ABSTRACT
Chordal rupture Chordal rupture may occur as a degenerative complication or as a complication of infective endocarditis in mitral valve prolapse or, more rarely, in a normal valve. The uniform consequence is (partial or total) flail of the affected leaflet,
Infective endocarditis with valvular destruction Papillary muscle rupture after myocardial infarction Degenerative chordal rupture, particularly in mitral valve prolapse Mitral prosthetic dysfunction • Bioprosthetic degeneration • Bioprosthetic endocarditis with leaflet destruction • Ring abscess with large paraprosthetic leak or prosthetic
dehiscence • Prosthetic thrombosis with fixed position of occluder • Fracture of prosthetic valve with occluder embolization Rare causes: trauma, postoperative suture dehiscence, postvalvotomy regurgitation, and others
with a regurgitant jet directed away from the affected leaflet (Figure 10.1) (V10.3A, V10.3B, and V10.3C). The ruptured chorda is often seen moving erratically in the left atrium during systole and in the left ventricle in diastole. The distinction between a degenerative and an endocarditic cause of a ruptured chorda, especially in the presence of a diffusely thickened valve, as in classic mitral valve prolapse, usually cannot be made with confidence on echocardiographic grounds alone, unless clear vegetations or a perforation is present. The presence or absence of general signs of infective endocarditis (fever, positive blood cultures, and serum markers of systemic inflammation, such as elevated blood sedimentation rate or C-reactive protein) is of critical importance in these cases. With TEE, the location of a prolapse or flail with the origin of the regurgitant jet can often be localized well in the transgastric, short-axis view of the left ventricle, or else through careful scanning of the whole mitral valve from a low transesophageal, fourchamber view position with stepwise increments in crosssection angle, or by three-dimensional TEE with en face or angled en face views of the mitral valve from the atrial side (V13.26B). A break in the continuity of the subvalvular apparatus, as in chordal or papillary muscle rupture, is often best visualized in the transgastric, two-chamber view at approximately 90°, the transesophageal, two-chamber view (at 60°–90°), or the transesophageal long-axis view (at 120°–150°) (V10.4A and V10.4B).
