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Cardiovascular Images

Three-Dimensional Transesophageal Echocardiography in a Patient With Early Failure of Mitral Valve Repair

Why Are We Still Looking at a Three-Dimensional Structure in 2 Dimensions?

Martin J. Swaans, MD; Richard L. Braam, MD, PhD; Robin H. Heijmen, MD, PhD; Herbert W.M. Plokker, MD, PhD and Wybren Jaarsma, MD, PhD

From the Departments of Cardiology (M.J.S., R.L.B., H.W.M.P., W.J.) and Cardiothoracic Surgery (R.H.H.), St Antonius Hospital, Nieuwegein, The Netherlands.

Correspondence to Martin J. Swaans, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands. E-mail m.swaans{at}antonius.net

A 47-year-old man was admitted with a massive inferolateral wall infarction due to proximal circumflex artery obstruction. After emergent percutaneous coronary intervention, the patient remained hemodynamically unstable because of severe mitral valve insufficiency due to massive annular dilatation combined with diffuse 3-vessel coronary disease and poor left ventricular function. Mitral valve annuloplasty and concomitant coronary bypass grafting were performed with good recovery initially. On the ward, the patient became progressively dyspnoeic with a new systolic apical murmur. Because of inadequate transthoracic acoustic windows, transesophageal echocardiography (TEE) was performed.

Two-dimensional TEE showed severe mitral valve regurgitation. Posterior dehiscence of the annuloplasty ring was suggested (Figure 1A and 1B). Three-dimensional TEE images (3D transesophageal Philips probe, transducer X7-2t) provided a comprehensive anatomic overview almost undisputedly confirming our suspicion of annuloplasty ring dehiscence (Movie I; Figure 2). The patient was scheduled for early reoperation. Operative findings correlated fully with the preoperative 3D images (Figure 3). Because of the massively dilated posterior annulus, rerepair was not attempted and mitral valve replacement was performed with uneventful recovery.

View larger version (28K): [in this window] [in a new window] [Download PPT slide]   Figure 1. A, Two-dimensional TEE (0°) suggesting partial dehiscence of the mitral valve annuloplasty ring (red arrow). B, With color Doppler flow, severe mitral regurgitation with an excentric jet is shown.

 

View larger version (55K): [in this window] [in a new window] [Download PPT slide]   Figure 2. A, Peroperative photograph confirming partial dehiscence of the mitral valve annuloplasty ring. Similarity to the preoperative 3D images is excellent (B; Movie 1). Notice the torn stitches that are still connected to the annuloplasty ring. These are also visible on the 3D images (red arrows).

 
In contrast to late failure of mitral valve repair, which is valve related in most cases, early recurrent mitral regurgitation is usually procedure related, with suture dehiscence as the predominant cause.¹ It may result in dehiscence of commissural repairs or ring annuloplasty, as demonstrated in our case.²

Three-dimensional echocardiography can provide detailed anatomic information additional to standard 2D TEE.^3,4 It is conceivable that 3D TEE will evolve to become a cornerstone in the management of patients with valvular heart disease, especially mitral valve disease.

	Disclosures

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None.

	Footnotes

 
The online-only Data Supplement is available at http://circimaging.ahajournals.org/cgi/content/full/1/3/282/DC1.

	References

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1. Dumont E, Gillinov AM, Blackstone EH, Sabik JF III, Svensson LG, Mihaljevic T, Houghtaling PL, Lytle BW. Reoperation after mitral valve repair for degenerative disease. Ann Thorac Surg. 2007; 84: 444–450.[Abstract/Free Full Text]

2. Cerfolio RJ, Orzulak TA, Pluth JR, Harmsen WS, Schaff HV. Reoperation after valve repair for mitral regurgitation: early and intermediate results. J Thorac Cardiovasc Surg. 1996; 111: 1177–1183.[Abstract/Free Full Text]

3. O'Gara P, Sugeng L, Lang R, Sarano M, Hung J, Raman S, Fischer G, Carabello B, Adams D, Vannan M. The role of imaging in chronic degenerative mitral regurgitation. J Am Coll Cardiol Cardiovasc Img. 2008; 1: 221–237.

4. García-Orta R, Moreno E, Vidal M, Ruiz-Lopéz F, Oyonarte JM, Lara J, Moreno T, García-Fernándezd MA, Azpitarte J. Three-dimensional versus two-dimensional transesophageal echocardiography in mitral valve repair. J Am Soc Echocardiogr. 2007; 20: 4–12.[CrossRef][Medline]

This Article Extract Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Swaans, M. J. Articles by Jaarsma, W. Search for Related Content PubMed Articles by Swaans, M. J. Articles by Jaarsma, W. Related Collections Epidemiology Other heart failure Congestive