A 74 year old man was admitted with chest pain of 12 hours duration accompanied in the preceding hours by severe dyspnoea. On auscultation of the chest, crackles were noted all over the left lung, as well as an apical pansystolic murmur radiating to the left axilla. The baseline ECG revealed significant ST segment depression in the precordial leads with raised concentrations of creatine kinase and creatine kinase-MB fraction. Chest x ray showed extensive haziness in the left lung field (panel A). Echocardiography revealed inferior akinesis, a reduced global left ventricular ejection fraction, and a large eccentric mitral regurgitation jet reaching the left pulmonary veins (panels B and C). Urgent coronary angiography was not done (time window). High dose parenteral furosemide and glyceryl trinitrate treatment resulted in rapid improvement of symptoms and the resolution of left sided haziness on chest x ray by the next day. Coronary angiography later revealed severe three vessel disease with an occluded circumflex artery.

Asymmetric x ray findings usually have a pulmonological origin. However, if the murmur of mitral regurgitation is heard, unilateral pulmonary oedema caused by papillary muscle dysfunction and an eccentric regurgitation jet should be considered; transoesophageal echocardiography and rapid response to diuretics are the two most useful clues to making the diagnosis.

Anteroposterior chest x ray performed on the hour of admission revealing the presence of left sided pulmonary oedema. (A temporary pacemaker lead was inserted from the right subclavian vein because of transient complete atrioventricular block on admission.)

Transoesophageal echocardiography documented a retrograde jet towards the left pulmonary veins.