A 53-year-old man was admitted to our institution because of palpitations and epigastric pain. He had a history of moderate mitral regurgitation secondary to a prolapse of the posterior leaflet diagnosed 6 months before in a routine echocardiographic examination during the study of a cardiac murmur. Eight hours after admission he experienced acute onset of dyspnoea with signs of heart failure on physical examination. Within a few minutes he developed progressive hypotension (blood pressure 80/40 mm Hg) and arterial desaturation. Mechanical ventilation, dopamine and norepinephrine infusion were started and the patient was transferred to the coronary care unit.

Transoesophageal echocardiography (TOE) showed a non-dilated hypercontractile left ventricle with the presence of severe mitral regurgitation secondary to acute chordal rupture with the posterior leaflet flailing into the left atrium (fig 1).

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Figure 1 (A) Four chamber transoesophageal echocardiograpthy (TOE) view showing the presence of chordal rupture (arrows) with a mitral leaflet prolapsing into the left atrium.

(B) Four chamber view with colour Doppler. An eccentric jet of mitral regurgitation can be observed. (C, D) Long axis TOE view showing the jet of severe mitral insufficiency directed towards the anterior portion of the left atrium.

The mitral leaflets, chordae tendinae and annulus may all be affected by myxomatous degeneration which results in systolic prolapse of the redundant leaflets into the left atrium (Barlow’s syndrome). Spontaneous chordal rupture is one of the possible complications of the disease and is most likely due to the excessive tension imparted to weak chordae tendineae, with a reported incidence of 7%.1 The patient may fit into a wide clinical spectrum ranging from no symptoms to acute pulmonary oedema and cardiogenic shock.2 Incidental chordal rupture is seen in 12% of patients undergoing mitral surgery, but less than 4% of these present as acute mitral regurgitation and cardiogenic shock.3

We would like to note that an acute and severe deterioration of a patient with a previous history of mitral prolapse should raise the suspicion of acute mitral rupture. TOE is the tool to confirm the diagnosis and patients should undergo mitral surgery without further delay.