Images in Cardiovascular Medicine Accessory Mitral Valve With Cordal Attachments to Mitral and Aortic Valves An Unusual Cause of Left Ventricular Outflow Tract Obstruction and

We introduce the case of a 72-year-old woman referredwith exertional dyspnea and chest pain. On clinical examination, a grade III/VI harsh systolic murmur radiating to the neck was audible. Transthoracic echocardiography showed a structure attached to the proximal left ventricular outflow tract (LVOT) causing significant obstruction (maxi-mum and median gradients of 55 and 33 mm Hg, respec-tively), which led to the initial diagnosis of subaortic mem-brane (Figure 1A and 1B; Movie I in the online-only Data Supplement). Transesophageal echocardiography allowed the visualization of a mobile structure in the proximal left ventricular outflow tract, with cordal attachments to the subvalvular mitral apparatus and apparently to an aortic cuspid, conditioning severe mitral and moderate aortic insuf-ficiencies (Figure 1C and 1D; Movie II in the online-only Data Supplement). These findings were consistent with th