Transcript One Leaflet or Two?

Seán Hendley
Cardiac Technician
Mater Private Hospital
Initial Presentation
 63 year old female smoker (20/day) presented to G.P. with
respiratory tract infection.
 Medical history included osteopoenia diagnosed in 2007,
old tuberculosis and more recently, influenza.
 No surgical history noted.
 Family history: Mother – osteoporosis
Brother – Lung cancer
S.O.A.P.
 Subjective symptoms included general lack of energy,
dyspnoea on exertion, cough.
 Objective findings as follows:
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BP 132/89
Chest clear
Loud bruit over right renal angle
 Plan of action: for specialist cardiology review
Regional General hospital
 Patient attended her regional general hospital where
upon examination, a possible diagnosis of mitral
regurgitation and left ventricular hypertrophy were
queried.
 Trans-thoracic echocardiogram and chest X-ray
ordered.
ECG
ECG
 Abnormal
 Sinus rhythm
 Borderline left ventricular hypertrophy criteria
 Poor R-wave progression
Chest X-Ray
 PA & lateral views obtained
 Bilateral apical pleural thickening and apical fibrosis due to old
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TB.
Lungs are hyper-inflated with changes of COPD & emphysema.
Lung markings generally increased on both sides.
No focal lung lesion to suggest pneumonic consolidation noted.
No pneumothorax detected
Heart size within normal limits
Lateral view shows hyperinflation of lungs with increased AP
diameter of the chest
 Conclusion: COPD & emphysema. No pneumonia.
Consultant Physician’s thoughts
 ? Radiation of murmur to upper abdomen
 Murmur described as Loud++ , 4/6.
 ? Serious cardiac lesion
 Further echo, TOE, Cardiac catheterisation under care
of invasive cardiologist
TTE PLAX
PLAX Valve Open
PLAX Valve Closed
Mitral Leaflet Tip M-Mode
Colour M-Mode
PSAX at MV level
PSAX at MV level
Apical 4 chamber
Mitral valve CW
PSAX Pap-muscle
TOE
Official Echo Report
 Left ventricle normal in size with normal systolic function.
 Both atria appear normal in size.
 There appears to be only a single mitral valve leaflet,
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represented by a thickened anterior mitral leaflet.
No posterior mitral leaflet is visualised.
Despite this anatomic variant, the mitral valve is competent
with only trivial regurgitation seen.
Tri-leaflet aortic valve, with trivial, central aortic regurgitation.
Dilation of coronary sinuses with an AP diameter of 4cm.
Plus 1 TR with estimated right ventricular systolic pressure of 3035mmHg.
Future Plan
 Sinus rhythm; no further action warranted.
 Should she have any extra systoles, aspirin
recommended.
 Plan a re-echo in 1 year’s time.
 Patient feels her dyspnoea was related to urti and is
much improved.
To wrap up….
 Congenital anomalies of the mitral valve apparatus are rare.
 Of such cases, congenital mitral stenosis, atresia, accessory valvular
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tissue, and cleft mitral valve are more common.
Descriptions of functionally uni-leaflet mitral valves, either partial or
complete leaflet agenesis/hypoplasia are extremely rare and largely
limited to a few case reports.
In the most severe form (complete leaflet absence,) cases are usually
considered to be incompatible with life beyond the neonatal period.
Asymptomatic patients, however, do exist.
The prognosis in these asymptomatic patients is uncertain. The
potential for worsening mitral regurgitation and hence potential
morbidity and mortality primarily as a consequence of annular
dilation, has also been put forward.
Therefore, long-term monitoring with serial echocardiography seems
most appropriate.