Transesophageal echocardiography in diagnosing supramitral ring: A game changer

Sir, A supramitral ring (SMR) is a rare congenital defect affecting the mitral valve, potentially causing severe mitral stenosis and debilitating symptoms, particularly in young patients.[1,2] This case describes a 24-year-old female with New York Heart Association Class IV symptoms of dyspnea, whose transthoracic echocardiography showed significant mitral stenosis. The anterior mitral leaflet displayed thickening with a doming appearance, whereas the posterior mitral leaflet exhibited restricted mobility. The transmitral peak and mean pressure gradients were elevated at 28 and 16 mmHg, respectively, with a calculated valve area of 1.1 cm2, confirming severe stenosis and warranting surgical intervention. Upon preoperative transesophageal echocardiography (TEE) performed with a Philips HD11XE machine, an unexpected finding of an SMR was noted in the mid-esophageal 4-chamber (ME-4C) view [Figure 1]. This transverse membrane above the mitral valve apparatus showed blood flow aliasing on color Doppler, indicating obstruction. SMR was then confirmed surgically upon opening the left atrium, shifting the surgical plan from mitral valve replacement to SMR resection. Intraoperative TEE postbypass validated the adequacy of excision by assessing unobstructed transvalvular flow, significantly influencing the patient’s outcome with a successful return to normal mitral function and symptom resolution [Figure 2].Figure 1: Preoperative trans esophageal echocardiographic picture of supramitral ring in mid esophageal four chamber viewFigure 2: Postoperative trans esophageal echocardiographic picture after resection of supramitral ringSMR is categorized as either supramitral or intramitral, based on its anatomical location. Unlike intramitral rings, which involve the mitral valve apparatus itself, SMRs are located above the valve, sparing the valve structure. SMRs rarely present in isolation and often coincide with other congenital anomalies, particularly in Shone’s syndrome, where they associate with parachute mitral valve, subvalvular aortic stenosis, and aortic coarctation.[3] While SMR is a rare cause of mitral stenosis, this case underscores the need for heightened suspicion during preoperative evaluations to identify unusual or rare congenital anomalies. The diagnostic and intraoperative value of TEE in cardiac surgeries is highlighted here, as it enables accurate visualization of structural anomalies such as SMR, confirmation of complete resection, and immediate postresection assessment of mitral valve function. The recommended TEE views for SMR diagnosis include the ME-4C, commissural, 2-chamber, and long-axis views, with a supplemental transgastric 2-chamber view for enhanced visualization.[4] Case reports frequently support TEE’s role in changing intraoperative strategies and postoperative outcomes, particularly by identifying anomalies or residual complications that alter surgical approaches. TEE’s accuracy and real-time feedback enable dynamic surgical decisions, such as confirming patch placement, assessing for residual shunts or valve regurgitation, and ensuring the adequacy of corrective resections.[5] Therefore, this case supports TEE as the standard of care in cardiac surgery, especially in congenital cases with structural anomalies, to optimize surgical precision and patient outcomes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.