Rare Echocardiographic Finding Research Articles

THE SIGN OF THE HORNS: A RARE CASE OF DOUBLE PERI–COMMISSURAL MITRAL FLAIL

Abstract A 80–year–old man with history of hypertension and dyslipidemia was admitted to our Cardiology Unit for exertional dyspnea (NYHA III) occurred during the last few days. The physical examination showed a systolic heart murmur (4/6 on Levine scale) and signs of pulmonary congestion. Transthoracic echocardiography revealed a massive mitral regurgitation (Fig.1) together with severe dilation of the left atrium, mild–to–moderate aortic regurgitation, high probability of pulmonary hypertension and normal biventricular systolic function. A transesophageal echocardiography (TEE) was performed to clarify mitral valve anatomy. A double flail of the posterior leaflet was present involving the peri–commissural portions due to a single chordal rupture on P1 scallop and a double chordal rupture on P3 scallop (Fig.2). P2 scallop was prolapsing and there was a billowing of the anterior leaflet. In addiction mitral annulus was dilated (antero–posterior diameter of 43 mm and intercommissural diameter of 45 mm). We named this finding “sign of the horns” for his 3D echocardiographic appearance (Fig.3) given the double flail resembling two fingers. A surgical correction was performed with 3 GoreTex neochords implantation on the posterior leaflet and an annuloplasty ring (Physio II n. 34) implantation during extracorporeal circulation through right anterior minithoracotomy. Surgical and echocardiographic results were optimal. The patient was discharged after 7 days of hospitalization. Conclusion Coexistence of a double peri–commissural flail in the same leaflet is a very rare echocardiographic finding and we named it “double horn sign”. TEE is an essential examination in this scenario in order to understand the exact mechanism of the regurgitation for an optimal preoperative planning.

LAMBL EXCRESCENCE IN A PATIENT WITH SEPSIS: COULD IT BE JUST ENDOCARDITIS?

LAMBL EXCRESCENCE IN A PATIENT WITH SEPSIS: COULD IT BE JUST ENDOCARDITIS?

A case of ‘snake thrombus’ in the right heart secondary to renal cell carcinoma: a rare echocardiographic finding

A case of ‘snake thrombus’ in the right heart secondary to renal cell carcinoma: a rare echocardiographic finding

Quadricuspid aortic valve – a case report of a rare echocardiographic finding

Quadricuspid aortic valve – a case report of a rare echocardiographic finding

Giant Pulmonary Artery Aneurysm in Bicuspid Pulmonary Valve: Does the Right Side Mimic the Left One?

Bicuspid pulmonary valve is a rare echocardiographic finding, particularly if not associated with other congenital heart diseases. We report the incidental case of a severe giant pulmonary arterial aneurysm associated to bicuspid pulmonary valve in an asymptomatic 79-year-old patient. Multimodality cardiac imaging was important for the correct diagnosis and to exclude any other potential complication. (Level of Difficulty: Beginner.)

PP-106 - Isolated Papillary Muscle Hypertrophy: Part or Begining of Hypertrophic Cardiomyopathy

Objective: Isolated papillary muscle hypertrophy (IPMH) is a rare echocardiographic finding, with very few cases reported in the literature. There are scarce data about clinical implication of IPMH especially in patients with myocardial bridging (MB). Physcians should pay sufficient attention with regard to coincidence of IPMH and MB. Definition of HCM might be broadened due to limited definition criteria. Further studies and investigations are needed to clinical implication of IPMH.

Multimodality imaging assessment of a caseous calcification of the mitral valve annulus

Caseous calcification of the mitral annulus (CCMA) is a rare echocardiographic finding. It is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. Since it is a benign process, differentiating it from malignant intra-cardiac mass is primordial to avoid unnecessary surgery. Various imaging modalities can be complimentary for definitive diagnosis. We present a case of CCMA in a 71-year-old female patient. Her medical history revealed hypertension, diabetes mellitus, hyperlipidaemia and coronary artery disease. She was referred to our department for coronary catheterization because of angina symptoms upon minimal exertion. The lesion was detected during echocardiography and was defined as a mass of heterogeneous content with calcification points, located at the posterior side of the mitral valve annulus. Restricted motion of the posterior leaflet and the mass effect caused only minimal mitral regurgitation. To establish the correct diagnosis, we performed the full spectrum of noninvasive cardiac imaging modalities. Transesophageal echocardiography identified well-organized, composite lesion with regular edges, markedly calcified margins and more echolucent central portion. A computed tomography (CT) was performed, showing a hyperdense mass with hypodense center and a calcified peripheral rim located at the posterior mitral ring. Cardiac magnetic resonance imaging (MRI) showed that the mass was hypointense with respect to the myocardium in the T1 and T2-weighted sequences and only presented late-phase enhancement in the surrounding capsule. Based on the CT and MRI findings, the diagnosis of CCMA was established. The patient was managed conservatively.

Aortic redissection after glue repair: a rare echocardiographic finding.

A 66-year-old male patient underwent supracoronary ascending aortic grafting and resuspension of the incompetent aortic valve because of a type A aortic dissection. Three months later, he presented with ongoing low-grade fever and sternal wound discharge. Wound and blood cultures were positive for methicillinresistant Staphylococcus aureus. Sinography was consistent with mediastinitis and infection of the vascular prosthesis. Magnetic resonance angiography and computed tomography angiography showed redissection at the distal anastomotic site extending down to the abdominal aorta and both of the common iliac arteries. Transesophageal echocardiography (TEE) findings were equivocal (Fig. 1). We considered the possibility of vegetation on the vascular graft. After a 6-week-long unsuccessful treatment with intravenous antibiotics, the patient was referred for redo surgery. Surgical findings included: (1) dehiscence of the distal anastomotic site and (2) a piece of surgical adhesive (BioGlue , CryoLife, Inc., Kennesaw, GA), which was used during the first operation, found protruding into the false aortic lumen (Fig. 2). This piece of surgical glue produced the rare echocardiographic picture seen on TEE.

Solitary papillary muscle hypertrophy: Is it hypertrophic cardiomyopathy or athlete's heart

Papillary muscle hypertrophy is a rare echocardiographic finding. We report a case of solitary papillary muscle hypertrophy in a football player presenting with atypical chest pain and high QRS voltage on ECG.

A Case of an Anomalous Hypertrophied Muscle Band in the Left Ventricle

A hypertrophied muscle band (HMB) in the left ventricle (LV), which can be misinterpreted as apical hypertrophic cardiomyopathy, is a rare echocardiographic finding in a patient with normal LV wall thickness. Not only are symptoms produced, but changes in the electrocardiogram (ECG) are limited to the repolarization phase and show no progression even in a large HMB. Hence, we report a case of a 25-year-old woman who visited a local medical clinic due to epigastric discomfort in January 2007. The 24-hour Holter ECG showed multiple premature ventricular complexes. An HMB (3.23 × 10.8 cm) was observed on two-dimensional echocardiography that ran toward the interventricular septum (IVS) across the LV and divided the LV into apical and basal cavities at the apical one-third of the LV. Although LV wall thickness showed normal range, flow acceleration was observed between the HMB and IVS and revealed dagger-shaped with a high pressure gradient up to 30 mmHg in continuous wave Doppler examination. Circumferential band-like myocardial hypertrophy was observed at the LV apex on cardiac magnetic resonance imaging. Myocardial thinning and prominent trabeculae were present from the proximal to distal HMB. However, contractility was normal at the myocardial thinning site, regional wall motion abnormality was not observed in cine images. Focal fatty accumulation was evident at the base of the HMB. Coronary angiography revealed no significant stenosis, whereas left ventriculography showed septation at the apical one-third of the LV. The patient was discharged without any medication.

Caseous Calcification of the Mitral Annulus, a Rare Echocardiographic Finding

Caseous calcification of mitral annulus, also known as caseoma, is a rare echocardiographic finding. Because it often presents asymptomatically, the diagnosis is usually incidental. The condition arises due to caseous degeneration in the internal material of the mitral annulus calcification. On echocardiography, the calcification is a round mass with a central echolucent area, typically located at the base of the posterior leaflet, and can be mistaken for cardiac tumors or abscesses. We describe 3 patients with the condition, one of whom required surgical removal of the mass to obtain a definitive diagnosis.

Calcificación caseosa del anillo mitral, un raro hallazgo ecocardiográfico

Caseous calcification of mitral annulus, also known as caseoma, is a rare echocardiographic finding. Because it often presents asymptomatically, the diagnosis is usually incidental. The condition arises due to caseous degeneration in the internal material of the mitral annulus calcification. On echocardiography, the calcification is a round mass with a central echolucent area, typically located at the base of the posterior leaflet, and can be mistaken for cardiac tumors or abscesses. We describe 3 patients with the condition, one of whom required surgical removal of the mass to obtain a definitive diagnosis. Full English text available from: www.revespcardiol.org

Mitral and aortic valve aneurysms secondary to infective endocarditis: impressive images of a rare echocardiographic finding

Mitral and aortic valve aneurysms are uncommon, but the coexistence of both mitral and aortic valve aneurysms in the same patient is a rather unusual finding in the literature. We report a rare clinical case of a patient with both mitral and aortic valve aneurysms and a rupture of the mitral valve aneurysm, as the main echocardiographic manifestations of infective endocarditis. This clinical case emphasizes infective endocarditis as the most frequent cause of valve aneurysms, reminding that this diagnosis should be suspected even in the absence of vegetations. This case demonstrates that transoesophageal echocardiography plays a major role on diagnosis of valve aneurysms, revealing the rupture of the mitral valve aneurysm and defining this rupture as the main mechanism of mitral valve regurgitation. This case also underlines the role of transoesophageal echocardiography on management decisions, allowing a morphological evaluation of the mitral valve and selection of the appropriate surgical strategy.

False Tendon Rupture Mimicking Chorda Rupture

False tendons are fibromuscular intracavitary bands that can mimic pathologic structures such as intraventricular chorda rupture, vegetation, or thrombus. False tendon rupture is a rare echocardiographic finding, reported in only a few case reports. In this case report, the authors present a patient with false tendon rupture that mimicked intraventricular chorda rupture.

Congenital Right Ventricular Diverticulum Associated With a Ventricular Septal Defect: A Rare Echocardiographic Finding

A neonate presented on the first day of life with tachypnea and poor feeding. The infant's initial echocardiogram demonstrated outpouching of the lateral wall of the right ventricle (RV) associated with a large ventricular septal defect (VSD). At 9 days of age he was diagnosed with osteogenesis imperfecta (OI). Despite treatment with digoxin, diuretics, and captopril he required hospitalization twice during his first 2 months of life for congestive heart failure (CHF). The VSD was closed at three and one-half months of age without resection of the diverticulum and CHF symptoms resolved. At 26 months of age he is doing well despite the residual RV diverticulum. Congenital cardiac diverticula are rare forms of cardiac malformations and their echo-Doppler features are herein discussed.

A rare echocardiographic finding after cardiac surgery

From the Departments of *Anesthesiology and Intensive Care Medcine; and †Cardiac, Thoracic and Vascular Surgery, Friedrichchiller-University of Jena, Jena, Germany. Address reprint requests to Egbert Huttemann, MD, DEAA, Klinik fur nasthesiologie und Intensivtherapie, Universitatsklinik, Friedrichchiller-Universitat Jena, Bachstrasse 18, D-07740 Jena, Federal Reublic of Germany. E-mail: egbert.huettemann@med.uni-jena.de © 2004 Elsevier Inc. All rights reserved. 1053-0770/04/1804-0025$30.00/0 doi:10.1053/j.jvca.2004.05.013

Truncus Arteriosus With Patent Ductus Arteriosus and Normal Aortic Arch

In hearts with a common arterial trunk (truncus arteriosus), there is almost always an inverse development of the aortic arch and the ductus arteriosus. Truncus with a normal aortic arch and a patent ductus is a rare echocardiographic and surgical finding. In this report, we describe 2 neonates in whom truncus arteriosus with a normal aortic arch and a medium or large patent ductus was diagnosed by preoperative echocardiography (without catheterization) and confirmed intraoperatively.