The Heart Under Stress: What Happens When Both Ventricles Fail?

We present the case of a 52-year-old male with severe primary mitral regurgitation, with biventricular dilatation and systolic impairment. Pre-operative exercise stress echocardiography revealed absence of left and right ventricular contractile reserve suggestive of increased surgical risk possibly requiring postoperative mechanical circulatory support. In the immediate postoperative period, the transesophageal echocardiogram revealed severe left ventricular systolic impairment with very low cardiac output, resulting in significant challenges in weaning the patient off cardiopulmonary bypass. Left ventricular function gradually improved with judicious use of intravenous fluids and inotropic support. Our case highlights the importance of stress echocardiography in the risk stratification and periprocedural planning of patients undergoing cardiac surgery for severe mitral regurgitation.