Echo Findings

PLAx and PSAx show a hyperdynamic LV and RV, no pericardial effusion.  

In PLAx the LV walls seem hyertrophic. The LA is significantly dilated. This may be due to LV diastolic dysfunction with preserved systolic function. But usually in these patients, the LV is mild- moderately dilated. The small hyperdynamic LV in this case, makes diastolic dysfunction less likely.

Prior MV pathology and MR could cause a pre-existing dilated LA. The LV is not opened adequately (off axis imaging) in the PLAx and it is difficult to discern the MV leaflets. Colour at the MV in PLAx shows turbulence and maybe come regurgitation. 

It is unusual to go into APO with 1L of fluid with such a hyperdynamic LV.

The A4C gives us the answer. There is an anterior mitral valve prolapse into the LA. The patient had a trop rise and the MVP was thought to be due to acute ischaemic pap muscle dysfunction. The treatment for acute MVP with APO is surgical valve repair or replacement. 

This was a difficult case to put together. In patients with a hyperdynamic LV and hypotension, the knee jerk response is to think hypovolaemia, peripheral vasoldilation or PE. But remember this case and also think about acute valvular dysfunction as a cause. 

Often MVP is best seen in A4C.