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Abstract

A 62-year-old male presented with a sudden onset of dyspnea following a racquetball session. Vital signs revealed a blood pressure of 136/63 mm Hg, heart rate of 116 beats/min, respiratory rate of 26 breaths/min, temperature of 98.7º F, and oxygen saturation of 85% on room air. The physical examination was notable for tachycardia, no audible murmur, and bilateral coarse breath sounds on lung auscultation. Pertinent laboratory data showed leukocytosis, elevated lactic acidosis, and elevated brain natriuretic peptide. Arterial blood gas analysis on room air revealed a pH of 7.39, partial pressure of carbon dioxide of 32 mm Hg, and arterial oxygen pressure of 116 mm Hg. A chest X-ray revealed right perihilar and infrahilar infiltrate. Antimicrobial coverage for presumptive pneumonia was initiated. He was upgraded to the intensive care unit after a significant respiratory decline requiring non-invasive ventilation, ultimately necessitating endotracheal intubation. Because of persistent hypotension after the intubation, he was initiated on vasopressor support. A transthoracic echocardiogram demonstrated a preserved left ventricular ejection fraction and a myxomatous mitral valve with a flail posterior mitral valve leaflet with eccentric, immeasurable mitral regurgitation. Transesophageal echocardiography confirmed the diagnosis. Right and left cardiac catheterization showed elevated right and left heart hemodynamics, cardiac index of 2.8 L/min/m2, elevated pulmonary capillary wedge pressure of 31 mm Hg, and minimal coronary atherosclerosis. An intra-aortic balloon pump was inserted. The patient underwent an urgent mechanical mitral valve replacement and fully recovered.

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