Transcatheter Mitral Valve Implantation: Implications of Interventional Technique and 3D Echocardiography for Complex Valve-in-Valve Paravalvular Leak

Figures

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  Figure 1. 2D TEE mid-esophageal bi-plane view of four-chamber and two-chamber with adjusted color scale revealing PISA radius and severity of mitral regurgitation. (LA = left atrium; LV = left ventricle; white arrow = mitral valve-in-valve: outer bioprosthetic valve with inner SAPIEN XT THV)

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  Figure 2. (a) 3D image with a cropped en-face view of the mitral valve from LA with color Doppler in a mid-systolic frame revealing crescentic valve-in-valve regurgitant jet. (b) Post-processed image using Philips QLAB revealing valve-in-valve PVL between two bioprosthetic valves. Note the crescentic shape of the regurgitant orifice area. (LA = left atrium; PVL = valve-in-valve paravalvular leak; blue arrow = outer bioprosthetic mitral valve; red arrow = inner SAPIEN valve)

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  Figure 3. 3D TEE image of the mitral valve structure with superimposed markings revealing valve position and relationship of the inner SAPIEN XT valve and outer bioprosthetic valve. Note the PVL areas marked in green on the right

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  Figure 4. (a) 3-D TEE image with en-face view of mitral structure revealing a guidewire passing between the two bioprosthetic valves to close the leak. (b) Flouroscopic image of the outer bioprosthetic mitral valve and inner SAPIEN XT valve during attempted amplatzer vascular plug occlusion of the paravalvular leak (red circle). (LA = left atrium; LV = left ventricle ;blue arrow = outer bioprosthetic mitral valve; red arrow = inner SAPIEN XT transcatheter heart valve; PVL = paravalvular leak)

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  Figure 5. 2D TEE mid-esophageal commissural view revealing ballooning of the valve-in-valve structure to relieve PVL. (LA = left atrium; LV = left ventricle; white arrow = mitral valve-in-valve; yellow arrow = balloon dilation)

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  Figure 6. Fluoroscopy image revealing the existing SAPIEN XT THV (red arrow) and the new second SAPIEN 3 THV implantation in progress (white arrow)

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  Figure 7. Post-processed image using Philips QLAB from an acquired 3D en-face view of the mitral valve in mid-systolic frame revealing slight reduction in crescentic-shaped valve-in-valve regurgitant jet after ballooning. (LA = left atrium; LV = left ventricle; white arrow = mitral valve-in-valve: outer bioprosthetic valve with inner THV; blue arrow = outer bioprosthetic mitral valve; red arrow = inner SAPIEN XT valve; PVL = valve-in-valve paravalvular leak)

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  Figure 8. (a) 2D echocardiographic image in mid-esophageal commissural view revealing valve-in-valve-in-valve structure after placement of new SAPIEN 3 valve. Note the resolution of PVL. (white arrow = newly deployed second SAPIEN 3 valve within the mitral valve structure) (b) Continuous wave Doppler measurement of trans-mitral flow after the valve-in-valve-in-valve procedure revealing normal trans-mitral gradient. (LA = left atrium; LV = left ventricle)

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  Figure 9. 3D full-volume view of the valve-in-valve-in-valve structure: newly deployed SAPIEN 3 valve within the existing mitral valve-in-valve structure. (LA = left atrium; LV = left ventricle)