Three patients with signs of acute flail mitral leaflet seen on emergency department echo: a critical constellation within the focused cardiac exam

Abstract

Acute flail mitral leaflet is a time‐sensitive, reversible cause of cardiogenic shock. Transthoracic echocardiography (echo) is increasingly becoming a vital tool for non‐cardiologist physicians who treat patients with undifferentiated chest pain and dyspnoea. The sonographic abnormalities seen in acute flail mitral leaflet are within the boundaries of a focused echo. Individually, these findings are non‐specific. As a constellation, however, they are highly suggestive of this disease process. We present a case series of three patients with acute flail mitral leaflet seen on emergency department echo along with a discussion of the findings and the disease itself.

Unexpected Causes and Complications of ST-Segment Myocardial Infarction That Highlight the Importance and Limitations of Point-of-Care Ultrasound in the Emergency Department

“…Acute severe mitral valve regurgitation is an etiology of shock that can be difficult to diagnose clinically but is identifiable on POCTE in the ED. Sonographic features include a regurgitant jet from the left ventricle to the left atrium with color doppler, hyperdynamic left ventricle, papillary muscle head visualized in the left atrium, dilated inferior vena cava with minimal respiratory variation, pleural effusions, and pulmonary edema [ 3 , 4 ].…”

“…POCTE in the ED is typically directed at identifying pericardial effusion or tamponade, identifying cardiac activity, global assessing contractility, and characterizing central venous volume status [ 15 ]. Identification of valvular insufficiency and/or vegetation is not typically included but is feasible by an experienced sonographer [ 3 , 4 , 14 ].…”

“…Papillary muscle rupture with acute valvular regurgitation is an uncommon cause of cardiogenic shock that carries a high mortality rate [ 2 ]. Emergency physicians (EPs) can identify evidence of papillary muscle rupture on point-of-care transthoracic echocardiography (POCTE) in patients with cardiogenic shock [ 3 , 4 ]. Early diagnosis of this emergent condition is useful to direct subsequent care.…”

Emergent Diagnosis of a Flail Mitral Leaflet With Bedside Echocardiography

“…Echocardiography is imperative for the early recognition and timely management of ADHF due to FML with severe MR. A previous case report described the utility of bedside echocardiography for identifying acute MV insufficiency (ultimately diagnosed by formal echocardiogram as FML secondary to ruptured chordae) in the clinical context of new-onset congestive heart failure [ 9 ]. To the best of our knowledge, there are only two other previous reports that have described EP-performed FOCUS in the emergent diagnosis of FML [ 10 , 11 ]. This case report highlights the pivotal role that an EP-performed FOCUS and LUS had in initiating timely ED management for a patient with ADHF and a suspected FML.…”