Editorial Type:
Article Category: Research Article
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Online Publication Date: 01 Aug 2014

Commissural Prolapse of the Mitral Valve Identified on 3-Dimensional Transesophageal Echocardiography

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MD
Page Range: 447 – 448
DOI: 10.14503/THIJ-13-3526
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A 62-year-old man presented with progressive exertional dyspnea and a holosystolic murmur. A transthoracic echocardiogram showed severe eccentric mitral regurgitation (Fig. 1). A 2-dimensional transesophageal echocardiogram (2D TEE) showed possible anterior mitral leaflet perforation (Fig. 2). The patient was referred for surgery. Intraoperative, real-time 3-dimensional (3D) TEE clearly showed isolated posteromedial commissural prolapse involving the anterior and posterior leaflets (A3 and P3 scallops) (Fig. 3). The cause was fibroelastic deficiency that resulted in rupture of the commissural chordae (Fig. 4), which was confirmed upon surgical inspection (Fig. 5). The mitral valve was successfully repaired.

Fig. 1. Transthoracic echocardiogram with color-flow Doppler shows severe mitral regurgitation. / LA = left atrium; LV = left ventricleFig. 1. Transthoracic echocardiogram with color-flow Doppler shows severe mitral regurgitation. / LA = left atrium; LV = left ventricleFig. 1. Transthoracic echocardiogram with color-flow Doppler shows severe mitral regurgitation. / LA = left atrium; LV = left ventricle
Fig. 1. Transthoracic echocardiogram with color-flow Doppler shows severe mitral regurgitation. LA = left atrium; LV = left ventricle

Citation: Texas Heart Institute Journal 41, 4; 10.14503/THIJ-13-3526

Fig. 2. Two-dimensional transesophageal echocardiogram with color-flow Doppler suggests anterior mitral leaflet perforation. / LA = left atrium; LV = left ventricle. / Supplemental motion image is available for Figure 2.Fig. 2. Two-dimensional transesophageal echocardiogram with color-flow Doppler suggests anterior mitral leaflet perforation. / LA = left atrium; LV = left ventricle. / Supplemental motion image is available for Figure 2.Fig. 2. Two-dimensional transesophageal echocardiogram with color-flow Doppler suggests anterior mitral leaflet perforation. / LA = left atrium; LV = left ventricle. / Supplemental motion image is available for Figure 2.
Fig. 2. Two-dimensional transesophageal echocardiogram with color-flow Doppler suggests anterior mitral leaflet perforation. LA = left atrium; LV = left ventricle Supplemental motion image is available for Figure 2.

Citation: Texas Heart Institute Journal 41, 4; 10.14503/THIJ-13-3526

Fig. 3. Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional intraoperative echocardiographic view of the mitral valve (wide-sector acquisition mode) shows prolapse of the posteromedial commissure (arrowhead) with chordal rupture (arrow). / AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leaflet. / Supplemental motion image is available for Figure 3.Fig. 3. Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional intraoperative echocardiographic view of the mitral valve (wide-sector acquisition mode) shows prolapse of the posteromedial commissure (arrowhead) with chordal rupture (arrow). / AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leaflet. / Supplemental motion image is available for Figure 3.Fig. 3. Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional intraoperative echocardiographic view of the mitral valve (wide-sector acquisition mode) shows prolapse of the posteromedial commissure (arrowhead) with chordal rupture (arrow). / AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leaflet. / Supplemental motion image is available for Figure 3.
Fig. 3. Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional intraoperative echocardiographic view of the mitral valve (wide-sector acquisition mode) shows prolapse of the posteromedial commissure (arrowhead) with chordal rupture (arrow). AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leaflet Supplemental motion image is available for Figure 3.

Citation: Texas Heart Institute Journal 41, 4; 10.14503/THIJ-13-3526

Fig. 4. Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional echocardiogram (wide-sector acquisition mode) shows an angulated view of the mitral valve, with 90° clockwise rotation, indicating posteromedial commissural prolapse with chordal rupture (arrow). / AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leafletFig. 4. Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional echocardiogram (wide-sector acquisition mode) shows an angulated view of the mitral valve, with 90° clockwise rotation, indicating posteromedial commissural prolapse with chordal rupture (arrow). / AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leafletFig. 4. Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional echocardiogram (wide-sector acquisition mode) shows an angulated view of the mitral valve, with 90° clockwise rotation, indicating posteromedial commissural prolapse with chordal rupture (arrow). / AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leaflet
Fig. 4. Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional echocardiogram (wide-sector acquisition mode) shows an angulated view of the mitral valve, with 90° clockwise rotation, indicating posteromedial commissural prolapse with chordal rupture (arrow). AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leaflet

Citation: Texas Heart Institute Journal 41, 4; 10.14503/THIJ-13-3526

Fig. 5. Intraoperative photograph of the mitral valve shows posteromedial commissural prolapse (black arrow) with chordal rupture (white arrow). / AML = anterior mitral leaflet; PML = posterior mitral leafletFig. 5. Intraoperative photograph of the mitral valve shows posteromedial commissural prolapse (black arrow) with chordal rupture (white arrow). / AML = anterior mitral leaflet; PML = posterior mitral leafletFig. 5. Intraoperative photograph of the mitral valve shows posteromedial commissural prolapse (black arrow) with chordal rupture (white arrow). / AML = anterior mitral leaflet; PML = posterior mitral leaflet
Fig. 5. Intraoperative photograph of the mitral valve shows posteromedial commissural prolapse (black arrow) with chordal rupture (white arrow). AML = anterior mitral leaflet; PML = posterior mitral leaflet

Citation: Texas Heart Institute Journal 41, 4; 10.14503/THIJ-13-3526

Comment

Commissural prolapse, an infrequent form of mitral valve prolapse, is difficult to diagnose with use of 2D echocardiography. The prolapse typically affects the posteromedial commissure.1 The echocardiographic appearance of this entity can mimic leaflet perforation.2 Determination of leaflet, chordal, or papillary muscle involvement by means of careful preoperative imaging evaluation can play a crucial role in surgical staging and planning. Real-time 3D TEE has the potential to enable accurate evaluation and diagnosis and thereby lead to improved surgical outcomes.

References

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Copyright: © 2014 by the Texas Heart® Institute, Houston 2014
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Fig. 1.
Fig. 1.

Transthoracic echocardiogram with color-flow Doppler shows severe mitral regurgitation.

LA = left atrium; LV = left ventricle

Fig. 2.
Fig. 2.

Two-dimensional transesophageal echocardiogram with color-flow Doppler suggests anterior mitral leaflet perforation.

LA = left atrium; LV = left ventricle

Supplemental motion image is available for Figure 2.

Fig. 3.
Fig. 3.

Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional intraoperative echocardiographic view of the mitral valve (wide-sector acquisition mode) shows prolapse of the posteromedial commissure (arrowhead) with chordal rupture (arrow).

AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leaflet

Supplemental motion image is available for Figure 3.

Fig. 4.
Fig. 4.

Two-dimensional transesophageal echocardiograms of the mitral valve at A) 0° (4-chamber view) and B) approximately 90° (2-chamber view). C) Real-time 3-dimensional echocardiogram (wide-sector acquisition mode) shows an angulated view of the mitral valve, with 90° clockwise rotation, indicating posteromedial commissural prolapse with chordal rupture (arrow).

AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leaflet

Fig. 5.
Fig. 5.

Intraoperative photograph of the mitral valve shows posteromedial commissural prolapse (black arrow) with chordal rupture (white arrow).

AML = anterior mitral leaflet; PML = posterior mitral leaflet

Contributor Notes

From: Departments of Cardiology (Drs. Kareti and Mahenthiran) and Cardiothoracic Surgery (Dr. Storey), Community Heart and Vascular Hospital, Indianapolis, Indiana 46250

Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute, 6624 Fannin St., Suite 2480, Houston, TX 77030

Address for reprints: Kiran Kareti, MD, Department of Cardiology, Community Heart and Vascular Hospital, 8075 N. Shadeland Ave., Suite 200, Indianapolis, IN 46250-2694, E-mail: kkareti@ecommunity.com
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