gical approach. Ann Surg 170:460, 1969 4 Kitamura S, Mendea A, Kay lA: Ventricular septal defect following myocardial infarction: Experience with surgical repair through a left ventriculotomy and review of ~~~:. ture. 1 Thorac Cardiovasc Surg 61:186, 1970 . 5 Shumadcer HI Jr: Suggestions concerning operative management of post infarction septal defects. J Thorac Cardiovasc Surg 64:452, 1972 6 Giuliani ER, Danielson GK, Pluth JR, et al: Post infarction venbicular septal rupture: Surgical comiderations and results. Circulation 49:455, 1974 7 Sanders RJ, Oem WH, Blount SG: Perforation of the interventricular septum complicating myocardial infarction. Am Heart J 51:736, 1956 8 Sanders RJ, Neuberger KT, Ravin A: Rupture of papillary muscles: Occurrence of rupture of posterior muscle in posterior myocardial infarction. Dis Chest 31:316-323, 1957 9 Friedberg CK: General treabnent of acute myocardial infarction: Circulation 39 ( suppl 4) :252, 1969 10 Tikoff G, Schmidt AM, Thorne SL, et al: Clinical and physiologic sequelae of large venbicular septal defect. Am J Moo 42:497, 1967 11 Meister SG, Helfant RH: Rapid bedside differentiation of rnptured interventricular septum from acute mitral insufficiency. N Engl J Moo 287: 1024, 1972 12 Cheng TO: Late systolic murmur in coronary artery disease. Chest 61:346-356, 1972 13 Buckley MJ, Mundth ED, Dagget WM, et al: Surgical management of ventricular septal defects and mitral regurgitation complicating acute myocardial infarction. Am Thorac Surg 16:598, 1973 14 Daicoff GR, Rhodes ML: Surgical repair of ventricular septal rupture and venbicular aneurysm. JAMA 203:457, 1968 15 Javid H, Hunter JA, Najafi H, et al: Left ventricular approach for the repair of ventricular septal perforation and infarctectomy. J Thorac Cardiovasc Surg 63:14, 1972
Posterior Leaflet Motion in Mitral Stenosis· Stephen P. Glasser, M.D.,·· and James V. Faris, M.D.t
The ecbocardlographlc features of mitral valvular motion in a patient with classic rheumatic mitral stenosis are presented. Two unusual features were noted, and the importance of careful ecboeardlo....phlc sc8DlliDg of the mitral valve II emphasized. The theories for the classic echoeanUographic abDormaUdes of mitral stenosis are brlefty considered ID Ught of the findings In this case. classic criterion developed for the echocardioT hegraphic diagnosis of mitral stenosis has been the
reduced rate of early diastolic mitral valvular closure (EF slope).1 Subsequently, it was learned that conditions -From the School of Medicine, Louisiana State University Medical Center, Shreveport. • - Associate Professor of Medicine and Chief, Cardiology Section. t Assistant Professor of Medicine and Director, Card1ac Catheterization Laboratory.
CHEST, 71: 1, JANUARY, 1977
other than mitral stenosis resulted in a similar reduction in the rate of closure. 2 In 1972, Duchak et als demonstrated that in true mitral stenosis the anterior and posterior mitral·..valvular leaflets moved in the same For editorial comment, see page 4 direction (concordantly) in diastole, whereas in those conditions other than mitral stenosis, the posterior mitral valve leaflet maintained its nonnal diastolic "mirror image" (discordant) motion. Recently, several reports of discordant mitral valve motion have been documented in cases of true mitral stenosis.·,S Presented in this report is a case of documented severe and otherwise typical rheumatic mitral stenosis with several interesting echocardiographic features. First, both discordant and concordant motions of the posterior leaflet were noted from the same patient as the mitral valve was echocardiographically scanned. Second, the anterior leaflet motion was classic for mitral stenosis with no cea" wave (in spite of nonnal sinus rhythm), while the posterior leaflet demonstrated a clear "a·· wave. CASE REPORT
A 30-year-old woman was referred for evaluation because of increasing dyspnea. She had undergone two mitral commissurotomies 12 and 10 years earlier and had done well until the preceding several months. Atrial biopsies taken at the time of her second commissurotomy demonstrated Aschoff's bodies. Physical examination revealed the findings of pure mitral stenosis, and cardiac catheterization documented this clinical impression with a calculated mitral valvular area of 0.6 sq em (Fig 1). Moderate mitral valve calcification was detected on fluoroscopic examination. Echocardiograms consistently demonstrated the features seen in Figure 2. Mitral valvular replacement was recommended, and at surgery a typical calcified mitral valve was removed. The cusps were thickened, commiSsural fusion was p~~~~~ ~ ~~~ chordae tendineae were noted. DISCUSSION
Echocardiographic studies have been used extensively in the diagnosis and evaluation of mitral stenosis. The major echographic features are reduction in the E-F slope of the anterior leaflet and concordant motion of the anterior and posterior mitral leaflets. The importance of this finding is related to the knowledge that reductions in the E-F slope can be caused by conditions other than true mitral stenosis, such as hypertrophic cardiomyopathy, pulmonary hypertension, and others; however, Duchak et als demonstrated that in contrast to hue mitral stenosis, these conditions were associated with discordant mitral leaflet motion. Although by no means obviating the importance of these features, several reports recently have documented mirror-image motion of the anterior and posterior mitral leaflets in true mitral stenosis. 4 ,a The reasons for reduced E-F slopes and for concordant mitral leaflet motion in patients with mitral stenosis remain unclear. A common theory is that the high left atrial pressure and the continuous pressure gradient
PomRIOR LEAFLET MOTION IN MITRAL STENOSIS 87
LV and
pew p
FIctJRE 1. Simultaneous recordings of left venbicular (LV) and pulmonary capillary wedge pressure (PCWP) demonstrate mitral valve gradient of 25 mm Hg.
across the valve keeps the valve leaflets in the full opened position throughout diastole. In addition, the common association of thickened, rigid cusps fused together at their commissures adds to this abnormal pattern of motion. The case reported herein is important in relation to these concepts. That the high left atrial pressure or pressure gradient is not solely responsible for this abnormal mitral valve motion is evident from the different leaflet motions recorded from our patient. The unexpected concordant mitral motion might be explained in part by an unequal degree of thickening and fibrosis of the two leaflets, the extent of commissural fusion, and involvement of chordae tendineae; however, at surgery, there was no apparent anatomic explanation. Also, this case emphasizes the importance of careful scanning of the mitral valve, since either discordant or concordant motion of the posterior leaflet could have
APEX
been the sole finding in an incomplete study.
REFERENCES
1 Segal 81., LikolJ W, Kingsley 8: Ecbocardiography: Clinical application in mitral stenosis. JAMA 195:99-104, 1966 2 McLaurin LP, Gibson TC, Waider W, et al: An appraisal of mitral valve echocardiograms mimicking mitral stenosis in conditions with right venbicular pressure overload. Circulation 48:801-809, 1973 3 Duchalc JM, Chang S, Feigenbaum H: The posterior mitral valve echo and the echocardiographic diagnosis of mitral stenosis. Am J CardioI29:628-632, 1972 4. LevismaQ JA, Abbasi AS, Pearce ML: Posterior mitral leaSet motion in mitral stenosis. Circulation 51:511-514, 1975 5 Flaherty JT, Livengood S, Fortuin NJ: Atypical posterior leaSet motion in echocardiogram in mitral stenosis. Am J Cardiol 35:675-678, 1975
BASE
FIctJRE 2. Scan from free edge of mitral valve toward base. Note mirror-Image motion of mitral lea8ets phasing into classic concordant motion of mitral stenosis. Also note presence of mitral valvular "a" wave from posterior mitral leaflet (PML) and its absence on anterior mitral leaSet ( AML ). Thiclcened band of echoes are consistent with documented mitral calcification.
88 GlASSER, FARIS
CHEST, 71: 1, JANUARY, 1977
Posterior Leaflet Motion in Mitral Stenosis· Stephen P. Glasser, M.D.,·· and James V. Faris, M.D.t
The ecbocardlographlc features of mitral valvular motion in a patient with classic rheumatic mitral stenosis are presented. Two unusual features were noted, and the importance of careful ecboeardlo....phlc sc8DlliDg of the mitral valve II emphasized. The theories for the classic echoeanUographic abDormaUdes of mitral stenosis are brlefty considered ID Ught of the findings In this case. classic criterion developed for the echocardioT hegraphic diagnosis of mitral stenosis has been the
reduced rate of early diastolic mitral valvular closure (EF slope).1 Subsequently, it was learned that conditions -From the School of Medicine, Louisiana State University Medical Center, Shreveport. • - Associate Professor of Medicine and Chief, Cardiology Section. t Assistant Professor of Medicine and Director, Card1ac Catheterization Laboratory.
CHEST, 71: 1, JANUARY, 1977
other than mitral stenosis resulted in a similar reduction in the rate of closure. 2 In 1972, Duchak et als demonstrated that in true mitral stenosis the anterior and posterior mitral·..valvular leaflets moved in the same For editorial comment, see page 4 direction (concordantly) in diastole, whereas in those conditions other than mitral stenosis, the posterior mitral valve leaflet maintained its nonnal diastolic "mirror image" (discordant) motion. Recently, several reports of discordant mitral valve motion have been documented in cases of true mitral stenosis.·,S Presented in this report is a case of documented severe and otherwise typical rheumatic mitral stenosis with several interesting echocardiographic features. First, both discordant and concordant motions of the posterior leaflet were noted from the same patient as the mitral valve was echocardiographically scanned. Second, the anterior leaflet motion was classic for mitral stenosis with no cea" wave (in spite of nonnal sinus rhythm), while the posterior leaflet demonstrated a clear "a·· wave. CASE REPORT
A 30-year-old woman was referred for evaluation because of increasing dyspnea. She had undergone two mitral commissurotomies 12 and 10 years earlier and had done well until the preceding several months. Atrial biopsies taken at the time of her second commissurotomy demonstrated Aschoff's bodies. Physical examination revealed the findings of pure mitral stenosis, and cardiac catheterization documented this clinical impression with a calculated mitral valvular area of 0.6 sq em (Fig 1). Moderate mitral valve calcification was detected on fluoroscopic examination. Echocardiograms consistently demonstrated the features seen in Figure 2. Mitral valvular replacement was recommended, and at surgery a typical calcified mitral valve was removed. The cusps were thickened, commiSsural fusion was p~~~~~ ~ ~~~ chordae tendineae were noted. DISCUSSION
Echocardiographic studies have been used extensively in the diagnosis and evaluation of mitral stenosis. The major echographic features are reduction in the E-F slope of the anterior leaflet and concordant motion of the anterior and posterior mitral leaflets. The importance of this finding is related to the knowledge that reductions in the E-F slope can be caused by conditions other than true mitral stenosis, such as hypertrophic cardiomyopathy, pulmonary hypertension, and others; however, Duchak et als demonstrated that in contrast to hue mitral stenosis, these conditions were associated with discordant mitral leaflet motion. Although by no means obviating the importance of these features, several reports recently have documented mirror-image motion of the anterior and posterior mitral leaflets in true mitral stenosis. 4 ,a The reasons for reduced E-F slopes and for concordant mitral leaflet motion in patients with mitral stenosis remain unclear. A common theory is that the high left atrial pressure and the continuous pressure gradient
PomRIOR LEAFLET MOTION IN MITRAL STENOSIS 87
LV and
pew p
FIctJRE 1. Simultaneous recordings of left venbicular (LV) and pulmonary capillary wedge pressure (PCWP) demonstrate mitral valve gradient of 25 mm Hg.
across the valve keeps the valve leaflets in the full opened position throughout diastole. In addition, the common association of thickened, rigid cusps fused together at their commissures adds to this abnormal pattern of motion. The case reported herein is important in relation to these concepts. That the high left atrial pressure or pressure gradient is not solely responsible for this abnormal mitral valve motion is evident from the different leaflet motions recorded from our patient. The unexpected concordant mitral motion might be explained in part by an unequal degree of thickening and fibrosis of the two leaflets, the extent of commissural fusion, and involvement of chordae tendineae; however, at surgery, there was no apparent anatomic explanation. Also, this case emphasizes the importance of careful scanning of the mitral valve, since either discordant or concordant motion of the posterior leaflet could have
APEX
been the sole finding in an incomplete study.
REFERENCES
1 Segal 81., LikolJ W, Kingsley 8: Ecbocardiography: Clinical application in mitral stenosis. JAMA 195:99-104, 1966 2 McLaurin LP, Gibson TC, Waider W, et al: An appraisal of mitral valve echocardiograms mimicking mitral stenosis in conditions with right venbicular pressure overload. Circulation 48:801-809, 1973 3 Duchalc JM, Chang S, Feigenbaum H: The posterior mitral valve echo and the echocardiographic diagnosis of mitral stenosis. Am J CardioI29:628-632, 1972 4. LevismaQ JA, Abbasi AS, Pearce ML: Posterior mitral leaSet motion in mitral stenosis. Circulation 51:511-514, 1975 5 Flaherty JT, Livengood S, Fortuin NJ: Atypical posterior leaSet motion in echocardiogram in mitral stenosis. Am J Cardiol 35:675-678, 1975
BASE
FIctJRE 2. Scan from free edge of mitral valve toward base. Note mirror-Image motion of mitral lea8ets phasing into classic concordant motion of mitral stenosis. Also note presence of mitral valvular "a" wave from posterior mitral leaflet (PML) and its absence on anterior mitral leaSet ( AML ). Thiclcened band of echoes are consistent with documented mitral calcification.
88 GlASSER, FARIS
CHEST, 71: 1, JANUARY, 1977
