PMC5079137_01
2D-echocardiographic short axis view showing dumbbell-shaped anomalous papillary muscle in the left panel. The right panel shows mid-ventricular short axis after excision of the muscle bundle.
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The left atrium was enlarged; there was a solitary large PM attached to the lateral and the posterior wall and appeared like a cantilever bridge in the short axis (Fig. 1).
Modified apical 4-chamber view showing anomalous papillary muscle with attachment to the interventricular septum (yellow arrow). The right panel shows the residual portion of the muscle bundle (yellow arrow) after excision.
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Apical 4-chamber view in diastole (left) and 5-chamber view in systole (right panel) showing direct attachment of the mitral leaflets to the papillary muscle.
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Left panel shows anomalous papillary muscle in the modified short axis view. The right upper panel shows continuous-wave Doppler spectrum of mitral regurgitation and mid-cavity obstruction (red arrow). The right lower panel shows continuous-wave Doppler spectrum across the mitral funnel.
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Moderate mitral regurgitation (vena contracta = 5 mm) and an intra-ventricular peak gradient of 30 mmHg were recorded (Fig. 4).
PMC5079137_02
Apical 4-chamber (A) and parasternal long axis (B) views showing thick mitral valve leaflets, short tendinous chords, and a single anomalous papillary muscle. PM, papillary muscle; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
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The patient underwent extended myomectomy, excision of the PM, and mitral valve replacement (Fig. 5, Fig. 6, Fig. 7).
Parasternal long axis view (left panel) and the apical 5-chamber view (right panel) showing narrow left ventricular outflow tract due to anteriorly inserted papillary muscle and the abnormal orientation of the thickened anterior leaflet.
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The patient underwent extended myomectomy, excision of the PM, and mitral valve replacement (Fig. 5, Fig. 6, Fig. 7).
PMC5079137_03
2D-echocardiographic parasternal long axis view in systole (A) and in diastole (B). Note reduced opening of the mitral orifice with short chords.
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Her trans-thoracic 2D echocardiographic examination revealed markedly enlarged left atrium, reduced motion of the mitral leaflets with restricted opening, single large PM attached to the inferolateral and anterolateral walls, short chordae, and mitral valve area of 1.4 cm2 (Fig. 8, Fig. 9, Fig. 10).
Left lower panel shows multi-plane 3D reconstruction of the left ventricular mid-cavity showing a large anomalous papillary muscle (arrow) attached from 1 o'clock till 6 o'clock position. Right panel shows continuous wave Doppler interrogation of the mitral funnel and a peak gradient of 8 mmHg.
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Her trans-thoracic 2D echocardiographic examination revealed markedly enlarged left atrium, reduced motion of the mitral leaflets with restricted opening, single large PM attached to the inferolateral and anterolateral walls, short chordae, and mitral valve area of 1.4 cm2 (Fig. 8, Fig. 9, Fig. 10).
PMC5079137_04
Left panel (A) shows single large papillary muscle in short axis view (red arrow) while right panel (B) shows short chords, calcification of the posterior annulus, and a large, thick club-like papillary muscle in apical 4-chamber view.
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Continuous-wave Doppler examination showed trans-mitral peak and mean gradients of 15 and 7 mmHg respectively (Fig. 11, Fig. 12).
PMC5079137_05
Left panel shows parasternal long axis view in systole with two heads of a single papillary muscle and short chords. Right panel shows single papillary muscle in short axis view.
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PM, and short chords with systolic anterior motion. Peak gradient across mitral valve in diastole was 7 mmHg and moderately severe mitral regurgitation was noted (Fig. 13, Fig. 14).
PMC5079137_06
Upper panel shows continuous wave Doppler spectrum of mitral stenosis with a mean gradient of 10 mmHg. Lower left panel shows narrow jet of mitral diastolic flow and the right lower panel in short axis view shows narrow orifice of the mitral valve with no commissural fusion or calcification.
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Current echocardiogram shows thickened mitral valve leaflets with no commissural fusion, short chords, and a single large PM placed centrally (Fig. 15, Fig. 16).