Systolic Anterior Motion of the Mitral Valve and Outflow Obstruction After Mitral Valve Reconstruction

ACKNOWLEDGMENT: The authors wish to thank Dr. Charles Bredin for referring the patient to us. Dr. Wen-hsien Wu solved the complex anesthesia problems necessitated by the rigid bronchoscopy performed by Dr. Paul BoJanowski. Ms. Jean Norwood provided secretarial assistance. REFERENCES

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Fraser RG, Pare JAP. Neoplastic diseases of the chest. In: Fraser RG, Pare JAP, eds. Diagnosis of diseases of the chest. 2nd ed. Philadelphia: WB Saunders Co, 1978 Spencer H. Rare pulmonary tumors. In: Spencer H, ed. Pathology of the lung. 3rd ed. New York: Pergamon Press, 1977 Danos M, Keebler CM. Cytopreparatory technique: a manual of cytotechnology, 5th ed. Chicago: American Society of Clinical Pathologists, 1977:301 Kaufman G, Klopstock R. Papillomatosis of the respiratory tree. Am Rev Respir Dis 1968; 88:839 Popovich J Jr, Kvale PA, Eichenhom MS, Radke JR, Ohorodnik JM, Fine G. Diagnostic accuracy of multiple biopsies from flexible fiberoptic bronchoscopy: a comparison of central versus peripheral carcinoma. Am Rev Respir Dis 1982; 125:521-23 Martini N, McCormick PM. Assessment of endoscopically visible bronchial carcinomas. Chest 1978; 73:718-20 Ruckdeschel JC, Caradonna R, Paladine WJ, Hillinger SM, Horton J. Small cell anaplastic carcinoma of the lung: changing concepts and emerging problems. CA 1979; 29:84

Systolic Anterior Motion of the Mitral Valve and Outflow Obstruction After Mitral Valve Reconstruction* Petn- E. Gallet'ltein, M.D .;t Marvin Berger, M.D., F.C.C .P.;* Stephen Rubenatein, M.D .;§ Rtusell L. Berdoff, M.D.;II and Emanuel Goldberg, M.D., F.C.C.P.*

A 62-year-old woman with acute mitral regurgitation due to ruptured chordae tendineae underwent mitral valve reconstruction. Postoperatively, subaortic outflow obstruction developed. Echocardiography revealed marked systolic anterior motion of the mitral valve. We did not find a similar case in the literature.

CASE REPORT

A 62-year-old woman was referred because of the recent onset of severe dyspnea. Other than being told of a "functional murmur" as a child, she had a history of excellent health and denied any history of cardiac disease. Four days prior to hospital admission, she noted the abrupt onset of severe shortness of breath. At no time did she experience any chest pain, and there was no history of recent dental work, fever, or infection. Physical examination revealed a regular pulse rate of 108/min, a blood pressure of 110172 mm Hg supine, a respiratory rate of 20/min, and a temperature of 37.1"C. Chest examination was remarkable for dullness to percussion and decreased breath sounds at both bases and rales to the level of the scapula bilaterally. The cardiac apex was displaced laterally. The S, was normal, S1 was physiologically split, and an S3 was present. A grade 316 blowing holosystolic murmur was best heard at the apex with radiation over the entire precordium; no diastolic murmur was present. An ECG revealed sinus tachycardia, left atrial enlargement, and nonspecific ST-T wave changes. Chext x-ray film showed pulmonary vascular congestion and bilateral pleural effusions. M-mode echocardiography revealed dilation of both the left atrium (54 mm) and left ventricle (end-diastolic dimension of 65 mm); interventricular septal thickness was normal (8 mm). The left ventricular outflow tract width, measured from the point of mitral valve closure to the left side of the septum, was also normal (32 mm).7 There was marked systolic prolapse of the posterior leaflet (Fig 1) suggestive of mitral valve prolapse and/or a flail leaflet. Twodimensional echocardiography was consistent with a Bail leaflet. Cardiac catheterization showed 4 + mitral regurgitation and no gradient between the left ventricle and aorta. The patient was referred for mitral valve surgery two weeks after initial hospitalization. At the time of surgery, examination of the mitral valve revealed three ruptured chordae in the midportion of the posterior leaflet, and this area was excised. The medial portion of the anterior leaflet showed elongated chordae, one of which was shortened by approximately 6 mm, and an annuloplasty was then done using a No. 32 Carpentier-Edwards ring. After removal of the patient from cardiopulmonary bypass, there was no evidence of mitral insufficiency or of a gradient across the mitral valve. However, I

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he most common etiology ofsubvalvular aortic stenosis is hypertrophic obstructive cardiomyopathy (HOCM). One of the associated echocardiographic findings in this disorder is systolic anterior motion (SAM) of the mitral valve, first described by Shah et al' in 1969. Since then, SAM has been described in other disorders, including mitral valve prolapse (MVP) 2.. and atrial septal defect" as well as hypercontractile states.• We report a case of SAM with a subaortic outflow gradient following a mitral valvuloplasty and annuloplasty. *From the DeJ>811ment of Medicine, Division of Cardiology, Beth Israel Medicil Center, and the Department of Medicine, The Mount Sinai School of Medicine of the City University of New York, New York. t Assistant Professor of Clinical Medicine. *Associate Professor of Clinical Medicine. §Clinical Instructor in Medicine. lllnstructor in Medicine. Reprint requests: Dr: Gallerstein, Beth Israel Medical Center, 330 East 17th Street, New York 10003

FIGURE 1. Preoperative M-mode echocardiogram showing marked systolic prolapse of the posterior leaflet (PML). AM L =anterior mitral leaflet. CHEST I 83 I 5 I MAY, 1983

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tioning of the mitral valve closer to the septum, as suggested by the decrease in left ventricular outflow tract width. This would enhance any Venturi effect contributing to the production of SAM. In a recent review by Carpentier et alu of mitral valve reconstructive surgery, outflow obstruction was not mentioned as a complication. The findings in this patient indicate that SAM and dynamic subaortic obstruction may occur as a result of such surgery.

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REFERENCES

FIGURE 2. Postoperative M-mode echocardiogram showing marked SAM (arrows) and phonocardiogram showing systolic ejection murmur (SM). Sep =intraventricular septum ; AML =anterior mitral leaflet; PML =posterior mitral leaflet. a 20 to 30 mm Hg gradient was measured between the body of the left ventricle and the ascending aorta. Repeated M-mode and twodimensional echocardiograms were performed. There was a decrease in left ventricular diastolic dimension (48 mm) and left ventricular outflow tract width (22 mm). The most remarkable finding (Fig 2) was that of SAM with direct apposition of the septum and mitral valve. Physical examination now revealed an ejectiontype murmur along the left sternal border; the blowing apical murmur was no longer present. Pathologic study of the excised portion of mitral valve showed fibrosis and myxoid degeneration. DISCUSSION

Various mechanisms for SAM have been proposed, including a Venturi effect created by rapid ejection of blood which draws the anterior leaflet forward, •-• buckling of the chordae tendineae,l-• narrowing of the outflow tract," and displacement of the posterior papillary muscle. 10 The most common setting for the finding of SAM is HOCM, though it has been described in other disorders including MVP.•-• Our patient had no evidence of HOCM, and, though the pathologic findings are consistent with MVP, no SAM or gradient was present prior to surgery. We believe that the surgery resulted in anatomic changes that are responsible for the findings in our patient. In addition to excision of a portion of the mitral valve apparatus and placement of the Carpentier-Edwards ring, one of the chordae attached to the anterior leaflet was shortened. Due to this latter procedure, the anterior leaflet may be drawn further into the outflow tract than normally occurs during ventricular systole and papillary muscle contraction. This could result in the SAM and outflow gradient. The mitral regurgitation and left ventricular volume overload were corrected by the surgery, and there was an appropriate decrease in the left ventricular end-diastolic dimension. The decrease in left ventricular size and shortening of the chordae may have resulted in end-diastolic posi820

1 Shah PM , Gramiak R, Kramer DH. Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy. Circulation 1969; 40:3-11 2 Kerin NZ, Wajszczuk WJ, Cascade PN, Shairer J, Ruben6re M. Echocardiographic source of early anterior systolic motion in late systolic mitral valve prolapse. Chest 1980; 77:567-570 3 Gardin JM , Talano JV, Stephanides L, Fizzano J, Lesch M. Systolic anterior motion in the absence of asymmetrical septal hypertrophy: a buckling phenomenon of the chordae tendineae. Circulation 1981; 63:181-188 4 Terasawa Y, 1imaka M, Konno K, Niita K, Kashiwagi M, Mieguro, et al. Mechanism of productionof midsystolic click in a prolapsed mitral valve. Jpn Heart J 1977; 18:652-663 5 Tajik AJ, Grau GT, Schattenberg TT. Echocardiographic "pseudo-IHSS" pattern in atrial septal defect. Chest 1972; 62:324-325 6 Come PC, Bulkley BH, Goodman ZD, Hutchins GM , Pitt B, Fortuin NJ. Hypercontractile states simulating hypertrophic cardiomyopathy. Circulation 1977; 55:901-908 7 Gramiak R, Shah PM . Cardiac ultrasonography: a review of current applications. Radio! Clin North Am 1971; 9:469-490 8 Wigle ED, Felderhof CH , Silver MD, Adelman AG. Hypertrophic obstructive cardiomyopathy (muscular or hypertrophic subaortic stenosis). In: Fowler Nu, ed. Myocardial diseases. New York: Grune & Stratton, 1973 9 Henry WL, Clark CE, Griffith JM . Mechanism ofleft ventricular outflow obstruction in patients with obstructive asymmetrical septal hypertrophy (idiopathic hypertrophic subaortic stenosis). Am J Cardiol1975; 35:337-345 10 Rodger JC. Motion of mitral apparatus in hypertrophic cardiomyopathy. Br Heart J 1976; 38:732-737 11 Carpentier A, Chauvaud S, Fabiani JN, Deloche A, Reiland J, Lessani A, et al. Reconstructive surgery of mitral valve incompetence. J Thorac Cardiovasc Surg 1980; 79:338-348

Noninvasive Diagnosis Cervical Aortic Arch*

of Right

Ivan A D'Cruz, M.D .; Ava Stanley, M.D. ; Dolores VituUo , M.D. ; Padma Desai, M.D .; and Pipit Chiemmangkoltip, M.D.

A two-year old asymptomatic boy presented with a systolic right supraclavicular thrill. Two-D echography revealed a pulsating loop of tubular echo-free space at this site. Barium esophagogram showed a large curved retroesophageal impression. A noninvasive diagnosis of right cervical aortic arch with left descending aorta can be made on the basis of this combination of findings. *From the Cardiovascular Institute, Departments of Medicine and Pediatrics, Michael Reese Medical Center and University of Chicago, Pritzker School of Medicine, Chicago. Reprint requests: Ms. A Indovina, Cardiovascular Institute, Michael Reese Hospital and Medical Center, Chicago 60616 NonlnvasiYe Olagnosla of Right Cervical Aortic Arch (D'Cruz et all