Use of point of care ultrasound for detecting flail mitral valve leaflet

Focused cardiac ultrasound in the emergency department can be used for more than just assessment of cardiac function and the presence of effusions. We present a case of missed opportunity and hindsight reflection of flail mitral valve leaflet. A 50-year-old male presented to the emergency department for several days of cough, fatigue, chills, with increasing dyspnea on exertion. He was ill-appearing, tachypneic, tachycardiac, and diaphoretic. A point of care focused cardiac ultrasound reveal normal ejection fraction, pleural effusions, and B-lines. Chest X-Ray showed diffuse bilateral infiltrates. He was given furosemide but then developed worsening respiratory distress, placed on BPAP and a nitroglycerin drip. He was taken to the ICU and had a TTE performed revealing posterior flail leaflet with an eccentric regurgitant jet, and then a subsequent TEE revealing perforation of a segment of the posterior mitral valve leaflet. Intraoperatively valvular vegetations were noted, the valve was replaced, and the patient was started on antibiotics and discharged to complete his antibiotic course. Deliberate careful review of his initial FOCUS exam in the emergency department reveals presence of a flail segment. The case highlights the need for review of valvular pathology in the crashing dyspneic patient. Early detection can change management and expedite cares appropriately.