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Liu J, Tan T, Wei P, Ma J, Zhong L, Qiu H, Wang S, Zhuang J, Zhu W, Guo H, Chen J. Anomalous papillary muscle insertion into the mitral valve leaflet in hypertrophic obstructive cardiomyopathy: a lip nevus sign in echocardiography. Front Cardiovasc Med 2023; 10:1292142. [PMID: 38124897 PMCID: PMC10731039 DOI: 10.3389/fcvm.2023.1292142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
Background Anomalous papillary muscle (APM) insertion into the mitral valve leaflet is rare but clinically important in hypertrophic obstructive cardiomyopathy (HOCM). In this study, we report the detection rate of APM insertion into the mitral valve using preoperative imaging modalities and the surgical outcomes of the patients. Methods By retrospectively reviewing the clinical records of patients with HOCM who underwent surgical treatment by a single operation group at our center from January 2020 to June 2023, patients with APM insertion into the mitral valve leaflet were identified. Baseline data, image characteristics, and surgical outcomes were analyzed. Results The incidence of APM insertion into the mitral valve leaflet was 5.1% (8/157). The insertion site was located at A3 in six cases, which was more common than at A2 (n = 2). Preoperative echocardiography was used to identify two patients (25%) with APM insertion. We observed a particular echocardiographic feature for APM in HOCM patients, which was noted as a "lip nevus sign", with a higher detection rate (62.5%). All patients successfully underwent septal myectomy with concomitant APM excision or mitral valve replacement via the transaortic (n = 5) or transmitral (n = 3) approach. The mean age was 49.0 ± 17.4 years and seven patients (87.5%) were female. Interventricular septum thickness (17.0 mm vs. 13.3 mm, P = 0.012) and left ventricular outflow gradient (117.5 mmHg vs. 7.5 mmHg, P = 0.012) were significantly decreased after surgery. Residual outflow obstruction, systolic anterior motion, and ≥3+ mitral regurgitation were negative. During the follow-up of 26.2 ± 12.2 months, there were no reported operations, adverse events, mitral regurgitation aggravations, recurrences of outflow obstruction, or instances of SAM. Conclusions Papillary muscles inserted into the mitral valve leaflet are a subtype of subvalvular malformation in HOCM that requires surgical correction. The lip nevus sign on echocardiography is a characteristic of APM insertion in HOCM and may improve the preoperative detection rate. Adequate myectomy with anomalous papillary muscle excision has achieved good results in reducing the outflow gradient and eliminating mitral regurgitation, with good outcomes at short-to-intermediate follow-up.
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Affiliation(s)
- Jian Liu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical
Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Tong Tan
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical
Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
- Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vascular Diseases, Beijing, China
| | - Peijian Wei
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical
Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Jianrui Ma
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical
Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Lishan Zhong
- Division of Adult Echocardiography, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
| | - Hailong Qiu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical
Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Shengwen Wang
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical
Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Jian Zhuang
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical
Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Wei Zhu
- Division of Adult Echocardiography, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
| | - Huiming Guo
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical
Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Jimei Chen
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical
Sciences, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
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Tao J, Duan F, Long J, Meng Q, Zhang B, Zhu Z, Wang H. The Role of the Submitral Apparatus in Hypertrophic Obstructive Cardiomyopathy. J Am Soc Echocardiogr 2023; 36:133-145. [PMID: 36191671 DOI: 10.1016/j.echo.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/14/2022] [Accepted: 09/25/2022] [Indexed: 02/06/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease, is characterized by unexplained hypertrophy of any myocardial segment, and has a prevalence of 0.2% to 0.5% among the general population. As one of the phenotypes of hypertrophic cardiomyopathy, left ventricular outflow tract obstruction (LVOTO) is associated with high morbidity and mortality, including cardiac death. The integration of various factors, including septal hypertrophy, malformation of the mitral valve apparatus, and an anomalous mitral subvalvular apparatus, may contribute to the occurrence of LVOTO. Previous studies have thoroughly discussed the role of the mitral valve in the mechanisms of systolic anterior motion and LVOTO. Recent studies have shown the importance of determining the potential mechanism of the submitral apparatus in inducing systolic anterior motion and LVOTO. The authors review recent advances in knowledge regarding the submitral apparatus of patients with hypertrophic cardiomyopathy.
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Affiliation(s)
- Jia Tao
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fujian Duan
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jili Long
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qinglong Meng
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Zhang
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenhui Zhu
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Wang
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Usui A, Mutsuga M. Surgical Management for Systolic Anterior Motion (SAM) of the Mitral Valve in Obstructive Hypertrophic Myopathy. Ann Thorac Cardiovasc Surg 2022; 28:239-248. [PMID: 35851569 PMCID: PMC9433892 DOI: 10.5761/atcs.ra.22-00103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In patients with obstructive hypertrophic cardiomyopathy, left ventricular outflow tract (LVOT) obstruction can be created by the hypertrophic interventricular septum (IVS) as well as systolic anterior motion (SAM) of the anterior mitral leaflet (AML). Sufficient septal myectomy is a fundamental surgical technique to treat LVOT obstruction, however, direct surgical management for SAM is another key aspect. Besides the hypertrophic IVS, mitral valve, subvalvular apparatus, and papillary muscle may play important role for SAM and several surgical techniques have been proposed to treat SAM in literature. In this review, each surgical technique is classified by the anatomical structure on which the surgical procedure is applied. The AML is the main surgical site and is applied with plication (vertical plication, resection–plication–release strategy), extension (the AML extension, transverse incision of the AML), sutured (edge-to-edge repair, anterior leaflet retention plasty), or traction (floating stitch, papillary muscle-to-anterior annulus stitches, paradoxical stitches, transposition of a directed chorda tendinea to the AML). Height reduction of the posterior mitral valve leaflet and papillary muscle reorientation are other techniques. We should understand theoretical aspects of each technique on correction of anatomical and functional abnormalities of the structure and should apply them under proper indication.
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Affiliation(s)
- Akihiko Usui
- Department of Cardiovascular Surgery, Fujita Health University Okazaki Medical Center, Okazaki, Aichi, Japan
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Bagameri G, Dearani JA. Papillary Muscle Resection During Myectomy: A Word of Caution. Ann Thorac Surg 2020; 111:1519. [PMID: 33279549 DOI: 10.1016/j.athoracsur.2020.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
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