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).

In this population our study demonstrates a discontinuation rate of 10% due to side effects of dabigatran, similar to the rate reported in RE-LY. The majority of patients are satisfied with their treatment and preferred dabigatran to warfarin, mainly due to the reduced requirement for blood testing.

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