Extract

A 66-year-old man with a history of smoke, hypertension, and dyslipidaemia was referred for chest pain. Baseline ECG and chest X-ray were normal. Transthoracic echocardiography revealed a long, mobile, thick fibrous structure in the left ventricular (LV) cavity which originated from the mitral valve (MV) anterior leaflet and protruded into the LV outflow tract (LVOT) during systole, not associated with MV prolapse or regurgitation. No resting outflow gradient was demonstrated, and a mild reduction in LV systolic function was shown including apical akinesia and hypokinesis of the anterior septum. The patient underwent coronary angiography which showed significant obstructions of the left coronary, circumflex, and posterior interventricular arteries.

Assuming an elevated systemic embolic risk within significant ischaemic heart disease, the patient underwent urgent coronary bypass surgery associated with resection of the mobile LV mass. At 2D and real-time 3D intraoperative transoesophageal echocardiography (TOE), the fibrous structure appeared as a thick, elongated MV chorda between the postero-medial papillary muscle and the anterior MV leaflet (Panels A, C, and D). Macroscopic inspection demonstrated that the mass resulted from twisted MV accessory chordae protruding into the LVOT (Panel B).

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