A 50 year old with a past medical history significant for the pathology shown above presents with sudden onset rapidly progressing shortness of breath. On arrival to the ED, he is noted to be hypotensive in cardiogenic shock. Exam shows peripheral vasoconstriction, pallor, and diaphoresis. The arterial pulse is rapid and thready. JVD is elevated. The cardiac impulse is hyperdynamic and not displaced. You feel a right ventricular heave. There is a soft, low-pitched, decrescendo systolic murmur best heard along the left sternal border.
Surprisingly, EKG is sinus tachycardia with no ischemic changes. CXR shows normal cardiac silhouette but asymmetric pulmonary edema, predominantly in the right upper lobe. Laboratory values are all within normal limits.
Challenge: Although your consultants suggest pneumonia and ARDS, you are smarter! What is your diagnosis?
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Medieval Weapons
This is flail mitral leaflet causing acute mitral regurgitation. The echo shows mitral valve prolapse with billowing of the mitral valve leaflet. Myxomatous disease can lead to ruptured mitral chordae tendinae and this presentation. The hemodynamic changes are severe and dramatic because the left atrium and ventricle do not have time to adapt to the MR.
Source: UpToDate.
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