Utilization of Two- and Three-Dimensional Transesophageal Echocardiography in Successfully Guiding Transcatheter Mitral Valve in Bioprosthetic Mitral Valve/Mitral Ring Implantation without Complications in Patients with Thrombus in Left Atrium/Left Atrial Appendage

Figures

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  Figure 1. (A–K), Video S1. 78-year-old female with severe bioprosthetic mitral valve stenosis (Case 10). Pre-procedure. Two-dimensional transthoracic echocardiography with color Doppler guided continuous wave Doppler in (A) shows a mean pressure gradient (PG) of 14 mmHg across mitral valve replacement (MVR) consistent with severe stenosis. Two-dimensional transesophageal echocardiography (B,C) using the same technique as in (A) shows a mean pressure gradient of 13.1 mmHg across MVR also consistent with severe stenosis in (B). Turbulent flow across MVR as well as a thrombus (TH) in the left atrial appendage (LAA) and adjacent left atrium (LA) body are demonstrated in (C). Live/real-time three-dimensional transesophageal echocardiography (D–G, Video S1). The arrow in (D) points to the MVR orifice which measures 0.72 cm2 in multiplanar reconstruction (MPR) mode consistent with severe stenosis. Viewing the LA body en face by cropping the full volume dataset from below shows the TH (arrows) extending to near the MVR in (E). Video S1 shows both fixed (left arrow) and mobile (right arrow) components of the TH. The right upper panel in F shows the TH involving LAA almost completely and extending…

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  Figure 2. (A,B). 56-year-old female with severe MVR stenosis (Case 2). Pre-procedure. Live/real-time three-dimensional transesophageal echocardiography (A,B). A TH is noted in LAA and adjoining LA body in A. During procedure. The arrow in B points to the catheter deployment device passing through MVR avoiding the TH. Abbreviations as in Figure 1.

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  Figure 3. (A–C). The same patient (Case 2 above) returned 2 years and 8 months later with severe stenosis of the new MVR. Pre-procedure. Two-dimensional transesophageal echocardiography (A). A much smaller and poorly organized residual confined to LAA is noted in A. Live/real-time three-dimensional transesophageal echocardiography with color Doppler (B). The MVR orifice (red arrow) viewed in MPR mode in B measures 0.68 cm2 by direct planimetry indicative of severe restenosis. Post-procedure. Live/real-time three-dimensional transesophageal echocardiography (C). A short-axis view in full volume mode shows all the three MVR rings in C. # 1 points to the outermost ring of the original surgically implanted MVR. # 2 shows the middle ring of the first transcatheter implanted MVR. # 3 demonstrates the innermost ring of the second transcatheter implanted MVR. Abbreviations as in previous Figures.

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  Figure 4. (A,B). 67-year-old male with severe MVR stenosis (Case 4). During procedure. Live/real-time three-dimensional transesophageal echocardiography (A,B). The arrow points to the catheter deployment device passing through MVR and bypassing the TH in MPR mode in A and in full volume mode in B Abbreviations as in previous Figures.

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  Figure 5. (A–D), Video S2. 58-year-old female with severe mitral valve stenosis following mitral annuloplasty ring implantation 4 years previously (Case 8). Pre-procedure. Two-dimensional transesophageal echocardiography (A). Shows a large TH (arrow) attached to the LA body wall adjacent to AO in A. Spontaneous contrast echoes suggestive of a low flow state are also noted adjacent to the TH. Live/real-time three-dimensional transesophageal echocardiography (B). The large TH attached to the LA body viewed in different cutting planes is demonstrated in B together with spontaneous contrast echoes. Areas of echolucencies noted within the thrombus are consistent with thrombus lysis. During Procedure. Live/real-time three-dimensional transesophageal echocardiography (C, Video S2). The arrow in C points to the catheter deployment device passing through the ring (R) and avoiding the thrombus in full volume mode (Video S2). Post-procedure. Two-dimensional transesophageal echocardiography (D). Demonstrates the new prosthesis in the fully open position in D. Abbreviations as in previous Figures.