Images in Cardiovascular Medicine
Three-Dimensional Transesophageal Echocardiography Shows Dehiscence of Mitral Valve Repair
Ryoji Iida, MD, PhD Miriam Shanks, MD, FRCPC
A
56-year-old man was referred to transesophageal echocardiography (TEE) for post-surgical follow-up. He had undergone mitral valve repair 3 months before, with an annuloplasty ring and with triangular resection of the posteromedial scallop of the posterior leaflet (P3). The posteromedial region of the posterior leaflet had been reattached to the posteromedial segment of the anterior leaflet (A3). The patient had been hospitalized due to pulmonary edema and had been treated with diuresis one week before his presentation for TEE. The 2-dimensional (2D) TEE suggested partial dehiscence of the mitral annuloplasty ring with severe mitral regurgitation, probably originating from malcoaptation between A3 and P3 (Fig. 1). The dehiscence of the mitral annuloplasty ring was clearly shown at the 0° and 75° angles (Figs. 1 and 2). On the other hand, the mitral annuloplasty ring did not appear to be detached from the mitral annulus at the 106° angle, although it seemed to be rocking (Fig. 3). The 3-dimensional (3D) TEE from the left atrial side showed the entire extent of the ring dehiscence, which was along the anterior portion of the mitral annulus (Fig. 4). The 3D TEE from the left ventricular side showed that the mi-
Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute at St. Luke’s Episcopal Hospital, 6624 Fannin St., Suite 2480, Houston, TX 77030 From: Division of Cardiol ogy, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 8440–112 St., Edmonton, Alberta T6G 2B7, Canada Address for reprints: Ryoji Iida, MD, PhD, Department of Anesthe siology, Nihon University Itabashi Hospital, 30-1, Oyaguchi-Kamicho, Itabashi-Ku, Tokyo 173-8610, Japan E-mail:
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Dehiscence of Mitral Valve Repair
Fig. 1 Mitral regurgitant jet orig inates from the posteromedial region, bifurcates anteriorly to the dehiscing mitral annuloplas ty ring, and merges again pos teriorly to the dehiscing ring at a 75º angle on a 2-dimensional transesophageal echocardio gram. The arrow indicates the dehiscing ring. Real-time motion image is avail able at www.texasheart.org/ journal.
Fig. 2 Dehiscence of the mi tral annuloplasty ring (arrow) is shown by 2-dimensional trans esophageal echocardiography at a 0º angle. Real-time motion image is avail able at www.texasheart.org/ journal.
Volume 39, Number 5, 2012
tral leaflets did not coapt well at the A3–P3 juncture (Fig. 5). Open-heart surgery was undertaken to clarify the problem and to make repairs. The annuloplasty ring was detached from the mitral annulus in the area shown in the 3D TEE images, and the attachment of P3 to A3 was also disrupted as shown in the 3D TEE. Both of these were re-repaired. Postoperative TEE revealed no residual mitral regurgitation.
Comment It has been reported that the dehiscence of mitral annuloplasty rings can be clearly seen with 3D TEE.1,2 In
Fig. 5 Three-dimensional transesophageal echocardiography from the left ventricular side revealed that the mitral leaflets did not coapt well at the posteromedial region (arrow). The arrow also shows the dehiscing mitral annuloplasty ring through the malcoapted leaflets. AML = anterior mitral leaflet; Ao = aortic valve; PML = posterior mitral leaflet Real-time motion image is available at www.texasheart.org/ journal.
Fig. 3 The mitral annuloplasty ring did not appear to be detached from the mitral annulus at a 106° angle on a 2-dimensional trans esophageal echocardiogram. Real-time motion image is available at www.texasheart.org/ journal.
our patient, 3D TEE revealed not only dehiscence of the mitral annuloplasty ring but detachment of P3 from A3. This case shows that 3D TEE from the left ventricular side can be useful in identifying the pathologic anatomy of the mitral valve. It is difficult to see the coaptation of mitral valve leaflets in 3D TEE from the left atrial side in patients with a mitral annuloplasty ring. However, 3D TEE gave us incremental information over 2D TEE to locate the dehiscence of the mitral valve repair and thereby assisted interpretation in preparation for surgery.
References 1. Kronzon I, Sugeng L, Perk G, Hirsh D, Weinert L, Garcia Fernandez MA, Lang RM. 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(17):1543-7. 2. Swaans MJ, Braam RL, Heijmen RH, Plokker HW, Jaarsma W. Three-dimensional transesophageal echocardiography in a patient with early failure of mitral valve repair: why are we still looking at a three-dimensional structure in 2 dimensions? Circ Cardiovasc Imaging 2008;1(3):282-3. Fig. 4 Three-dimensional transesophageal echocardiography from the left atrial side identified the dehiscence of the mitral annuloplasty ring, along the anterior of the mitral annulus. AML = anterior mitral leaflet; Ao = aortic valve; Ring = mitral annuloplasty ring Real-time motion image is available at www.texasheart.org/ journal.
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