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      Eclipsed mitral regurgitation successfully treated with a combination of surgical and pharmacological therapies: a case report

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          Abstract

          Background

          Eclipsed mitral regurgitation (MR), which is characterized by a transient and reversible massive functional MR, usually causes recurrent episodes of acute pulmonary oedema in patients with a preserved left ventricular ejection fraction. The pathophysiological mechanism and optimal treatment of eclipsed MR are not yet fully understood.

          Case summary

          A 72-year-old woman was hospitalized with cardiogenic shock and takotsubo cardiomyopathy. After hospitalization worsening dyspnoea again appeared, and urgent transthoracic echocardiography revealed severe MR, which spontaneously resolved in a few minutes. At this point, eclipsed MR was detected for the first time. Diagnostic examination revealed that the eclipsed MR was caused by a left ventricular afterload increase. Ultimately, the patient began medical therapy and underwent mitral valve replacement. The subsequent clinical course was favourable.

          Discussion

          This case illustrates the importance of early intervention for eclipsed MR. A combination of surgical and pharmacological therapies can serve as one treatment option for an eclipsed MR.

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          Most cited references6

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          Eclipsed Mitral Regurgitation: A New Form of Functional Mitral Regurgitation for an Unusual Cause of Heart Failure with Normal Ejection Fraction

          Jean-François Avierinos, Franck Thuny, Laurence Tafanelli … (2008)
          Background: Transient functional mitral regurgitation (MR) has never been reported as a cause of heart failure (HF) with normal ejection fraction (EF) in the absence of epicardial coronary artery stenosis. Results: Performance of echocardiography in patients with acute HF before initiation of HF medical treatment allowed identification of three patients with normal EF but transient massive functional MR during the HF episode. In all patients, massive MR occurred as a consequence of sudden extreme apical tenting of both leaflets with total lack of coaptation, despite normal EF and absence of detectable left ventricular (LV) remodeling, and despite absence of significant stenosis on coronary arteries. In all patients MR was triggered by methylergonovine injection and was reversible either spontaneously or after nitroglycerine administration, leaving patients with normal echocardiogram between HF episodes. In two patients, long-term administration of calcium channel blockers prevented recurrences of MR and HF, whereas in one, mitral valve was eventually replaced. Conclusion: Sudden reversible apical tenting of mitral leaflets with subsequent torrential MR and acute HF can occur despite normal EF, absence of pre-existing LV remodeling and absence of coronary artery stenosis. This atypical type of functional MR is an unusual mechanism of HF in patients with normal LVEF.
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            Mitral valve surgery for transient severe mitral regurgitation: an alternative to medical treatment?

            N. Messas, H. Samet, J Brocchi … (2014)
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              Transient severe reversible functional mitral regurgitation: a three-dimensional transoesophageal perspective.

              Vincent Labbe, Patrick Charlier, Eric Brochet … (2010)
              Mrs B, a 49-year-old female, was referred to our institution for severe mitral regurgitation. Transthoracic echocardiography showed only a moderate organic mitral regurgitation, but a transient severe reversible functional mitral regurgitation was observed during transoesophageal echocardiography (TEE). Three-dimensional TEE clearly demonstrated the functional nature of the regurgitation with a transient and sudden tenting of the mitral leaflets with a circular mitral annulus resulting in a total absence of leaflet coaptation.
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                Author and article information

                Contributors
                Georg Goliasch: Role: Handling Editor
                Domenico D'Amario: Role: Editor
                Esther Cambronero-Cortinas: Role: Editor
                Didem Oguz: Role: Editor
                Christian Fielder Camm: Role: Editor
                Peregrine Green: Role: Editor
                Journal
                Journal ID (nlm-ta): Eur Heart J Case Rep
                Journal ID (iso-abbrev): Eur Heart J Case Rep
                Journal ID (publisher-id): ehjcr
                Title: European Heart Journal: Case Reports
                Publisher: Oxford University Press
                ISSN (Electronic): 2514-2119
                Publication date Collection: June 2019
                Publication date (Electronic): 21 April 2019
                Publication date PMC-release: 21 April 2019
                Volume: 3
                Issue: 2
                Electronic Location Identifier: ytz039
                Affiliations
                Department of Cardiovascular Medicine, Okayama University, 2-5-1 Shikata-cho, Okayama-kitaku, Okayama, Japan
                Author notes
                Corresponding author. Tel: +81 86 235 7351, Fax: +81 86 235 7353, Email: ichikawa1987@ 123456gmail.com
                Article
                Publisher ID: ytz039
                DOI: 10.1093/ehjcr/ytz039
                PMC ID: 6601157
                SO-VID: 7f182c88-59ae-48a1-9617-56187e0baaab
                Copyright © © The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                Date received : 29 October 2018
                Date accepted : 3 April 2019
                Page count
                Pages: 5
                Categories
                Subject: Case Reports

                Keywords: eclipsed mr,transient acute mitral regurgitation,mitral valve surgery,takotsubo cardiomyopathy,case report
                Data availability:
                Keywords: eclipsed mr, transient acute mitral regurgitation, mitral valve surgery, takotsubo cardiomyopathy, case report

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