A 52-year-old woman was referred to our hospital due to progressive dyspnea with orthopnea for four months. She had no pertinent medical history. Physical examination revealed that the apical heartbeat shifted downward to the 6th intercostal space and leftward to the anterior axillary line, reflecting cardiomegaly. There was a grade III/VI holosystolic murmur at the cardiac apex radiating to the axilla. She also had a fine crackle in both lungs. A 12-lead electrocardiogram (ECG) showed the voltage criteria for left ventricular hypertrophy. Chest radiograph demonstrated an increased cardiothoracic ratio with a sign of pulmonary vascular cephalization. The transthoracic and transesophageal echocardiogram depicted DOMV with a severe posteriorly directed jet mitral regurgitation (MR) resulting from the ruptured chordae tendineae of the lateral scallop of the anterior mitral valve leaflet (AMVL) (Figure 1A-1F). There was moderate tricuspid regurgitation (TR) with an estimated right ventricular systolic pressure of 85 mmHg, indicating pulmonary hypertension.
Because of symptomatic severe MR and moderate TR, MV replacement with a 33-mm St. Jude Medical mechanical valve and tricuspid valve annuloplasty with a 28-mm Edwards annuloplasty ring were performed. Intraoperative findings confirmed an adhesion between AMVL and the posterior leaflet of MV with fibrous tissue forming 2-orifice MV together with thickening and the lateral scallop of AMVL. The perioperative period was uneventful. At the 3-month follow-up visit, she could perform routine daily activities and light exercises without symptoms of heart failure. A postoperative echocardiogram showed the normal functioning prosthetic MV without residual MR.