Mitral valve regurgitation and emotional dysregulation secondary to long-standing Graves' thyrotoxicosis

Graves' disease is common, with an estimated prevalence of 0.2-2% and multiple associated complications. We present a case of severe mitral regurgitation secondary to poorly controlled Graves' disease for 11 years, highlighting the need for definitive treatment. A 30-year-old female attended hospital with palpitations, agitation and generalised pain. Her past medical history included Graves' disease diagnosed in 2014, with poor compliance and engagement with secondary care and medical treatment. Biochemical investigations and clinical examination confirmed thyrotoxicosis (TSH < 0.05 mIU/L, free T3 > 30.72 pmol/L and free T4 34.7 pmol/L). Carbimazole 40 mg once daily and propranolol 40 mg three times daily were restarted. She later developed worsening dyspnoea, attributed to decompensated heart failure. An echocardiogram showed severe mitral regurgitation secondary to anterior mitral valve prolapse. She also displayed psychiatric abnormalities, including anxiety and anger outbursts. Multiple conversations were thus needed with the patient, her family and the multidisciplinary team regarding treatment options, and an inpatient thyroidectomy was agreed upon. She recovered well postoperatively and is awaiting mitral valve repair. Our case highlights two crucial complications occurring secondary to long-standing uncontrolled Graves' thyrotoxicosis: mitral valve regurgitation with heart failure and neuropsychiatric complications with an impact on capacity for treatment decisions. We emphasise the complex support needed for these vulnerable patients to prevent end-stage complications of Graves' disease.