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A 28 year old man presented to the emergency department with a history of sudden onset dyspnoea of two days’ duration following a brief argument with his employer. On examination the patient was experiencing class 4 shortness of breath, with bilateral diffuse coarse rales in both lung fields. He had a grade 3/6 soft blowing early systolic murmur in the apex radiating to the axilla. The ECG was unremarkable. Chest x ray showed bilateral fluffy shadows in both lung fields suggestive of pulmonary oedema. Heart size was normal. Two dimensional echocardiographic study showed that the annulus of the mitral valve was elevated by the dissection, with the entry point just below the posterior mitral leaflet and the exit point in the free wall of the left atrium into the cavity. Turbulent flow is seen entering the false lumen and entering the left atrial cavity through the exit point. The echocardiographic grading of the mitral regurgitation thus produced was severe. The patient was treated with oxygen, diuretics, glyceryl trinitrate, and angiotensin converting enzyme (ACE) inhibitors. The patient improved within 48 hours and after seven days his shortness of breath had improved to class 2.
The patient is to undergo cardiac surgery and is being treated with ACE inhibitors.