Brief Case Description

The patient is a 54 year-old female with a past medical history of rheumatic fever who presented with dyspnea on exertion.

In this case, we describe valvular dysfunctions and their localization on echocardiography and correlate them with intraoperative valve analysis.

Transthoracic Echocardiography (TTE)

Transthoracic echocardiography (parasternal long axis and four-chamber views) showed type IIIa mitral valve dysfunction (restricted leaflet motion in diastole and systole). Both anterior and posterior leaflets were severely thickened and retracted. On Doppler echocardiography, there was severe mitral regurgitation with a posteriorly directed jet. Quantitative measurements showed an effective regurgitant orifice area (ROA) of 69 mm2. Pisa radius was 1.3 cm. There was also moderate mitral stenosis with a valve area of 1.4 cm2 and a mean transmitral gradient of 9 mmHg.

TTE also showed associated valvular lesions including moderate to severe aortic regurgitation with moderate stenosis and mild to moderate tricuspid regurgitation (Type I dysfunction due to annular dilatation). Left and right ventricular functions were preserved.

The patient was referred for triple valve surgery. Preoperative cardiac catheterization showed normal coronaries. Pulmonary artery pressure was 65/25 mmHg.

Operative Procedure

Mitral Valve Analysis

Intraoperative valve analysis confirmed the findings of echocardiography by demonstrating type IIIa dysfunction. Mitral valve lesions were multiple, complex and severe and could be summarized as follows (Video 1):

Mitral Valve Analysis (Video 1)


Anterior Leaflet Analysis (Video 2)

Subvalvular Analysis (Video 3)



As leaflet lesions were extensive, the patient underwent mitral valve replacement. In addition, she underwent aortic valve replacement and tricuspid valve remodeling annuloplasty.