'Whisper from the mitral valve': delayed diagnosis of traumatic mitral valve regurgitation in an elderly farmer-a case report

Abstract

Background: Traumatic mitral regurgitation (MR) is an exceptionally rare complication associated with blunt chest trauma, particularly following relatively low-impact injuries. In the critical and chaotic settings of polytrauma, its diagnosis is often delayed and can easily be overlooked. This oversight can lead to progressive haemodynamic deterioration and, ultimately, fatal outcomes.

Case summary: A 73-year-old man sustained blunt chest trauma after falling ∼2.5 m from a truck bed. Initial assessment revealed a left haemopneumothorax and multiple rib fractures, with no audible heart murmur or signs of haemodynamic compromise. A chest drain was inserted, and he was discharged after conservative management. However, 3 weeks post-injury, a Grade III systolic regurgitant murmur was newly detected. Transthoracic and transoesophageal echocardiography revealed severe eccentric MR due to posterior mitral valve prolapse caused by chordal rupture. Intraoperative inspection confirmed a P2 chordal rupture with myxomatous degeneration. The patient underwent successful mitral valve repair and had an uneventful postoperative recovery.

Discussion: This case highlights that traumatic MR, though extremely rare, can occur even after relatively minor trauma in elderly individuals, potentially due to underlying degenerative changes. Clinical signs of acute MR can be obscured by coexisting injuries, and auscultatory findings may only become apparent after these conditions have been treated. While echocardiography is crucial for identifying traumatic valvular dysfunction, its effectiveness can be limited by various factors associated with polytrauma. Therefore, a high index of suspicion is essential to prevent overlooking this potentially life-threatening complication in cases of blunt chest trauma.

Keywords: Blunt chest trauma; Case report; Mitral regurgitation; Traumatic mitral valve injury.

Figure 1

Chest radiography and electrocardiography of a 73-year-old man. Chest radiography confirmed a collapsed left lung parenchyma (A). Electrocardiography showed low voltage at the precordial leads (B).

Figure 2

Chest computed tomographic images of a 73-year-old man. Chest computed tomography exhibited a collapsed left lung parenchyma (A) concomitant with blood components in the thoracic cavity (B, arrows), indicating haemopneumothorax. The three-dimensional image exhibited multiple rib fractures across the left fourth, fifth, and ninth ribs (C, arrows).

Figure 3

Two-dimensional transthoracic echocardiography of a 73-year-old man. Transthoracic echocardiography revealed prolapse of the posterior mitral leaflet with mobile filamentous structures attached to the leaflet tip (A, white arrow), suggesting chordal rupture. Severe eccentric regurgitant jet toward the anterior left atrial wall was observed (B). LA, left atrial.

Figure 4

Three-dimensional transoesophageal echocardiography of a 73-year-old man. Transoesophageal echocardiography confirmed mitral leaflet prolapse resulting from chordal rupture of the middle scallop of the posterior mitral leaflet (A, arrows) concomitant with significant regurgitant jet (B).

Figure 5

Intraoperative findings of the mitral valve of a 73-year-old man. Intraoperative inspection confirmed the presence of ruptured chordae mainly at the P2 segment, concomitant with moderate myxomatous degeneration.