Downloaded from http://heart.bmj.com/ on August 26, 2015 - Published by group.bmj.com
Heart failure
IMAGE CHALLENGE
An echocardiographic abnormality in an HIV patient with coronary disease CLINICAL INTRODUCTION A patient with a history of HIV and known coronary artery disease presented with fevers. Chest x-ray showed bilateral infiltrates, and a trans-thoracic echocardiogram (TTE) obtained on the first hospital day showed an ejection fraction of 43% with hypokinesis of the basal and mid-anterior segments. The patient’s course was complicated by continued fevers but blood cultures remained negative; upon rereview of the initial TTE, a highly mobile echogenic linear mass was appreciated on the left
ventricular outflow tract side of the aortic valve (see online supplementary video 1, figure 1). Trans-oesophageal echocardiography was performed to assess both the size and attachment of the mass as well as the presence of aortic regurgitation (see online supplementary video 2, figure 1).
CLINICAL QUESTION What is the most likely aetiology of this patient’s aortic valve mass? A. Myxoma B. Fibroelastoma C. Thrombus D. Mitral chord E. Calcification F. Vegetation For answers see page 265 Heart 2014;100:238. doi:10.1136/heartjnl-2013-304964
Figure 1 Trans-thoracic echocardiographic image acquired in the parasternal long axis (A) and trans-oesophageal echocardiographic image acquired at 120° rotation (B) demonstrating a highly mobile, echogenic linear mass (*) in the left ventricular outflow tract.
238
Ruys TPE, et al. Heart 2014;100:231–238. doi:10.1136/heartjnl-2013-304888
Downloaded from http://heart.bmj.com/ on August 26, 2015 - Published by group.bmj.com
PostScript
IMAGE CHALLENGE
Table 1 Characteristics of patients in whom asymptomatic redundant mitral chordae tendineae without other valvular pathology have been described
An echocardiographic abnormality in an HIV patient with coronary disease
Author
Sex
Age (years)
Presenting symptom
Grenadier et al4 Grenadier et al4 Current case
Male Female Male
3 72 47
Systolic murmur Non-specific chest pain Fever
ANSWER:DISCUSSION From question on page 238 The structure was determined to be a redundant mitral chordae tendineae as it was found to be discontinuous with the aortic valve and continuous with the mitral apparatus on transoesophageal echocardiography. All other possibilities (myxoma, fibroelastoma, thrombus, calcification and vegetation) were excluded based on appearance, as all would be connected to the aortic valve or nearby structures. The patient was treated with appropriate antibiotics to cover community-acquired pneumonia, and the patient recovered without further intervention. Maron and Epstein first described redundant mitral chordae tendineae causing valvular abnormalities in the early 1980s.1 Subsequent reports described redundant chordae tendineae as causing obstruction,1 mitral prolapse2 or mitral regurgitation.3 Grenadier and colleagues first described a series of two patients with redundant mitral chordae tendineae and no other valvular pathology in 1984;4 our patient is the third such case but is the first to present with symptoms concerning for endocarditis. The data from the three cases are summarised in table 1. No patients described had mitral valve prolapse, mitral regurgitation or aortic regurgitation. We present this case as a reminder that redundant mitral chordae tendineae can masquerade as valvular vegetations in patients with clinical suspicion of endocarditis and no other valvular abnormality. Jimmy Kerrigan,1 Majesh Makan2 1
Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
Heart February 2014 Vol 100 No 3
2
Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA Correspondence to Dr Majesh Makan, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St. Louis, MO 63110-1093, USA; [email protected] Contributors JK drafted the manuscript and made revisions as suggested by Professor Otto. He is the guarantor. MM revised the draft manuscript. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/heartjnl-2013-304964). To cite Kerrigan J, Makan M. Heart 2014;100:265.
Received 12 September 2013 Accepted 12 September 2013 Published Online First 15 November 2013 Heart 2014;100:265. doi:10.1136/heartjnl-2013-304964a
REFERENCES 1 2 3 4
Maron BJ, Epstein SE. Hypertrophic cardiomyopathy. Am J Cardiol 1980;45:141–54. Kessler KM, Anzola E, Sequeira R, et al. Mitral valve prolapse and systolic anterior motion: a dynamic spectrum. Am Heart J 1983;105:685–9. Ishimitsu T, Hiranuma Y, Kamiya H, et al. Mitral regurgitation due to redundant chordae. Abstract. J Cardiol Suppl 1991;25:95–104. Grenadier E, Keidar S, Dembo L, et al. Redundant mitral chordae tendineae prolapsing to the left ventricular outflow tract area in normal subjects. Eur Heart J 1984;5:954–6.
265
Downloaded from http://heart.bmj.com/ on August 26, 2015 - Published by group.bmj.com
An echocardiographic abnormality in an HIV patient with coronary disease Jimmy Kerrigan and Majesh Makan Heart 2014 100: 238 originally published online November 15, 2013
doi: 10.1136/heartjnl-2013-304964 Updated information and services can be found at: http://heart.bmj.com/content/100/3/238
These include:
Supplementary Supplementary material can be found at: Material http://heart.bmj.com/content/suppl/2013/11/15/heartjnl-2013-304964. DC1.html
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This article cites 4 articles, 1 of which you can access for free at: http://heart.bmj.com/content/100/3/238#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Image challenges (48) Clinical diagnostic tests (4619) Echocardiography (2031) Drugs: cardiovascular system (8425) Aortic valve disease (385) Mitral valve disease (218)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Heart failure
IMAGE CHALLENGE
An echocardiographic abnormality in an HIV patient with coronary disease CLINICAL INTRODUCTION A patient with a history of HIV and known coronary artery disease presented with fevers. Chest x-ray showed bilateral infiltrates, and a trans-thoracic echocardiogram (TTE) obtained on the first hospital day showed an ejection fraction of 43% with hypokinesis of the basal and mid-anterior segments. The patient’s course was complicated by continued fevers but blood cultures remained negative; upon rereview of the initial TTE, a highly mobile echogenic linear mass was appreciated on the left
ventricular outflow tract side of the aortic valve (see online supplementary video 1, figure 1). Trans-oesophageal echocardiography was performed to assess both the size and attachment of the mass as well as the presence of aortic regurgitation (see online supplementary video 2, figure 1).
CLINICAL QUESTION What is the most likely aetiology of this patient’s aortic valve mass? A. Myxoma B. Fibroelastoma C. Thrombus D. Mitral chord E. Calcification F. Vegetation For answers see page 265 Heart 2014;100:238. doi:10.1136/heartjnl-2013-304964
Figure 1 Trans-thoracic echocardiographic image acquired in the parasternal long axis (A) and trans-oesophageal echocardiographic image acquired at 120° rotation (B) demonstrating a highly mobile, echogenic linear mass (*) in the left ventricular outflow tract.
238
Ruys TPE, et al. Heart 2014;100:231–238. doi:10.1136/heartjnl-2013-304888
Downloaded from http://heart.bmj.com/ on August 26, 2015 - Published by group.bmj.com
PostScript
IMAGE CHALLENGE
Table 1 Characteristics of patients in whom asymptomatic redundant mitral chordae tendineae without other valvular pathology have been described
An echocardiographic abnormality in an HIV patient with coronary disease
Author
Sex
Age (years)
Presenting symptom
Grenadier et al4 Grenadier et al4 Current case
Male Female Male
3 72 47
Systolic murmur Non-specific chest pain Fever
ANSWER:DISCUSSION From question on page 238 The structure was determined to be a redundant mitral chordae tendineae as it was found to be discontinuous with the aortic valve and continuous with the mitral apparatus on transoesophageal echocardiography. All other possibilities (myxoma, fibroelastoma, thrombus, calcification and vegetation) were excluded based on appearance, as all would be connected to the aortic valve or nearby structures. The patient was treated with appropriate antibiotics to cover community-acquired pneumonia, and the patient recovered without further intervention. Maron and Epstein first described redundant mitral chordae tendineae causing valvular abnormalities in the early 1980s.1 Subsequent reports described redundant chordae tendineae as causing obstruction,1 mitral prolapse2 or mitral regurgitation.3 Grenadier and colleagues first described a series of two patients with redundant mitral chordae tendineae and no other valvular pathology in 1984;4 our patient is the third such case but is the first to present with symptoms concerning for endocarditis. The data from the three cases are summarised in table 1. No patients described had mitral valve prolapse, mitral regurgitation or aortic regurgitation. We present this case as a reminder that redundant mitral chordae tendineae can masquerade as valvular vegetations in patients with clinical suspicion of endocarditis and no other valvular abnormality. Jimmy Kerrigan,1 Majesh Makan2 1
Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
Heart February 2014 Vol 100 No 3
2
Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA Correspondence to Dr Majesh Makan, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St. Louis, MO 63110-1093, USA; [email protected] Contributors JK drafted the manuscript and made revisions as suggested by Professor Otto. He is the guarantor. MM revised the draft manuscript. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/heartjnl-2013-304964). To cite Kerrigan J, Makan M. Heart 2014;100:265.
Received 12 September 2013 Accepted 12 September 2013 Published Online First 15 November 2013 Heart 2014;100:265. doi:10.1136/heartjnl-2013-304964a
REFERENCES 1 2 3 4
Maron BJ, Epstein SE. Hypertrophic cardiomyopathy. Am J Cardiol 1980;45:141–54. Kessler KM, Anzola E, Sequeira R, et al. Mitral valve prolapse and systolic anterior motion: a dynamic spectrum. Am Heart J 1983;105:685–9. Ishimitsu T, Hiranuma Y, Kamiya H, et al. Mitral regurgitation due to redundant chordae. Abstract. J Cardiol Suppl 1991;25:95–104. Grenadier E, Keidar S, Dembo L, et al. Redundant mitral chordae tendineae prolapsing to the left ventricular outflow tract area in normal subjects. Eur Heart J 1984;5:954–6.
265
Downloaded from http://heart.bmj.com/ on August 26, 2015 - Published by group.bmj.com
An echocardiographic abnormality in an HIV patient with coronary disease Jimmy Kerrigan and Majesh Makan Heart 2014 100: 238 originally published online November 15, 2013
doi: 10.1136/heartjnl-2013-304964 Updated information and services can be found at: http://heart.bmj.com/content/100/3/238
These include:
Supplementary Supplementary material can be found at: Material http://heart.bmj.com/content/suppl/2013/11/15/heartjnl-2013-304964. DC1.html
References Email alerting service
Topic Collections
This article cites 4 articles, 1 of which you can access for free at: http://heart.bmj.com/content/100/3/238#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Image challenges (48) Clinical diagnostic tests (4619) Echocardiography (2031) Drugs: cardiovascular system (8425) Aortic valve disease (385) Mitral valve disease (218)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
