A 65-year-old woman with a history of hypertension and diabetes was evaluated for progressive dyspnoea. Her blood pressure was 150/90 mmHg. Examination revealed pulmonary crackles and leg oedema. The results of the electrocardiogram were normal. Echocardiography displayed a non-hypertrophied and non-dilated left ventricle (end-diastolic volume, 40 mL/m 2 ) with left ventricular ejection fraction at 55%. Neither segmental wall-motion abnormality nor asynchrony was found. The left atrium was enlarged (area, 30 cm 2 ) with a moderate MR (effective regurgitant orifice area, 9 mm 2 ; regurgitant volume, 20 mL) ( Fig. 1 , Supplementary data, Loop 1 , left panel). The valvular and subvalvular mitral apparatus were normal, but with increased valvular tenting ( Fig. 1 , Supplementary data, Loop 2 ). Pulsed-wave Doppler showed a restrictive mitral-inflow pattern and an increased E/Ea ratio of 18 ( Fig. 2 , left panel). Transtricuspid gradient was 38 mmHg. Loop diuretics improved the patient’s symptoms, while MR severity ( Fig. 1 , right panel), E/Ea ratio ( Fig. 2 , right panel) and mitral tenting (3.6–2.5 cm 2 ) decreased, without changes in leaflet tethering and global longitudinal strain (−17%).
