Intermittent Severe Mitral Regurgitation

Cardiac catheterization in a patient with episodic pulmonary edema, a systolic murmur of varying intensity and normal heart size revealed a transient precipitous elevation of left atrial and ventricular pressures. The magnitude and contour of the left atrial and diastolic left ventricular pressure tracings resembled those seen in acute severe mitral regurgitation. The pressures returned to normal, and the murmur disappeared after sublingual administration of isosorbide dinitrate. Left ventricular cineangiography, performed when the patient was asymptomatic and pressures were normal, revealed minimal mitral regurgitation, left ventricular dyskinesis and no angiographic evidence of structural derangement of the mitral valve. The patient was concluded to have intermittent severe functional mitral regurgitation (papillary-muscle dysfunction) related to ischemic heart disease. On medical management, consisting of digitalis and isosorbide dinitrate, he has remained essentially asymptomatic over the subsequent 18 months.