A 72-year-old woman with atrial fibrillation underwent surgical treatment for severe mitral regurgitation and worsening breathlessness. Previous echocardiography showed preserved systolic function with prominent septal knuckle. Coronary angiography identified two vessel coronary disease.

Operative findings revealed an essentially unremarkable mitral valve with dilated annulus and dilated poorly contractile left ventricle. A Carpentier Edwards prosthesis was inserted leaving the entire mitral apparatus intact to preserve ventricular function. Severe tricuspid regurgitation …