European Journal of Echocardiography Advance Access originally published online on July 24, 2008
European Journal of Echocardiography 2008 9(6):868-869; doi:10.1093/ejechocard/jen203
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Real-time three-dimensional TEE-guided repair of a paravalvular leak after mitral valve replacement
Gregory W. Fischer1,2,* and
David H. Adams2
1 Department of Anesthesiology, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1010, New York, NY 10029, USA
2 Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY, USA
Received 21 March 2008; accepted after revision 5 July 2008; online publish-ahead-of-print 24 July 2008.
* Corresponding author. Tel: +1 212 241 7473; fax: +1 212 876 3906. E-mail address: gregory.fischer{at}mountsinai.org
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Abstract
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Paravalvular leaks are well-known complications seen following
cardiac valve surgery. We report a case in which real-time three-dimensional
TEE (3D-TEE) was utilized intraoperatively to identify the number,
severity, and precise locations of a paravalvular leak at the
time of surgery for mitral valve replacement.
Keywords: Real-time 3D-TEE; Paravalvular leak; Mitral valve replacement
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Introduction
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Paravalvular leaks are well-known complications seen following
cardiac valve surgery. Fifteen years after mitral valve replacement
(MVR), 17% of patients will present with a paravalvular leak.
1,2 Interestingly, 25% of all paravalvular leaks are diagnosed in
the immediate postoperative period. Based on the patient's symptoms
and on the degree of haemolysis, a reoperation may become necessary.
This is associated with increased morbidity and mortality. Recognizing
and repairing paravalvular leaks at the time of the initial
surgery can potentially avoid the need for a reoperation.
We report a case in which real-time three-dimensional-TEE (3D-TEE) was utilized intraoperatively to identify the number, severity, and precise locations of a paravalvular leak at the time of surgery for MVR. The 3D image enabled the surgeon to pinpoint the location of the leaks prior to returning to cardio-pulmonary bypass (CPB).
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Case report
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A 79-year-old female with past medical history of severe symptomatic
mitral regurgitation (MR) presented to the operating theatre
for mitral valve surgery. She stood 165 cm tall and weighted
73 kg. The pre-procedural TEE confirmed the diagnosis of severe
MR showing severe posterior annular and posterior leaflet calcification.
Additionally, P2 and P3 segment prolapse with ruptured chordae
tendinae could be identified (
Figure 1,
Supplementary data online, Movies 1 and 2).
Owing to the heavy degree of calcification, lack of mobile tissue
of the posterior leaflet, and the patient's advanced age, the
surgeon decided to replace the mitral valve with a bioprothesis
(Hancock II porcine, size 27). Moderate tricuspid regurgitation
and a patent foramen ovale were also identified echocardiographically
and surgically corrected.
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Figure 1 Pre-procedural live 3D ‘zoom’ mode. ‘Surgeon's View’ of the mitral valve apparatus from the orientation of the left atrium looking down towards the apex. Heavily calcified and mostly immobile posterior leaflet with ruptured chordae and prolapsing scallops P2 and P3.
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After separation from CPB, a paravalvular leak was identified
by two-dimensional echocardiography (2DE) (
Supplementary data online, Movie 3).
The image obtained in the mid-oesophageal commissural view shows
a paravalvular leak in the vicinity of where the postero-medial
commissure of the native mitral valve would be located. Subsequently,
real-time 3D colour Doppler was utilized to gain better understanding
of the precise anatomical location of this paravalvular leak
(Matrix T, Philips Medical Systems, Andover, MA, USA). The 3D
image revealed a second paravalvular leak that had not been
previously appreciated by 2D imaging. While the first leak was
in close proximity to the posterior commissure, the second leak
was further posterior (
Figure 2,
Supplementary data online, Movies 4 and 5).
The decision was made to return to CPB to repair the leaks.
After separating from CPB for the second time, no paravalvular
leaks could be identified (
Supplementary data online, Movies 6 and 7).
The patient was brought to the intensive care unit in stabile
condition. She was extubated on postoperative day 1 and discharged
from hospital on postoperative day 14.
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Figure 2 Three-dimensional colour flow full-volume image. ‘Surgeon's view’. Viewer examines the bioprosthetic valve form the left atrium looking down towards the apex of the left ventricle. Aortic valve at top of image. Paravalvular leaks at 3 o'clock and 5 o'clock, respectively.
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Discussion
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Although two-dimensional trans-oesophageal echocardiography
(2D-TEE) is very sensitive in accurately identifying the presence
of a paravalvular leak (88%),
3 pinpointing the exact anatomical
location can be very challenging. Currently, to properly assess
anatomical and pathological structures, the echocardiographer
integrates multiple ‘standardized’ 2D views to create
a ‘mental’ 3D image. Conveying this ‘mental’
image to non-echocardiographers can be very difficult.
In order to successfully close the leaks, especially when they are small, the echocardiographer must effectively communicate the anatomical location(s) to the surgeon because the localization of paravalvular leaks becomes even more difficult once the heart is arrested and flaccid.3
Three-dimensional echocardiography was first described in the 1970s,1 but until recently was rarely utilized on a regular basis in the busy operating theatre environment. This was because the acquisition of ECG and respiratory-gated 2D images, which subsequently required off-line reconstruction, was very time-consuming. The Matrix T probe, introduced clinically in 2007, can quickly and easily collect real-time 3D images, enabling the echocardiographer to provide the surgeon with a view that contains all pertinent information and can be interpreted even by non-echocardiographers. This in turn results in better understanding of a patient's specific pathology.
Gregory W. Fischer, M.D. has received speaker fees from Philips Medical.
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Supplementary data
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Supplementary data are available at European Journal of Echocardiography online.
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References
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- Hammermeister K, Sethi GK, Henderson GW, Grover FL, Oprian C, Rahimtoola SH. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veteran's Affairs Randomized Trial. J Am Coll Cardiol (2000) 36:1152–58.[Abstract/Free Full Text]
- Jindani A, Neville EM, Venn G, Williams BT. Paraprosthetic leak: a complication of cardiac valve replacement. J Cardiovasc Surg (1992) 32:503–508.
- Matsumoto M, Inoue M, Tamura S, Tanaka K, Abe H. Three-dimensional echocardiography for spatial visualization and volume calculation of cardiac structures. J Clin Ultrasound (1981) 9:157–65.[Web of Science][Medline]
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Abstract
Introduction