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Acute mitral valve dysfunction: a new case of leaflet escape

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Leaflet escape is a rare cause of heart valve prosthesis dysfunction. We present a new case occurring five years after mitral valve replacement. A 45 year old man was transferred to the emergency unit of our hospital with acute pulmonary oedema which appeared following a violent episode. He had a history of rheumatic valvulopathy. In 1995 he had undergone mitral valve replacement with a 29 mm Edwards Tekna (Baxter, USA) bileaflet prosthesis, and aortic valve replacement with a 23 mm St Jude Medical (SJM, USA) prosthetic heart valve. On admission he presented severe orthopnoea; blood pressure was 110/60 mm Hg in both arms, pulse was 120 beats/min, and respiratory rate was 22 breaths/min. Rales presented to the midscapular region. A grade 3/6 mitral holosystolic murmur was audible. The chest xray showed bilateral pleural effusion, interstitial pulmonary oedema, but no cardiomegaly. The ECG showed sinusoidal tachycardia and left ventricular hypertrophy. The patient was given intravenous furosemide (frusemide) and glyceryl trinitrate. A transthoracic echocardiogram demonstrated elevated mean pressure gradient across the mitral valve (27 mm Hg), mitral insufficiency, normal mean pressure gradient across the aortic valve, no aortic insufficiency, and normal left ventricular function (shortening fraction 40%). Transoesophageal echocardiography confirmed severe mitral regurgitation extending into the pulmonary veins. The mitral regurgitation mechanism was identified; only one leaflet motion was visible and the characteristic shadow usually seen behind the leaflet in the closed position had disappeared (top) (arrow indicates lack of mask field; LA, left atrium). Moreover, cinefluoroscopy demonstrated leaflet escape (bottom). Two leaflets were visible at the aortic position and only one at the mitral position. The patient underwent emergency surgical removal of the mitral valve and had an uneventful recovery. The escaped leaflet was subsequently found in the terminal aortic bifurcation.