Hospital de Braga

The authors report the case of a 66 years old man with previous story of hypertension, dyslipidemia who resorted to the emergency room for dyspnea, orthopnea, generalized myalgia and blood-tinged secretions. A thoracic X-ray was performed and opacity at the inferior lobe of the right lung was observed. He has discharged with the diagnosis of pneumonia and was medicated with azithromycin. Two days later, the patient returned to the hospital for no improvement in his symptoms. When asked he mentioned an episode of constrictive thoracic pain with irradiation to the left shoulder 4 days ago. The patient had a previously unnoted apical systolic murmur. The patient was hypotensive and showed severe signs of acute respiratory failure with desaturation, needing non-invasive ventilator support. The thoracic X-ray showed exuberant opacities in “bat wings” shape. The thoracic CT also showed bilateral densification of the pulmonary parenchyma with pleural effusion. His blood analyses presented acute renal lesion, hyponatremia and elevation of myocardial necrosis markers. His electrocardiogram revelead sinus rhythm with qs complexes at the inferior leads and descendent infra-ST in V4-V6. A transthoracic echocardiogram was performed and presented an hyperdynamic left ventricle with akinesia at the medium and basal segments of the inferior wall, hypokinesia at the medium and basal segments of the posterolateral wall as well as mitral posterior leaflet flail with moderate to severe mitral regurgitation and an highly eccentric jet. He was send to the hemodynamic laboratory and an occlusion of the medium segment of the right coronary artery was revealed. He also had disease of the left anterior descending artery (60-70% stenosis ate the medium segment) as well the first diagonal (80% stenosis). In this scenario, the patient underwent urgent cardiothoracic surgery. A mitral valvuloplasty (anchorage of P3, suture of the posteromedial commissure and semi-rigid anuloplasty ring) and a coronary artery bypass graft were performed. The echocardiogram perfomed after the surgery showed normofunctional a mitral valve as well as preserved biventricular function. His post-operatory period was marked by hemodynamic instability in the first 48 hours with progressive resolution. He was discharged 12 days asymptomatic.
Mitral valve regurgitation may occur during the subacute phase of myocardial infarction due to LV dilatation, papillary muscle dysfunction or rupture of the tip of the papillary muscle or chordae tendinae. It usually presents as haemodynamic instability with pulmonary congestion and a new systolic murmur. The diagnosis should be confirmed by emergency echocardiography. Emergency surgery is required. This case represents the importance of the anamneses, clinical examination and high clinical suspicious in the pursuing of an acute cause of heart failure.