Images in cardiovascular medicine: prosthetic aortic valve and conduit dehiscence with large periconduit cavity, ascending aortic aneurysm and severe mitral regurgitation.

Prosthetic aortic valve and conduit dehiscence with periconduit cavity and ascending aortic aneurysm is an uncommon complication of aortic root surgery. It is usually recognizable at echocardiography due to an abnormal position of the prosthetic valve and conduit in relation to the native aortic annulus in conjunction with an abnormal echolucent periconduit space that fills with color flow. Mitral regurgitation is an unusual complication of this condition. We present a patient with severe mitral regurgitation secondary to prosthetic aortic valve and conduit dehiscence with a large periconduit cavity and aneurysm of the intervalvular fibrosa. The mechanism of mitral regurgitation is secondary to functional involvement of the anterior mitral valve leaflet and intervalvular fibrosa with anterior mitral leaflet restriction in conjunction with mild left ventricular remodeling. Significant mitral regurgitation persisted post resection of the periconduit cavity and aortic valve replacement, requiring mitral valve replacement. This case study reports a new mechanism of mitral regurgitation in the setting of prosthetic aortic valve and conduit dehiscence.

Transesophageal echocardiography to guide pulmonary vein mapping and ablation for atrial fibrillation.

BACKGROUND: This study describes the use and outcomes of transesophageal echocardiography to guide atrial fibrillation (AF) ablation procedures. METHODS: Under general anesthesia, 25 patients with a history of AF underwent multiplane transesophageal echocardiography in conjunction with catheter placement under fluoroscopy. RESULTS: In this series, a combined fluoroscopic/echocardiographic approach obviated the need for angiographic imaging. Anatomic variation in pulmonary veins (PV) was common; the shortest distance between the ostia ranged from 2 to 11 mm. Individual PV diameters did not predict the presence of ectopic foci. The number of radiofrequency pulses delivered per vein was 2.6 +/- 2.3 (range: 0-10). Mean fluoroscopy time per procedure was 31 +/- 13 minutes and mean procedure time was 110 +/- 31 minutes. At follow-up, 68% of patients were free from AF. CONCLUSIONS: Transesophageal echocardiography enables identification and cannulation of the ostia and proximal branches of PV during AF ablation. Fluoroscopy, procedure times, and outcomes compare favorably with series using PV angiography and, as such, suggest that a controlled trial is warranted.

Edge-to-edge repair for functional mitral regurgitation: an echocardiographic study of the hemodynamic consequences.

BACKGROUND AND AIM OF THE STUDY: The study aim was to characterize changes in mitral valve area and flow, and left ventricular (LV) size and function, following edge-to-edge (E-E) repair for severe functional mitral regurgitation (MR). The possibility that preoperative dobutamine stress echocardiography (DSE) might be used to predict post-repair recovery in LV function was also examined. METHODS: Seventeen patients underwent preoperative transthoracic echocardiography (TTE) and DSE, intraoperative transesophageal echocardiography, and three-month postoperative TTE. RESULTS: After repair, mitral valve area was reduced from 8.5 +/- 1.9 cm2 to 3.8 +/- 0.9 cm2 by planimetry (p < 0.0001) and to 2.9 +/- 0.9 cm2 by pressure half-time. Valve area by pressure half-time correlated with the planimetered area (r = +0.55), but was consistently lower (p = 0.004). Sixxteen of 17 patients had mean transmitral gradients <5 mmHg. Postoperative LV end-diastolic diameter improved from 72 +/- 11 to 64 +/- 10 mm (p < 0.01), and end-systolic diameter from 56 +/- 14 to 46 +/- 12 mm (p < 0.05). Mean ejection fraction improved from 25 +/- 12% before repair to 38 +/- 17% after repair (p < 0.02) in patients with evidence of LV function improvement on DSE, but was unchanged (15 +/- 5% versus 17 +/- 5%, p = NS) in patients without evidence of improvement. Postoperatively, 13 patients had no or mild MR, and two patients had moderate MR. There was one perioperative death. CONCLUSION: E-E repair, in combination with ring annuloplasty, reduces LV cavity dimensions and functional MR severity, without causing significant valve stenosis. Improvement on DSE may predict those patients in whom EF will improve following repair.

Multisite infective endocarditis with widespread pulmonary and systemic embolization in the setting of overwhelming staphylococcal sepsis.

The presence of simultaneous left- and right-sided endocarditis affecting the cardiac structures is rare and information regarding clinical presentation, pathophysiologic mechanisms, and prognosis is limited. We report the case of a young woman who presented to our institution with severe staphylococcal peritonitis and generalized sepsis who had tricuspid valve and left ventricular (LV) mural endocarditis. Significant transpulmonary shunting was demonstrated using transesophageal imaging and saline contrast injection. In this case transesophageal echocardiography (TEE) provided enhanced imaging of an unusual form of right- and left-sided endocarditis. More importantly, the use of TEE and saline contrast injection suggested an interesting hypothesis that might ultimately contribute to an improved understanding of pathophysiologic mechanisms in infective endocarditis and severe sepsis.

Techniques for percutaneous closure of prosthetic paravalvular leaks.

Percutaneous transcatheter closure techniques are now routinely applied in the management of atrial and ventricular septal defects, patent ductus arteriosus, and other pathological cardiac and vascular communications. Recently, these same techniques have been applied to paravalvular defects. Reports are few; success variable and techniques vary widely. We review the current considerations and techniques of percutaneous transcatheter closure of paravalvular leaks.

Percutaneous closure of prosthetic paravalvular leaks: case series and review.

BACKGROUND: Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valve replacement. Most are asymptomatic and benign, but some may cause symptoms due to a large regurgitant volume or hemolysis. Medical therapy is palliative, while reoperation carries significant morbidity and mortality. Percutaneous transcatheter closure techniques, now routinely applied in the management of pathological cardiac and vascular communications, may be adaptable to PVL closure, potentially offer symptomatic relief. METHODS: We reviewed our experience with attempted percutaneous closure of PVLs, using data from medical and procedural records. RESULTS: Between 2001 and 2004, 14 procedures were performed in 10 patients, all under general anesthesia, with transesophageal and radiographic guidance. Mitral (9) and aortic (1) valve replacements were involved, both mechanical and bioprosthetic. A variety of devices were used, including atrial septal occluders, patent ductus arteriosus occluders, and coils (all of label use). Six had a single procedure, which was technically successful in four: in two, the PVL could not be crossed. Four underwent a second procedure, which was technically successful in three; in one the previously deployed device was dislodged necessitating urgent, but ultimately uneventful, surgical removal and leak repair. One patient had transient severe hemolysis, which resolved after 1 week. At 1-year follow-up (9/10 pts) three had died, five had sustained symptomatic improvement while 1 patient with a residual leak still required regular blood transfusions. CONCLUSIONS: Percutaneous closure of PVLs is time-consuming but feasible in selected patients, with a reasonable degree of technical and clinical success. A second procedure may be necessary and a variety of complications can occur.