The Role of 3D Transesophageal Echocardiography During Percutaneous Closure of Paravalvular Mitral Regurgitation
Christian Hamilton-Craig, MBBS, BMedSci (Hons)*,
Tau Boga, MBBS,
David Platts, MD,
Darren L. Walters, MBBS,
Darryl J. Burstow, MBBS,
Greg Scalia, MBBS
The Prince Charles Hospital, Brisbane, Queensland, Australia
PARAVALVULAR MITRAL REGURGITATION (MR) after mitral valve replacement may lead to heart failure and hemolysis. There are data to suggest that closure of paravalvular mitral regurgitant leaks confers an improved prognosis, with reduced hemolysis and improved functional status (1). These patients may be at increased risk for redo cardiac surgery. Consequently, transcatheter percutaneous closure of paravalvular mitral regurgitation is an increasingly performed procedure (2).
Transesophageal echocardiography (TEE) is used to assess the site and severity of paravalvular MR before percutaneous closure and to guide trans-septal puncture (2). Defining the anatomic site and spatial orientation of the paravalvular leak in relation to the valve annulus and surrounding structures can be challenging due to acoustic shadowing from the mechanical prosthetic ring and the complex and varied nature of the paravalvular MR geometry. Three-dimensional (3D) real-time transesophageal echocardiography (TEE) using a matrix array transducer offers a true "surgeon's eye view" of the mitral annulus from within the left atrium, with the aortic valve at the top of the live 3D field, the left atrial appendage to the left of the frame, and interatrial septum to the right. Live 3D TEE allows improved evaluation of the paravalvular leak geometry and assessment of suitability for percutaneous closure. It is also of benefit during the procedure by guiding the interventionist in crossing the lesion and deploying the device.
The following images depict the use of TEE and live 3D TEE in guidance of transcatheter percutaneous closure of paravalvular MR (Fig. 1). The importance of echocardiographic imaging is highlighted, including the assessment of large defects unsuitable for percutaneous closure and detection of complications such as residual paravalvular MR and prosthetic leaflet entrapment (Fig. 2).
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Figure 1 Guidance by 3D TEE in Percutaneous Closure of Mitral Paravalvular Defects
A severe paravalvular leak is suspected in a patient presenting with hemolysis and heart failure 2 years after mechanical valve replacements (ATS Medical Inc., Minneapolis, Minnesota) in the aortic and mitral positions. The leak is located at the postero-medial portion of the valve annulus on standard 2-dimensional transesophageal echocardiography (TEE) with color Doppler (A), using live 3-dimensional (3D) TEE (B, white arrow) and 3D TEE with color Doppler (C) (Online Video 1). Note that the mitral valve replacement is inserted in an "anti-anatomical" orientation, with the hinges in an antero-posterior fashion. Trans-septal puncture is performed under TEE guidance (D). A sheath and 2 wires can be seen on live 3D TEE crossing into the left atrium (E). The paravalvular defect is crossed with a wire (F), and the distal disc of the Amplatzer (AGA Medical Corp., Golden Valley, Minnesota) muscular ventricular septal defect occluder is deployed into the left ventricular cavity as seen in the 3D trangastric view (G). The disc is pulled back against the paravalvular defect and the device position is confirmed to be optimal (H). The left atrial disc is then deployed, and wire released (I) (Online Video 2). The final result reveals unimpeded valve occluder motion, normal inflow gradients, and minimal residual mitral regurgitation.
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Figure 2 Evaluation by 3D TEE of Paravalvular Leak Complications
Intraprocedural imaging provides vital information and detection of complications during percutaneous closure of paravalvular leaks. (A to E) TEE and 3D TEE reveal an ATS mitral valve replacement with an anterolateral paravalvular leak (A, B). The defect is crossed with a wire (C) and a muscular ventricular septal defect occluder device is inserted. Deployment of the device (D, arrow) results in entrapment of the lateral valve occluder (D, E, arrowheads) and a rise in the mean transmitral gradient (9 mm Hg) (Online Video 3). The device was successfully retrieved. F and G demonstrate a large crescentic defect involving greater than one-third of the annular circumference (F, black arrow). During ventricular systole, the "puff" of turbulent mitral regurgitation is seen on live 3D TEE imaging (G) (Online Video 4). Due to the circumferential extent of this defect, it was deemed unsuitable for percutaneous device closure. Three-dimensional TEE is able to define the presence and location of multiple paravalvular leaks (H) (Online Video 5). During ventricular systole, full-volume color 3D TEE (I) reveals a dominant posterolateral leak (long arrow), and a smaller unsuspected anterolateral leak (short arrow). The normal transvalvular regurgitant jets for this mechanical prosthesis are also seen at the valve hinge points (arrowheads). Multiple percutaneous closure devices or surgery would be required in such cases. Abbreviations as in Figure 1.
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Appendix
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For accompanying Videos 1, 2, 3, 4, and 5, please see the online version of this article.
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Footnotes
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Dr. Hamilton-Craig is supported by a grant from the National Heart Foundation of Australia.
* Address for correspondence: Dr. Christian Hamilton-Craig, Fellow in Cardiac Imaging, The Prince Charles Hospital, Rode Road, Chermside 4032, Brisbane, Queensland, Australia (Email: chamiltoncraig{at}gmail.com).
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REFERENCES
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- Genoni M, Franzen D, Vogt P, et al. Paravalvular leakage after mitral valve replacement: improved long-term survival with aggressive surgery? Eur J Cardiothorac Surg 2000;17:14-19.[Abstract/Free Full Text]
- Cortes M, Garcia E, Garcia-Fernandez MA, et al. Usefulness of transesophageal echocardiography in percutaneous transcatheter repairs of paravalvular mitral regurgitation Am J Cardiol 2008;101:382-386.[CrossRef][Web of Science][Medline]
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