The Complex Hemodynamic Interplay between Mitral Arcade, Midventricular Obstruction, and Prosthetic Aortic Valve

Figures

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  Figure 1. Two-dimensional TTE, parasternal short-axis (A) and apical 2-chamber (B) diastolic views demonstrate the anomalous fibrous bands (arrows) connecting the 2 hypertrophic papillary muscles. Midesophageal three-dimensional TEE, volume-rendered en face diastolic views of the MV from the left atrial (C) and LV (D) perspective demonstrate the normal opening of the leaflets and the narrowed subvalvular orifice.

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  Figure 2. Two-dimensional TTE-guided continuous-wave Doppler spectral profiles from the apical 4-chamber view demonstrate (A) the diastolic mean gradient (7 mm Hg) across the MV; (B) the maximal tricuspid regurgitation velocity (367 cm/sec) and estimated gradient (54 mm Hg); (C) the “dagger-shaped” midventricular functional systolic resting gradient (70 mm Hg) across the LV outflow tract; and (D) the peak (94 mm Hg) and mean (57 mm Hg) fixed systolic gradients across the aortic prosthesis.

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  Figure 3. Volume-rendered, three-dimensional cardiac computed tomography (CCT) reconstructions performed along 2 vertical long-axis diastolic views demonstrate the fibromuscular bands (arrows) on a medial (A) and lateral (B) location.

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  Figure 4. Multiplanar, basal short axis–guided (A), vertical long axis (B-D) cardiac computed tomography reconstructions through the pathologic mitral apparatus demonstrate the subvalvular orifice (1.4 cm2) defined anteriorly by the anterolateral papillary muscle, posteriorly by the tip of posteromedial papillary muscle, medially (blue slice), and laterally (green slice) by 2 fibrous bands (blue and green arrows). An accessory muscular bundle, parallel to the anterolateral papillary muscle and running from the apex to the anterior basal septum close to the mitral annulus, is best demonstrated in a more medially aligned reconstruction (yellow slice) and further highlighted in panels B (yellow arrow) and C (yellow arrowhead).