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J Gen Intern Med. Sep 2011; 26(9): 1075–1076.
Published online Mar 3, 2011. doi:  10.1007/s11606-011-1661-5
PMCID: PMC3157513
Mitral Regurgitation and Pulmonary Edema
Arti D. Shah, MD,corresponding author1 Elyse Foster, MD,2 and Russell J. Cucina, MD3
1Department of Medicine, University of California San Francisco, 505 Parnassus Ave., Room M-987, San Francisco, CA 94143 USA
2Division of Cardiology, University of California San Francisco, San Francisco, CA USA
3Division of Hospital Medicine, University of California San Francisco, San Francisco, CA USA
Arti D. Shah, Phone: +1-562-5952940, Fax: +1-415-3532583, Arti.Shah/at/ucsf.edu.
corresponding authorCorresponding author.
Received June 30, 2010; Revised September 28, 2010; Accepted February 7, 2011.
Key words: mitral regurgitation, pulmonary edema, pulmonary vein
An asymptomatic 88-year-old Asian male with hypertension presented with a right upper lobe infiltrate on chest x-ray. A chest CT (Fig. 1) demonstrated a geographic 3.5 × 2.2-cm ground-glass opacity in the right apex. A 3/6 holosystolic murmur was heard at the apex radiating to the axilla. Transthoracic echocardiography showed a flail posterior mitral valve leaflet secondary to a ruptured chordae tendinae.
Figure 1
Figure 1
Chest CT image.
In patients with a flail posterior mitral valve leaflet, the regurgitant jet is directed towards the right superior pulmonary vein1 (Fig. 2), causing higher hydrostatic pressures in that location. This may lead to focal edema in the right upper lobe2. Prior studies have shown that up to 38% of patients with a ruptured chordae tendinae remain asymptomatic in the subacute to chronic setting despite severe mitral insufficiency3,4. In most cases, surgical repair is highly successful5. However, given this patient’s age and his excellent response to medical therapy with an angiotensin receptor blocker, surgery was not performed. In the setting of upper lobe infiltrates where infection and cancer seem unlikely or have been excluded, mitral regurgitation with segmental pulmonary edema should be considered.
Figure 2
Figure 2
The mitral regurgitant jet is directed towards the right superior pulmonary vein.
Acknowledgments
Contributor Gurpreet Dhaliwal, MD.
Funders None.
Prior Presentation Presented as a clinical vignette poster at the Society of General Internal Medicine National Meeting on April 29, 2010.
Conflict of Interest None disclosed.
Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
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2. Roach JM, Stajduhar KC, Torrington KG. Right upper lobe pulmonary edema caused by acute mitral regurgitation: Diagnosis by transesophageal echocardiography. Chest. 1993;103:1286–1288. doi: 10.1378/chest.103.4.1286. [PubMed] [Cross Ref]
3. Benhalima B, Cohen A, Chauvel C, et al. Morphological study by transesophageal echocardiography and clinical aspects of ruptured chordae tendineae in the elderly. Arch Mal Coeur Vaiss. 1995; 88: 345–352. [Article in French] [PubMed]
4. Bergeron GA. Minimally symptomatic patients with ruptured chordae tendinae due to myxomatous degeneration of the mitral valve. Am J Med. 1986;81:333–335. doi: 10.1016/0002-9343(86)90273-1. [PubMed] [Cross Ref]
5. Carabello BA. Mitral valve repair in the treatment of mitral regurgitation. Curr Treat Options Cardiovasc Med. 2009;11:419–425. doi: 10.1007/s11936-009-0044-2. [PubMed] [Cross Ref]
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