Diminutive posterior mitral valve leaflet with an extremely elongated anterior leaflet is a rare phenomenon. We share such a case discovered in an 82-year-old patient with severe, symptomatic mitral regurgitation. LA, left atrium; LV, left ventricle; MR, mitral regurgitation. Congenital mitral valve (MV) insufficiency is a rare cardiac finding, especially in adults. An absent or diminutive posterior leaflet usually results in a poor prognosis in early childhood, necessitating surgical intervention for severe mitral regurgitation (MR) sooner.1 Rare cases of asymptomatic adults with this condition have been reported.2 We present an octogenarian discovered to have a super-elongated anterior mitral leaflet and diminutive posterior leaflet. An 82-year-old woman with a history of stage III invasive ductal carcinoma of the right breast treated with chemotherapy and radiation, diabetes type II, hyperlipidemia, and MR was referred to the cardiology service. At presentation, she had worsening shortness of breath and bilateral lower-extremity edema. Transthoracic echocardiography demonstrated an elongated, thickened anterior leaflet with prolapse and a diminutive posterior leaflet with severe, mid to late systolic, posteriorly directed MR with a regurgitant volume of 61 cc (Figure 1A,B). The short-axis view at the papillary muscle level showed separate anterolateral and posteromedial papillary muscles (Figure 1C), which excluded parachute MV. Transesophageal echocardiography (TEE) confirmed these findings (Videos 1 and 2). The anterior mitral leaflet was 4.8 cm long (Figure 1D,E). An analysis of patients undergoing coronary artery bypass grafting and aortic valve replacement found an MV anterior leaflet median length of 2.5 cm and maximal length of 3.4 cm.3 Figure 1F shows the thickened, prolapsing anterior leaflet on three-dimensional TEE. In light of worsening heart failure refractory to medical therapy, valve repair or replacement was recommended. The patient was referred to the valvular heart clinic to discuss options. Her risk was high for open heart surgery, and because she presented with a diminutive posterior leaflet, transcatheter edge-to-edge repair (TEER) was not possible. Cardiac computed tomography (CCT) heart structure was completed. Mitral annular perimeter in diastole was 12.3 cm and area 11.4 cm2, qualifying her for a 48-mm Medtronic Intrepid valve. The neo-left ventricular outflow tract (neo-LVOT)—the residual LVOT area that would be created after implanting the transcatheter MV prosthesis—was measured from the CT heart structure.4 Given the super-elongated anterior mitral leaflet, her neo-LVOT was 0.48 cm2 (Figure 2), prohibitive for transcatheter MV replacement. The minimum neo-LVOT needed to avoid LVOT obstruction is >1.5 cm2. Palliative therapy was recommended. Super-elongated anterior and diminutive posterior mitral leaflet is a rare phenomenon, especially in adults, usually presenting with severe MR. TEE and CCT are essential in the diagnosis and procedural planning of MV disease. TEE allows for structural analysis of the valve apparatus and quantification of MR. This is critical for surgical or procedural planning of MV repair/replacement. This specific mitral morphology makes TEER impossible. The only non-surgical option is transcatheter MV replacement, for which CCT is critical during preprocedural planning. The neo-LVOT measurement is needed to prevent LVOT obstruction post-procedure. In this patient, the extremely elongated anterior leaflet created an unacceptable neo-LVOT, excluding percutaneous replacement options. Awareness of this super-elongated anterior mitral leaflet is important, especially while planning transcatheter MV therapies. Multimodality imaging is crucial for procedural planning, particularly in patients with adult congenital heart disease. The authors declare no conflict of interest. Given that this is not human research and uses deidentified data, permission from the local institutional review board was not required and informed consent was not obtained. Patient consent is not required because this is a case report with deidentified data. Data sharing is not applicable to this article as no new data were created or analyzed in this study. VIDEO 1 The elongated anterior leaflet is seen overriding the diminutive posterior leaflet, causing malcoaptation. VIDEO 2 Severe mitral regurgitation is seen on color Doppler. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
The aim of the study is to evaluate current trends and long-term durability of both drug-eluting stents (DES) and drug-coated balloons (DCB) in the treatment of peripheral artery disease (PAD).
A 49-year-old man with a history of tobacco use presented with progressive shortness of breath since the age of 20 years. Laboratory data showed a hemoglobin level of 16.3 g/dL. Transthoracic echocardiography showed a right-sided aortic arch with an aberrant left subclavian artery, a persistent left superior vena cava (PLSVC) draining into the left upper pulmonary vein, and a normal coronary sinus. Agitated saline injected into a vein in the left hand was visualized in the left atrium with a subsequent appearance in the left ventricle. During cardiopulmonary exercise testing, the patient exercised for 5 minutes and 19 seconds with shortness of breath and peak oxygen saturation of 90%. Computed tomography confirmed the presence of a bridging innominate vein connecting the right superior vena cava and the PLSVC. It also showed drainage of the hemiazygos venous system into the PLSVC. A multidisciplinary decision was made to proceed with percutaneous endovascular occlusion of the PLSVC. Access was obtained via the left subclavian vein with a 5F sheath. In the pediatric population or young adults, the right subclavian or femoral venous access may provide a better approach for occlusion of PLSVC. In our patient, whose height was 1.85 m, we decided to use a left subclavian vein approach for ease of access and a shorter distance for equipment delivery. Using a 0.035-inch angled Glidewire (Terumo), a Berenstein catheter (Boston Scientific) was navigated through the PLSVC to the left atrium. This was exchanged for a stiff 0.035-inch Supra Core guidewire (Abbott). The sheath was exchanged over the wire to a 7F 23-cm sheath. A 12-mm × 16-mm Amplatzer Vascular Plug II (Abbott) was then placed successfully in the PLSVC. The intended placement was as distally into the PLSVC as possible in order to interrupt the flow from both the PLSVC and hemiazygos vein (Figure 1D). Periprocedural transesophageal echocardiography provided verification that shunting was no longer present from the defect after plug deployment. On postprocedure follow-up, the patient confirmed resolution of symptoms and improved exercise capacity. The incidence of PLSVC is about 0.3% to 0.5% in the general population.1Perles Z. Nir A. Gavri S. et al.Prevalence of persistent superior vena cava and association with congenital heart anomalies.Am J Cardiol. 2013; 112: 1214-1218https://doi.org/10.1016/j.amjcard.2013.05.079Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar PLSVC is an embryologic remnant that results from the failure of the left superior cardinal vein to regress. In about 90% of cases, the PLSVC drains into the coronary sinus.2Goyal S.K. Punnam S.R. Verma G. Ruberg F.L. Persistent left superior vena cava: a case report and review of literature.Cardiovasc Ultrasound. 2008; 6: 50https://doi.org/10.1186/1476-7120-6-50Crossref PubMed Scopus (176) Google Scholar This is hemodynamically insignificant but may lead to challenges related to venous access and possible complications. In the remaining 10% of cases, the PLSVC may drain into the left atrium with subsequent right-to-left shunt creation. This may lead to hypoxemia and has also been reported to be a possible cause of paradoxical thromboembolism.3Irwin R.B. Greaves M. Schmitt M. Left superior vena cava: revisited.Eur Heart J Cardiovasc Imaging. 2012; 13: 284-291https://doi.org/10.1093/ehjci/jes017Crossref PubMed Scopus (68) Google Scholar,4Hutyra M. Skala T. Sanak D. Novotny J. Köcher M. Taborsky M. Persistent left superior vena cava connected through the left upper pulmonary vein to the left atrium: an unusual pathway for paradoxical embolization and a rare cause of recurrent transient ischaemic attack.Eur J Echocardiogr. 2010; 11: E35https://doi.org/10.1093/ejechocard/jeq079Crossref Scopus (33) Google Scholar The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Massive bupropion overdose has a known association with cardiogenic shock. We describe a clinical case of a 48-year-old female who was brought to the hospital by emergency medical services after ingesting numerous psychiatric medications. Her hospital course was complicated by worsening cardiogenic shock and ventricular tachycardia storm. Transthoracic echocardiography showed left ventricular (LV) hypokinesis with an ejection fraction of 9%. Then the patient underwent placement of a percutaneous Impella CP device (Abiomed, Danvers, MA). The Molecular Adsorbent Recirculating System was started for protein-bound bupropion clearance. After 24 hours, the patient returned to an organized sinus rhythm. A repeat echocardiogram done on the next day demonstrated improved LV function, and the patient had profound clinical improvement. The case illustrates how the use of extracorporeal membrane oxygenation in combination with Impella device and Molecular Adsorbent Recirculating System was able to support the patient's recovery.
