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Every Now and Then I Fall Apart: Total Eclipse of the Mitral Valve.

A 74-year-old woman presented with progressive exertional breathlessness. Exam was unremarkable. Local echocardiogram was notable for grade 1 diastolic dysfunction, normal ejection fraction (EF), and mild MR. Coronary angiogram showed nonobstructive disease but sluggish flow suggesting microvascular disease. Right heart catheterization at another facility revealed normal filling pressures, pulmonary artery pressures, and cardiac output at rest. With exercise, systolic pulmonary artery pressure increased to 82, but the pulmonary artery wedge pressure (PCWP) was normal at 13 mm Hg. She was diagnosed with Group 1 exercise-induced pulmonary hypertension and started on sildenafil. Symptoms worsened and sildenafil was discontinued, with initiation of macitentan. Four days later, she had severe dyspnea prompting a call to Emergency Medical Services and was intubated. Findings were consistent with flash pulmonary edema of unclear cause. Repeat echocardiogram showed mild-moderate MR. After dismissal, she sought a second opinion and was referred for right heart catheterization with exercise and concurrent echocardiography (Figure 1). At baseline, there was mild MR (Movie I in the Data Supplement), with borderline elevated filling pressures and pulmonary artery pressures. With passive leg raise, she felt dyspneic. PCWP increased with V wave to 65 mm Hg (Figure 2). MR became severe on echocardiogram (Movie II in the Data Supplement). Nitroglycerin was administered, with normalization of filling pressures and resolution of symptoms. With exercise testing, she again became severely dyspneic, with development of giant V waves in PCWP with torrential MR on echocardiogram (Figure 3 and Movie III in the Data Supplement). Cardiac output increased by only 0.3 L/min during exercise. Subsequent transesophageal echocardiogram revealed a normalappearing mitral valve with trivial MR, but with leg raise, there was torrential central MR (Movie IV in the Data Supplement). The patient was diagnosed with severe MR due to an eclipsed mitral valve and underwent bioprosthetic mitral valve replacement. Four months postoperatively, she was asymptomatic.