Dramatic geometric transformation of the mitral annulus captured by three-dimensional transoesophageal echocardiography during eclipsed mitral regurgitation

Le résumé fourni par la source

An 80-year-old woman with persistent atrial fibrillation was admitted with acute pulmonary oedema and hypotension following sudden-onset dyspnoea. During hospitalization, despite otherwise stable heart failure status, she developed recurrent, abrupt-onset episodes of severe mitral regurgitation (MR) without identifiable triggers. Each episode resolved within minutes with non-invasive positive pressure ventilation, returning to mild MR on transthoracic echocardiography (Panels A and B). Coronary angiography showed no significant stenosis; although acetylcholine provocation induced coronary spasm, this was not accompanied by worsening of MR. On this basis, mitral valve replacement was planned as definitive therapy for eclipsed MR (EcMR). During intraoperative monitoring under general anaesthesia, EcMR was unexpectedly reproduced (Panels C and D). Three-dimensional transoesophageal echocardiography analysis demonstrated a striking geometric reconfiguration of the mitral annulus: the anteroposterior diameter markedly increased, whereas the orthogonal diameter slightly decreased, resulting in a paradoxical shift from a horizontally to a vertically elongated configuration (Panels E and F). This abrupt annular deformation was accompanied by increased leaflet tethering, leading to loss of leaflet coaptation.

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