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The British Journal of Radiology, 81 (2008), e266–e268 CASE REPORT Multidetector CT presentation of a parachute-like asymmetric mitral valve 1 O UCAR, MD, 2M VURAL, MD, 1 H CICEKCIOGLU, MD, 2 L PASAOGLU, MD, 1 S AYDOGDU, MD and 2 S KOPARAL, MD Departments of 1Cardiology and 2Radiology, Ankara Numune Education and Research Hospital, Talatpasa Bulvari, 06430, Sihhiye, Ankara, Turkey ABSTRACT. A 24-year-old man with a complaint of exertional dyspnoea had a Grade III/ VI apical pansystolic murmur on physical examination. He underwent a transthoracic echocardiogram, which revealed a funnel-shaped mitral valve with moderately thick leaflet tissue and an eccentric orifice, as well as a bicuspid aortic valve. The mitral valve was mildly stenotic and severely regurgitant. Although demonstration of a single Received 25 February 2007 papillary muscle in the parasternal short axis view suggested a parachute mitral valve, Revised 1 July 2007 the diagnosis was uncertain owing to poor echocardiographic acoustic quality. 16-row Accepted 17 September multidetector CT (MDCT) clearly demonstrated two papillary muscles and the patient 2007 was diagnosed as having a parachute-like asymmetric mitral valve. In conclusion, MDCT DOI: 10.1259/bjr/20218809 can be used as a complementary imaging technique for the evaluation of subvalvular mitral apparatus and papillary muscles, especially in patients with poor ’ 2008 The British Institute of echocardiographic acoustic quality. Radiology A 24-year-old man presented with exertional dyspnoea. apparatus. The MDCT was performed using a 16-slice He had a non-documented history of rheumatic valvular Toshiba multidetector Aquilion system (Toshiba Medical heart disease. His vital signs were stable and he had no Systems, Otawara, Japan). 120 ml of non-ionic contrast signs of pulmonic disease. On cardiac auscultation, the material was injected in the antebrachial vein with a flow patient had a Grade III/VI pansystolic murmur best heard rate of 4.5 ml s21. The imaging and reconstruction at the apex. His electrocardiogram was normal except for parameters were as follows: detector collimation 16 6 a biphasic P-wave with terminal negativity in lead V1, 0.75 mm, voltage 120 kV, current 350 mA, rotation time suggesting left atrial abnormality. His physician ordered 0.42 s, reconstruction slice width 1 mm and increment an echocardiogram. On transthoracic echocardiography, 0.5 mm. Retrospective electrocardiographic gating was left ventricular ejection fraction and peak systolic pul- used to eliminate cardiac motion artefacts, and sagittal monary artery pressure were within normal limits. The coronal multiplanar reformats were reconstructed on a mitral valve was funnel-shaped with moderately thick Vitrea post-processing workstation. Image reconstruction leaflet tissue and an eccentric orifice (Figure 1). There was was performed in 10% steps through the entire R–R a prominent systolic prolapse of the anterior mitral leaflet. interval, and 0–90% phase cine displays were evaluated in Severe mitral regurgitation was seen with colour Doppler, the short- and long-axis of the heart. MDCT clearly and the left atrium was enlarged. The mean diastolic demonstrated two seperate papillary muscles settled gradient between the left atrium and left ventricle was abnormally close to each other. The posteromedial detected as 5 mmHg by continuous wave Doppler. The papillary muscle had two heads and the anterolateral aortic valve was bicuspid with normal function. Although papillary muscle seemed to be dominant (Figure 3). the morphological characteristics of the mitral valve Abnormal disorientation and asymmetry of the papillary resembled those of rheumatic valvular heart disease, muscles caused valvular dysfunction similar to PMV, demonstration of a single posteromedial papillary muscle with both stenosis and prolapse (Figure 4). The bicuspid with multiple heads in the parasternal short axis view, aortic valve was also displayed on MDCT (Figure 5). The together with the bicuspid aortic valve, suggested a patient was diagnosed as having ‘‘parachute-like asym- diagnosis of ‘‘parachute mitral valve’’ (PMV) (Figure 2). metric mitral valve’’ with bicuspid aortic valve. Exclusion However, owing to poor echocardiographic acoustic of rheumatic valvular heart disease aborted the need for quality, a definite diagnosis could not be made. The long-term penicillin prophylaxis. patient refused a transoesophageal echocardiographic examination and underwent 16-row multidetector CT (MDCT) in order to evaluate the subvalvular mitral Discussion Address correspondence to: Ozgul Ucar, Keklikpinari Mah, 463/7, PMV is a congenital abnormality characterized by a 06450, Dikmen, Ankara, Turkey. E-mail: firstname.lastname@example.org single centrally located papillary muscle that receives all e266 The British Journal of Radiology, November 2008 Case report: MDCT presentation of a parachute-like asymmetric mitral valve Figure 1. Transthoracic echocardiogram demonstrating a funnel-shaped mitral valve with a moderately thick leaflet tissue and an eccentric orifice in a modified apical four- chamber view. LA, left atrium; LV, left ventricle. chordae . The leaflets and chordae are also abnormal, Figure 3. Oblique coronal multiplanar reformatted image demonstrating abnormally close papillary muscles. The with variable degrees of thickening and shortening. The posteromedial papillary muscle has two heads and the mitral valve can be stenotic and regurgitant. PMV anterolateral papillary muscle appears to be dominant. usually appears as a part of the Shone complex (PMV, supravalvular mitral ring, subaortic stenosis and coarc- tation of the aorta) . In one study, a bicuspid aortic muscles. However, in cases of poor echocardiographic valve was present in 50% of patients with PMV . A acoustic quality, transthoracic echocardiography may differential diagnosis of PMV should be made from a not yield a definite diagnosis. In such situations, MRI is a parachute-like asymmetric mitral valve and rheumatic reasonable alternative with which to evaluate the mitral mitral disease. In contrast to true PMV, a parachute-like valve. However, owing to technical insufficiencies, we asymmetric mitral valve has two separate papillary continued to use MDCT. Although MDCT of the heart is muscles, with one being more dominant. The dominant used largely to evaluate the coronary arteries, there is papillary muscle is usually located higher in the left accumulating evidence for its utility in the evaluation of ventricle and is attached to the ventricular wall from heart valves and chambers [5–7]. In our case, MDCT both the base and the lateral side . The papillary gave complementary information about the papillary muscle anatomy is normal in rheumatic valvular heart muscle anatomy of the mitral valve and helped in the disease, in which the leaflets and subvalvular apparatus final diagnosis. are thickened and fused. Transthoracic echocardiogra- phy is the primary tool used in the differential diagnosis. A parasternal short axis view is the main window for evaluation of the number and orientation of papillary Figure 2. Transthoracic echocardiogram showing a single Figure 4. Oblique short-axis image of the papillary muscles; posteromedial papillary muscle with multiple heads in the abnormally close papillary muscles and systolic prolapse of parasternal short-axis view. LV, left ventricle. the anterior mitral leaflet are seen. The British Journal of Radiology, November 2008 e267 O Ucar, M Vural, H Cicekcioglu et al papillary muscles, especially in patients with poor echocardiographic acoustic quality. References 1. Oosthoek PW, Wenink AC, Wisse LJ, Gittenberger-de Groot AC. Development of the papillary muscles of the mitral valve:morphogenetic background of parachute-like asym- metric mitral valves and other mitral valve anomalies. J Thorac Cardiovasc Surg 1998;116:36–46. 2. Shone JD, Sellers RD, Anderson RC, Adams P Jr. The developmental complex of ‘‘parachute mitral valve’’, supra- valvular ring of left atrium, subaortic stenosis, and coarcta- tion of aorta. Am J Cardiol 1963;11:714–25. 3. Schaverien MV, Freedom RM, McCrindle BW. Independant factors associated with outcomes of parachute mitral valve in 84 patients. Circulation 2004;109:2309–13. 4. Oosthoek PW, Wenink AC, Macedo AJ, Gittenberger-de Groot AC. The parachute-like asymmetric mitral valve and its two papillary muscles. J Thorac Cardiovasc Surg 1997;114:9–15. 5. Alkadhi H, Bettex D, Wildermuth S, Baumert B, Plass A, Grunenfelder J, et al. Dynamic cine imaging of the mitral valve with 16-MDCT: a feasibility study. AJR Am J Figure 5. Axial oblique multiplanar reformatted image Roentgenol 2005;185:636–46. showing the bicuspid aortic valve. 6. Pannu HK, Jacobs JE, Lai S, Fishman EK. Gated cardiac imaging of the aortic valve on 64-slice multidetector row computed tomography:preliminary observations. J Comput Conclusions Assist Tomogr 2006;30:443–6. 7. Vogel-Claussen J, Pannu H, Spevak PJ, Fishman EK. Cardiac MDCT can be a complementary imaging technique for valve assessment with MR imaging and 64-section multi- the evaluation of subvalvular mitral apparatus and detector row CT. Radiographics 2006;26:1769–84. e268 The British Journal of Radiology, November 2008
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