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An 80-year-old woman with chronic obstructive pulmonary disease and mitral-valve prolapse presented with progressive dyspnea, orthopnea, and dry cough, which she reported having had for the previous 3 days. She was receiving oxygen therapy at home, and her oxygen saturation at rest was 70%. There was no antecedent chest pain, fever, hemoptysis, weight gain, or edema of the legs. The blood pressure was normal; a cardiovascular examination revealed a midsystolic click with a grade 2/6 systolic murmur. A chest radiograph obtained at the time of admission (Panel A) showed mild cardiomegaly as well as air-space disease in the upper lobes of both lungs (arrows), which was more pronounced on the right side than on the left, with reticulation. A computed tomographic scan of the chest (Panel B), obtained with the use of maximum intensity projection, showed asymmetric pulmonary edema, predominantly in the right upper lobe. The scan also revealed that the left ventricle, mitral valve, left atrium, right superior pulmonary vein, and edema of the upper right lobe were aligned along the path expected for a regurgitant jet caused by mitral insufficiency, with a resulting increase in hydrostatic pressure in the right superior pulmonary vein. Echocardiography (see video) showed turbulent flow at the mitral valve, indicating a posteriorly directed mitral regurgitant jet, with a flail segment of the posterior mitral-valve leaflet, suggesting a new rupture of the chordae tendineae. The patient underwent mitral-valve repair, and rupture of the chordae tendineae was confirmed during the procedure. Asymmetric pulmonary edema concentrated in the right upper lobe is typically associated with mitral regurgitation resulting from a flail posterior leaflet, which can be caused by rupture of the chordae tendineae or papillary muscle.
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