An 80-year-old woman with a history of mitral and aortic prosthesis replacement with
biological prostheses due to endocarditis presented worsening dyspnea. A transthoracic
echocardiogram demonstrated a paravalvular regurgitation between the left ventricle and
left atrial appendage. Given her high-risk surgery (EuroSCORE-II: 38%), a percutaneous
approach was performed for definitive closure.Transesophageal echocardiography (TEE) peri-procedure allowed the visualization of a
partial dehiscence of the mitral prosthesis (Panel A, Figure 1). Through the 3D images, a tunneled defect with wall dissection
measuring 12.5 mm of maximum diameter (Panel B, Figure
1) was observed. Using a transapical pathway and collecting three-dimensional
(3D) images in real time, a 12 mm Amplatzer septal prosthesis was positioned, occluding
the entire defect. The TEE 3D image demonstrated savings of adjacent structures and
absence of pericardial effusion during closure. Coronary angiography demonstrated no
arterial compromise. A slight residual flow was detected after device implantation (C-F
Panels Figure 1).
Figure 1
Panel A: 2D peri-processual transesophageal echocardiography (TEE) shows
paravalvular regurgitation (yellow arrow) between left ventricle and left
atrial appendage; Panel B: Defect 3D TEE with diameter measurement; Panel C:
3D TEE guiding the guidewire through the defect; Panel D: 3D TEE showing the
device (asterisk) through the defect; Panel E: left coronary angiography
without vascular involvement after occlusal implant (yellow arrow); Panel F:
Light residual flux detected after device deployment (asterisk).
Panel A: 2D peri-processual transesophageal echocardiography (TEE) shows
paravalvular regurgitation (yellow arrow) between left ventricle and left
atrial appendage; Panel B: Defect 3D TEE with diameter measurement; Panel C:
3D TEE guiding the guidewire through the defect; Panel D: 3D TEE showing the
device (asterisk) through the defect; Panel E: left coronary angiography
without vascular involvement after occlusal implant (yellow arrow); Panel F:
Light residual flux detected after device deployment (asterisk).Paravalvular regurgitation may result from suture dehiscence of the mitral prosthesis.
Symptoms of heart failure are an indication for closure. A transapical approach allows
direct access to the defect, providing good technical support. The TEE 3D image is
essential for guiding the guidewire through the defect, confirming the correct position
of the device and relating it to critical structures. The anatomy of the defect and the
surrounding structures make this case a challenge, on both imaging acquisition and
percutaneous technique
Figure 1