Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
We described a case of a 40-year-old Indian gentleman with background history of Diabetes Mellitus and Hypertension, presented with chest pain and ECG showed ST segment depression over the anterolateral leads with positive Troponin T. He was diagnosed with Non-ST-Elevation Myocardial Infarction (NSTEMI). Physical examination showed pan systolic murmur over the mitral area and initial echocardiography showed moderate to severe eccentrics mitral regurgitation (MR).
Relevant test results prior to catheterization
Baseline echocardiography showed left ventricular was normal in size with severe hypokinesia of the inferior and posterior walls. Ejection fraction (EF) visually was 50%. There was moderate to severe (2-3+) eccentric posteriorly directed MR. the mitral valve leaflets were morphologically normal. However, there was tethering of the posterior mitral valve leaflet (PMVL) leading to the malapposition of the mitral valve leaflets. This serves as the culprit for the functional eccentric MR. Due to eccentric flow, accurate PISA measurement of the MR was not possible. The assessment of the MR was mainly from the colour Doppler study. Left atrium (LA) was not dilated and there was no tricuspid regurgitation or elevated right heart pressure thus suggesting the MR is likely to have occurred recently.
Relevant catheterization findings
He underwent coronary angiography which showed the following findings:
• Left main stem: Normal
• Left anterior Descending artery: Severe stenosis over proximal segment
• Left circumflex artery: Severe stenosis over proximal segment obtuse marginal branch and distal segment of circumflex
• Right coronary artery: Non-dominant, small and diffuse disease
Patient was counselled for coronary artery bypass (CABG) with mitral valve repair (MVR) but he was not keen.
The right radial approach with EBU 3.5/6F guiding catheter.
LAD was wired with Sion Blue wire and predicated with Sapphire 3.0 x 20 mm at 8 atm and stented with Absorb BVS 3.0 x 23 mm, post-dilated with NC trek 3.0 x 15 mm at 20 atm.
Obtuse marginal branch was wired with Sion Blue and direct stented with Coroflex Isar 2.5 x 15 mm at 18 atm.
Circumflex artery was wired with Sion Blue wire, the distal segment was predilated with Sapphire 2.5 x 12 mm and stented with Xience Prime 2.5 x 18 mm at 18 atm. It was further postdilated with NC Trek 2.75 x 15 mm.
Post-procedure echocardiography showed very mild hypokinesia of the inferoposterior wall in contrast to the previous severe hypokinesia seen in the last echocardiography. EF was around 55% visually. Colour Doppler of the mitral valve demonstrated only mild MR (1+) with no further evidence of previously tethered posterior mitral valve leaflet.
Ischemic MR is a form of MR which occurred as a result of myocardial ischemia in the presence of normal valve leaflet and subvalvular apparatus. In this case, the post-procedure echocardiography showed a significant reduction in the severity of the MR. We postulate that the initial significant MR was due to the tethering of the PMVL because of the severe hypokinesia of the inferoposterior wall. With the restoration of coronary blood flow, it is thought that it leads to positive left ventricular remodeling and improves left ventricular function as well as a reduction in functional MR.