Clear demonstration of the different mechanisms of severe mitral regurgitation caused by mitral ring dehiscence during transesophageal echocardiography

A 55-year-old man was admitted to the outpatient clinic with dyspnea that occurs with minimal effort. He had a mitral repair with a Memo annuloplasty ring due to severe mitral regurgitation (MR) associated with annular dilation caused by atrial fibrillation 3 years ago and there was no residual MR in the postoperative echocardiography. Transthoracic echocardiography revealed a left ventricular ejection fraction of 55% and moderate-severe MR. Transesophageal echocardiography (TEE) was decided as a next step. Rocking prosthetic ring and dehiscence were present in the TEE views respectively, with a severe MR (Fig. 1a, Video 1, 2). There were two MR jets. As observed in the TEE views, the first jet originated from the perimitral ring, while the second jet came from the basal portion of the posterior mitral leaflet (PML), which was suitable with the location of the mitral ring suture (Fig.1b, Video 3). Interestingly, mitral ring dehiscence possibly led to the occurrence of a defect in the PML of the junction zone, and this defect emerged as another source of MR (Fig. 1c, 1d, Video 4). Another surgical treatment was planned.