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Use of 3D Transesophageal Echocardiography and the Clock-Face Model to Localize and Facilitate Closure of a Mitral Paravalvular Defect

Anderson, Paul C. MD*; Mehta, Anand R. MD*; Jaber, Wael A. MD, FACC, FASE; Duncan, Andra E. MD, MS, FASE*

doi: 10.1213/XAA.0000000000000704
Echo Rounds

From the Departments of *Cardiothoracic Anesthesiology and Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.

Accepted for publication September 6, 2017.

Paul C. Anderson, MD, is currently affiliated with Jefferson Hospital, Jefferson Hills, PA.

Funding: This investigation was supported by the Department of Cardiothoracic Anesthesia at the Cleveland Clinic.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Paul C. Anderson, MD, Department of Anesthesiology, Jefferson Hospital, 565 Coal Valley Rd, Jefferson Hills, PA 15025. Address e-mail to

A 40-year-old man with a history of intravenous drug use, recurrent endocarditis, and 3 previous mitral valve replacements presented with worsening heart failure. Transthoracic echocardiography demonstrated paravalvular mitral regurgitation (MR). Percutaneous repair was recommended, rather than reoperative surgery, due to his history of recurrent drug use and multiple previous surgeries. We were unsuccessful in contacting this patient for consent; thus, our institutional review board determined that consent was not required.

In a hybrid operating room, general anesthetic induction was uneventful. A transesophageal echocardiogram (TEE) demonstrated a 33-mm Biocor bioprosthetic mitral valve (St Jude Medical, St. Paul, MN) with slight rocking motion and partial dehiscence. Severe MR originated from an extensive curvilinear, crescent-shaped, inferior to anterolateral paravalvular defect, spanning from 6 o’clock to 9:30 (Figure 1A and 1B; Supplemental Digital Contents 1 and 2, Videos 1 and 2,, Three-dimensional (3D) planimetric analysis using multiplanar reconstruction (MPR) yielded a cross-sectional area of 3.1 cm2 in midsystole (Figure 1C). The transmitral mean pressure gradient was 14 mm Hg (heart rate, 117 bpm).

Figure 1.

Figure 1.

Figure 2.

Figure 2.

With TEE and fluoroscopic guidance, a transseptal puncture was performed. A stiff-angled guidewire was passed antegrade through the paravalvular defect into the left ventricle and across the aortic valve. It was snared within the descending aorta by another wire inserted via the femoral artery. Guided by a 3D en face view of the mitral valve, an Amplatzer vascular plug (AVP-II; St Jude Medical) was passed over the stiff-angled guidewire and deployed at 9 o’clock (Figure 2; Supplemental Digital Content 3, Video 3, Two additional AVP-II plugs were placed over the wire between 8 o’clock and 10 o’clock. A second guidewire, advanced through the defect, deployed 3 additional plugs. Finally, 2 additional plugs were subsequently placed within the same defect. A total of 8 Amplatzer plugs ranging from 8 to 14 mm in diameter deployed between 5 o’clock and 10 o’clock were needed to (partially) occlude this massive defect (Supplemental Digital Content 3, Video 3, MR was reduced to 1–2+ (visual assessment), with a mean transmitral gradient of 8 mm Hg (heart rate, 102 bpm). The postoperative course was uneventful, and he was discharged home 4 days later. At 3-month follow-up, his shortness of breath had resolved.

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Paravalvular MR occurs after 2%–12% of mitral valve replacements,1,2 and may lead to heart failure and/or hemolysis.1–3 Although surgical closure is recommended for symptomatic patients,3 risk of morbidity and mortality is high.1–3 Alternatively, percutaneous closure may be considered in symptomatic, high-risk surgical patients with suitable anatomy.1,3 Success rates are 77%–90%,1–3 defined by mild (or less) residual MR without a major complication.1 Two-dimensional (2D) and 3D TEEs, with or without color flow Doppler, are essential to assess the size and shape of the paravalvular defect and the severity of regurgitation. However, “blooming” or improper gain settings may exaggerate the size and severity measurements. When multiple regurgitant jets are seen on 2D color flow Doppler, 3D imaging may identify whether the jets originate from a single or from multiple defects.

Three-dimensional large-volume imaging with multiplanar reconstruction allows for precise analysis. Using 3D analytic software, 3 orthogonal planes (x-, y-, z-axes) are aligned to traverse the area of interest and create an en face view of the defect. Length (height, width, and depth) and cross-sectional area measurements are used to asses the shape and size of the defect.3 A closure device is selected based on the size and shape of the defect.3 Although no devices are currently designed specifically for paravalvular leak closure,2 several (including Amplatzer devices) have been successfully used off-label. AVP-II and AVP-III (not approved in the United States) devices are popular options for round and small defects.3 AVP-II diameters range from 3 to 22 mm, although smaller devices are often used when interference with valve leaflets is a concern.3 Devices can be upsized, or additional devices can be added if necessary.3 The Amplatzer Septal Occluder, VSD Occluder, and Duct Occluder (St. Jude Medical, St. Paul, MN) may also be considered.2,3 Defects that are large, elliptical, or close to the prosthesis may require multiple smaller devices rather than larger occluders.1,3

In contrast to a native mitral valve, for which the Carpentier classification (eg, A1–A3, P1–P3 leaflet cusps; Figure 3A) allows communication of the precise site of pathology, prosthetic mitral valves lack anatomic characteristics for orientation and reference points.3 Consequently, other methods of orientation and localization are necessary. No standardized approach describes prosthetic mitral valve pathology,3 although various methods exist (Table). One simple, reliable technique, the “clock-face method,” uses a surgeon’s view of the mitral valve prosthesis, along with a superimposed clock face to localize and describe paravalvular pathology. The clock is oriented with the aortic valve at 12 o’clock and the left atrial appendage at 9 o’clock2,3,5,6 (Figure 3B). This technique facilitates precise localization of the defect and communication with the interventionalist.3



Figure 3.

Figure 3.

Using 3D TEE, along with the clock-face method, complements standard 2D views in localizing mitral pathology. Three-dimension has the advantage of showing the entire cross-section of the valve at once, whereas 2D midesophageal views only reveal 1 orthogonal view at a time (eg, 3 and 9 o’clock in a midesophageal commissural view). Subtle probe manipulation (rotation, anteflexion, etc) during 2D imaging yields additional information, but may complicate interpretation if oblique cuts of the valve are obtained. Also, a 2D transgastric basal short-axis view may be obtained; however, interpretation may be challenging due to shadowing effects of the prosthesis.

TEE is critical in interrogating paravalvular defects and guiding percutaneous closure.1–3 TEE imaging modalities to consider for localizing/assessing the defect and guiding wire placement include 2D, biplane (simultaneous orthogonal 2D views), 2D color flow Doppler, 3D narrow volume, 3D large volume, 3D zoom (live or multibeat), and 3D with color flow Doppler.3 Proper antegrade (via transseptal puncture), retrograde (across the aortic valve), or transapical (via left ventricular apex) wire placement,1,2 and advancement of the guidewire and catheter through the paravalvular defect,3 is guided and confirmed by TEE, fluoroscopy, and possibly computed tomography.2,3 TEE confirms proper positioning of the closure device(s) within the defect. Close evaluation of the spatial relationship between the device(s) and valve leaflets must ensure that the device has not interfered with normal valvular motion.2,3 Restriction of mitral leaflet motion did not occur in our case, as confirmed by TEE and a reduced transvalvular gradient. After device deployment, color flow Doppler (2D or 3D) detects and localizes residual paravalvular leak.3 TEE should carefully assess final device position and potential complications or the need for additional interventions. Finally, a postintervention gradient should be obtained and should be similar to or less than the preintervention gradient due to reduced transmitral flow.3

In summary, percutaneous closure of paravalvular leaks provides a desirable alternative in high-risk or inoperable surgical candidates. TEE is instrumental in evaluating these defects and guiding the procedure. The clock-face method provides a simple and effective tool to enhance communication of paravalvular pathology between providers.

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Name: Paul C. Anderson, MD.

Contribution: This author helped with manuscript preparation, acquisition and interpretation of data, creation of figures, tables, and videos, and approval of the final manuscript. This author attests to the integrity of the original data and analysis.

Name: Anand R. Mehta, MD.

Contribution: This author helped with manuscript preparation, data interpretation, and approval of the final manuscript. This author attests to the integrity of the original data and analysis.

Name: Wael A. Jaber, MD, FACC, FASE.

Contribution: This author helped with manuscript preparation, data acquisition and interpretation, and approval of the final manuscript. This author attests to the integrity of the original data and analysis.

Name: Andra E. Duncan, MD, MS, FASE.

Contribution: This author helped with manuscript preparation, data interpretation, and approval of the final manuscript. This author attests to the integrity of the original data and analysis.

This manuscript was handled by: Nikolaos J. Skubas, MD, DSc, FACC, FASE.

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1. Sorajja P, Bae R, Lesser JA, Pedersen WAPercutaneous repair of paravalvular prosthetic regurgitation: patient selection, techniques and outcomes. Heart. 2015;101:665673.
2. Krishnaswamy A, Kapadia SR, Tuzcu EMPercutaneous paravalvular leak closure- imaging, techniques and outcomes. Circ J. 2013;77:1927.
3. Quader N, Davidson CJ, Rigolin VHPercutaneous closure of perivalvular mitral regurgitation: how should the interventionalists and the echocardiographers communicate? J Am Soc Echocardiogr. 2015;28:497508.
4. Meloni L, Aru GM, Abbruzzese PA, Cardu G, Martelli V, Cherchi ALocalization of mitral periprosthetic leaks by transesophageal echocardiography. Am J Cardiol. 1992;69:276279.
5. Foster GP, Isselbacher EM, Rose GA, Torchiana DF, Akins CW, Picard MHAccurate localization of mitral regurgitant defects using multiplane transesophageal echocardiography. Ann Thorac Surg. 1998;65:10251031.
6. Mahjoub H, Noble S, Ibrahim R, et al.Description and assessment of a common reference method for fluoroscopic and transesophageal echocardiographic localization and guidance of mitral periprosthetic transcatheter leak reduction. JACC Cardiovasc Interv. 2011;4:107114.
7. Spoon DB, Malouf JF, Spoon JN, et al.Mitral paravalvular leak: description and assessment of a novel anatomical method of localization. JACC Cardiovasc Imaging. 2013;6:12121214.

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