Navigating the Dynamic Nature of Mitral Regurgitation With the Use of Multimodality Imaging in a Young Woman

The mechanism and severity of mitral valve (MV) regurgitation (MR) play a critical role in guiding treatment decisions. Transthoracic echocardiography (TTE) is the primary diagnostic modality for evaluating MV disease. Discordant findings on TTE can be further quantified through transesophageal echocardiography (TEE). We describe the case of a young woman with worsening exertional dyspnea who was found to have restricted posterior MV leaflet and moderate to severe eccentric MR on TTE. TEE was subsequently performed to determine the exact mechanism of MR revealing the prolapse of the A2 segment of the MV. However, TEE significantly underestimated MR severity, downgrading it to visually mild to moderate MR and quantitatively moderate MR. This discrepancy highlights the potential for significant variation in MR severity assessment under general anesthesia, emphasizing the impact of hemodynamic loading conditions. In our case, intravenous sedatives may have altered the loading conditions reducing MR severity on TEE compared to TTE. Given her symptom severity, MV pathology, left ventricular dilatation, and the higher MR severity observed on TTE, she underwent surgical MV repair, in alignment with the Class I recommendation by the American College of Cardiology/American Heart Association (ACC/AHA) valvular heart disease guidelines. Postoperatively, she experienced significant improvement in symptoms and quality of life.