4D TEE-Guided Thrombolysis for Mechanical Mitral Valve Obstruction

Visual Summary. How 4D TEE Guided Thrombolysis for Mechanical Mitral Valve Obstruction 2D = 2 dimensional; 4D = 4 dimensional; INR = international normalized ratio; LV = left ventricle; MVR = mitral valve replacement; PND = paroxysmal nocturnal dyspnea; TEE = transesophageal echocardiography.

Figure 1. Transthoracic Echocardiographic Assessment of Mechanical Mitral Valve Dysfunction (A) Apical 4-chamber view showing mechanical mitral prosthesis with acoustic shadowing obscuring and a subtle left ventricular-side echodensity (arrow). (B) Continuous-wave Doppler demonstrating markedly elevated transvalvular gradients, consistent with prosthetic obstruction.

Figure 2. Fluoroscopic and 4-Dimensional Transesophageal Echocardiographic Evaluation of Mechanical Mitral Valve Obstruction (A) Cine-fluoroscopic image before thrombolysis demonstrating restricted motion of a single leaflet of the mechanical mitral prosthesis. (B) Cine-fluoroscopic image after thrombolysis showing restoration of leaflet mobility. (C) Four-dimensional transesophageal echocardiographic en face views from the left atrial and left ventricular aspects before thrombolysis demonstrating obstructive prosthetic valve thrombosis with associated pannus. (D) Repeat 4-dimensional transesophageal echocardiographic views after thrombolysis showing normally functioning prosthetic leaflets with residual nonobstructive pannus on the left ventricular side.

Figure 3. Transesophageal Echocardiographic Assessment Before and After Thrombolysis (A) Two-dimensional transesophageal echocardiographic view before thrombolysis showing restricted opening of the mechanical mitral prosthesis with obstructive thrombus. (B) Repeat transesophageal echocardiographic view after thrombolysis demonstrating improved prosthetic leaflet motion. (C) Continuous-wave Doppler across the prosthetic mitral valve before thrombolysis showing markedly elevated transmitral velocity and gradient, consistent with severe prosthetic obstruction. (D) Repeat Doppler after thrombolysis showing a clear reduction in transmitral velocity and gradient, indicating successful hemodynamic relief of obstruction. LA = left atrium; LV = left ventricle.