The correct answer is C. The parasternal views demonstrate a thickened mitral valve with significant mitral regurgitation. At first glance, the severity may appear to some mild or at most moderate since the color jet does not “fill” the majority of the left atrium. However, the jet is eccentric, pointing to the limitations of jet area. Paying close attention to the other important components of a regurgitant jet (flow convergence and vena contracta) raise significant concern about a very significant regurgitation (vena contracta > 0.7 cm). Other views and modalities shown below in fact substantiated this initial “red flag”.

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Figure 1

As shown above, all signs point to severe mitral regurgitation: large flow convergence, large vena contracta, eccentric but impressive jet, high mitral inflow velocity (>1 m/s), complete blunting or reversal of the systolic wave in the pulmonary venous flow, a triangular early peaking of the mitral jet recording by continuous wave Doppler. All these signs, their advantages and disadvantages and the approach to evaluation of valvular regurgitation severity has been recently outlined in a document from the American Society of Echocardiography and endorsed by the ACC/AHA/ESC (see reference).

To better evaluate the valve anatomy and the etiology of mitral valve dysfunction, the patient underwent a transesophageal echocardiogram (TEE). The mitral valve is shown from the esophageal level.

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Based on the TEE, the most likely etiology of the mitral valve disease and regurgitation is:

1. Rheumatic heart disease
2. Myxomatous degeneration with prolapse
3. Valvulitis (Systemic lupus erythematosus or similar illness)
4. Flail mitral valve
5. Degenerative/calcific