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Case Reports
. 2025 Jun 25;30(16):104342.
doi: 10.1016/j.jaccas.2025.104342.

Mitral Annular Disruptions

Rachel L Goldberg  1 , Eric Isselbacher  1 , Sean P Murphy  2 , Ignacio Inglessis-Azueja  1 , Borek Foldyna  3 , Nathaniel B Langer  4 , Molly L Paras  5 , Evin Yucel  6
Affiliations
Case Reports

Mitral Annular Disruptions

Rachel L Goldberg et al. JACC Case Rep. .

Abstract

Background: Mitral annular disruption is increasingly recognized in our clinical practice and is most commonly due to infective endocarditis or transcatheter or hybrid balloon-expandable mitral valve deployment in the setting of mitral annular calcification.

Case summary: A case series is presented of 4 patients with mitral annular disruption in 4 distinct clinical scenarios, each requiring multimodality imaging for diagnosis.

Discussion: These defects are often difficult to detect on transthoracic imaging and challenging to interpret on transesophageal echocardiography given the unique flow pattern and a general unfamiliarity among echocardiographers with such a defect.

Take-home messages: These 4 cases describe mitral annular disruption caused by infective endocarditis or mitral valve replacement in the setting of mitral annular calcification. These cases stress the importance of careful multimodality cardiac imaging and maintaining a high clinical suspicion for mitral annular disruption, as it is often challenging to diagnose.

Keywords: endocarditis; mitral valve replacement.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Inglessis-Azueja has been a consultant for Edwards Lifesciences. Dr Foldyna has reported institutional research support from the National Institutes of Health/National Heart, Lung, and Blood Institute, AstraZeneca, MedImmune, Cleerly, and MedTrace. Dr Langer has been a consultant for Edwards Lifesciences. Dr Paras has received travel support from the Infectious Diseases Society of America and grant support from the Centers for Disease Control and Prevention. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Visual Summary
Visual Summary
Mitral Annular Disruption Can Be Seen in Cases of Infective Endocarditis and High-Pressure Balloon-Expandable Valve Deployment in the Setting of Mitral Annular Calcification Complications of mitral annular disruption include valvular dysfunction, tamponade, and death. Management depends on the underlying etiology.
Figure 1
Figure 1
Transesophageal Echocardiography for Patient 1 (A) Mid-esophageal 4-chamber view demonstrating a large mitral valve (MV) vegetation. (B) Mid-esophageal 4-chamber view showing severe mitral regurgitation (MR) and posterior leaflet perforation (white asterisk). (C) Three-dimensional short-axis MV view. (D) Three-dimensional short-axis MV view demonstrating mitral annular disruption by color Doppler (red star). LA = left atrium; LV = left ventricle.
Figure 2
Figure 2
Cardiac Computed Tomography With and Without Contrast Enhancement for Patient 1 (A) Modified 4-chamber view and (B) 2-chamber view both demonstrating mitral valve dehiscence and pseudoaneurysm formation (red asterisk). Abbreviations as in Figure 1.
Figure 3
Figure 3
Transesophageal Echocardiography for Patient 2 and Cardiac Computed Tomography for Patient 3 (A) Transesophageal echocardiography for patient 2 demonstrating off axis view of the mitral valve showing severe mitral regurgitation with a complex jet directed toward the left ventricular free wall, resulting from posterior mitral valve leaflet perforation and fistula through the annular abscess, mitral annular abscess (black asterisk), and mitral annular fistula (black arrow). (B) Cardiac computed tomography for patient 3 demonstrating mitral annulus pseudoaneurysm (orange arrow), measuring 10 mm × 25 mm (red asterisk). Abbreviations as in Figure 1.
Figure 4
Figure 4
Cardiac Computed Tomography and Transesophageal Echocardiography for Patient 4 (A) Computed tomography demonstrating mitral valve replacement in mitral annular calcification. Arrows show pieces of calcium violating the mitral annulus. (B) Transesophageal echocardiography short-axis mitral valve view demonstrating mitral annular disruption resulting in paravalvular leak. Abbreviations as in Figure 1.
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References

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