Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging

INTERESTING CASE REPORT
Year
: 2019  |  Volume : 3  |  Issue : 1  |  Page : 27--29

Isolated parachute mitral valve detected by two-dimensional echocardiography and cardiac magnetic resonance imaging in asymptomatic healthy adult


Sushama Krishnat Jotkar, Gayatri G Harshe 
 Department of Medicine and Cardiology, Dr. D. Y. Patil Medical College and Hospital Research Centre, Kolhapur, Maharashtra, India

Correspondence Address:
Sushama Krishnat Jotkar
5 A Survey Colony, Radhanagari Road, Kolhapur - 416 012, Maharashtra
India

Abstract

A 55 year old female patient presented for preoperative evaluation for vaginal hysterectomy. Preoperative transthoracic echocardiography revealed mitral valve (MV) abnormality, with only one papillary muscle having parachute appearance. Her cardiac magnetic resonance imaging with contrast confirmed the MV abnormality. Since she was hemodynamically stable, she underwent hysterectomy uneventfully.



How to cite this article:
Jotkar SK, Harshe GG. Isolated parachute mitral valve detected by two-dimensional echocardiography and cardiac magnetic resonance imaging in asymptomatic healthy adult.J Indian Acad Echocardiogr Cardiovasc Imaging 2019;3:27-29


How to cite this URL:
Jotkar SK, Harshe GG. Isolated parachute mitral valve detected by two-dimensional echocardiography and cardiac magnetic resonance imaging in asymptomatic healthy adult. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2019 [cited 2020 Aug 4 ];3:27-29
Available from: http://www.jiaecho.org/text.asp?2019/3/1/27/254251


Full Text

 Introduction



Parachute mitral valve (PMV) exists because the chordae tendinae from both leaflets converge on a centrally placed, single papillary muscle instead of diverging to insert into two papillary muscles. PMV is a rare congenital anomaly which presents in infancy and childhood, mostly associated with other obstructive cardiac lesions like Shone's complex. Adults presenting with PMV are rare. We report a female patient having PMV with uneventful noncardiac surgery.

 Clinical Presentation



A 55-year-old female having uterine prolapse and procidentia was presented to the department of cardiology for preoperative evaluation for vaginal hysterectomy. She denied any cardiac and respiratory symptoms. Her medical history revealed hypertension for 5 years, and she was recently detected to have type 2 diabetes mellitus. Both were well controlled with oral medications. Her developmental history was normal without any dysmorphic features and without any cardiac symptoms in childhood or during pregnancy. She had two pregnancies and normal deliveries which went uneventful.

Her heart rate was 78/min, regular, blood pressure was 120/80 mmHg in both upper and lower limbs. There was nonradiating short systolic murmur of Grade I/VI without S3, S4 gallop. Rest of the physical examination was normal. Electrocardiogram and chest X-ray [Figure 1]a and [Figure 1]b were also normal.{Figure 1}

On transthoracic two-dimensional echocardiography, something was seen wrong with the mitral valve (MV). The anterior mitral leaflet was very long, doming [Figure 2]b and [Video 1] and posterior leaflet was very small. A short-axis window in the mid-ventricle showed that there was only one true papillary muscle present [Figure 2]a and [Video 2]. The apical four-chamber view showed that MV and left atrium formed a pear shape [Figure 2]b and [Video 3]. It was clear that there was a single papillary muscle attached to the anterior leaflet. A color window showed, in addition, that there was Grade I eccentric mitral regurgitation. Doppler assessment [Figure 2]c yielded a peak MV gradient of 3.15 mm Hg and a valve area of 3.6 cm2.{Figure 2}

[MULTIMEDIA:1]

[MULTIMEDIA:2]

[MULTIMEDIA:3]

The patient was sent for cardiac magnetic resonance imaging (MRI). Cardiac MRI was done on Siemens 3 T machine with contrast showed single papillary muscle, chordate from both Anterior Mitral Leaflet and Posterior Mitral Leaflet [Figure 3]a,[Figure 3]b,[Figure 3]c This case was consistent with a “congenital PMV.”{Figure 3}

Since the patient was hemodynamically stable and no other cardiac anomalies were detected, she was posted for her elective vaginal hysterectomy. Intraoperative and postoperative period went uneventful, and she recovered completely.

As the detected cardiac anomaly was congenital, her siblings – brother and her children – were screened for the presence of PMV, but it revealed no abnormality.

 Discussion



Adult PMV is an uncommon condition, with only nine cases identified after a systematic literature review in 2010 over the last half-century.[1] Asymptomatic patients may be detected incidentally. Mitral stenosis is the usual abnormality in symptomatic patients with atrial fibrillation or dyspnea. Sudden death can occur. Whenever mitral stenosis is symptomatic, it requires mitral valve replacement. These findings are in contrast to the pediatric age group.[1]

Adult PMV occurs when all the chordae tendineae are inserted into a solitary papillary muscle. It is part of Shone's complex: a group of obstructive systemic lesions that can include coarctation of the aorta, bicuspid aortic valve, subaortic membrane, and PMV.

Childhood PMV can cause severe congenital mitral stenosis, with the MV comprising of a funnel-shaped fused mesh of chordae. Adult PMV is often milder with a more mobile valve and anterior chordal redundancy.[2]

Compared to pediatric PMV, concomitant cardiac abnormalities are uncommon in adult PMV.[3]

 Conclusion



True PMV is characterized by a unifocal attachment of the mitral chordate tendinae resulting in mitral inflow obstruction. This developmental anomaly is most often associated with other obstructive lesions on the left side of the heart (supra valvular mitral ring, subaortic stenosis, or coarctation of aorta known as Shone's complex). The outcome is generally poor because of multiple hemodynamically significant lesions requiring several complex surgeries with high mortality. The outcome of patients with isolated PMV depends on the severity of mitral inflow obstruction.[1]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Hakim FA, Kendall CB, Alharthi M, Mancina JC, Tajik JA, Mookadam F, et al. Parachute mitral valve in adults – A systematic overview. Echocardiography 2010;27:581-6.
2Purvis JA, Smyth S, Barr SH. Multi-modality imaging of an adult parachute mitral valve. J Am Soc Echocardiogr 2011;24:351.e1-3.
3Schaverien MV, Freedom RM, McCrindle BW. Independent factors associated with outcomes of parachute mitral valve in 84 patients. Circulation 2004;109:2309-13.