Unusual papillary muscle hypertrophy in a septuagenarian

Abstract

A 73-year-old nonhypertensive man was admitted to the GB Pant Hospital for chest pain and dyspnea on exertion. Transthoracic echocardiography revealed severe mitral regurgitation with mild aortic stenosis (mean gradient, 24 mm Hg) and concentric left ventricular hypertrophy (LVH). The ejection fraction was 0.67. Mitral valve replacement with intraoperative transesophageal echocardiography was planned. During surgery, gross hypertrophy of the anterolateral papillary muscle (Figure 1) was found, which prompted a review of the patient's charts. Apart from increased voltages consistent with LVH, electrocardiogram revealed a peculiar pattern in leads V3 and V4: prominent, positive U waves that were missed on initial evaluation (Figure 2).Hypertrophic cardiomyopathy (HCM) is a highly heterogeneous disorder with mutations in genes coding for proteins of the cardiac sarcomere, manifesting as LVH without obvious cause. 1 Papillary muscle hypertrophy and positive U waves are rare but documented features of HCM. 2 In view of the patient's age, nonobstructive nature of his disease, and absence of atrial fibrillation, no further surgical intervention was planned. Because calcium antagonists are the preferred therapy for nonobstructive HCM with normal systolic function, 1 the patient was prescribed oral diltiazem postoperatively. He was discharged uneventfully and continues to do well on follow-up.

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“…Not until recently, morphological papillary muscle anomalies without features of phenotypic LV hypertrophy (isolated papillary muscle hypertrophy) had gradually been recognized to be an uncommon HCM variant [8,10]. The clinical features of LV mid-cavity obstruction caused by papillary muscle hypertrophy may vary greatly from asymptomatic to dyspnea, angina, syncope, and even sudden cardiac death [8][9][10], with prominent U wave and left ventricular hypertrophy by ECG [11,12], which is concordant with our current case findings.…”

Solitary accessory and papillary muscle hypertrophy manifested as dynamic mid-wall obstruction and symptomatic heart failure: diagnostic feasibility by multi-modality imaging

“…Not until recently, morphological papillary muscle anomalies without features of phenotypic LV hypertrophy (isolated papillary muscle hypertrophy) had gradually been recognized to be an uncommon HCM variant [8,10]. The clinical features of LV mid-cavity obstruction caused by papillary muscle hypertrophy may vary greatly from asymptomatic to dyspnea, angina, syncope, and even sudden cardiac death [8-10], with prominent U wave and left ventricular hypertrophy by ECG [11,12], which is concordant with our current case findings.…”

Type III hemifacial microsomia in a kitten

“…12–15 It is thought to be either a new subtype or early form of HCM, 12 and is rare in humans. 16,17 In contrast, the most commonly seen heart defects in humans with OAVS are tetralogy of Fallot and ventricular septal defect; however, no single cardiac lesion is characteristic. 18,19…”

“…[12][13][14][15] It is thought to be either a new subtype or early form of HCM, 12 and is rare in humans. 16,17 In contrast, the most commonly seen heart defects in humans with OAVS are tetralogy of Fallot and ventricular septal defect; however, no single cardiac lesion is characteristic. 18,19 This case was successfully managed with dental extractions, as reported previously in an 11-year-old DSH cat with class 1 malocclusion of the mandibular canine teeth and maxillary right and left third incisor teeth.…”