Case-of-the-Week

Case of the Week

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AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.

Case-of-the-Week Information

The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

You can change the size and the format of the image or video loops by using the links below the image or video loop.

= MP4 Video	= Ogg Video
= WebM Video	= GIF Image
Image/Video Sizes	= JPG Image
1X = 200x150 pixels 2X = 400x300 pixels	3X = 600x450 pixels 4X = 800x600 pixels

Loop Text Key
Preop	Preop TEE or TTE
Intraop	An Intraop TEE
IntraopPreOp	Intraop TEE or TTE before Operation
IntraopPostOp	Intraop TEE or TTE after Operation
IntraopEnd	Intraop TEE or TTE at End of Anesthesia
Post Op	Postop TEE or TTE

Case of the Month Information Table

IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE

More than Unusual MR

Case#: 15

AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits

Presentation:
54 y.o. female with history of SOB, increasing DOE, with a systolic murmur.

What is your diagnosis of the mechanism of the mitral regurgitation?
Any other diagnoses?
What are your recommendation(s)?

Loops:

Case Discussion/CME Questions

The TEE shows severe mitral regurgitation, trace of aortic regurgitation and a trace of tricuspid regurgitation. The A1 scallop of the mitral valve is exhibiting prolapse. The aortic valve has Lambl's excressences. The TEE also shows a membranous ventricular septal aneurysm.

Zhang repaired anterior mitral valve leaflet prolapse by utilizing chordal transfer in 21 patients. 1 patient had a mitral valve replacement. All of the other patients had good results based upon MV area ((3.3-4.8 cm2), mitral regurgitation (jet area 0.45 cm2), decreased LV dimension, and decreased LA dimension.

Zonghua compared chorda shortening to chorda replacment and found that chordal replacement resulted in superior results for anterior mitral valve leaflet prolapse. The chordal replacement group had better 5 year survival and slightly more freedom from operation than the chordal shortening group.

Morimoto studied multiple repair techniques in anterior mitral valve prolapse ranging from chordal replacement, transfer, shortening to resection, folding, and Alfieri repair. He noted 95% and 89% survival at 10 and 15 years after the repair.

Most membranous septal aneurysms are considered a rare congenital anomaly. The membranous septum is the weakest portion of the septum and separates the right and left ventricles and also the left ventricle and the right atrium behind the tricupsid valve. A LV to RA defect is called a Gerbode defect. The membranous septal aneurysm is usually small (1-3 cm) but can become larger and occlude the RVOT. Membranous septal aneurysms can be acquired by infection, trauma, or myocardial infarction. The membranous septal aneurysm may have a VSD. Membranous septal aneurysms have been associated with aortic regurgitation, membranous subaortic stenosis, complete AV block, mongolism, coarctation of the aorta and thromboembolism.

Other etiologies for the membranous septal aneurysm may be the closure of a VSD by the membranous septum. The VSD spontaneously closes and leaves behind a membranous septal aneurysm.

Membranous septal aneurysms have been associated with fatal ventricular tachyarrhtyhmias.

The recommendations are to repair the mitral valve A1 scallop but not repair the membranous septal aneurysm.

Please answer the following questions correctly to obtain your CME.

Web Links/References

Aneurysm of the membranous ventricular septum.
Ventricular septal defect associated with aneurysm of the membranous septum
Importance of (perimembranous) ventricular septal aneurysm in the natural history of isolated perimembranous ventricular septal defect
Aneurysm of membranous interventricular septum
Edge-to-edge chordal transfer repair for anterior leaflet prolapse of mitral valve in 21 patients.
[Efficacy of mitral valve repair for anterior leaflet prolapse of mitral valve].
[Repair of anterior leaflet mitral valve prolapse: the comparison between chordal replacement and chordal shortening].
Mitral valve repair for anterior leaflet prolapse: surgical techniques review and 16-year follow-up results.

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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of University of Nebraska Medical Center, Center for Continuing Education and JLS Interactive, LLC.

The University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

This activity is approved by the American Society of Radiologic Technologists (ASRT) as sonography-related continuing education (CE). Credit(s) issued for successful completion of ASRT-approved CE activities are accepted by the American Registry of Diagnostic Medical Sonography, American Registry of Radiological Technologists, Cardiovascular Credentialing International and Canadian Association of Registered Diagnostic Ultrasound Professionals. Contact the applicable registry for additional information / restrictions on their acceptance of ASRT CE credit.