Image in Cardiology
Anomalous insertion of the papillary muscle in a patient with sickle cell disease: A normal variant with no left ventricular outflow obstruction
Inserção anómala do músculo papilar num doente com drepanocitose: Uma variante do normal sem obstrução do tracto de saída do ventriculo esquerdo
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"apellidos" => "Gibbs" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Petros" "apellidos" => "Nihoyannopoulos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "National Heart and Lung Institute, Hammersmith Campus, Imperial College London, United Kingdom" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto Cardiovascular, Lisboa, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital de Santa Maria, Centro Académico de Medicina de Lisboa, Serviço de Cardiologia I, CCUL, Lisboa, Portugal" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Inserção anómala do músculo papilar num doente com drepanocitose: Uma variante do normal sem obstrução do tracto de saída do ventriculo esquerdo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 744 "Ancho" => 999 "Tamanyo" => 87149 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Apical 4-chamber view of the anomalous insertion of the papillary muscles in 2D transthoracic echocardiography.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Abnormalities of the papillary muscle (PM) are a rare disorder that has been described in patients with hypertrophic cardiomyopathy<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> or cardiac amyloidosis causing significant left ventricular outflow tract (LVOT) obstruction. These anomalies are often challenging to diagnose with 2D echocardiography, and real-time 3D echocardiography (RT3D) facilitates the diagnosis by providing accurate imaging and delineation of the spatial relationship between the cardiac structures.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 43-year-old black African woman, asymptomatic at presentation (blood pressure 105/71<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 82<span class="elsevierStyleHsp" style=""></span>bp<span class="elsevierStyleHsp" style=""></span>m, body surface area 1.52<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>), diagnosed with sickle cell disease, was investigated for pulmonary hypertension in our department. Echocardiography was requested for the assessment of cardiac function and estimation of pulmonary artery pressures.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Full 2D and 3D transthoracic echocardiography (TTE) was performed and 3D images were acquired and analyzed using Philips Qlab offline analysis software. The echocardiogram revealed a dilated left ventricle (LV) with normal wall thickness and good global systolic function.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In parasternal long-axis 2D view, the anterolateral PM appeared in an unusual position, and in short-axis view and apical 4 chambers view (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) it was clearly inserted lower than normal. A complete Doppler assessment revealed no high velocity or turbulent flow pattern and no significant LVOT or intracavitary gradient was identified.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">3D echocardiography clearly showed the lower insertion of the PM and the hypertrophied chordae (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). A follow-up echocardiography study was recommended to assess left ventricular hypertrophy but the patient died a few months later due to a subarachnoid hemorrhage. No post-mortem was performed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Anomalous insertion of PMs not causing LVOT obstruction is a rare abnormality.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> RT3D is being increasingly used in the clinical setting to accurately identify cardiac structures and anatomy.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Its role is mainly in providing additional spatial information to 2D TTE in the identification of complex anatomic structures. The normal variant of low insertion of the anterolateral PM without LVOT obstruction may be observed in healthy individuals but an association with sickle cell disease cannot be excluded; further investigations are needed to confirm this association. To our knowledge, this is the first case in sickle cell disease of an anomalous insertion of PMs not causing LVOT obstruction reported in the literature.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in the study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and/or subjects mentioned in the article. The author for correspondence is in possession of this document.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] ] ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-03-19" "fechaAceptado" => "2012-03-28" "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0060" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 744 "Ancho" => 999 "Tamanyo" => 87149 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Apical 4-chamber view of the anomalous insertion of the papillary muscles in 2D transthoracic echocardiography.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 779 "Ancho" => 1033 "Tamanyo" => 98412 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Real-time 3D echocardiography demonstrating the low insertion of the anterolateral papillary muscle in apical 4-chamber view.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.avi" "ficheroTamanyo" => 2571776 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] 3 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.avi" "ficheroTamanyo" => 2469888 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Abnormally thickened papillary muscle resulting in dynamic left ventricular outflow tract obstruction: an unusual presentation of hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B.A. Austin" 1 => "D.H. 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Chaliki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ejechocard/jen197" "Revista" => array:6 [ "tituloSerie" => "Eur J Echocardiogr" "fecha" => "2008" "volumen" => "9" "paginaInicial" => "855" "paginaFinal" => "860" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18621781" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "3D echocardiography: a review of the current status and future directions" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Hung" 1 => "R. Lang" 2 => "F. Flachskampf" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2007.01.010" "Revista" => array:6 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "2007" "volumen" => "20" "paginaInicial" => "213" "paginaFinal" => "233" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17336747" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003100000010/v1_201305151709/S2174204912001584/v1_201305151709/en/main.assets" "Apartado" => array:4 [ "identificador" => "9915" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in cardiology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003100000010/v1_201305151709/S2174204912001584/v1_201305151709/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204912001584?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 4 | 7 |
| 2024 October | 37 | 33 | 70 |
| 2024 September | 50 | 29 | 79 |
| 2024 August | 50 | 40 | 90 |
| 2024 July | 35 | 28 | 63 |
| 2024 June | 42 | 26 | 68 |
| 2024 May | 41 | 18 | 59 |
| 2024 April | 24 | 18 | 42 |
| 2024 March | 48 | 20 | 68 |
| 2024 February | 29 | 18 | 47 |
| 2024 January | 39 | 20 | 59 |
| 2023 December | 37 | 26 | 63 |
| 2023 November | 40 | 25 | 65 |
| 2023 October | 47 | 14 | 61 |
| 2023 September | 44 | 26 | 70 |
| 2023 August | 31 | 8 | 39 |
| 2023 July | 48 | 6 | 54 |
| 2023 June | 36 | 21 | 57 |
| 2023 May | 61 | 24 | 85 |
| 2023 April | 57 | 5 | 62 |
| 2023 March | 106 | 23 | 129 |
| 2023 February | 143 | 17 | 160 |
| 2023 January | 105 | 16 | 121 |
| 2022 December | 78 | 24 | 102 |
| 2022 November | 84 | 31 | 115 |
| 2022 October | 58 | 16 | 74 |
| 2022 September | 77 | 35 | 112 |
| 2022 August | 57 | 23 | 80 |
| 2022 July | 98 | 39 | 137 |
| 2022 June | 96 | 32 | 128 |
| 2022 May | 74 | 27 | 101 |
| 2022 April | 70 | 35 | 105 |
| 2022 March | 63 | 30 | 93 |
| 2022 February | 44 | 21 | 65 |
| 2022 January | 71 | 16 | 87 |
| 2021 December | 48 | 24 | 72 |
| 2021 November | 68 | 47 | 115 |
| 2021 October | 83 | 47 | 130 |
| 2021 September | 56 | 27 | 83 |
| 2021 August | 69 | 38 | 107 |
| 2021 July | 57 | 29 | 86 |
| 2021 June | 70 | 16 | 86 |
| 2021 May | 64 | 42 | 106 |
| 2021 April | 93 | 30 | 123 |
| 2021 March | 88 | 26 | 114 |
| 2021 February | 60 | 18 | 78 |
| 2021 January | 42 | 7 | 49 |
| 2020 December | 33 | 6 | 39 |
| 2020 November | 31 | 20 | 51 |
| 2020 October | 24 | 17 | 41 |
| 2020 September | 55 | 12 | 67 |
| 2020 August | 25 | 4 | 29 |
| 2020 July | 57 | 7 | 64 |
| 2020 June | 32 | 6 | 38 |
| 2020 May | 48 | 4 | 52 |
| 2020 April | 35 | 12 | 47 |
| 2020 March | 46 | 7 | 53 |
| 2020 February | 83 | 13 | 96 |
| 2020 January | 33 | 4 | 37 |
| 2019 December | 35 | 4 | 39 |
| 2019 November | 31 | 4 | 35 |
| 2019 October | 27 | 5 | 32 |
| 2019 September | 97 | 16 | 113 |
| 2019 August | 23 | 5 | 28 |
| 2019 July | 57 | 11 | 68 |
| 2019 June | 35 | 6 | 41 |
| 2019 May | 47 | 14 | 61 |
| 2019 April | 27 | 14 | 41 |
| 2019 March | 37 | 8 | 45 |
| 2019 February | 54 | 13 | 67 |
| 2019 January | 28 | 4 | 32 |
| 2018 December | 44 | 8 | 52 |
| 2018 November | 63 | 6 | 69 |
| 2018 October | 180 | 17 | 197 |
| 2018 September | 62 | 11 | 73 |
| 2018 August | 31 | 5 | 36 |
| 2018 July | 38 | 4 | 42 |
| 2018 June | 62 | 6 | 68 |
| 2018 May | 58 | 7 | 65 |
| 2018 April | 60 | 10 | 70 |
| 2018 March | 73 | 7 | 80 |
| 2018 February | 68 | 7 | 75 |
| 2018 January | 43 | 5 | 48 |
| 2017 December | 71 | 10 | 81 |
| 2017 November | 55 | 6 | 61 |
| 2017 October | 37 | 5 | 42 |
| 2017 September | 50 | 12 | 62 |
| 2017 August | 50 | 11 | 61 |
| 2017 July | 45 | 9 | 54 |
| 2017 June | 56 | 14 | 70 |
| 2017 May | 73 | 15 | 88 |
| 2017 April | 37 | 2 | 39 |
| 2017 March | 107 | 32 | 139 |
| 2017 February | 192 | 4 | 196 |
| 2017 January | 47 | 2 | 49 |
| 2016 December | 65 | 11 | 76 |
| 2016 November | 92 | 4 | 96 |
| 2016 October | 60 | 9 | 69 |
| 2016 September | 93 | 7 | 100 |
| 2016 August | 40 | 3 | 43 |
| 2016 July | 34 | 3 | 37 |
| 2016 June | 34 | 2 | 36 |
| 2016 May | 17 | 5 | 22 |
| 2016 April | 17 | 1 | 18 |
| 2016 March | 32 | 4 | 36 |
| 2016 February | 56 | 13 | 69 |
| 2016 January | 48 | 7 | 55 |
| 2015 December | 42 | 5 | 47 |
| 2015 November | 36 | 3 | 39 |
| 2015 October | 36 | 7 | 43 |
| 2015 September | 45 | 5 | 50 |
| 2015 August | 30 | 9 | 39 |
| 2015 July | 22 | 5 | 27 |
| 2015 June | 22 | 0 | 22 |
| 2015 May | 22 | 6 | 28 |
| 2015 April | 33 | 7 | 40 |
| 2015 March | 29 | 1 | 30 |
| 2015 February | 30 | 3 | 33 |
| 2015 January | 30 | 4 | 34 |
| 2014 December | 35 | 9 | 44 |
| 2014 November | 28 | 8 | 36 |
| 2014 October | 35 | 3 | 38 |
| 2014 September | 33 | 4 | 37 |
| 2014 August | 27 | 5 | 32 |
| 2014 July | 47 | 7 | 54 |
| 2014 June | 32 | 3 | 35 |
| 2014 May | 26 | 3 | 29 |
| 2014 April | 27 | 4 | 31 |
| 2014 March | 45 | 8 | 53 |
| 2014 February | 54 | 9 | 63 |
| 2014 January | 46 | 9 | 55 |
| 2013 December | 68 | 9 | 77 |
| 2013 November | 44 | 8 | 52 |
| 2013 October | 50 | 9 | 59 |
| 2013 September | 49 | 12 | 61 |
| 2013 August | 52 | 14 | 66 |
| 2013 July | 67 | 12 | 79 |
| 2013 June | 49 | 6 | 55 |
| 2013 May | 62 | 6 | 68 |
| 2013 April | 78 | 16 | 94 |
| 2013 March | 54 | 6 | 60 |
| 2013 February | 52 | 16 | 68 |
| 2013 January | 51 | 13 | 64 |
| 2012 December | 36 | 8 | 44 |
| 2012 November | 29 | 16 | 45 |
| 2012 October | 13 | 1 | 14 |
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