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Case of the Week
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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).

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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
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)?


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.

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