Echocardiography in the diagnosis of Shone’s complex and analysis of the causes for missed diagnosis and misdiagnosis

Figure 1 A case of Annulo-Leaflet mitral ring. A: Two-dimensional ultrasonography at the parasternal left ventricular long-axis view revealed thickened mitral valve and a mitral ring adhered to the anterior and posterior leaflets of the mitral valve, restricting the opening of the valve leaflets and causing mitral valve inflow tract obstruction; B: Color Doppler ultrasonography at the parasternal left ventricular long-axis view revealed that blood flow velocity increased at the mitral annulus, and the forward flow velocity of the mitral valve was increased; C: Color Doppler ultrasonography at the apical four-chamber view revealed that blood flow velocity increased at the mitral annulus, and the forward flow velocity of the mitral valve was increased; D: The forward flow velocity of the mitral valve was increased significantly, at 2.29 m/s; E: Real-time three-dimensional echocardiography showed a narrow mitral valve orifice.

Figure 2 Image of a patient with incomplete Shone’s complex. Echocardiography missed the ALMR. Intraoperative exploration revealed that the mitral valve adhered to the anterior leaflet, close to the anterior leaflet of the mitral valve. A: The parasternal left ventricular long-axis view showed a significant thickening of the left ventricular wall; B: The forward flow velocity at the mitral valve was increased significantly, at 2.4 m/s, and the mean transvalvular pressure gradient was 11 mmHg; C: The aortic valve was bicuspid and arranged on the left and right; D: The flow velocity of the aortic valve was increased significantly, at 5.45 m/s, and the mean transvalvular pressure gradient was 73 mmHg.

Figure 3 A case in which the Annulo-Leaflet mitral ring was missed by echocardiography at the outpatient. Intraoperative exploration revealed that the supramitral ring was adhered to the anterior and posterior leaflets, close to the anterior and posterior leaflets of the mitral valve. A: The parasternal mitral short-axis view showed a significant reduction in the area of the mitral valve orifice, which was only 0.78 cm²; B: Two-dimensional ultrasonography at the apical four-chamber view showed thickened mitral valve with restricted opening; C: There are both annulo-leaflet mitral ring and parachute mitral valve. Preoperative echocardiography after admission showed a tiny septum on the anterior leaflet of the mitral valve; D: Spectral Doppler of the abdominal aorta showed low velocity and low resistance, suggesting coarctation of the aorta.

Figure 4 The long-axis view of the aortic arch of the suprasternal fossa showed coarctation of the aorta.