Left atrial dissection associated with eccentric mitral regurgitation in mitral valve prolapse

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A 69-year-old man was admitted with progressive dyspnoea and congestive heart failure. Physical examination revealed a prominent holosystolic murmur at the apex and bilateral pitting oedema. Transthoracic echocardiography demonstrated severe mitral regurgitation (MR) caused by prolapse of the P2 segment with chordal rupture and preserved left ventricular systolic function. Two-dimensional transoesophageal echocardiography (TOE) revealed a markedly eccentric MR jet directed towards the anterior wall of the left atrium. At the site impacted by the jet, a dissection (Arrows in Panel) of the left atrial (LA) endocardium extending towards the LA appendage was identified (Panel A, Supplementary data online, Video S1). Three-dimensional TOE demonstrated the spatial relationship between the eccentric MR jet and the dissected LA wall (Panel B, Supplementary data online, Video S2). Contrast-enhanced computed tomography confirmed LA dissection extending from the mitral annular region towards the LA appendage without thrombus or intramural haematoma (Panel C). The patient underwent surgical mitral valve repair. Intraoperative findings (Panel D) confirmed prolapse of the medial P2 segment with ruptured chordae from the posterior papillary muscle. A pocket-like dissection cavity extending towards the LA appendage with an entry point near the anterior commissure was identified. Mitral valve repair with artificial chordae and annuloplasty was successfully performed together with direct closure of the dissected cavity (dot circle in Panel D).

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