Fifty-seven-year-old man with progressive dyspnoea

Clinical introduction A 57-year-old man from the USA with a history of atrial fibrillation and hypertension was evaluated for progressive dyspnoea and decreased energy. The patient denied a history of congestive heart failure, systemic symptoms or myocardial infarction. He was found to have a 3/6 holosystolic murmur radiating to the axilla. Transthoracic echocardiography (TTE) reported a reduced ejection fraction of 40%, mitral valve regurgitation and absence of interatrial shunts. The remaining cardiac valves were without abnormality. A nuclear stress test reported 18% fixed inferolateral defect. Subsequent coronary angiography was negative for obstructive coronary artery disease. To better evaluate the mitral valve apparatus, transoesophageal echocardiography (TEE) was performed. Question Which of the following best explains the TEE findings (figure 1) of the mitral valve? Carcinoid heart disease. Drug-induced valvular heart disease. Infective endocarditis. Ischaemic mitral regurgitation (MR). Rheumatic mitral valve disease.