Anomalous Muscle Research Articles

A rare anomalous muscle in the popliteal region - a case report.

Anomalous muscles are rarely seen in the popliteal region of the lower limb. Some of them are harmless and go unnoticed and some create problems such as neuropathies. We report a novel case of an unusual additional muscle in this region. The additional muscle was closely associated with the short head of the biceps femoris muscle. It took its origin from the lower part of the lateral supracondylar line and the adjoining popliteal surface of the femur. The muscle was 10cm in length, 1cm in breadth and was fleshy throughout. It was oriented parallel to the medial side of the tendon of biceps femoris. It was inserted to the posterior aspect of the head of the fibula, medial to the insertion of the biceps femoris. The additional muscle derived its nerve supply from the sciatic nerve. The common peroneal nerve was closely related to the medial border of the additional muscle.

A Rare Case of Carpal Tunnel Syndrome with Bifid Median Nerve and Palmaris Profundus Muscle

Summary: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. We report an extremely rare case of CTS associated with a bifid median nerve and palmaris profundus muscle. A 68-year-old man presented with numbness and pain in the right hand. Intraoperatively, a bifid median nerve was identified, with the ulnar branch severely compressed by the palmaris profundus muscle. The muscle was resected, leading to symptom resolution. Anatomical variations of the median nerve and anomalous muscles should be considered in CTS. Preoperative imaging and open carpal tunnel release are recommended to identify and address such variations.

Surgical Technique For Chronic Symptomatic Peroneal Sheath Pain in Young Patients

To present the clinical and radiographic data, emphasize our surgical technique and how it was used, and the outcome measures in a case series of patients with chronic symptomatic peroneal sheath pain. A retrospective chart and radiograph review was conducted involving 36 adolescent patients (ages 8 to 20 y) treated surgically for chronic symptomatic peroneal sheath pain from 2010 to 2020. Findings that include chief complaint, magnetic resonance imaging findings, and surgical measures were documented. The patients’ postoperative and clinic visit notes were analyzed and outcome scores (FAOS Foot & Ankle Survey, AOFAS Ankle-Hindfoot Scale, and Kaikkonen Functional Scale) were calculated to determine the long-term results of the procedure. In our case series of 36 patients undergoing surgical treatment for chronic symptomatic peroneal sheath pain the procedures performed were as follows: 35 peroneal sheath repairs (97.22%), 34 ankle arthroscopies (94.44%), 27 resections of anomalous peroneus brevis muscle belly (75.00%), 2 resections of accessory peroneus quartus muscle (5.56%), 7 partial synovectomies (19.44%), 29 debridements (80.56%), and 6 Brostrom repairs (16.67%). magnetic resonance imaging findings showed 50% of our patient population had low-lying peroneus brevis muscles, and on examination during surgery, 61.11% of peroneus brevis muscles extended past the fibular tip. The average time in the cast post-operatively was 4.33 weeks. The average time from surgery to return to activity was 9.03 weeks. Twenty-two of the 36 patients (61.11%) were athletes and 100% were able to return to their sport. Outcome scores were retrospectively determined to be 99.27 for the FAOS Foot and Ankle Survey, 98.72 for the AOFAS Ankle-Hindfoot Scale, and 99.31 for the Kaikkonen Functional Scale. Complications were minimal and included 1 postoperative infection, 3 cast impingements, and 2 reported instances of post-operative pain. In our retrospective case series of 36 patients, the outcomes of surgical intervention for peroneal tendon pathology unresponsive to nonsurgical management in pediatric patients were evaluated. Our surgical method utilizes debridement, synovectomy, excision of low lying peroneus brevis muscle belly, excision of peroneus quartus if present, repair of split-tears of the tendons, and repair of the peroneal tendon sheath using “pants over vest” sutures to tighten the sheath. Our chart review shows all 36 patients were satisfied with the outcome, demonstrated improvement in relevant patient-reported outcome measures, and would elect to undergo the procedure again. Therefore, the novel surgical techniques outlined in this study appear to be viable options to treat chronic symptomatic peroneal tendon sheath pain resistant to conservative methods. Level of Evidence: Retrospective Case Series, Level IV.

Acroparesthesias: An Overview.

Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.

A three-headed psoas major muscle: a case report.

Multiple anatomical variations, from anomalous courses to additional structures, have been reported in muscles from different compartments of the human body. We report an extremely rare case of a psoas major muscle presenting as a three-headed structure with variable morphology. During a routine dissection of the posterior abdominal wall of a 82-year-old male cadaver, an anomalous PM muscle with supernumerary head was identified, photographed and subjected to further measurement. Although the anatomy of the dissected posterior abdominal wall structures was typical, a three-headed psoas major muscle composed of superficial, intermediate and deep heads was identified. It is important to be aware of morphological variability of muscles, especially those considered to be constant, since an anomalous structure might interfere not only with their functions, but also lead to further clinical consequences.

Uncommon Anatomical Causes of Ulnar Compression: A Narrative Review.

Some patients develop ulnar nerve compression due to rare anatomical variations or malformations. The aims of this review are to provide a comprehensive overview of anatomical structures and variations that can cause ulnar nerve compression and to evaluate treatment options. Case reports and case series about rare cases of unusual ulnar nerve compression published from January 2000 until April 2022 were obtained from databases Embase, MEDLINE, and Web of Science. A total of 48 studies describing 64 patients were included in our study. The following structures have proven to cause ulnar nerve compression: anconeus epitrochlearis, accessory abductor digiti minimi, vascular anomalies, palmaris longus, fibrous bands, and flexor carpi ulnaris. All cases except one have had a surgical release of the ulnar nerve resulting in diminished symptoms or complete recovery at follow-up. In addition to considering common compression points, it is important to be aware that proximal compression symptoms, such as pain and a positive Tinel sign at the medial elbow, may be attributed to a hypertrophic AE or vascular anomaly. Distal compression symptoms encompass swelling, along with pain and a positive Tinel sign at the distal forearm. Various structures contributing to distal compression include an accessory abductor digiti minimi muscle, an accessory or anomalous palmaris longus muscle, or an accessory or hypertrophic flexor carpi ulnaris muscle. The occurrence of fibrous bands exhibits variability, manifesting in diverse locations across the arm.Level of Evidence: IV.

Isolated Double-Chambered Right Ventricle: A Rare Congenital Heart Disease

Double-chambered right ventricle (DCRV) is an uncommon congenital heart condition characterized by a progressive obstruction in the right ventricular outflow tract. This obstruction is caused by anomalous muscles or fibrous tissues that divide the right ventricle into two cavities: a proximal high-pressure chamber (anatomically lower) and a distal low-pressure chamber (anatomically higher). We present a case of a middle-aged man with a medical history of recurrent symptomatic dyspnea. Upon presentation, there were no signs of congestive cardiac failure. The diagnosis was confirmed using transthoracic two-dimensional (2-D) echocardiography and Transesophageal echocardiography (TEE) for more precise characterization. The primary objective of this case report is to highlight the rarity of this congenital heart disease, particularly in adults.

Accessory Flexor Carpi Ulnaris Muscle in Humans: A Rare Anatomical Case with Clinical Considerations.

Anatomical variations of the forearm flexor muscles are occasionally encountered. Though usually observed incidentally during autopsies or imaging studies, they may at times cause concern due to associated clinical symptoms. This report presents a case of unilateral accessory flexor carpi ulnaris (AFCU) muscle observed in a human male cadaver aged 78 years. During routine cadaveric dissection, an anomalous AFCU muscle was observed in the left forearm of a human male cadaver aged 78 years. Standard institutional guidelines pertaining to the use of human cadaver for teaching and research were followed. A thorough literature review about the flexor carpi ulnaris (FCU) through the PubMed, Embase and Google scholar databases was undertaken, using the keywords - accessory flexor carpi ulnaris muscle, aberrant flexor carpi ulnaris muscle and anatomical variation of flexor carpi ulnaris muscle. Relevant gross anatomical findings were recorded and photographed. AFCU was identified on the medial aspect of the distal third of the left forearm. The AFCU was found originating from the ante-brachial fascia and the fascia covering the FCU on the left forearm, forming a small separate belly deep to the main muscle. It terminated as a thin tendon running alongside the hypothenar muscles and attached distally to the base of the proximal phalanx of the little finger. The AFCU was found to be innervated by a branch of the ulnar nerve. Awareness about the rare AFCU muscle is clinically important as a possible cause of ulnar nerve compression but also as a possible graft in reconstruction surgeries.

Anomalous papillary muscle insertion into the mitral valve leaflet in hypertrophic obstructive cardiomyopathy: a lip nevus sign in echocardiography.

Anomalous papillary muscle (APM) insertion into the mitral valve leaflet is rare but clinically important in hypertrophic obstructive cardiomyopathy (HOCM). In this study, we report the detection rate of APM insertion into the mitral valve using preoperative imaging modalities and the surgical outcomes of the patients. By retrospectively reviewing the clinical records of patients with HOCM who underwent surgical treatment by a single operation group at our center from January 2020 to June 2023, patients with APM insertion into the mitral valve leaflet were identified. Baseline data, image characteristics, and surgical outcomes were analyzed. The incidence of APM insertion into the mitral valve leaflet was 5.1% (8/157). The insertion site was located at A3 in six cases, which was more common than at A2 (n = 2). Preoperative echocardiography was used to identify two patients (25%) with APM insertion. We observed a particular echocardiographic feature for APM in HOCM patients, which was noted as a "lip nevus sign", with a higher detection rate (62.5%). All patients successfully underwent septal myectomy with concomitant APM excision or mitral valve replacement via the transaortic (n = 5) or transmitral (n = 3) approach. The mean age was 49.0 ± 17.4 years and seven patients (87.5%) were female. Interventricular septum thickness (17.0 mm vs. 13.3 mm, P = 0.012) and left ventricular outflow gradient (117.5 mmHg vs. 7.5 mmHg, P = 0.012) were significantly decreased after surgery. Residual outflow obstruction, systolic anterior motion, and ≥3+ mitral regurgitation were negative. During the follow-up of 26.2 ± 12.2 months, there were no reported operations, adverse events, mitral regurgitation aggravations, recurrences of outflow obstruction, or instances of SAM. Papillary muscles inserted into the mitral valve leaflet are a subtype of subvalvular malformation in HOCM that requires surgical correction. The lip nevus sign on echocardiography is a characteristic of APM insertion in HOCM and may improve the preoperative detection rate. Adequate myectomy with anomalous papillary muscle excision has achieved good results in reducing the outflow gradient and eliminating mitral regurgitation, with good outcomes at short-to-intermediate follow-up.

Wnt signaling regulates ion channel expression to promote smooth muscle and cartilage formation in developing mouse trachea.

Ion channels play critical roles in the physiology and function of the nervous system and contractile tissue; however, their role in noncontractile tissue and embryonic development has yet to be understood. Tracheobronchomalacia (TBM) and complete tracheal rings (CTR) are disorders affecting the muscle and cartilage of the trachea and bronchi, whose etiology remains poorly understood. We demonstrated that trachealis muscle organization and polarity are disrupted after epithelial ablation of Wntless (Wls), a cargo receptor critical for the Wnt signaling pathway, in developing trachea. The phenotype resembles the anomalous trachealis muscle observed after deletion of ion channel encoding genes in developing mouse trachea. We sought to investigate whether and how the deletion of Wls affects ion channels during tracheal development. We hypothesize that Wnt signaling influences the expression of ion channels to promote trachealis muscle cell assembly and patterning. Deleting Wls in developing trachea causes differential regulation of genes mediating actin binding, cytoskeleton organization, and potassium ion channel activity. Wnt signaling regulates the expression of Kcnj13, Kcnd3, Kcnj8, and Abcc9 as demonstrated by in vitro studies and in vivo analysis in Wnt5a and β-catenin-deficient tracheas. Pharmacological inhibition of potassium ion channels and Wnt signaling impaired contractility of developing trachealis smooth muscle and formation of cartilaginous mesenchymal condensation. Thus, in mice, epithelial-induced Wnt/β-catenin signaling mediates trachealis muscle and cartilage development via modulation of ion channel expression, promoting trachealis muscle architecture, contractility, and cartilaginous extracellular matrix. In turn, ion channel activity may influence tracheal morphogenesis underlying TBM and CTR.NEW & NOTEWORTHY Ion channels play critical roles in the physiology and function of the nervous system and contractile tissue; however, their role in noncontractile tissue and embryonic development has yet to be understood. In this study, we focused on the role of ion channels in the differentiation and patterning of the large airways of the developing respiratory tract. We identify a mechanism by which Wnt-beta-catenin signaling controls levels of ion channel-encoding genes to promote tracheal differentiation.

A cadaveric case study of the fibulo calcaneus internus muscle as a rare accessory muscle of calf region

The fibulocalcaneus (peroneocalcaneus) Internus (FCI) muscle which is also called as Peroneo calcaneus Internus (PCI) muscle (of MacAlister) is a rare variation of calf muscle with a low prevalence of <1%-3% in cadaveric dissection and imaging studies. The FCI arises from the posterior-medial aspect of the distal 1/3 of the fibula, descends posterior and lateral to the flexor hallucis longus (FHL) muscle. It than traverses the tarsal tunnel inferior to the sustentaculum tali of the Calcaneus, and get inserted into the plantar surface of the calcaneus. However, controversy exists concerning the exact location of the insertion site of FCI muscle. Recently the insertion of the FCI muscle has been described as distal to the coronoid fossa, a small depression between the anterior tuberosity and the anterior apex of the sustentaculum tali of the calcaneus. However, chronological descriptions described the FCI as inserting into either the sustentaculum tali itself or a small tubercle on the medical surface of the calcaneus distal to the sustentaculum tali. During routine dissection for under graduate students, about 56-year old Indian male, a Fibulocalcaneus (peroneocalcaneus) Internus (FCI) muscle was identified, which originated from the posterior medial surface of distal third of the fibula and tendon merges with 2 slip of flexor digitorum longus and get inserted on base of distal phalanx of second toe. Knowledge of the FCI muscle is important due its involvement with various ankle pathologies, including predisposing individuals to tarsal tunnel syndrome, FHL tenosynovitis, and posterior ankle impingement and pain. The FCI muscle is one of the least common muscular variants associated with the ankle joint, and it has been implicated in posterior ankle pain and impingement. This muscle is often confused with the flexor digitorum accessorius longus (FDAL) muscle. Additionally, this study describes ways to differentiate between the FCI and FDAL muscles in the lower leg. Radiologists and clinicians should be aware of this anomalous muscle when considering various diagnoses, interpreting radiographs, and pursuing surgical involvement to reduce symptoms of posterior ankle region.

Anomaly originated flexor digitorum superficialis muscle of the small finger: A case report.

We present a clinical case of flexor digitorum superficialis (FDS) muscle belly of the small finger originating from the palm of a patient undergoing carpal tunnel surgery with a literature review. A 28-year-old right-handed woman visited our hospital with a chief complaint of a continuous tingling sensation and weakness in the right hand, which began after the volar side of her wrist was crushed by a machine during work 2 weeks prior. The patient complained of a continuous tingling sensation in the thumb, index, and middle fingers. The patient had a positive result on Tinel test of the median nerve of the wrist. As electromyography and nerve conduction velocities showed signs of severe injury in the right median nerve, exploration and carpal tunnel release were planned. Carpal tunnel release was performed under regional anesthesia using the classical open approach. The median nerve in the distal forearm and distal portion of the flexor retinaculum appeared to be narrowed and compressed. An anomalous muscle originating from the flexor retinaculum is also observed. The FDS muscle of the small finger was excised at the flexor retinaculum and musculotendinous junction and sutured to the flexor digitorum profundus tendon. At the 37-month follow-up, the patient did not experience any tingling sensation or weakness. She showed excellent range of motion of the right small finger. The grip strength was 20 kg on both the right and left sides. Quick disabilities of the arm, shoulder, and hand score was 2.3. Asymptomatic small finger FDS muscle anomalies can occur, as demonstrated in this case study. Thus, physicians should familiarize themselves with small finger FDS muscle anomalies during interactions with patients to facilitate future treatments of patient complaints related to the hand, as well as wrist laceration or trauma requiring hand exploration.

Prevalence and anatomy of the anomalous subclavius posticus muscle and its clinical implications with emphasis in neurogenic thoracic outlet syndrome: Scoping review and meta-analysis

BackgroundThe subclavius muscle runs underneath the clavicle. However, there have been a few reports of a duplicated subclavius muscle which is commonly referred to as subclavius posticus muscle due to its orientation being posterior to the proper subclavius muscle. Its occurrence seems to potentially create a narrowing interval at the superior thoracic aperture as it crosses over the brachial plexus. It might also have functional influence on the shoulder girdle. PurposeTo provide comprehensive gross anatomy description of the variant “subclavius posticus muscle” and to investigate its reported clinical implications with emphasis on its involvement in causing brachial plexus compression. Basic proceduresA scoping review with meta-analysis of the gross anatomy of the subclavius posticus muscle was conducted along with investigating its correlation to the thoracic outlet syndrome. Forty-seven articles were pooled through two rounds of the selection process. The relevant information was extracted and meta-analyzed. Main findingsThe scoping review and meta-analysis of the 47 articles revealed a total prevalence of 11/2069 (4.9%); 10/1369 (5.1%) in cadaveric studies, and 1/700 (5.0%) in MRI studies. The subclavius posticus muscle is a short triangular muscle with an average length of 12 cm and an average width of 1 cm. It originates from the sternal end of the first rib in most cases with reported variants of one case originating from the costoclavicular ligament and one case where it was fused with the proper subclavius muscle. Its insertion is more variable: on the superior border of the scapula with variable length in 71.35%, on the coracoid process of the scapula in 25.42%, and on the clavicle in 0.90%. The subclavian nerve seems to be the dominant nerve supply with a 57.6% prevalence, while 25.8% are innervated by the suprascapular nerve. Other reported nerves were the nerve to the myolohyoid (4.5%), accessory phrenic nerve (4.5%), and a direct branch from the brachial plexus (2.0%). The blood supply was reported (only once) to be from the suprascapular artery. However, the venous drainage was not established at all. Principal conclusionsThe subclavius posticus muscle is a variant muscle occurring with a reported overall prevalence of 4.9%. It can compress the brachial plexus as it runs across at the space of the superior thoracic aperture with exquisite contact, and this can lead to a neurogenic thoracic outlet syndrome. It also can be involved in the vascular thoracic outlet syndrome. Lastly, it is important not to omit its potential influence in shoulder joint instability to some extent.

Flexor Carpi Radialis Brevis: A Case Report

The flexor carpi radialis brevis is a rare anomalous muscle, with incidence ranging from 1.6-7.5%. While this anatomical variation is typically benign, it is of clinical importance as it can contribute to neurovascular and musculoskeletal dysfunction. Surgeons should be made aware of this variation during distal radius volar plating procedures and carpal tunnel releases. The flexor carpi radialis brevis muscle may also cause confusion when interpreting imaging results. We report here a rare case of bilateral flexor carpi radialis brevis muscles that travel through the carpal tunnel found during cadaveric dissection in a graduate course for physical therapy students. To our knowledge, this is the second published example of a flexor carpi radialis brevis muscle traveling through the carpal tunnel.

1116 DOUBLE-CHAMBERED RIGHT VENTRICLE AND VENTRICULAR SEPTAL DEFECT IN AN ELDERLY WOMAN: A RARE CASE.

Abstract Introduction Double-chambered right ventricle (DCRV) is a rare congenital heart defect with right ventricular outflow tract (RVOT) obstruction. The right ventricle (RV) is divided into anatomically proximal high-pressure and distal low-pressure chambers by abnormal muscle bundle. DCRV is frequently associated with others congenital heart defects, particularly ventricular septal defects (VSDs). Although its typically presents during childhood and adolescence, it can also present in adulthood. Case Presentation An 84-years-old woman was admitted to our hospital, in emergency department, with a 30-days history of worsening dyspnea and exercise intolerance. She was Ukrainian and did not speak Italian or English. The patient past medical history was unknow except for untreated bilateral glaucoma complicated by blindness. Vital signs were notable for tachycardia, tachypnea (respiratory rate, 28/minute), blood pressure of 118/76 mm Hg, SpO2 of 91%. Physical exam revealed left-sided parasternal systolic murmurs, abolished vesicular murmur at lung bases and jugular vein distension with hepatojugular reflux. The ECG showed atrial fibrillation. Chest X-ray showed moderate cardiomegaly, bilateral pleural effusions, and pulmonary congestion. Transthoracic echocardiography (TTE) was performed and revealed a normal-sized left ventricle with mildly reduced left ventricle ejection fraction (EF 48%), left atrial enlargement, biventricular hypertrophy with asymmetrical interventricular septal hypertrophy. Also, we found massive right atrium and enlarged right ventricle with reduced longitudinal contractility (TAPSE of 13 mm and tricuspid annular tissue Doppler S’ velocity = 7.0 cm/sec). Color flow Doppler in parasternal short-axis view revealed a turbulent systolic flow into the right ventricle. Continuous-wave spectral Doppler analysis showed a peak velocity of 5.6 m/ sec corresponding to a peak gradient of 120 mmHg. Real time 3D-TTE confirmed the of mid-ventricular obstruction due to abnormal trabecular tissue. Therapy including diuretics, beta-blockers and anticoagulants was started. Subsequently, a transesophageal echocardiography (TOE) confirmed the presence of an anomalous mid-ventricular muscle bundle and revealed an associated small sub-aortic ventricular septal defect (VSD) leading to the diagnosis of acute RV failure due to double-chambered RV with VSD and atrial fibrillation. Due to the high risk of complications, patient was considered not amenable for surgery. She was discharged on medical therapy. Conclusions We report a rare case of DCRV and VSD diagnosed in an elderly patient. Due to its rarity, DCRV continues to be misdiagnosed, especially in adulthood. Three-dimensional echocardiography and TOE were most useful tool to define diagnosis and pathophysiology in such an elderly and non-compliant patient.

724 AN UNUSUAL CASE OF ECHOCARDIOGRAPHY-ESTIMATED PULMONARY HYPERTENSION

Abstract Case Presentation 48-years-old woman was diagnosed with severe pulmonary hypertension at transthoracic echocardiography during cardiological evaluation for bariatric surgery. PAPs was estimated 110 mmHg, mild-moderate tricuspidal insufficiency with no dilatation of right chambers and LVEF preserved (65%). The patient had history of heart murmur since childhood and now presented with type 2 diabetes mellitus on metformin treatment, third grade obesity (BMI 55) and dyslipidemia (LDL col. 120 mg/dL). Diagnostic Workup: The patient was symptomatic dyspnea for mild-moderate exertion (NYHA II-III). Heart-beat was rhythmic with 4/6 ubiquitous systolic sharp murmur. Lung auscultation was normal. Bilateral pretibial edema was noted. The cardiac catheterization showed: A transesophageal echocardiography confirmed post-tricuspidal right intraventricular obstruction due to mid-ventricular fibro-muscular rims and disclosed a small restrictive membranous defect on interventricular septum with minimum left-to-right shunt. A cardiac-MRI confirmed an hypertrophic moderator band with obstruction of the outflow tract. The patients was discharged with a program of sleeve-gastrectomy and after surgical correction of cardiac congenital defects. Conclusion The double-chambered right ventricle (DCRV) is an uncommon congenital anomaly: the right ventricle (RV) is divided into two chambers due to the presence of an abnormally located muscular band or anomalous muscle hypertrophy in the sub-infundibular part of RV outflow tract, with a variable grade of obstruction. This anomaly may be missed by the estimation of high pulmonary pressure through tricuspidal regurgitation. Due to limitations of echocardiography in adult patients additional imaging methods, such as MRI, combined with cardiac catheterization data are required for a definitive diagnosis.

Anomalous papillary muscle insertion into mitral valve leaflet: Autopsy study and implications

Anomalous papillary muscle (APM) insertion into the anterior mitral valve leaflet is often associated with hypertrophic cardiomyopathy (HCM) but is reported in other cases as a rare finding. Mere presence does not strictly imply hemodynamic disturbance, and several types exist, with various impacts on left ventricular outflow tract (LVOT) obstruction. The interpretation of isolated anomaly is challenging at autopsy because significant LVOT obstruction is dynamic. We analyzed autopsy cases with APM regarding the site of PM insertion and origin, number of PM bellies, anomalous insertions, heart weight, left ventricle (LV) thickness, LV endocardial fibrosis, subjects' age, sex, cause, and manner of death. A total of 20 cases were identified. Fourteen were identified incidentally, while in 670 systematically examined hearts, the APM was identified in six cases, indicating a prevalence of 0.9%. In eight cases, the manner of death was natural (one case with HCM), and in 12 non-natural. Type II anomaly of PM was most frequent (n=8), followed by Type III (n=7) and Type I (n=5). Subjects who died of natural causes were significantly older and had heavier hearts (median 455 g vs. 330 g; p < 0.05) without difference in LV thickness (median 16 mm vs. 15 mm; p > 0.05). Histology performed in four cases showed a pattern of direct insertion of cardiomyocytes into the leaflet's thick fibrous tissue with a narrow overlapping zone. The APM is rare, can be easily overlooked, and does not imply significant pathology per se. We discussed proper assessment of the significance of this anomaly at autopsy.

Accessory Soleus: Posterior Ankle Pain in Two Adolescent Athletes

Category: Sports Introduction/Purpose: Accessory soleus muscles are a rare cause of posterior ankle pain and swelling in adolescent athletes. The increased accessibility of MRI imaging has been a helpful aid its proper diagnosis and treatment. Different surgical treatment also exists including partial fasciotomy as well as surgical excision. This case report offers 2 cases of adolescent athletes with this finding causing pain and swelling in the posterior ankle limiting rigorous athletic activities that were treated with surgical excision of the accessory soleus. Methods: Two patients were evaluated in clinic for posterior ankle pain during participation in rigorous athletic activities. The first patient was a 13-year-old girl with posterior ankle pain and swelling while playing softball that limited her ability to pitch more than one inning. The second patient was a 17-year-old boy with posterior ankle pain and swelling that limited his ability to perform at peak performance during basketball games. Both patients had MRI evaluation of the ankles after months of no improvement with nonoperative treatment. MRI demonstrated accessory soleus muscles that was attributed to be the cause of their symptoms. After unsatisfactory symptom relief with nonoperative treatment measures, the two patients underwent surgical excision of the accessory soleus muscle. Results: Both patients underwent surgical excision of the accessory soleus muscle through a posteromedial approach. The accessory soleus muscle was found just anterior and medial to the Achilles tendon. The muscle was detached from its insertion into the calcaneus distally and traced back proximally. The muscle was then truncated proximally approximately 5-6 cm proximal to its insertion on the calcaneus. Both patients began weight bearing to tolerance in a walking boot immediately postoperatively. Both patients experienced resolution of their symptoms after surgical excision. Conclusion: Accessory soleus muscles are rare anomalous muscles of the posterior ankle that can cause pain and swelling with activity. Increased accessibility of MRI imaging has led to its diagnosis and treatment. Surgical excision is a reasonable surgical treatment option when nonoperative treatment fails to alleviate symptoms.

Isolated double-chambered right ventricle in a young female – a rare congenital heart disease: Evaluation by transthoracic color echocardiography and cardiac computed tomography

A double-chambered right ventricle (DCRV) is a rare congenital heart disease and an uncommon cause of congestive cardiac failure. An anomalous muscle band divides the right ventricle into two cavities, the proximal high-pressure chamber, and distal low-pressurechamber. Its origin is debated. Most cases are diagnosed and treated during childhood. Furthermore, there is tendency for progression, if not treated. Echocardiography is considered useful for diagnosis. About 80–90% patients have associated congenital anomalies, such as ventricular septal defect, pulmonary stenosis, and subaortic stenosis. Isolated DCRV is exceptionally rare. Hence, we are reporting a case of an isolated DCRV in an asymptomatic young female patient.

Subaortic Stenosis in Adult Patients With Atrioventricular Septal Defect

BackgroundPatients with atrioventricular septal defects (AVSD) are at risk for development of subaortic stenosis throughout their lifetime. The early and midterm outcomes of adults with AVSD undergoing primary operation or reoperation for subaortic stenosis remain unknown. MethodsAll patients aged 18 years or more with partial or complete AVSD who underwent operation for subaortic stenosis at our institution from 1992 to 2020 were retrospectively reviewed. ResultsNineteen patients were identified: 15 patients with partial AVSD (79%); 3 (16%) with complete AVSD; and 1 (5%) with transitional AVSD. Fifteen patients (79%) had previously corrected AVSD (median 8 years; interquartile range, 3.6-23.1) and 7 (37%) had previous repair of subaortic stenosis. The mechanism for obstruction included subaortic membrane (n = 19, 100%); septal hypertrophy (n = 11, 58%); anomalous papillary muscle, chordae, or left atrioventricular valve tissue (n = 9, 47%); and tunnel obstruction (n = 5, 26%). All patients underwent transaortic membrane resection, and septal myectomy was done in 18 patients (95%). There was no early mortality. During follow-up (median 8.3 years, maximum 28), survival was 100% at 5 years and 95% at 10 years. One patient required reintervention for subaortic stenosis 15 years after the operation at our institution. ConclusionsSurgical correction of subaortic obstruction in adult patients with AVSD can be accomplished with low morbidity and mortality. Subaortic stenosis can appear late after the initial repair of AVSD, and these patients remain at risk for recurrence after resection.