The Yin-Yang Sign of Severe Mitral Regurgitation

J INVASIVE CARDIOL 2021;33(4):E314. 

Key words: cardiac imaging, MitraClip implantation, transthoracic echocardiogram

In select patients with severe, eccentric mitral regurgitation (MR), we have observed that the regurgitant jet may entrain blood along the left atrial wall to produce a Chinese yin-yang symbol on color Doppler. The Chinese yin-yang symbol consists of a circle divided by an S-shaped line into black (yin) and white (yang) segments, with yin (representing darkness) and yang (representing light) complementing each other harmoniously. Classically, this symbol has been described to represent the color Doppler appearance of circular blood flow related to high-flow arterial pseudoaneurysms. 

An 81-year-old woman with symptomatic, severe, functional MR secondary to non-ischemic cardiomyopathy was referred for transcatheter mitral valve repair. Her transthoracic echocardiogram (TTE) demonstrated ejection fraction of 35%, left ventricular end-systolic dimension of 6.41 cm, severe left atrial and mitral annular dilation, and 4+ eccentric MR that generated systolic pulmonary vein flow reversal and a prominent yin-yang symbol (Figure 1). Quantitative evaluation demonstrated effective regurgitant orifice area of 46 mm² and regurgitant volume of 72 mL. After placement of 2 MitraClip NTR clips (Abbott Vascular) to the A2-P2 segment, there was significant reduction in the patient’s MR evidenced by resolution of the yin-yang sign and normal systolic pulmonary vein flow. 

We demonstrate a patient with severe, eccentric MR whose regurgitant jet generated a yin-yang symbol. We have observed this unique color Doppler finding in other patients with severe eccentric MR and it has not been previously reported.

From the Division of Cardiology, Department of Internal Medicine, University of California Davis Medical Center, Sacramento, California.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Rogers reports research funding to his institution from Abbott and Boston Scientific; consultant to Abbott, Boston Scientific, and Gore. The remaining authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted April 15, 2020.

Address for correspondence: Jason H. Rogers, MD, Division of Cardiovascular Medicine, University of California, Davis Medical Center, Sacramento, CA 95817. Email: jhrogers@ucdavis.edu