Figure 13

Panels A-C show color Doppler images of mitral regurgitation in the apical 4 chamber view and D-F show right upper pulmonary vein pulsed wave Doppler, at baseline with an AV of 180 ms and LV pre-excitation of 20 ms (A and D), during an AV delay of 220 ms and VV delay of 0 ms (B and E) and during an AV delay of 210 ms and RV pre-excitation of 20 ms. Inset in panel A shows prolapse of the middle segment of posterior leaflet (white arrow) causing malcoaptation between anterior and posterior leaflets and an eccentric severe anterior mitral regurgitation jet entering the right superior pulmonary vein (white asterisk, A) and panel D shows systolic pulmonary vein flow reversal. Prolonging the AV delay to 220 ms no longer causes MR jet to enter the pulmonary vein (B) which in turn produces a somewhat blunted but upright pulmonary vein S wave (E). Right ventricular pre-excitation causes further reduction in mitral regurgitation severity with a dominant systolic flow entering the left atrium (orange red color marked with a black asterisk in C) and a systolic dominant pulmonary vein S wave in F.