Echocardiographic assessment of a 72-year-old woman revealed a posterior mitral valve prolapse with an unusual central regurgitation jet. The use of three-dimensional (3D) transesophageal echocardiography elucidated the mismatch between morphologic and color Doppler echocardiographic findings: There was a cleft in the posterior mitral valve in addition to the posterior mitral valve prolapse. This case illustrates that the use of high-quality real-time 3D transesophageal echocardiography (including 3D color Doppler) facilitates the understanding of the anatomy and the mechanism and severity of regurgitation in complex mitral valve pathology and is clearly superior to two-dimensional transesophageal echocardiography alone.
A 72-year-old woman was referred to the Toronto General Hospital for echocardiographic assessment of mechanism and severity of mitral regurgitation. Two-dimensional (2D) transesophageal echocardiography (TEE) showed prolapse of segments 2 (P2) and 3 (P3) of the posterior mitral valve ( Figure 1 A). Given these findings, we expected an anteriorly directed regurgitation jet. However, the main regurgitation jet on color Doppler was centrally directed ( Figure 1 B). Further investigation with real-time three-dimensional (3D) TEE using an X7-2t probe (Philips Ultrasound) elucidated the true mechanism of regurgitation and the underlying valve pathology. Unlike the 2D images, the 3D images clearly demonstrated a cleft posterior mitral valve ( Figure 2 , Video 1 ) in addition to the posterior mitral valve prolapse.
Assessment of the mechanism and severity of mitral valve regurgitation is of paramount importance for therapeutic management. However, its comprehensive evaluation on 2D echocardiography can be difficult. The 3D TEE images in our patient demonstrated that the slit-like, centrally directed regurgitation jet in early systole was caused by the cleft ( Figure 3 A, B), whereas the prolapse of segments P2 and P3 resulted in a broader regurgitation jet with a slightly anterior direction toward the end of systole ( Figure 3 C, D; Video 2 ). 3D TEE also depicted a small ruptured chord attached to segment P3 ( Figure 2 A).