Images in cardiovascular ultrasound
A 64-year-old Japanese man was referred to our hospital because of palpitation. An electrocardiogram revealed first-degree atrioventricular block without ST-T change. An echocardiography showed structural abnormality into the left ventricular outflow tract (LVOT), mitral valve leaflet cleft without mitral regurgitation, and single papillary muscle (loss of posterior papillary muscle) (Figs. 1, 2). A structural abnormality was attached between the base of the intraventricular septum and anterior mitral leaflet, which was mobile in the cardiac cycle. Peak velocity of LVOT was 1.7 m/s. Cardiac systolic function was normal. We diagnosed accessory mitral valve tissue (AMVT) with mitral complex structural abnormality (mitral valve leaflet cleft and single papillary muscle).
Fig. 1.
a Transthoracic echocardiography in the apical long-axis view shows accessory mitral valve tissue (AMVT) (arrow) into the left ventricular outflow tract (LVOT). LV left ventricle, LA left atrium, Ao aorta, AMVT accessory mitral valve tissue. b Transthoracic echocardiography in the parasternal short-axis view in diastole shows mitral valve leaflet cleft and AMVT (arrow) attached from the base of the intraventricular septum to anterior mitral leaflet. AML anterior mitral leaflet, PML posterior mitral leaflet. c Transthoracic echocardiography in the parasternal short-axis view in systole. d Transthoracic echocardiography in the parasternal short-axis view shows single papillary muscle (loss of posterior papillary muscle)
Fig. 2.
a Three-dimensional transesophageal echocardiography shows in diastole show mitral valve leaflet cleft and AMVT (arrow) attached from base of intraventricular septum to anterior mitral leaflet. b Three-dimensional transesophageal echocardiography in the long-axis view shows accessory mitral valve tissue (AMVT) (arrow) into the LVOT
AMVT is a rare congenital cardiac malformation. The age of AMVT diagnosis ranged from newborns to 77 years [1]. It was reported that the incidence of AMVT in adults was 1/26,000 echocardiogram [2]. Although the exact embryologic mechanism of AMVT formation is not clear, it may stem from the abnormal or incomplete separation of the mitral valve from the endocardial cushions [3]. AMVT is associated with other congenital intracardiac and vascular malformations such as ventricular septal defect [4]. In this case, we found AMVT with a combination of mitral valve leaflet cleft and single papillary muscle (loss of posterior papillary muscle). To our knowledge, this is the first reported case of AMVT with a combination of mitral valve leaflet cleft and single papillary muscle.
An echocardiography can be considered the gold standard modality for the diagnosis of AMVT with other cardiac abnormality.
Although single papillary muscle usually combined the parachute mitral valve, the parachute mitral valve was not observed in this case. The majority of patients with AMVT have no symptoms, such as chest pain, palpitation, and syncope [5–7]. However, this patient was referred to our hospital because of palpitation. No arrhythmia was observed in electrocardiogram monitoring.
Conflict of interest
Koichiro Imai, Mariko Kawata, Hiroyuki Okura, and Shiro Uemura declare that they have no conflicts of interest.
Human rights statements and informed consent
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revisions. Informed consent was obtained from all patients included in the study.
References
- 1.Prifti E, Bonacchi M, Bartolozzi F et al. Postoperative outcome in patients with accessory mitral valve tissue. Med Sci Monit. 2003;9:RA126–33. [PubMed]
- 2.Rovner A, Thanigaraj S, Perez JE. Accessory mitral valve in an adult population: the role of echocardiography in diagnosis and management. J Am Soc Echocardiogr. 2005;18:494–498. doi: 10.1016/j.echo.2005.01.027. [DOI] [PubMed] [Google Scholar]
- 3.Cremer H, Bechtelsheimer H, Helpap B. Forms and development of subvalvular aortic stenosis. Virchows Arch A Pathol Pathol Anat. 1972;355:123–134. doi: 10.1007/BF00556314. [DOI] [PubMed] [Google Scholar]
- 4.Yuan SM, Shinfeld A, Mishaly D, et al. Accessory mitral valve tissue: a case report and an updated review of literature. J Card Surg 2008;23:769–72. [DOI] [PubMed]
- 5.Musumeci B, Spirito P, Parodi MI, et al. Congenital accessory mitral valve tissue anomaly in a patient with genetically confirmed hypertrophic cardiomyopathy. J Am Soc Echocardiogr. 2011;24:592. doi: 10.1016/j.echo.2010.08.006. [DOI] [PubMed] [Google Scholar]
- 6.Panduranga P, Eapen T, Al-Maskari S, et al. Accessory mitral valve tissue causing severe left ventricular outflow tract obstruction in a post-Senning patient with transposition of the great arteries. Heart Int. 2011;6:e6. doi: 10.4081/hi.2011.e6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.D’Aloia A, Vizzardi E, Chiari E, et al. Dynamic mild subaortic left ventricular obstruction caused by an accessory mitral valve attached to the anterior mitral valve in a young pregnant woman. Eur J Echocardiogr. 2008;9:160–161. doi: 10.1016/j.euje.2007.05.008. [DOI] [PubMed] [Google Scholar]