Congenital Double-Orifice Mitral Valve with Mitral Regurgitation due to Flail Leaflet in an Elderly Patient
A 75-year-old woman was referred to our hospital because of her mild exertional dyspnea and cardiac murmur. She had a long history of hypertension: 5 years earlier, she underwent a coronary angiographic study at our hospital because of her chest pain; no significant stenosis was found except for some minimal narrowing that was noted at the middle portion of the left anterior descending artery. During the same period, the precordial echocardiographic study revealed a slight left atrial enlargement and mild mitral regurgitation, but the quality of imaging resolution was poor and any further evaluation was not performed. The patient reported that she had been doing well until a few weeks earlier when she started suffering from a shortness of breath during mild exercise. Three days before her referral to the hospital, she had visited a general practitioner to get an evaluation of her symptoms. The doctor heard the murmur during the examination of the heart and he found blunting of the right costophrenic angle on the chest X-ray, so he referred her to us for further evaluation.\nAt the time of her second presentation, the patient had light dyspnea and a harsh pansystolic murmur (grade 3/6) was heard at the apex of the heart. The blood pressure was 140/80 mmHg. The EKG showed a sinus rhythm with nonspecific ST-T segment abnormalities. Echocardiography (Vivid 7, GE) revealed left ventricular hypertrophy and dilatation of the left atrium. The ventricle was not dilated and it had good contractility. There was also a very eccentric mitral regurgitation, but the morphology of the valve and the severity of the mitral regurgitation could not be precisely determined due to the poor image quality of the patient's test results.\nTransesophageal echocardiography (TEE) clearly showed that the mitral valve was composed of two distinct orifices that were separated by a central fibrous bridge. It is interesting that each orifice had its own chordae tendineae tethered to a different papillary muscle (). The transgastric short axis view revealed a larger posteromedial orifice and a smaller anterolateral orifice (). The posteromedial orifice was competent without any evidence of regurgitation or stenosis. At the level of anterolateral orifice, the color Doppler revealed moderate to severe eccentric regurgitation due to the flail posterior leaflet (). No other congenital cardiac anomalies were noted except for the persistent left superior vena cava that was demonstrated by injecting agitated saline at the antecubital vein of the left arm (). The patient became asymptomatic with the administration of angiotensin-converting enzyme inhibitor and diuretics. She was scheduled for long term follow-up and prophylaxis was recommended for any potential infectious endocarditis.