case_images: PMC10847002_01
case_images: Preoperative TTE imaging. (A) Apical 4-chamber view with poor nearfield delineation of LV wall motion. (B) Global longitudinal strain of LV and RV in apical 4-chamber view was -23.2% and -26.1%, respectively. (C) Continuous-wave Doppler tracing of LVOT and AV blood flows in the modified apical 4-chamber view is approximately 1.5 m/sec. (D) The distance between the MV coaptation and LV septum (C-Sept) is far greater than 2.5 cm in the parasternal long-axis view (two white dotted lines indicates the anterior and posterior MV leaflets). (E) In the absence of AV stenosis, SAM of anterior MV leaflet or LVOT obstruction, the systolic jet flow in the LVOT area is noted in the parasternal long-axis view. Ao: aortic valve opening, AV: aortic valve, C-sept: the distance between the mitral valve coaptation and left ventricular septum (yellow dotted line with reversed arrows in both ends), LA: left atrium, LV: left ventricular cavity, LV GLS A4C: LV global longitudinal strain in apical four-chamber view, LVOT: LV outflow tract, MV: mitral valve, RA: right atrium, RV: right ventricle, RV FWS: RV free wall strain, SAM: systolic anterior motion, TTE: transthoracic echocardiography.
case_images: apm-23124f1.jpg
case_images: PMC10847002_01_apm-23124f1.jpg
case_images: f1-apm-23124
case_images: An attending anesthesiologist performed POC 2-dimensional (2D) transthoracic echocardiography (TTE, Epiq CVX  cardiovascular ultrasound system and X5-1  3-dimensional [3D] transducer, Philips) to evaluate whether the systolic murmur had a potential association with severe AV stenosis or LVOT obstruction (Fig. 1A, Video 1A). The parasternal long-axis TTE image provided detailed information on the LVOT flow around the AV, MV apparatus, hypertrophied LV septum, and LVOT: no apparent pathology suggesting AV stenosis, such as calcification, fusion, or limited motion of AV leaflets, was noted (Fig. 1D, Video 1C).
case_images: Intraoperative TEE imaging. (A) Modified 2D deep transgastric long-axis view with color Doppler delineates the systolic jet flow (arrow) arising from the tip of anterolateral papillary muscle and anterior LV wall, traversing LVOT area and ending just before the AV opening. (B) 3D mid-esophageal TrueVue  image visualizes the narrow structure in the LV cavity where the jet flow arises (arrow). (C) Multi-planar images, reconstructed from a 3D volume color data, delineates the long-axis tracing (direction) of the jet flow, the origin of the jet flow (a narrow space between the tip of the posteromedial papillary muscle and the LV inferior wall in the left upper green plane and right upper red plane), and the short-axis tracing of the jet origin (vena contracta, in the left lower blue plane). (D) Rotated 3D TrueVue  live image localizes the origin of the jet flow (arrow) with adjacent cardiac structures. The size of the jet flow color Doppler was variable to the changes in LV filling status and contractility. Ao: aortic valve opening, AV: aortic valve, LV: left ventricular cavity, LVw: LV anterior wall, LVOT: LV outflow tract, P: anterolateral papillary muscle, TEE: transesophageal echocardiography, 2D: 2-dimensional, 3D: 3-dimensional.
case_images: apm-23124f2.jpg
case_images: PMC10847002_01_apm-23124f2.jpg
case_images: f2-apm-23124
case_images: It provided much more detailed information about the origin and the nature of the murmur: the systolic jet flow arose from the narrow space surrounded by the anterior MV chordae tendineae (at the tip of the posteromedial papillary muscle) and the hypertrophied inferior LV wall (Fig. 2A and B, Video 2A and B). The jet traversed the LVOT area and reached the AV annulus, and its flow intensity was variable to the changes in the LV filing status (Fig. 2C, D).