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

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.