The role of echocardiography, including three-dimensional (3D) echocardiography, during interventional procedures in the cardiac catheterization laboratory is continuing to expand as interventional cardiologists perform more catheter-based interventions. Echocardiography often complements angiographic imaging of cardiac structures and sometimes provides additional information not available by angiography and fluoroscopy. The closure of perivalvular leaks using catheter-based techniques is one of the areas in which 3D echocardiography can be helpful. This case report describes the use of 3D real-time and color flow imaging during the closure of a mitral perivalvular leak. Three-dimensional echocardiography was used to assess the leak prior to intervention and the success of the intervention at the completion of the case.
Percutaneous closure of mitral prosthetic perivalvular leaks is being performed more often in patients who are high surgical risk candidates. The role of three-dimensional (3D) transesophageal echocardiography (TEE) during percutaneous closure has been previously reported. Recent publications have detailed the use of 3D echocardiography during interventional procedures in the cardiac catheterization laboratory as well as detailed descriptions of the systematic characterization of the mitral valve. In this case study, we used 3D TEE during a mitral perivalvular leak percutaneous closure, including color flow imaging, to precisely locate the area of dehiscence, provide guidance for catheter placement, and assess the severity of the regurgitation before, during, and after percutaneous closure.
The patient was a 63-year-old man who in March 2008 had a bioprosthetic valve placed in the mitral position because of mitral valve endocarditis. Prior to valve replacement, the patient was found to have a vegetative mass on the posterior leaflet of the mitral valve. It was described as a large and mobile mass >20 mm in length and involving the mitral annulus. At that time, the valve was replaced with a bioprosthetic valve.
In June 2009, the patient was referred to our facility with symptoms of heart failure. TEE was performed, and a moderately sized perivalvular leak was found. Although the perivalvular leak was seen on two-dimensional TEE, there was some ambiguity about its exact location and severity. Three-dimensional TEE was performed, including 3D color flow imaging. Not only did the 3D transesophageal echocardiographic images verify the presence of the leak, but by using cropping and manipulation of the 3D images, the precise location could be identified from both the superior (left atrial) side of the valve ( Figure 1 , Movie 1 ) and the inferior (left ventricle) side of the valve ( Figure 2 , Movie 2 ). Once the location of the perivalvular leak was identified using normal 3D TEE, 3D color flow imaging was used to confirm the location and better assess the severity ( Figures 3 A and 3 B, Movies 3 A and 3 B).
The patient was felt not to be an operative candidate, because of the extensive involvement of the mitral annulus and the complexity of the initial valve replacement surgery. On the basis of the information obtained from 3D TEE, it was felt that the perivalvular leak would be amenable to percutaneous closure, and the patient was scheduled for the procedure. It was also decided that the transapical approach would be used for simplicity and the ability to directly access the perivalvular leak en face.
Subsequently, the patient was taken to the cardiac catheterization laboratory. The procedure was performed in a hybrid catheterization laboratory that has been modified to full operating room standards of sterility and surgical support on standby. The patient was placed under general anesthesia, and right-heart and left-heart catheterization were performed. The apex of the left ventricle was identified using transthoracic echocardiography, and under echocardiographic guidance, the left ventricular apex was accessed with a micropuncture needle. Coronary angiography was performed simultaneously to ensure that the left anterior descending coronary artery was avoided. The micropuncture catheter was exchanged for a 5-French sheath. The perivalvular leak was crossed with a glidewire under transesophageal echocardiographic and fluoroscopic guidance. Initially an Amplatzer vascular plug (AGA Medical Corporation, Plymouth, MN) was positioned across the perivalvular leak, and the leak was reassessed. The images demonstrated that the plug was too small to occlude the opening, and there was significant residual regurgitation ( Figure 4 , Movie 4 ). It was felt that the vascular plug was too soft and provided inadequate tactile resistance to ensure stable deployment, so a decision was made to use an Amplatzer septal occluder device. It should be noted that neither of these devices is approved by the US Food and Drug Administration for perivalvular closure and that this is an “off-label” use of the devices.