Diagnostic dilemma| Volume 25, ISSUE 5, P891-893, October 2011

Feeling the Pressure? Anterior Mitral Leaflet Immobility in a Patient With Bicuspid Aortic Valve Disease

      A 32-YEAR-OLD, 87-kg, 173-cm man with a past medical history of a congenital bicuspid aortic valve was admitted to the authors' hospital for evaluation of dyspnea on exertion. The patient had been a frequent participant in strenuous athletic activities including full-court basketball. He reported that his stamina during these activities had declined substantially in recent months. The patient also described unusual episodes of fatigue while performing his job as a biomedical engineer. He denied a history of angina pectoris, syncope, palpitations, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. The physical examination was notable for a grade III of VI holodiastolic murmur heard best along the left sternal border. An Austin Flint murmur
      • Flint A.
      On cardiac murmurs.
      was not appreciated. The remainder of the physical examination was noncontributory. Noninvasive measurements of arterial blood pressure indicated the presence of a widened pulse pressure (75-80 mmHg). A plasma brain natriuretic peptide concentration was normal. Transesophageal echocardiography (TEE) was performed as part of the evaluation and confirmed the presence of a bicuspid aortic valve with thickened anterior-lateral (left and right coronary cusp fusion; type A)
      • Russo C.F.
      • Cannata A.
      • Lanfranconi M.
      • et al.
      Is aortic wall degeneration related to bicuspid aortic valve anatomy in patients with valvular disease?.
      and posterior-medial leaflets of approximately equal size. The TEE examination also revealed that the middle scallop of the anterior mitral leaflet (A2) was essentially immobile throughout the cardiac cycle (Fig 1, Fig 2 and Video 1 [supplementary videos are available online]). What is the cause of this anterior mitral leaflet immobility?
      Figure thumbnail gr1
      Fig 1The midesophageal long-axis view obtained during systole.
      Figure thumbnail gr2
      Fig 2The midesophageal long-axis view obtained during early diastole; the location and shape of the middle scallop of the anterior mitral leaflet (A2) are essentially unchanged compared with .

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