HOW TO TREAT 31
ausdoc. com. au 12 DECEMBER 2025
HOW TO TREAT 31
She has had two admissions for heart failure in the past six months. After the initial admission, it was decided to manage Anne medically.
On examination, she has an elevated jugular venous pressure, widespread crepitations in both lungs and bilateral pitting leg oedema suggestive of decompensated heart failure. Her heart auscultation demonstrates a pan-systolic murmur radiating to axilla. ECG shows atrial fibrillation with ventricular rate of 110.
Blood tests show only a slight deterioration of creatinine compared with her baseline. Chest X-ray shows findings consistent with pulmonary oedema in keeping with acute decompensated heart failure.
Repeat echo shows severe MR with mild global left ventricular dysfunction( see figure 10). There is no other significant valvular pathology. Anne’ s left heart catheterisation reveals severe stenosis in the mid-section of the right coronary artery. Her right heart catheterisation reveals mildly elevated pulmonary pressures.
A TOE confirms the severity of the MR, with the aetiology thought to be posterior MV prolapse with flail P2 segments.
The case is discussed in the heart team meeting. Anne is deemed an unsuitable candidate for surgical repair given her age, mild cognitive impairment and chronic kidney disease. Her anatomy, as assessed during the TOE, is thought to be suitable for a mitral clip procedure.
The treatment recommendation is for initial stabilisation of her decompensated heart failure, followed by treatment of coronary artery disease and then the mitral clip procedure, given the favourable anatomy for transcatheter end to end repair.
A
C
Figure 9. Transoesophageal images. A. 2D transoesophageal images showing posterior leaflet prolapse of the mitral valve. B. 2D transoesophageal images showing posterior leaflet prolapse of the mitral valve. C. Transesophageal doppler images showing severe mitral regurgitation due to posterior leaflet prolapse of the mitral valve. D. 3D transoesophageal images showing posterior leaflet prolapse of the mitral valve.
A
B
D
Case study three
Trevor, an 87-year-old male, has regularly been seeing his local physician for known stable moderate MR. He has recently become more fatigued than usual. There is no chest pain and no palpitation.
He has history of chronic atrial fibrillation( more than 10 years), diabetes mellitus and hypertension. He also has history of lung cancer that was treated with radiation and lobectomy eight years earlier. He has since had yearly reviews for his lung cancer and has been in remission.
Trevor lives at home with his wife, is independent in all activities of daily living and still drives. He is an ex-smoker of 20 pack-years and rarely drinks alcohol.
On examination, he is in rate-controlled atrial fibrillation, and is euvolemic. His heart auscultation demonstrates a pan-systolic murmur with no radiation. His chest is clear and there are no signs of heart failure.
His previous six-monthly echocardiograms had been stable for two years. However, his most recent transthoracic echocardiogram that was performed before this presentation showed severe MR and severe bi-atrial enlargement. His left ventricle was normal in size and function and there was no other significant valvular pathology.
Transoesophageal echocardiogram showed a restricted posterior MV leaflet resulting in an overriding anterior leaflet, with a small cleft
B C
Figure 10. Transoesophageal images. A. 2D transoesophageal images showing posterior leaflet prolapse of the mitral valve.
B. Transoesophageal doppler images showing severe mitral regurgitation due to posterior leaflet prolapse of the mitral valve.
C. 3D transoesophageal images showing posterior leaflet prolapse of the mitral valve.