A 53-year-old man was admitted for surgery with a diagnosis of aortic valve stenosis, left ventricular outflow tract (LVOT) obstruction by systolic anterior motion of the mitral valve, and moderate-to-severe mitral regurgitation. Peak and mean LVOT gradients measured by transthoracic echocardiography were 91 mmHg and 51 mmHg, respectively. Intraoperative transesophageal echocardiography (TEE) showed calcific aortic stenosis with moderate aortic insufficiency and systolic anterior motion of the anterior leaflet of the mitral valve. The interventricular septum measured 2.86 cm in diastole, with anomalous insertion of a band from the anterolateral papillary muscle to the basal septum. Peak LVOT gradient was 208 mmHg in concurrence with moderate-to-severe mitral regurgitation (Fig 1, Video clip 1). The aortic valve was bicuspid and calcified. He underwent aortic valve replacement with a mechanical prosthesis, extended septal myectomy, and excision of an abnormal band to the ventricular septum. The anterolateral papillary muscle was bifid, with 1 head giving rise to the chordae and the other continued as a band to insert into the anterobasal septum. Postoperative TEE showed no LVOT obstruction, mild mitral regurgitation, and a mean gradient of 14 mmHg across the aortic valve prosthesis.
Dr. Praveen Varma, Raman, S. Puthuvasse, Unnikrishnan, K. Pappu, Kundan, S., and Gadhinglajkar, S. Vitthal, “Intraoperative transesophageal echocardiography diagnosis of concomitant hypertrophic cardiomyopathy with anomalous insertion of a papillary muscle band to the interventricular septum in a patient for aortic valve replacement.”, J Cardiothorac Vasc Anesth, vol. 28, no. 6, pp. e56-58, 2014.