral regurgitation in the critically ill: the devil is in the detail

Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.

Different mechanisms of mitral regurgitation in hypertrophic cardiomyopathy: A clinical case and literature review

Background

Abnormalities of the mitral valve (MV) apparatus are typical features of hypertrophic cardiomyopathy (HCM). These abnormalities include leaflet elongation, thick leaflets, displacement of papillary muscle, and systolic anterior motion (SAM) of the MV anterior leaflet. Mitral valve chordal rupture associated with HCM is a rare but serious issue capable of change the clinical apparence and the prognosis of the patient.

Case summary

A 57-year-old lady with a history of diabetes, dyslipidemia, and a previous single episode of atrial fibrillation (treated with pharmacological cardioversion), presented to the Emergency Department for worsening dyspnea (New York Heart Association Classification class IV). A trans-thoracic echocardiogram (TTE) showed a significant, septal, and asymmetric left ventricular hypertrophy (basal anteroseptal wall diastolic thickness of 19 mm) with normal left ventricle systolic function. A SAM of AML was evident together with a left ventricular outflow tract gradient of 56 mmHg at rest, rising to 136 mmHg during the Valsalva maneuver. In addition, there was evidence of moderate to severe mitral regurgitation (MR) with an anteriorly directed jet, not very typical of MR related to SAM. A 2D-3D trans-esophageal echocardiogram (2D-3D TEE) revealed a combined MR mechanism based on PML degenerative prolapse with P2-flail from ruptured chordae with related eccentric anteriorly directed regurgitant jet, together with a second regurgitant posteriorly directed jet, related to SAM of AML. The patient underwent MV repair together with septal myectomy, with a good final outcome.

Conclusion

Pre-operative echocardiography (both TTE and 2D-3D TEE) is an essential tool in order to detect different MV abnormalities in patients with HCM. These types of patients should never be treated by septal reduction alone. Surgical MV repair or replacement, together with septal myectomy, may be the preferred approach.

Subaortic Membrane With Mitral Chordae Rupture Mimicking Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is an autosomal-dominant disorder that can lead to left ventricular outflow tract (LVOT) obstruction. Some patients present with syncope, dyspnea, chest pain, or sudden cardiac death. A subaortic membrane (SAM) is an unusual cause of ventricular outflow tract obstruction causing symptoms that can imitate HCM. It is essential to differentiate between these two entities, as it has important implications in guiding treatment and determining the type of intervention. Echocardiography is the gold standard modality for the diagnosis. In this report, we present a case of a 56-year-old man presenting with subaortic stenosis with ruptured mitral chordae misdiagnosed as HCM with SAM.

Complete Resolution of Left Ventricular Outflow Tract Obstruction After Spontaneous Mitral Valve Chordal Rupture in a Patient With Hypertrophic Cardiomyopathy

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Spontaneous mitral chordal rupture is a complication in hypertrophic cardiomyopathy (HCM).

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Mitral chordal rupture in HCM causes deterioration in heart failure.

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Symptoms improved when left ventricular outflow tract (LVOT) obstruction disappeared.

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Mitral valve has a role in LVOT obstruction and systolic anterior motion.