Mitral Valve Regurgitation (MR)

Clinical History

An 86-year-old woman with positive cardiovascular history (heart failure, mitral regurgitation, aortic stenosis, atrial fibrillation, stage 3 renal failure, peripheral artery disease, hypercholesterolaemia, and hypertension) and pulmonary oedema underwent a CT angiography examination of the thoracoabdominal aorta and iliofemoral arteries one month prior for percutaneous mitral valve replacement.

Imaging Findings

Previous Echocardiography was not available because it was performed in a different hospital.
CT revealed multiple calcifications involving the aortic arch, descending thoracic aorta, left subclavian artery (with stenosis >50%), mitral annulus and left anterior descendent artery. Further marked calcifications involved the abdominal aorta, especially at the infrarenal level, where ulcerated plaques also occurred. Renal and iliofemoral arteries were also extensively involved (Fig. 1a, b). A large pericardial effusion was present in the periatrial and perihilar pericardial sinuses, together with a rounded mass (1.5-cm diameter) with water density in the apical segment of the right lower lobe, adjacent to the ipsilateral pulmonary hilum (Fig. 2). These findings were related to the recent congestive heart failure episode. Other extravascular findings included mild bilateral pleural effusion and left atriomegaly (Fig. 3).

Discussion

Mitral regurgitation (MR) is the most common form of valvular heart disease with a prevalence of about 2% in the general population. It is a condition in which the mitral valve does not close properly during ventricular systole, and blood can flow back into the left atrium when the left ventricle contracts. The most frequent cause of MR a prolapsed mitral valve; other causes are rheumatic fever, ischaemic heart disease, endocarditis, untreated high blood pressure, or dilative cardiomyopathy. Signs and symptoms depend on regurgitation severity and how quickly the condition develops, and can include congestive heart failure (shortness of breath, pulmonary oedema, orthopnoea, and paroxysmal nocturnal dyspnoea), decreased exercise tolerance, palpitation, swollen feet and ankles, and even cardiogenic shock when acute MR is due to sudden rupture of papillary muscles or chordae tendineae [1]. In chronic conditions MR can be asymptomatic. Physical examination typically reveals a high pitched olosystolic apical murmur after the first heart sound. Chest X-rays show enlargement of the left heart chambers in chronic MR, or sign of interstitial, up to extensive, pulmonary oedema in acute MR. Echocardiography allows a prompt diagnosis, since it can provide information about blood flow during systole by means of colour Doppler. Other helpful diagnostic tools are ECG, exercise tests, Holter monitoring, transoesophageal echocardiography, and cardiac catheterization. Complications include heart failure, atrial fibrillation, endocarditis, or pulmonary hypertension. Treatment depends on MR severity and is based on patient monitoring and drugs (diuretics and antihypertensive medication) in mild cases; when symptoms are important, mitral valve repair (valvuloplasty) or replacement with prosthetic valves is required [2]. When valve repair is impossible, mitral replacement can be performed using two different types of valves: mechanical or biological. Mechanical valves may last more than 20 years, but require lifelong anticoagulant therapy to prevent formation of blood clots on the valve. On the other hand, biological valve prostheses do not require anticoagulation, but last less (about 10-15 years) [3]. The last option is percutaneous mitral valve repair or replacement; this technique, which is less invasive than surgery, is reserved to patients with high preoperative risk in whom cardiac surgery is contraindicated. In such cases, CT angiography of the thoracoabdominal aorta including the ilio-femoral arteries is required to obtain anatomical information that is useful for treatment planning [4].

Differential Diagnosis List

Final Diagnosis

Mitral regurgitation in patient with congestive heart failure

URL:	https://www.eurorad.org/case/10461
DOI:	10.1594/EURORAD/CASE.10461
ISSN:	1563-4086