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Paravalvular leak after mitral valve replacement: Advantage of 3D echo Sarvesh Pal Singh, Suruchi Hasija, Sandeep Chauhan Department of Cardiac Anaesthesia, C. N. Center, AIIMS, New Delhi, India
A systematic transesophageal echocardiography (TEE) examination is indispensable in the early post‑operative period after mitral valve replacement (MVR).[1] In this report, we emphasize the importance of repeat 2D TEE examination and 3D echocardiography examination 20‑30 min after weaning from cardiopulmonary bypass (CPB). 3D echocardiography examination confirmed the extent and position of paravalvular leak. In this modern era, 3D echocardiography is an established modality for imaging prosthetic mitral valve and surgical decision making.[2]
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A 30‑year‑old‑male underwent an uneventful mitral valve replacement with a 31 mm mechanical prosthesis ATS (ATS Medical, Inc., Minneapolis, MN) using interrupted sutures. The patient was weaned off CPB with minimal inotropic support using dobutamine 5 µg/kg/min. Post CPB, TEE examination showed left ventricle ejection fraction 65%, with the absence of any regional wall motion abnormality. In addition, an eccentric regurgitant jet was observed [Figure 1] from the posterior annulus (native P2). The finding was confirmed with real time 3D echocardiography (RT3DE) by observing the prosthetic mitral valve from the left atrium (en face view) in the mid esophageal four‑chamber view [Figure 2]. Repeat TEE examination, using color flow Doppler, after 20 min, showed an increase in the vena contracta of the regurgitant jet 4.3 mm from 2.8 mm [Figure 3]. A surgeon’s eye view was achieved by adjusting the aortic valve at 12 o’clock position in relation to the mitral valve. The defect between the annulus and prosthetic valve sewing ring had increased from posterior 6 o’clock position (native P2) to 1 o’clock (native A2) position covering nearly half the annulus [Figure 4]. The CPB
Figure 1: Midesophageal bicommissural view shows an eccentric regurgitation jet due to paravalvular leak from posterior mitral annulus
Figure 2: 3D transesophageal echocardiography view (as seen from the left atrium) of mitral valve in systole showing a defect between sewing ring and posterior mitral annulus
Figure 3: Midesophgeal bicommissural view shows an increase in the vena contracta of the regurgitant jet as compared with Figure 1
Address for correspondence: Dr. Sarvesh Pal Singh, Department of Cardiac Anaesthesia, C. N. Center, AIIMS, New Delhi ‑ 110 029, India. E‑mail:
[email protected]
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the site of the defect. This merit of 3D echo is more useful especially when we are looking for a single suture which is loose or has cut through the mitral annulus.[8] In our case we were able to pinpoint the paravalvular defect initially and its progression later during 3D TEE examination. If a significant paravalvular leak is missed on TEE valvular dehiscence may occur. The practice of repeat TEE examination before shifting the patient to intensive care unit can monitor the progress of small paravalvular leaks. REFERENCES Figure 4: 3D TEE “Surgeons eye view” shows an increase in the size of defect (propagating from posterior to the anterior annulus).The lower arrow shows the initial site of paravalvular leak and the upper arrow depicts the position of aortic valve and progression of the defect towards the anterior mitral annulus
was reestablished and a repeat MVR was performed. On direct examination of the valve, the findings of 3D echocardiography were confirmed. Following repeat MVR, the patient was weaned off CPB uneventfully and there was no paravalvular leak on 2D echocardiography. There was no defect seen between the annulus and the prosthetic valve on 3D echocardiography. This experience of the present patient emphasize advantage of 3D over 2D echocardiography in describing and detecting the defect around the valve[3] and its progression from a small paravalvular leak into a near valvular dehiscence during repeat TEE examination. The incidence of paravalvular leak after MVR is about 13%.[4] Paravalvular leaks are observed more frequently with mechanical valves than bioprosthetic valves. RT3DE is useful in the evaluation of paravalvular leak (site and size) and assessment of the surgical repair thereafter.[5] The RT3DE is sensitive enough to detect small paravalvular leaks of about 3 mm.[6] By convention, the mitral valve image, as viewed from the left atrial perspective, is rotated to position the aortic valve at 12 o’clock and the left atrial appendage at 9 o’clock.[5] Furthermore, with RT3D TEE one can rotate the image as per the orientation of surgeon (“surgeon’s eye view”)[7] and it is possible to describe exactly
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Mahdhaoui A, Majdoub MA, Bouraoui H, Jeridi G, S Ernez Hajri S, Zaaraoui J, et al. Value of early systematic transoesophageal ultrasonography after mitral valve replacement by Saint‑Jude prosthesis. Tunis Med 2002;80:781‑9. 2. Sugeng L, Shernan SK, Weinert L, Shook D, Raman J, Jeevanandam V, et al. Real‑time three‑dimensional transesophageal echocardiography in valve disease: Comparison with surgical findings and evaluation of prosthetic valves. J Am Soc Echocardiogr 2008;21:1347‑54. 3. Fischer GW, Adams DH. Real‑time three‑dimensional TEE‑guided repair of a paravalvular leak after mitral valve replacement. Eur J Echocardiogr 2008;9:868‑9. 4. Wąsowicz M, Meineri M, Djaiani G, Mitsakakis N, Hegazi N, Xu W, et al. Early complications and immediate postoperative outcomes of paravalvular leaks after valve replacement surgery. J Cardiothorac Vasc Anesth 2011;25:610‑4. 5. Tsang W, Weinert L, Kronzon I, Lang RM. Three‑dimensional echocardiography in the assessment of prosthetic valves. Rev Esp Cardiol 2011;64:1‑7. 6. Furukawa K, Kamohara K, Itoh M, Furutachi A, Mukae Y, Morita S. Real‑time three‑dimensional transesophageal echocardiography is useful for the localization of a small mitral paravalvular leak. Ann Thorac Surg 2011;91:e72‑3. 7. Hamilton‑Craig C, Boga T, Platts D, Walters DL, Burstow DJ, Scalia G. The role of 3D transesophageal echocardiography during percutaneous closure of paravalvular mitral regurgitation. JACC Cardiovasc Imaging 2009;2:771‑3. 8. Kronzon I, Sugeng L, Perk G, Hirsh D, Weinert L, Garcia Fernandez MA, et al. Real‑time 3‑dimensional transesophageal echocardiography in the evaluation of post‑operative mitral annuloplasty ring and prosthetic valve dehiscence. J Am Coll Cardiol 2009;53:1543‑7. Cite this article as: Singh SP, Hasija S, Chauhan S. Paravalvular leak after mitral valve replacement: Advantage of 3D echo. Ann Card Anaesth 2014;17:137-8. Source of Support: The Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota., Conflict of Interest: None declared.
Annals of Cardiac Anaesthesia Vol. 17:2 Apr‑Jun‑2014
