Don’t stop at two

An asymptomatic 35-year-old woman with history of coarctation repair underwent routine echo. This showed a bicuspid aortic valve with a significant gradient in the left ventricular outflow tract (LVOT). The anterior mitral valve leaflet appeared redundant. Transoesophageal echo showed thickened chordae tendineae from both mitral valve leaflets inserted into a single postero-medial papillary muscle—a parachute mitral valve. During systole, there was anterior motion of redundant mitral chordae into the LVOT producing significant obstruction. A diagnosis of partial Shone complex was made. She was referred for mitral (and possibly aortic) valve surgery. The combination of aortic coarctation with bicuspid aortic valve should stimulate a search for other levels of systemic obstruction-don’t stop at two!