A 68 year old woman with a history of rheumatic mitral stenosis who initially underwent valve replacement with a bovine pericardial prosthesis presented with symptoms of congestive heart failure. Her initial operation was complicated by malopposition of leaflets requiring repeat sternotomy and replacement of her bioprosthesis with a tilting disc bileaflet mechanical mitral valve (St. Jude Medical, Inc, St. Paul, Minn). The patient developed further multiple complications including acute renal failure and ischemic bowel. One week later she developed symptoms of congestive heart failure attributed to severe paravalvular mitral regurgitation diagnosed by transthoracic echocardiography (TTE) and TEE. She was reviewed by the Cardiac Surgery Service who felt she was too high risk for a third cardiac operation. The patient was referred for percutaneous repair of her paravalvular mitral regurgitation because of her ongoing symptoms of heart failure.
The patient proceeded to the cardiac catheterization lab for closure of paravalvular regurgitation under TEE and fluoroscopic guidance. By 2D TEE it appeared that the paravalvular regurgitation was originating from a defect which was posteromedially located along the prosthetic annulus. Live 3D TEE and simulataneous full volume 3D TEE with color clearly showed the position of the defect to in fact be along the posterior aspect of the mitral prosthesis (Figure 1A and 1B). From the 3D TEE image it appeared that the defect was a narrow channel along the annulus. The color 3D image was critical in this case, demonstrating the true extent of the defect resulting in a wide high velocity jet of paravalvular regurgitation (Figure 1B). Under TEE guidance, an Amplatzer Duct Occluder device (10/8 mm) was delivered across the paravalvular defect (Figure 2A). Full volume color 3D TEE demonstrated a moderate amount of residual paravalvular regurgitation despite device placement (Figure 2B). During this time, consideration was given to exchanging the device with a larger duct occluder however given the extent of the defect visualized by 3D TEE, placement of a second device appeared to be the best option. A second Amplatzer Duct Occluder device (10/8 mm) was delivered and placed adjacent to the first under TEE guidance (figure 6A). Following release of both devices, color 3D TEE demonstrated significant reduction of paravalvular mitral regurgitation (Figure 6B). The patient tolerated the procedure well and a TTE conducted 2 days later confirmed reduction of her paravalvular regurgitation from severe to mild.
Clinically significant paravalvular mitral regurgitation is a rare but important complication of MVR, in some cases requiring explantation and replacement to resolve symptoms of associated heart failure or hemolysis. In one study, a 3.8%/year event rate of para-prosthetic valve leak was reported in patients receiving a St. Jude mechanical valve in the mitral position[i] . Because of the morbidity and mortality associated with repeat sternotomy, percutaneous closure of para-prosthetic leaks has been viewed as an attractive alternative to cardiac surgery in patients at high risk for re-operation. Currently there is no percutaneous device dedicated to the closure of paravalvular regurgitant leaks but operators have extrapolated the use of other percutaneous devices to this problemi. Septal and duct occluder devices are emerging as the most commonly used percutaneous devices for paravalvular leak closure[ii].
Two-dimensional TEE has become an important tool in guiding the placement of guidewires and devices in the cardiac catheterization laboratory. Real-time three-dimensional TEE (RT3D TEE) surpasses the limits of 2D TEE and is emerging as a new and exciting tool in its ability to detect the position of a device or catheter relative to its surroundings[iii]. This case demonstrates the utility of RT3D TEE to guide percutaneous closure of a paraprosthetic leak. Real time 3D TEE allows en-face views of the paravalvular leak and provides unique views of the catheter and device placement. These clearly define the relationship between the defect and the device which cannot be attained as easily by any other imaging techniques. This case demonstrated the novel use of full volume color to define the extent of the regurgitant jet and provide information critical to device sizing and placement. Also highlighted was the need for close cooperation and constant communication between the echocardiographer and the interventionalist to simultaneously integrate 3D, 2D TEE and fluoroscopic imaging in such technically difficult cases. With the advent of full volume color and real-time 3D TEE, the ability to guide percutaneous closures in “live” fashion has become a reality.
Figure 1A and 1B
Figure 2A and 2B
[i] Schaff HV, Carrel TP, Jamieson E, Jones KW, Rufilanchas JJ, Cooley DA, Hetzer R, Stumpe F, Duveau D, Moseley P, van Boven WJ, Grunkemeier GL, Kennard ED, Holubkov R. Paravalvular leak and other events in Silzone-coated mechanical heart valves: a report from AVERT. Ann Thorac Surg 2002;73:785-792.
[ii] Momplaisir T, Matthews RV. Paravalvular mitral regurgitation treated with an Amplatzer Septal Occluder Device: A case report and review of the literature. J Invasive Cardiol 19(2):digital archive February 01 2007.