# Acute versus chronic mitral regurgitation: a case of perioperative cardiogenic shock in an athlete

## TL;DR

A rugby player with chronic heart issues faced severe complications after surgery, highlighting the risks of misdiagnosing chronic mitral regurgitation as acute.

## Contribution

This case highlights the diagnostic and management challenges of distinguishing acute from chronic mitral regurgitation in athletes.

## Key findings

- Chronic mitral regurgitation in athletes can mimic acute cases, leading to perioperative cardiogenic shock.
- Urgent mitral valve repair failed to prevent severe postoperative complications including kidney failure and pneumonia.
- Preoperative hemodynamic optimization is crucial to prevent decompensation in patients with chronic heart remodeling.

## Abstract

Mitral regurgitation (MR) poses challenges in distinguishing acute from chronic aetiologies in compensated patients. A 48-year-old male rugby player presented with 2 weeks of worsening dyspnoea on a background of chronic bilateral lower limb cellulitis. Found in atrial fibrillation, transoesophageal echocardiography revealed flail P2 with severe MR, ejection fraction 35%, and severe left ventricular dilation—indicating chronicity despite acute symptoms. He underwent urgent mitral valve repair. Post-induction instability necessitated emergency cardiopulmonary bypass. Repair consisted of P2 triangular resection, neochordae, and Cosgrove annuloplasty band. Weaning failed; central veno-arterial extracorporeal membrane oxygenation was instituted with open chest. Decannulated day 4, complications included anuric acute kidney injury requiring dialysis, pneumonia, and critical illness myopathy. Ejection fraction improved to 30% on medical therapy. This case underscores risks of presuming acute MR in athletes with chronic remodelling, where perioperative decompensation can precipitate shock. Preoperative haemodynamic optimization is critical to mitigate such events.