Bad to worse: mitral regurgitation increases from moderate–severe to torrential following cardioversion to sinus rhythm

A 68-year-old male was evaluated for new-onset atypical atrial flutter following the recent ablation of persistent atrial fibrillation. His medical history includes diabetes mellitus Type II, hypertension, and obstructive sleep apnoea. A transthoracic echocardiogram revealed moderate–severe mitral valve regurgitation thought to be atrial function in aetiology. He expressed no heart failure symptoms while in an atrial flutter with rapid ventricular response. Given persistent tachycardia, he was referred for transoesophageal echocardiogram (TEE)–guided cardioversion.

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At the time of TEE, moderate–severe mitral regurgitation was confirmed with Effective Regurgitant Orifice Area (EROA) by Proximal Isovelocity Surface Area (PSIA) 0.38 cm² and regurgitant volume 56 mL (Panels A–D and see Supplementary data online, Video S1). During cardioversion, the TEE probe was left in the oesophagus to evaluate mitral regurgitation while in sinus rhythm. Following successful cardioversion (heart rate 45 b.p.m.), he had torrential mitral regurgitation with EROA by PISA 0.88 cm² and regurgitant volume 154 mL (Panels E–H and see Supplementary data online, Video S2) and worsening heart failure symptoms.

We present an unusual case in which an asymptomatic patient with moderate–severe mitral regurgitation while in atrial flutter was shown to have torrential mitral regurgitation and severe heart failure symptoms while in sinus rhythm. Using 3D multiplane reconstruction, we show no change in mitral annulus size, but there was distortion of the annular shape with resultant leaflet malcoaptation. The worsening of regurgitation in sinus rhythm (Panels E and G, and see Supplementary data online, Video S2) is likely related to improved left ventricular filling at a slower heart rate. He has been referred to cardiothoracic surgery for mitral valve replacement.

Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.

Funding: None declared.

Data availability: No new data were generated or analysed in support of this research.

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