European Journal of Echocardiography 2005 6(4):291-293; doi:10.1016/j.euje.2004.10.009
Copyright © 2004, The European Society of Cardiology
Mitral paraprosthetic leak diagnosed by transesophageal echocardiography through nasal way
Demetrio Tallaricoa,*,
Pier Andrea Chiavaria,
Pasquale Molloa,
Fabio Miraldib and
Giuseppe Mazzesib
aII Division of Cardiology, Institute of Heart and Great Vessels, Attilio Reale, University of Rome, La Sapienza, Italy
bDivision of Cardiovascular Surgery, Institute of Heart and Great Vessels, Attilio Reale, University of Rome, La Sapienza, Italy
Received 21 July 2004; received in revised form 12 October 2004; accepted after revision 25 October 2004.
* Corresponding author. Tel.: +39 6 4997 0163; fax: +39 6 4997 2410. E-mail: demetrio.tallarico@uniroma1.it
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Abstract
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Paraprosthetic leaks are a postoperatively complication recurring
with a frequency from 15 to 30%, and mostly in the mitral than
in the aortic position. Transthoracic echocardiography can suspect
prosthesis valve dysfunction, but for both diagnosis and evaluation
of the paraprosthetic dysfunction severity, transesophageal
study is required. In this report a mitral paraprosthetic dehiscence
was diagnosed using a miniaturized, 10 F, monoplane probe inserted
through nasal way. This technique, that do not require topical
and general anesthesia, appears to be well tolerated providing
an accurate and more comfortable examination.
Keywords: AcuNav; Monoplane probe; Paraprosthetic leak; Transesophageal echocardiography; Transnasal
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Introduction
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Paraprosthetic leaks are the major complication of prosthetic
valves,
1 remaining a substantial source of morbidity and mortality.
Their prevalence is about 15%, with higher frequency in mitral
(31%) than in aortic position (14%),
2–4 and the average
time of presentation is nine months after surgery.
4 They can
be due to a suture's rupture or to an endocarditis infection.
Although transthoracic echocardiography (TTE) is the method
of choice for the non-invasive assessment of prosthetic valves,
for diagnosis of paraprosthetic jet transesophageal echocardiography
(TEE) is required.
5–9 We report a mitral bioprosthesis
dehiscence diagnosed by a TEE through nasal way (TEENW).
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Case report
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A 73-year-old man, with a porcine mitral valve implanted three
months before, referred for congestive heart failure. On presentation,
heart rate was 64 b/m, arterial blood pressure 120/70 mmHg and
a severe dyspnea as well as a massive pansystolic murmur were
present. ECG showed atrial fibrillation and a strain pattern.
TTE demonstrated bi-atrial and left ventricular dilatation with
a normal systolic function. Also, it suspected a paraprosthetic
leak. Clinical condition prompted us to avoid standard TEE and
to perform a TEENW, using a miniaturized, 10F, multifrequency
(5.5–10 MHz), monoplane probe (AcuNav, Acuson/Siemens),
10 developed for intracardiac ultrasounds. With the patient supine,
without topical and general anesthesia, the transducer has been
inserted, with a lubricant jelly, through a nostril. Two-dimensional
image of TEENW, corresponding to a 60–90° view of
a standard TEE, demonstrated a normal bioprosthetic valve, and
a large area of posteromedial dehiscence (
Fig. 1). Color-flow
imaging showed a severe eccentric paraprosthetic jet deforming
the atrial septum (
Fig. 2). Pulsed-Doppler interrogation of
the left upper pulmonary vein revealed a prominent systolic
backflow confirming the severe paraprosthetic regurgitation
(
Fig. 3). No variation of both blood pressure and O
2-saturation
were registered. Also, no complication occurred during and after
the procedure. Patient underwent to a re-surgery, but he died
for disseminated intravascular coagulation.
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Figure 1 Two-dimensional image of transesophageal echocardiography through nasal way, corresponding to 60–90° of a standard transesophageal examination, showing the porcine mitral prosthesis with a large area of posteromedial dehiscence (red arrow). (LA=left atrial; LV=left ventricle).
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Discussion
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Bioprosthesis or mechanical valve dysfunction is a postoperatively
complication that recurs with a prevalence of 15–30%.
Besides, mitral paraprosthetic leaks are more frequent than
these in the aortic position,
4 and haemodinamically significant
jets are treated by re-surgery.
4 Although TTE can suspect a
paraprosthetic dehiscence, TEE is generally required for diagnosis.
In a recent study the AcuNav probe, was used for transesophageal
examination with a good results.
11 Moreover, previous reports,
using a transesophageal prototype probe, demonstrated the nose
to be a good alternative approach for TEE.
12,13 We used the
AcuNav catheter and the nasal approach to evaluate this clinical
question. The nasal way, that avoids attempt at vomiting and
choking sensation, provided a comfortable and short examination.
Also, it did not require topical and general anesthesia, removing
possible complications as hypotension, mental changes, and allergic
reactions.
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Conclusion
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This report suggests the feasibility of the emerging nasal approach,
using the AcuNav transducer, to reach the esophagus. Moreover,
this technique showed a good accuracy in this clinical investigation.
TEENW might offer a feasible and equivalent echocardiographic alternative to standard TEE, especially in elderly patients, for target investigations.
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References
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Abstract
Introduction
