The Role of 3D Transesophageal Echocardiography During Percutaneous Closure of Paravalvular Mitral Regurgitation

Abstract

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).

Percutaneous Closure of an Aortic Prosthetic Paravalvar Leak: An Australian First

“…After deployment, device position and stability is assessed, and complications (including valve leaflet impingement) excluded, with fluoroscopy, 2D and 3D TOE. Additionally, colour Doppler and aortography are used to evaluate residual regurgitation [15,17].…”

Diagnosis and Treatment of Left-Sided Prosthetic Paravalvular Regurgitation

“…2). RT 3D TEE allows for precise anatomic localization of defect(s) with attention to shape (crescent-shaped vs. round), valve dehiscence, the distance from the sewing ring, the orientation and movement of prosthetic leaflets and the degree of regurgitation as well as improving the identification and quantification of multiple regurgitant jets [6,7]. Intracardiac echocardiography is less useful due to acoustic shadowing, but may be useful in certain instances.…”

The use of echocardiography in acute cardiovascular care: Recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

“…The extent of the prosthetic circumference on short-axis views showing leakage may be used to estimate severity, with > 20% (corresponding to > 72°) of the circumference indicating severe regurgitation ( Figure 16). 89,90 In acute regurgitation of an aortic prosthesis, premature mitral valve closure may be detected and indicates catastrophic regurgitation. New paraprosthetic leakage presenting in the acute/ emergency setting is predominantly due to endocarditis.…”