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The MV leaflets are thickened, especially at the leaflet edges. The MR is severe and is centrally located. No evidence of leaflet restriction or prolapse/flail could be found. The annulus is dilated. Therefore, the etiology of the MR was annular dilation.
The causes of post MVR high velocity jet in the LVOT or AV are the following:
SAM (Systolic Anterior Motion) of the anterior leaflet which partially occludes the LVOT is the most common cause of a high velocity jet. Much less commonly, the posterior mitral valve leaflet can cause SAM.
The CWD scan line could be interrogating an MR or TR jet and misinterpretation of the location of the high velocity jet could occur.
IHSS could be present preoperatively but, because of the increased LV volume, IHSS is not diagnosed preoperatively. Postoperatively, the LV volume is decreased after the MVR and IHSS is uncovered.
In both SAM and IHSS the CWD profile is typically dagger shaped. The CWD in this case was not dagger shaped. Also, with a huge cleft in the anterior mitral valve leaflet, it would take both anterior leaflets to exhibit SAM to cause a significant gradient at the LVOT. The PISA formation at the origin of the LVOT did not show any SAM.
AS gradients are flow related so increased flow through the AV after a MVR would increase the gradient. However, the echo showed an AV that almost fully opened but the leaflets appeared to be caught in a turbulent wave. Also, a very nice PISA formation was present at the origin of the LVOT.
Given the PISA formation at the LVOT, the turbulent pattern in the LVOT, and the CWD profile indicating a static stenosis/obstruction, and the AV leaflets fluttering in a turbulent jet, and no evidence of SAM, we felt that the increased jet velocity was due to increased flow resulting in a high velocity jet. The PISA formation image shows that the LVOT diameter to be around 1 cm. The differential diagnosis would be a subaortic valve membrane but the preop CWD of the AV didn't show a turbulent pattern or a subaortic valvular gradient. An intraventricular gradient would also be unlikely given the location of the PISA formation and a non-daggar-shaped CWD profile.
On week later, a repeat echocardiographic exam showed no gradient or high velocity jet through the LVOT/AV apparatus.
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