Anomalous Papillary Muscle Insertion Causing Dynamic Left Ventricular Outflow Tract Obstruction without Hypertrophic Obstructive Cardiomyopathy

Korabathina, Ravi; Chiu, Katherine; Gelder, Hugh M. van; Labovitz, Arthur J.

doi:10.1155/2017/9878049

Cited by 7 publications

(9 citation statements)

References 20 publications

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“…In addition, anomalies such as a small left ventricular cavity, prominent papillary muscles inserting into the AML, or concurrent mitral valve disease presence are risk factors predisposing to SAM, which might also be considered an alternative strategy for mitral valve. 29,30 Our study had several limitations. First, it was a single-arm, single-center, retrospective study.…”

Section: Discussionmentioning

confidence: 95%

“…In our experience, patients with a longer length of AML that could result in residual length of the anterior leaflet beyond the coaptation point was deemed unsuitable for patch extension. In addition, anomalies such as a small left ventricular cavity, prominent papillary muscles inserting into the AML, or concurrent mitral valve disease presence are risk factors predisposing to SAM, which might also be considered an alternative strategy for mitral valve 29,30 …”

Section: Discussionmentioning

confidence: 99%

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Primeval outcomes of thoracoscopic transmitral myectomy with anterior mitral leaflet extension for hypertrophic obstructive cardiomyopathy

Tan

Wei

Liu

et al. 2022

Journal of Cardiac Surgery

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Background The transaortic Morrow procedure is the current gold standard for hypertrophic obstructive cardiomyopathy (HOCM) patients who are resistant to maximum drug therapy. It is controversial whether concomitant mitral valve intervention is necessary. Only a few centers apply for concomitant anterior mitral leaflet extension with a bovine or autologous pericardial patch to further decrease systolic anterior motion. Our aim is to assess the primeval outcomes of thoracoscopic transmitral myectomy with anterior mitral leaflet extension (TTM‐AMLE) in symptomatic HOCM patients. Methods Between April 2019 and November 2020, 18 consecutive HOCM patients who underwent TTM‐AMLE were enrolled in this study. Preoperative, postoperative, and follow‐up outcomes were compared and statistically analyzed. Results The mean age was (50.17 ± 6.18) years and 10 (55.56%) were males. 18 (100%) patients had mitral regurgitation preoperatively, and they all successfully underwent TTM‐AMLE with a median cardiopulmonary bypass and aortic cross‐clamp time of 200.0 (150.8, 232.0), and 127.5 (116.0, 149.0) min, respectively. The median length of ICU stay was 2.7 (1.4, 5.2) days. The interventricular septum thickness was significantly reduced (from 18.03 ± 3.02 mm to 11.91 ± 1.66 mm, p < .001). There was no perioperative mortality, perforation of ventricular septum, or conversion to sternotomy observed. During a median follow‐up of 18 months (IQR, 5–24 months), 1 (5.56%) patient had severe mitral regurgitation due to patch detachment and received reoperation. Moderate degree of mitral regurgitation and more than 50 mmHg in left ventricular outflow tract gradient were found in 2 (11.11%), and 1 (5.56%) patients, respectively. 1 (5.56%) patient who had second‐degree atrioventricular block received permanent pacemaker implantation postoperatively. Overall, the maximum left ventricular outflow tract gradient (88.50 [59.50, 112.75] mmHg vs. 10.50 [7.00, 15.50] mmHg, p = .002), left ventricular outflow tract velocity (4.70 [3.86, 5.33] m/s vs. 1.60 [1.33, 1.95] m/s, p < .001) and the degree of mitral regurgitation (6.99 ± 4.47 cm2 vs. 2.22 ± 1.51 cm2, p = .001) were significantly decreased, with a significant reduction in the proportion of systolic anterior motion (94.44% vs. 16.67%, p < .001). Conclusions The TTM‐AMLE is a safe and effective surgical approach for selected patients with HOCM. In our series, it provides excellent relief of left ventricular outflow tract obstruction, while significantly eliminating mitral regurgitation. The early outcomes of TTM‐AMLE are satisfactory, but further studies and longer follow‐ups are awaited.

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Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%

Primeval outcomes of thoracoscopic transmitral myectomy with anterior mitral leaflet extension for hypertrophic obstructive cardiomyopathy

Tan

Wei

Liu

et al. 2022

Journal of Cardiac Surgery

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“…On the other hand, this anomaly produces significant LVOT obstruction in some people. The highlight of this pathophysiology is the dynamic component: potentially significant obstruction occurs only during systole [1,3,6,23,24]. During contraction, the papillary muscle can occupy an atypical location within the LV and form a rigid area of mid-cavity narrowing [25].…”

Section: Discussionmentioning

confidence: 99%

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

Leković

Živković

Nikolić

2022

Journal of Forensic Sciences

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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.

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“…The connection of LV false tendon is found between normal structures but not with accessory tissue. The echocardiographic feature of anomalous PM insertion is a large muscle with short chordae extending from the anterior MV; however, our case had relatively long chordae and a well-developed PM [ 12 ]. The vegetation, redundant MV chordae tendineae, and cardiac tumors were also excluded from the differential diagnosis [ 6 ].…”

Section: Discussionmentioning

confidence: 99%

Echocardiographic features of accessory mitral valve tissue presenting left ventricular outflow tract obstruction in a dog

2021

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In a 3-year-old Samoyed, aortic bulging was found on radiography during a general check-up. On echocardiography, turbulent flow was found in left ventricular outflow tract (LVOT) with high velocity (6.1 m/s). A linear structure was attached to the interventricular septum and connected to the chordae tendineae reaching the papillary muscle. A part of the structure moved during cardiac cycle, similar to mitral motion. This dog was diagnosed with LVOT obstruction caused by accessory mitral valve tissue (AMVT). This is the first report of AMVT in veterinary medicine. AMVT should be considered as a possible cause of LVOT obstruction in dogs.

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Anomalous Papillary Muscle Insertion Causing Dynamic Left Ventricular Outflow Tract Obstruction without Hypertrophic Obstructive Cardiomyopathy

Cited by 7 publications

References 20 publications

Primeval outcomes of thoracoscopic transmitral myectomy with anterior mitral leaflet extension for hypertrophic obstructive cardiomyopathy

Primeval outcomes of thoracoscopic transmitral myectomy with anterior mitral leaflet extension for hypertrophic obstructive cardiomyopathy

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

Echocardiographic features of accessory mitral valve tissue presenting left ventricular outflow tract obstruction in a dog

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