A 69-year-old Hispanic male came to the Coney Island Hospital emergency room with complaints of dyspnea for 2 days, reduced exercise tolerance, orthopnea, and paroxysmal nocturnal dyspnea. The patient denied any cough, loss of weight, night sweat, chest pain, palpitations, diaphoresis, or fever. The patient said his private physician had diagnosed a murmur a year ago but no work-up was done. He had no prior history of valvular heart disease or prior myocardial infarction. In the ER, the patient was noticed to have a temperature of 98 degrees Fahrenheit, a pulse of 112 beats per minute, regular, a blood pressure of 130/80 mm Hg with no Kussmaul's sign, and a respiratory rate of 30 per minute. He had jugular venous distention with regular S1 and S2 hear sounds. A systolic murmur 4/6 was appreciated in mitral area radiating to the axilla. A systolic murmur in the tricuspid area 4/6 was also appreciated radiating to the carotids. Peripheral pulses were regular. Lung field auscultation revealed bibasal rales. The chest x-ray revealed acute pulmonary edema and no pleural effusion. The electrocardiogram showed sinus tachycardia and P pulmonale. Arterial blood gas showed oxygen saturation of 98% on 3 liters of oxygen. Serum chemistry including electrolytes and renal and liver function tests were normal. Urine toxicology was negative. Serial creatinine phosphokinase was normal. The patient was admitted to a monitored unit and a transesophageal echocardiogram (TEE) was performed. It documented mitral and tricuspid valve prolapse with moderate to severe mitral regurgitation and moderate tricuspid regurgitation with pulmonary hypertension. There was thickened, myxomatous, and prolapsing mitral valve posterior leaflets into the left atrium with flail segment. The chordae were intact. Interior leaflets are slightly thickened but otherwise normal in structure. The tricuspid valve posterior leaflet was also thickened, redundant, and myxomatous. Posterior leaflet was also prolapsing into the left atrium with flail segment. Tricuspid valve leaflet chordae are also intact. Left ventricle was mild to moderately dilated with global hypokinesis. Left ventricular ejection fraction was moderately compromised and visually estimated 35%. Left atrium was severely enlarged. The patient was transferred to cardiac care unit and was given diuretics, ACE inhibitors, digoxin, and prophylaxis for infective endocarditis. The patient underwent emergency mitral valve replacement. He recovered well postoperatively and noted to be stable on discharge and on follow-up.
Conclusion Myxomatous prolapsing mitral valve may present late in a patient's life as acute pulmonary edema.
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