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Tuberculosis presenting as a mass on the mitral annulus

Authors: Dr. Julia Grapsa, Dr. Chrysoula Patsa, Dr. Andreas Kalogeropoulos, Dr. Grigorios Karamasis, Mr. David Dawson, Prof. Petros Nihoyannopoulos.

Hammersmith Hospital
Imperial College NHS Trust

Contact: Julia Grapsa,
EACVI ambassador for Greece

On behalf of the EACVI club 35 for Greece


 

Description

  • LD 68 years old female
  • Admitted with shortness of breath, signs of orthopnoea and left sided heart failure
  • Transthoracic echocardiogram revealed an echogenic mass in the mitral annulus.

Clinical case information

http://www.youtube.com/watch?v=OavmB1AYKB4
http://www.youtube.com/watch?v=mQ9Plxum_7I
Parasternal long axis view: The left atrium is dilated. The posterior mitral annulus is rather echogenic and it extends to the posterior mitral leaflet. Aortic valve is structurally normal. Parasternal long axis view: There is an echogenic mass which engages the posterior mitral annulus casing turbulence across the mitral annulus suggesting both mitral stenosis and regurgitation.

 

Parasternal long axis view: There is an echogenic mass which engages the posterior mitral annulus and extending below the posterior leaflet of the mitral valve.

http://www.youtube.com/watch?v=DnSAJ_-F1bA
http://www.youtube.com/watch?v=yg01Y-TKiOA
Parasternal long axis view Parasternal short axis of the mitral valve: good overall left and right ventricular systolic function. There is an echogenic mass in the posterior mitral annulus and extending below the posterior leaflet of the mitral valve. The anterior mitral leaflet is also affected as well.

 

http://www.youtube.com/watch?v=9wiU2MHuD7k
Parasternal short axis – focus on the right ventricle and the tricuspid valve. The right ventricle is mildly dilated and volume overloaded with good overall systolic function. There is severe tricuspid regurgitation, filling more than 70% of the right atrial area. Right atrium is dilated when indexed to the body surface area.

 

Apical four chamber view and assessment of the valve: Application of continuous wave – TR velocity: 3.3 m/sec (PPG, 43.6 mmHg) which corresponds to an estimated RVSP of 58.6 – 63.6 mmHg (RAP 15-20 mmHg).

 

http://www.youtube.com/watch?v=_zW1klqwl2g
http://www.youtube.com/watch?v=LUMkn5lKbDU
Apical four chamber view: Left ventricle is in the upper limits of normal in dimensions with good overall systolic function. Left atrium is dilated. The echogenous mass engages all the mitral annulus below the leaflets. Apical four chamber view and colour Doppler: Mitral flow turbulence suggest both mitral stenosis and regurgitation.

 

Mitral valve inflow: Mean transmitral valve gradient can be measured by tracing the outline of mitral diastolic inflow and the mean pressure gradient is automatically calculated.

 

Apical four chamber view: Continuous wave Doppler evaluation of mitral regurgitation showing a dense signal.

 

http://www.youtube.com/watch?v=Q0vS5r2LxnI
Subcostal view : Inferior vena cava is dilated (27 mm) with reduced respiratory collapse. Right atrial pressure is estimated as 15-20 mmHg.

 

Conclusion

The patient underwent biopsy of the mass. Histological diagnosis was tuberculosis. Subsequently she had pharmacological treatment for tuberculosis. After 6 months of therapy, the mass minimized but the patient had significant mitral regurgitation and underwent mitral valve surgery