Liquefaction Necrosis of Calcified Mitral Annulus

Echogenicity within the left atrioventricular groove can be due to many conditions, such as mitral annular calcification, abscess, dilated coronary sinus, and aneurysm of the left circumflex coronary artery. However, in a patient who has no systemic symptoms, a bright, round echodensity with central echolucency and smooth borders in the mitral annulus is characteristic of liquefaction necrosis of a calcified mitral annulus. We report the occurrence of this rare manifestation in a 60-year-old patient who presented with myocardial infarction.     

Mitral Annular Calcification Mimicking an Intracardiac Mass

We present two patients with atypical mitral annular calcification. In both instances, the annular calcification presented as a mass localized to the atrioventricular junction. In one instance, there was a mobile element of the mass which resulted in an embolic stroke. In conclusion, atypical mitral annular calcification can mimic an intracardiac mass. It is usually recognized by its typical location and echocardiographic characteristics.     

Multimodality Imaging of Mitral Perivalvular Abscess with Annular Fistula and Preserved Leaflet Function

A devastating complication of both native and prosthetic valvular infective endocarditis can involve periannular extension, which is associated with increased perioperative mortality and long‐term adverse outcomes. Cardiac imaging, both noninvasive and invasive, is essential to accurately identify the extent and complexity of these infections to perform effective surgical interventional strategies. We present the case of a 62‐year‐old woman who was found to have a perivalvular mitral valve abscess with an annular fistula without evidence of mitral valve leaflet involvement on histopathology, diagnosed by 3‐dimensional transesophageal echocardiography, computed tomography, and left ventriculography.     

Values for Mitral Valve Annulus Dimensions in Normals and Patients with Mitral Regurgitation

Objectives. The present study was designed to investigate the dimensions of mitral valve annulus in the presence of mitral regurgitation. Method. Fifty-four patients were examined. On transthoracic echocardiographic images, we performed linear measurements in the parasternal plane in order to define the size of the left ventricle, left atrium, and mitral valve annulus. We compared these findings with those obtained in 16 control subjects. Results. Twenty-one patients with mild or moderate mitral regurgitation demonstrated no significant change of the mitral valve annulus compared with the control group (P > 0.05). Seventeen patients with severe mitral regurgitation (grade of 4) had a significant increase of the dimensions of the mitral valve annulus, left ventricle, and left atrium (P < 0.05). The etiology of mitral regurgitation was degenerative in 32 patients, rheumatic in 2 patients, and mitral valve prolapse in 4 patients. All patients had normal left ventricular systolic function. Thirty-one patients were in normal sinus rhythm, and seven were in atrial fibrillation. Conclusions. The measurement of the diameter of the mitral valve annulus is feasible with transthoracic echo-cardiography. In addition to the evaluation of mitral valve leaflets and subvalvular apparatus, the measurement of the mitral valve annulus is important in the evaluation of mitral regurgitation, as its enlargement is indicative for severe mitral regurgitation .     

Imaging for Mitral Interventions: Methods and Efficacy

The mitral valve (MV) is a complex and intricate structure. With the development of transesophageal echocardiography in the 1990s, it became possible to evaluate MV anatomy and function in real time during surgical procedures. Subsequently, new surgical and percutaneous techniques for MV repair as well as replacement have evolved. Development of 3-dimensional and intracardiac echocardiography, as well as computed tomography, cardiac resonance imaging, and most recently fusion imaging, have paved the way for a more comprehensive evaluation of the MV as well as for the planning of percutaneous MV procedures such as balloon valvuloplasty, paravalvular mitral leak closure, percutaneous edge-to-edge repair, transcatheter MV annuloplasty, artificial chord implantation, and transcatheter MV replacement. The applicability and use of the various imaging modalities for the assessment and guidance of therapy for MV disorders is discussed in this paper.     

Live/Real Time Three‐Dimensional Transesophageal Echocardiographic Findings in Caseous Mitral Annular Calcification

We describe a 77‐year‐old female with hypertrophic cardiomyopathy in whom live/real time three‐dimensional transesophageal echocardiography (3DTEE) provided incremental value over two‐dimensional transthoracic and transesophageal echocardiography (2DTTE, 2DTEE) and three‐dimensional transthoracic echocardiography (3DTTE) in making a more comprehensive assessment and a more confident diagnosis of caseous mitral annular calcification. 3DTEE revealed a portion of the mass to consist of small, multiple, highly echogenic discrete band‐like and punctate areas within a relatively much less echogenic stroma and surrounded by a well defined highly echogenic border. This appearance correlated with the pathological findings of calcific granules/strands located in a liquefied or semiliquefied interior providing a typical toothpaste like appearance. The highly echogenic outer border represented the residual outer portion or rim of the calcific mass which did not undergo liquefaction. These findings on 3DTEE which correlated with the toothpaste like appearance seen at surgery were not visualized on 2DTTE, 2DTEE, and 3DTTE. (Echocardiography 2010;27:1147‐1150)     

Relation of Mitral Annular Dilation with Dynamic Mitral Regurgitation in Patients with Rheumatic Mitral Regurgitation

Introduction: Dynamic mitral regurgitation (MR) is frequently investigated in patients with left ventricular systolic dysfunction (LVSD). Data about the dynamic MR in patients with organic valve disease are limited. The aim of this study was to evaluate the alteration of MR by exercise in patients with rheumatic valve disease (RVD). Methods: Asymptomatic patients with rheumatic MR and normal left ventricular function had been included in our study. Transthoracic echocardiography and Doppler measurements were performed at rest and just after submaximal exercise test performed with treadmill. Severity of MR was evaluated quantitatively by measuring effective regurgitant orifice area (EROA) with flow convergence method. Results: A total of 34 patients with rheumatic MR had been included. Severity of MR increased in 10 patients with exercise (Group 1) and decreased in 24 of them (Group 2). When the variables of two groups were compared; diastolic blood pressure after exercise, EROA, left atrial volume, left ventricular diastolic volume and mitral annular area values were significantly higher in Group 1 patients. A linear regression model was constructed by considering change of EROA by exercise the dependent, and the variables showing significant differences as the independents. Mitral annular area was found to be independently associated with EROA increase with exercise (R²= 0.499; P < 0.001). Conclusion: Mitral annular dilation is independently associated with increase of MR with submaximal exercise in asymptomatic patients with MR due to RVD with normal left ventricular function.     

Assessment of Mitral Annular and Velocity Vector Imaging in Acute Myopericarditis

A 25‐year‐old student presenting with pleuritic chest pain, elevated troponin levels and subtle electrocardiogram abnormalities was treated for presumptive myopericarditis. On echocardiography, a lower than expected mitral annular displacement and systolic velocity were identified along with abnormalities in left ventricular strain generation that matched areas of edema and necrosis by cardiac magnetic resonance imaging. The patient was treated with nonsteroidal antiinflammatory drugs and colchicine, and both the symptoms and echocardiographic abnormalities rapidly resolved. These novel findings suggest that changes in mitral annular displacement and systolic velocity occur in acute myopericarditis and may be useful in following the course of the disease     

Rare Mycotic Aneurysm of the Mitral Valve without Aortic Valve Involvement

Mycotic aneurysms can be a rare, but serious complication of infectious endocarditis. We report the case of a 20‐year‐old woman who presented with fever and malaise from streptococcal bacteremia and found to have vegetation on the anterior leaflet of the mitral valve. On follow‐up visit, the patient was noted to have a mycotic aneurysm of the anterior mitral valve without aortic involvement. Her clinical course was complicated by mitral valve chordal rupture, severe mitral regurgitation, and dyspnea from severe mitral regurgitation for which she underwent successful surgical repair of the mitral valve.     

Congenital Mitral Stenosis by Multimodality Cardiac Imaging

This vignette illustrates a classic case of congenital mitral stenosis (Ruckman-VanPraagh type 1) presenting in adulthood and demonstrates the benefits of multimodality cardiac imaging prior to successful surgical intervention.     

Tumor-Like Mitral Annular Calcification with Central Liquefaction

Calcification of the mitral annulus is a degenerative process, which occurs mainly in older patients. Rarely, an extensive mitral annular calcification (MAC) with central liquefaction was reported. We report the case of extension of MAC into the adjacent left ventricular posterior wall along with central liquefaction and posterior mitral leaflet displacement in a 63-year-old woman. The abnormal size of the MAC and unusual echo density of pasty material inside made a correct diagnosis difficult and intracardiac tumor was suspected. Thus, similar uncommon clinical presentation of MAC should be considered in the differential diagnosis of intracardiac masses.     

Dynamic Change of Mitral Annular Geometry and Motion in Ischemic Mitral Regurgitation Assessed by a Computerized 3D Echo Method

Objective: In patients with ischemic mitral regurgitation (IMR), we assessed dynamic changes in mitral annular geometry and motion during the cardiac cycle, and examined their association with the severity of IMR, using our computerized three‐dimensional (3D) echo method. Methods: Real‐time 3D echo was performed in 12 normal controls and 25 patients with IMR. The saddle‐shaped annulus was reconstructed in every 3D volume/frame during a cardiac cycle. For each 3D volume/frame, we assessed the mitral annular area (MAA) and the annular contraction that was expressed as the percentage of the largest MAA accounted for by the change in MAA from largest to smallest calculated value. Results: In IMR patients, the minimum MAA occurred in late‐systole, while it occurred in early‐systole in the controls. IMR patients had a larger minimum MAA (6.7 ± 1.3 vs. 3.6 ± 0.8 cm², P < 0.001) and reduced annular contraction (23.0 ± 6.5 vs. 42.6 ± 7.0%, P < 0.001) when compared to controls. Both minimum MAA and annular contraction had significant correlations with IMR severity (r = 0.67 and r = 0.78, P < 0.001 for both). Conclusion: The contraction of the dilated mitral annulus occurred in late‐systole in patients with IMR. The alterations of annular geometry and motion may be associated with the development of IMR. (Echocardiography 2010;27:1069‐1077)