European Journal of Echocardiography 2008 9(2):304-305; doi:10.1016/j.euje.2006.11.006
Published on behalf of the European Society of Cardiography. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org
Flail mitral and tricuspid valves due to myxomatous disease
Bilen Senkaya Emine,
Akcay Murat*,
Bilge Mehmet,
Kurt Mustafa and
Ipek Gokturk
Department of Cardiology, Ankara Ataturk Education and Research Hospital, Ankara, Turkey
Received 17 September 2006; accepted after revision 12 November 2006; online publish-ahead-of-print 2 January 2007.
* Corresponding author. Umit Mah, Kermes Sitesi, 1, Blok No: 20, Umitkoy 06800, Ankara, Turkey. Tel: +90 312 235 91 62; fax: +90 312 291 27 25. E-mail address: drmuratakcay{at}yahoo.com
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Abstract
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Myxomatous disease generally affects mitral valve. However,
tricuspid valves also can be involved in 20% of the myxomatous
mitral valve disease. Valve prolapse, elongation of chordae
and chordae rupture are generally seen complications of the
myxomatous disease. There are some reports about severe tricuspid
regurgitation due to tricuspid valve prolapse and elongated
chordae, but no tricuspid and mitral chordae ruptures in the
same patient due to myxomatous disease have been reported. In
this case tricuspid chordae rupture accompanied to mitral chordae
rupture is discussed.
Keywords: Flail tricuspid leaflet; Flail mitral leaflet; Myxomatous disease
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Case report
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An 81-year-old patient was referred to our clinic because of
systolic murmur at the apex on his examination. He had a history
of hospitalization 6 months ago because of sudden onset of dyspnea.
Physical examination showed a temperature of 36.5 °C, pulse
rate of 72 beats per minute, blood pressure of 110/70 mmHg.
There was jugular venous distention with a prominent ‘V’
wave. There was a 3/6 systolic murmur at the left lower sternal
border and at the apex, which showed radiation to left axilla.
His electrocardiogram was normal. There was minimal cardiomegaly
on telecardiogram. On transthoracic echocardiography left ventricle
diastolic and systolic diameters were 58/33 mm. Left atrium
diameter was 45 mm. Mitral and tricuspid valves were thickened.
Mobile echodensity consistent with tricuspid and mitral chordae
ruptures was present. Flail mitral posterior and tricuspid anterior
leaflets were determined (
Figures 1 and
2).
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Figure 1 Transthoracic modified apical 2-chamber echocardiographic image showing tricuspid chordae rupture and flail tricuspid anterior leaflet. CR, chordae rupture; Flail TAL, Flail tricuspid anterior leaflet; RA, right atrium; RV, right ventricle; and TSL, tricuspid septal leaflet.
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Transesophageal echocardiography (TEE) showed that mobile echodensity
was consistent with ruptured chordae tendinea of posterior mitral
valve and anterior tricuspid valve (
Figure 3). Severe mitral
and tricuspid regurgitations were determined on TEE examination.
Operation was suggested to patient but he refused operation
and discharged with medical treatment.
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Figure 3 Transesophageal 2-dimensional image showing flail mitral posterior leaflet and chordae rupture in longitudinal plane (the array is 146°). Flail MPL, flail mitral posterior leaflet; LA, left atrium; LV, left ventricle; MAL, mitral anterior leaflet; and RC, ruptured chordae.
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Discussion
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Tricuspid chordae rupture is an uncommon clinical finding. Non-penetrating
chest trauma is the most common cause of tricuspid chordae rupture.
1,2 Penetrating chest trauma and right heart catheterization can
also cause chordae rupture by disrupting the structural components
of tricuspid valves.
3 Marfan syndrome and other variations of
myxomatous disease affecting the mitral and tricuspid valves
can lead to prolapsing leaflets, elongation of chordae or chordal
rupture producing valvular incompetence. Anterior and septal
leaflets of tricuspid valves are affected generally in tricuspid
valve prolapse. In patients with flail mitral valve due to myxomatous
disease intrinsic involvement of the tricuspid valve as an etiology
of severe tricuspid regurgitation should be investigated during
transthoracic and transesophageal echocardiography. In our case
both tricuspid and mitral leaflets were thickened and tricuspid
anterior and mitral posterior leaflets were flail due to chordae
rupture. On TEE examination mobile echodensity consistent with
chordae rupture was present. Severe mitral and tricuspid regurgitations
were determined. In the literature there are case reports about
tricuspid chordae rupture but tricuspid and mitral chordae ruptures
in the same patient have not been reported yet. This clinical
entity has a clinical importance in planning the type of the
surgery. Simple resection of the flail segment would be the
preferred method if there is only one flail leaflet. Otherwise
other techniques like implantation of artificial chordae, quadrangular
resection of the flail segment, transposition of chordae or
functional repair with ring annuloplasty must be performed.
4 In patients with flail mitral valve due to myxomatous disease
intrinsic involvement of the tricuspid valve as an etiology
of severe tricuspid regurgitation should be investigated during
transthoracic and transesophageal echocardiography.
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References
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- Messika-Zeitoun D, Thomson H, Bellamy M, Scott C, Tribouilloy C, Dearani J, et al. Medical and surgical outcome of tricuspid regurgitation caused by flail leaflets. J Thorac Cardiovasc Surg (2004) 128:296–302.[Abstract/Free Full Text]
- Van Son JA, Danielson GK, Schaff HV, Miller FA Jr. Traumatic tricuspid valve insufficiency. Experience in thirteen patients. J Thorac Cardiovasc Surg (1994) 108:893–8.[Abstract/Free Full Text]
- Smith WR, Glauser FL, Jemisson P. Ruptured chordae of the tricuspid valve. The consequence of flow-directed Swane Ganz catheterization. Chest (1976) 70:790–2.[CrossRef][Web of Science][Medline]
- De Bonis M, Lapenna E, La Canna G, Grimaldi A, Maisano F, Torracca L, et al. A novel technique for correction of severe tricuspid valve regurgitation due to complex lesions. Eur J Cardiothorac Surg (2004) 25:760–5.[Abstract/Free Full Text]
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Abstract
Case report