Rheumatic involvement of the cleft mitral valve

A 67-year-old female patient was referred to our transesophageal echocardiography (TEE) laboratory for the evaluation of the severity of valve pathologies. Two-dimensional (2-D) transthoracic echocardiography (TTE) revealed rheumatic mitral valve with moderate mitral regurgitation (MR), moderate mitral stenosis (MS), and severe tricuspid regurgitation (TR). In 2-D TEE, we also identified rheumatic mitral valve with moderate MR and MS (Fig. 1, Video 1–3); 2-D and threedimensional (3-D) TEE were obtained with the same machine (transducer X7-2t, Philips Electronics, Andover, MA). Live/Real-time 3D rather than off-line post-processing and 3-D reconstruction were performed. 3-D TEE revealed cleft-like defect on P2 scallop of posterior mitral leaflet (Fig. 2a, Video 4). 3-D TEE color Doppler confirmed that the regurgitation originated from where the cleft-like defect was (Fig. 2b, Video 5); herein, we saw a cleft mitral valve with rheumatic involvement. 3-D TEE provides comprehensive anatomical overview by showing the valve from enface view and the 3-D TEE color Doppler helps to distinguish the exact localization of regurgitation.