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American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

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Label_Title

Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
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Label_Title

Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

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Extreme Clinico-Echocardiographic Discordance in End-Stage Degenerative Mitral Regurgitation: A Fatal Case of Silent Ventricular Burn-Out

O. Taoussi*, M. Zoubidi, M. Mokhtari, G. Benouna, FZ. Merzouk

Department of Cardiology, Mohammed VI International University Hospital, Mohammed VI Foundation of Health and Sciences, Casablanca, Morocco

Abstract: Chronic degenerative mitral regurgitation (MR) can lead to profound, often asymptomatic, left ventricular (LV) remodeling. We report an exceptional and fatal case of end-stage MR, illustrating a dramatic mismatch between preserved clinical status and catastrophic structural damage on echocardiography. A patient with long-standing, untreated degenerative MR presented with minimal symptoms despite transthoracic echocardiography revealing extreme LV dilatation (end-diastolic diameter 105 mm), severe systolic dysfunction (ejection fraction 10-15%), torrential regurgitation (effective regurgitant orifice area 2.44 cm²), and massive left atrial enlargement. Strikingly, the clinical course was not dominated by heart failure symptoms but terminated abruptly in cardiac arrest due to ventricular fibrillation, likely precipitated by advanced LV dilatation, fibrosis, and electrical instability. This case underscores that end-stage degenerative MR can progress silently to an irreversible, lethal stage dominated by arrhythmic death, reinforcing the critical need for timely intervention before the onset of terminal remodeling.

Keywords: End-Stage Mitral Regurgitation, Left Ventricular Remodeling, Echocardiography, Ventricular Fibrillation, Sudden Cardiac Death, Clinical Discordance

Received November 27, 2025; Revised December 29, 2025; Accepted January 05, 2026

Citation: O. Taoussi, M. Zoubidi, M. Mokhtari, G. Benouna, FZ. Merzouk, Extreme Clinico-Echocardiographic Discordance in End-Stage Degenerative Mitral Regurgitation: A Fatal Case of Silent Ventricular Burn-Out. American Journal of Medical Case Reports, 14 (1). 1-4. January 2026. doi:10.12691/ajmcr-14-1-1

1. Introduction

Degenerative mitral valve disease represents a leading cause of chronic primary mitral regurgitation (MR) and is characterized by a prolonged asymptomatic phase despite progressive left ventricular (LV) remodeling [1]. This deceptive clinical quiescence frequently delays intervention until the development of irreversible myocardial damage or overt symptoms, a stage associated with prohibitive surgical risk and poor outcomes [2]. Consequently, current guidelines strongly advocate early surgical referral based on objective echocardiographic markers of LV dysfunction or enlargement rather than symptom status alone [3]. We report a compelling case of a patient who declined surgical intervention 13 years earlier and later presented electively, only to be found in an inoperable, end-stage condition. This case visually delineates the “point of no return” in chronic MR and underscores sudden arrhythmic death as a potential terminal event.

2. Case Presentation

A male patient in his seventh decade, with a known history of severe degenerative mitral regurgitation diagnosed 13 years prior, presented to our clinic. At the initial diagnosis, surgical mitral valve repair was strongly recommended but was declined by the patient. He now presented not for symptoms, reporting only mild, non-disabling fatigue (NYHA Class II) and denying any orthopnea or peripheral edema, but with the intention to finally undergo the long-postponed operation.

Admission Electrocardiogram showed atrial fibrillation with a controlled ventricular response and broad QRS complexes (QRS duration >120 ms), consistent with significant intraventricular conduction delay in the setting of extreme dilatation.

Physical examination revealed a holosystolic murmur at the apex radiating to the axilla. He was normotensive. There was no clinical evidence of acute heart failure.

Echocardiographic Findings (The Core of the Case):

Transthoracic echocardiography revealed catastrophic progression to an end-stage phenotype:

Extreme LV Remodeling: The parasternal long-axis view demonstrated a colossal LV with an end-diastolic diameter of 105 mm (indexed 68 mm/m²) and severe global wall thinning (Figure 1). Global systolic function was catastrophically depressed, with an LVEF of 10-15% and diffuse hypokinesia.

Figure 1. Parasternal long-axis view of end-stage left-ventricular remodeling: Parasternal long-axis view showing extreme left-ventricular dilatation (end-diastolic diameter 105 mm, indexed LVEDD 68 mm/m²) with marked wall thinning, consistent with terminal ventricular remodeling secondary to long-standing untreated degenerative mitral regurgitation

⇒ Massive Left Atrial Enlargement: The left atrium was profoundly dilated, with a volume of 198 mL (indexed 58 mL/m²).

⇒ Torrential Mitral Regurgitation: Color Doppler showed a giant holosystolic regurgitant jet completely filling the enlarged atrium, with systolic flow reversal in the pulmonary veins (Figure 2).

⇒ Quantitative assessment confirmed the severity of regurgitation: the PISA method yielded an effective regurgitant orifice area (EROA) of 2.44 cm² and a regurgitant volume of 251 mL (Figure 3A). Continuous-wave Doppler showed a dense, triangular, early peaking systolic envelope (Figure 3B).

⇒ Valve Morphology: The parasternal long-axis view revealed advanced myxomatous degeneration with leaflet thickening and a wide coaptation defect (Figure 4).

Clinical Course and Outcome:

Coronary angiography showed no significant obstructive disease. The heart team unanimously concluded that the risk of any surgical or transcatheter (MitraClip) intervention was prohibitively high due to the extreme LV dysfunction and dimensions, representing a "futility scenario."

During hospitalization for further evaluation and optimization of palliative therapy, the patient suffered an in-hospital cardiac arrest. The presenting rhythm was ventricular fibrillation (VF). Resuscitation efforts were unsuccessful, and death was attributed to refractory VF in the context of end-stage MR-induced cardiomyopathy.

Figure 2. Apical four-chamber color Doppler view of torrential mitral regurgitation. Apical four-chamber view demonstrating a massive holosystolic mitral regurgitant jet extending deep into the pulmonary veins, consistent with severely elevated left-atrial pressures

Figure 3. (A–B) Quantitative assessment of torrential mitral regurgitation (PISA and CW Doppler): (A) Color Doppler apical view showing a large proximal isovelocity surface area (PISA) with a measured radius of 1.4 cm and an aliasing velocity of 86 cm/s. The calculated regurgitant flow rate (1059 ml/s), effective regurgitant orifice area (EROA = 2.44 cm²), and regurgitant volume (251 ml) confirm torrential mitral regurgitation. (B) Continuous-wave Doppler tracing demonstrating a dense, triangular, holosystolic jet, consistent with massive mitral regurgitation and markedly elevated left-atrial pressures

Figure 4. Parasternal long-axis 2D view showing advanced LV dysfunction and structural valve degeneration Parasternal long-axis view showing severe LV systolic dysfunction with wall thinning, leaflet thickening, posterior leaflet restriction with mild anterior prolapse, and a wide coaptation defect consistent with advanced degenerative mitral regurgitation

3. Discussion

1. The window of opportunity and the “point of no return”: This patient’s clinical course exemplifies a missed therapeutic window. Despite a clear recommendation for intervention 13 years earlier, he re-presented only after progression to an irreversible “burned-out” ventricular phenotype. The echocardiographic parameters observed (LVEF <20%, LVEDD >100 mm) define a threshold beyond which the hemodynamic benefits of valve intervention become negligible and perioperative mortality markedly increases [4]. His elective presentation despite minimal symptoms underscores the dangerous dissociation between perceived clinical stability and ongoing silent myocardial injury.

2. Arrhythmic death as a terminal pathway in end-stage MR: Although death in advanced valvular disease is often attributed to progressive pump failure, sudden cardiac death has emerged as an important competing mechanism, particularly in the setting of severe LV dilatation and dysfunction [5]. Massive chamber enlargement, extensive interstitial fibrosis, and increased wall stress create a highly arrhythmogenic substrate conducive to re-entrant ventricular arrhythmias [6]. The presence of atrial fibrillation and broad QRS complexes further reflects advanced electrical remodeling. The occurrence of fatal VF in the absence of overt pulmonary edema illustrates that malignant arrhythmias may represent the final and abrupt mode of death in end-stage MR.

3. The imperative of timely intervention and patient education: This outcome reinforces guideline-based recommendations for early intervention guided by objective echocardiographic criteria (LVEF ≤60%, LVESD ≥40 mm) rather than symptom burden alone [3]. Evidence consistently demonstrates superior outcomes when intervention precedes severe LV dysfunction [7]. The case also highlights a persistent challenge in valvular heart disease management: ensuring patient adherence to follow-up and acceptance of pre-symptomatic intervention. Effective patient education must emphasize that severe MR is a mechanical disorder requiring timely mechanical correction before irreversible myocardial damage occurs.

4. Conclusion

In conclusion, this case highlights the devastating natural history of untreated severe degenerative MR and illustrates how irreversible myocardial damage may progress silently despite minimal symptoms. It emphasizes that once advanced LV remodeling and dysfunction are established, outcomes are determined not by valve severity alone but by the extent of myocardial injury and electrical instability. This report reinforces the critical importance of proactive echocardiographic surveillance, timely intervention before irreversible ventricular remodeling, and sustained patient education to prevent progression beyond the therapeutic point of no return.

ACKNOWLEDGEMENTS

The authors thank the cardiology department at Mohammed VI International University Hospital for its support. No external funding was received for this work.

Competing Interests

The authors declare that they have no competing interests.

List of Abbreviations

ECG – Electrocardiogram

EROA – Effective Regurgitant Orifice Area

ESC/EACTS – European Society of Cardiology / European Association for Cardio-Thoracic Surgery

LV – Left Ventricular (ou Left Ventricle)

LVEDD – Left Ventricular End-Diastolic Diameter

LVEF – Left Ventricular Ejection Fraction

LVESD – Left Ventricular End-Systolic Diameter

MIDA – Mitral Regurgitation International Database

MR – Mitral Regurgitation

NEJM – The New England Journal of Medicine

NYHA – New York Heart Association

PCI – Percutaneous Coronary Intervention

PISA – Proximal Isovelocity Surface Area

QRS – Représente les ondes Q, R et S de l'électrocardiogramme (durée d'un complexe ventriculaire)

VF – Ventricular Fibrillation

References

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