Figure 3

Echocardiographic images of asymmetric CIMR due to inferoposterior myocardial infarct and posterior leaflet tethering. These echocardiographic images were obtained from an 81 year-old male with a history of inferior and inferoposterior myocardial infarction with localized aneurysmal ventricular deformity and atrial fibrillation, when he was evaluated for dyspnea and congestive heart failure. The previous echocardiogram obtained three years prior had demonstrated mild posteriorly directed MR. The apical two chamber view at end-diastole from the current transthoracic echocardiogram shows the true inferobasal aneurysm indicated by an asterisk (A). Asymmetric mitral valve leaflet tenting is depicted in the parasternal long-axis view at mid-systole (B). Additional quantitative measures of tethering phenotype are described in the subsequent main text. The tenting height measured from the mitral annulus plane was 1.4 cm and the tenting area bounded by the mitral annular plane and leaflets was 4.0 cm²; tethering angles β and α measured approximately 55° and 40° respectively. The jet of MR was posteriorly directed and reported moderate in severity (C). TEE was then undertaken to confirm the mechanism of MR and this also revealed incomplete mitral valve closure due to PM displacement (D: mid-esophageal long-axis view at omniplane angle 140°, image taken at mid-systole) with pseudoprolapse (arrow) of the anterior leaflet tip relative to the more adversely tethered posterior leaflet. This locus of malcoaptation is the area from which the MR originates. There is severe MR with an eccentrically directed posterior jet (E: mid-esophageal long-axis view at omniplane angle 140°, image taken at mid-systole) with evidence of systolic flow reversal in pulmonary veins (not shown).