Three-Dimensional Transesophageal Echocardiographic Detection of Left Ventricular Outflow Tract Obstruction by Residual Native Mitral Leaflet following Mitral Valve Replacement in a Hypertrophic Obstructive Cardiomyopathy Patient

Figures

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  Figure 1. (a) Continuous wave Doppler across LVOT in deep transgastric long axis view shows dragger-shaped spectral Doppler waveform and high-pressure gradients during late systole; (b). Cropped 3D full volume midesophagal LV long axis view shows no midcavity obstruction; (c). Cropped 3D full volume midesophageal LV long axis view (focused on LV) shows no apical obstruction; (d). 3D enface view of LVOT (seen after cropping through LV) shows no accessory chordae or anomalous papillary muscle attachment to the anterior mitral leaflet. Abbreviations: 3D – three dimensional; CWD – continuous wave Doppler; IVS – interventricular septum; LA – left atrium; LAX - long axis; LV- left ventricle; LVOT – left ventricular outflow tract; ME – midesophageal; MV – mitral valve; TG - transgastric

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  Figure 2. (a). Midesophageal LV long axis view (2D echocardiography and color Doppler) shows flail anterior mitral leaflet and severe eccentric posteriorly directed mitral regurgitation jet; (b). 3D enface view of mitral valve shows flail A2-A3 segments of anterior mitral leaflet and prolapse of posteromedial commissure; (c). Continuous wave Doppler across prosthetic mitral valve in midesophagal four-chamber view shows mean gradient of 3 mmHg; (d). Continuous wave Doppler across LVOT in deep transgastric long axis view shows round symmetrical spectral Doppler waveform and high-pressure gradients across LVOT in mid systole. Abbreviations: 3D – three dimensional; AML – anterior mitral leaflet; AV – aortic valve; CWD – continuous wave Doppler; LA – left atrium; LV- left ventricle; LVOT – left ventricular outflow tract; MR – mitral regurgitation; Mitral Valve – mitral valve; PM – posteromedial; TV – tricuspid valve

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  Figure 3. (a) Live 3D view of LVOT seen through LV shows native mitral valve tissue causing fixed obstruction across the LVOT; (b). Cropped 3D full-volume view of the base of the heart shows residual native mitral valve tissue across the LVOT and aortic valve; (c). 3D full volume midesophagal LV long axis view shows residual anterior mitral leaflet tissue causing fixed LVOT obstruction; (d). Continuous wave Doppler across LVOT in deep transgastric long axis view reduced pressure gradients across LVOT after the excision of residual mitral tissue. Abbreviations: 3D – three dimensional; AML – anterior mitral leaflet; AV – aortic valve; CWD – continuous wave Doppler; LA – left atrium; LAX - long axis; LV- left ventricle; LVOT – left ventricular outflow tract; ME – midesophagal; MV – mitral valve; MVP – mitral valve prosthesis; PV – pulmonary valve; RVOT – right ventricular outflow tract; TV – tricuspid valve