Secondary Logo

Journal Logo

Cardiovascular Anesthesiology: Echo Rounds

Intraoperative, Real-Time Three-Dimensional Transesophageal Echocardiography for the Transcatheter Placement of an Edwards SAPIEN Aortic Valve in the Mitral Position for Severe Mitral Stenosis

Maxwell, Cory D. MD; Daley, Sean M. MD; Swaminathan, Madhav MD; Nicoara, Alina MD

Author Information
doi: 10.1213/ANE.0000000000000973

An 83-year-old man with a history of mitral valve replacement 11 years previously and aortic valve replacement (AVR) 5 years previously for rheumatic valve disease presented with symptoms of heart failure because of severe stenosis of the prosthetic mitral valve with a diastolic mean gradient of 23 mm Hg by transthoracic echocardiography. The prosthetic aortic valve was reportedly normal, with a mean systolic gradient of 4 mm Hg. He was deemed to be a poor operative candidate because of advanced age, previous sternotomies, and multiple comorbidities, including chronic atrial fibrillation, chronic obstructive pulmonary disease, and severe tricuspid regurgitation. He was evaluated by the multidisciplinary transcatheter valve team and was determined to have favorable anatomy for a transcatheter mitral valve replacement via a transapical approach. The previous valve was a 25-mm CE Perimount Plus bioprosthesis (Edwards Lifesciences Corporation, Irvine, CA). Written informed consent was obtained for publication of this report.

General anesthesia was induced and the procedure progressed without incident. Under fluoroscopic and transesophageal echocardiographic (TEE) monitoring, an Edwards SAPIEN® 26-mm prosthetic valve (Edwards Lifesciences Corporation, Irvine, CA) was deployed. Because of possible foreshortening of the left ventricle (LV) apex by TEE, transthoracic echocardiography was performed before thoracotomy to identify the appropriate incision site to access the true apex for wire insertion. After thoracotomy, the apical location was confirmed by the surgical team through palpation and by TEE. The apex was subsequently cannulated with a 5F sheath for placement of the guidewire. Real-time 3D TEE was used to confirm the placement of the wire through the valve. The sheath was upsized to 24F, and the new prosthetic valve was placed retrograde across the mitral valve and deployed during rapid ventricular pacing, aided by real-time 3D TEE and fluoroscopy. The patient was tracheally extubated at the end of the case and taken to the intensive care unit in stable condition.

The patient was discharged home on postoperative day 4, having received no transfusions or inotropic support during or after the procedure. At 1-month follow-up, the patient reported a dramatic improvement in symptoms.


The success of percutaneous intervention on the aortic valve has led to optimism regarding the feasibility of “minimally invasive” valve placement in the mitral position. Transcatheter AVR (TAVR) is indicated for patients with surgical indication for AVR because of aortic valve stenosis, life expectancy of >1 year, and who are considered to be high risk for surgery defined by a Society of Thoracic Surgeons’ risk >8%.1 Minimally invasive procedures of the mitral valve most often address the most common disease of the mitral valve, mitral regurgitation (MR). The MitraClip® (Abbott Vascular, Abbott Park, IL) device has been used to percutaneously simulate the edge-to-edge repair without annuloplasty via a transvenous approach. This device, compared with surgical correction, achieved noninferiority as a treatment option for severe, symptomatic MR.2

Transcatheter valve placement in the mitral position is made difficult by the “saddle” shape of the mitral valve compared with the standard cylindrical shape of available percutaneous valves. The mitral annular dilation that often accompanies MR exceeds larger size of commercially available percutaneous valves. Rheumatic and calcific mitral valve stenosis and preexistent bioprosthetic valves offer similar anatomic conditions to aortic valve stenosis treated by TAVR and make transcatheter treatment possible. As in TAVR, a lack of annular calcifications can encumber anchoring on deployment, proper seating, and permanent securing of a percutaneous valve in the mitral position, as well as the presence and severity of paravalvular leaks. Both Edwards SAPIEN valve and Medtronic CoreValve® (Medtronic, Minneapolis, MN) rely on calcifications of the aortic annulus to seat properly and secure permanently. However, the higher profile of the CoreValve and the self-expanding delivery method make it unsuitable for procedures in the mitral position.

The transapical and transseptal approach have both been reported for transcatheter valve-in-valve placement in the mitral position.3 Regardless of the approach to percutaneous mitral valve insertion, it is imperative to ensure accurate location of the guidewire, delivery system, and valve. The midesophageal long-axis views of the LV by 2D echocardiography ensure the coaxial placement of the guidewire and delivery system through both the LV apex and the mitral valve. Subsequently, attention can be turned toward adequate placement of the guidewire and delivery system through the mitral valve by using real-time 3D both en face from the left atrium and from the LV and long-axis views of the mitral valve. The optimal orientation of the delivery device will have the wire through the center of the mitral valve with the frame centered within the sewing ring of the existing valve.4 Although more challenging in a native valve, the existing sewing ring from the previous bioprosthesis facilitated accurate placement because it was readily apparent by 3D TEE; the largest series on percutaneous mitral replacement suggests positioning the new valve 3 to 5 mm atrially, beyond the existing sewing ring.5 The existing surgical valve must be bioprosthetic to qualify for this procedure because any mechanical valve would preclude a transcatheter approach to replacement. TEE also can aid in adequate sizing of the Edwards SAPIEN valve. In a case series of valve-in-valve replacement for degenerated bioprosthetic mitral valves, sizing was done by both internal diameter measured by TEE and internal diameter provided by the manufacturer. A 26-mm valve was chosen if the inner diameter was between 21.5 and 24.5 mm and for diameters larger than 24.5 mm, a 29-mm valve was chosen.6

In the case presented earlier, with the use of real-time 3D, we were able to confirm safe placement of the wire through the severely stenotic bioprosthetic valve (Fig. 1; Video 1, Supplemental Digital Content 1,, confirm improvement in the opening of the degenerated cusps of the bioprosthetic valve after balloon valvuloplasty (Fig. 2; Video 2, Supplemental Digital Content 2,, confirm adequate placement of the delivery system (Fig. 2; Video 2, Supplemental Digital Content 2,, and image the deployment of the new valve in real-time (Fig. 3; Video 2, Supplemental Digital Content 2, Although fluoroscopy was used in addition to TEE in the presented case, the transapical valve-in-valve deployment with echocardiographic guidance only, has been described.7

Figure 1
Figure 1:
(Left) Full volume 3D view of severely stenosed, previously replaced, mitral valve shown during atrial systole in the open position viewed from the left atrium. The sewing ring (red) and stenotic orifice (green) are clearly depicted. (Right) A color flow Doppler demonstrating moderate mitral regurgitation (blue) during ventricular systole, with the sewing ring of the existing prosthesis again seen (red).
Figure 2
Figure 2:
(Left) Real-time 3D view of the left atrium, left ventricle, and left ventricular outflow tract definitively confirming the placement of the wire (green) from the left ventricular apex through the mitral valve (red). (Right) Real-time 3D view of successful deployment of the Edwards SAPIEN valve within the existing bioprosthetic valve (red), with the delivery system in place (blue).
Figure 3
Figure 3:
(Left) Full volume 3D color flow Doppler of the new valve demonstrating mild intravalvular regurgitation (blue) without a perivalvular component. (Right) Full-volume 3D view from the left atrium of the new valve (red) shown during atrial systole in the open position with fully mobile leaflets within the previous bioprosthetic sewing ring (green).

Use of TEE, both 2D and 3D, has the benefit of minimizing fluoroscopy and reducing patient and provider exposure to ionizing radiation and potentially reducing the amount of nephrotoxic contrast dye administered. In addition, 3D TEE at the midesophageal level, through its unique perspective of the mitral valve, is superior to both 2D TEE and fluoroscopy, which only provide 2D insight into valvular pathology and transvalvular wire/catheter position. A 3D TEE of a heavily calcified or prosthetic valve may have fewer artifacts because of the simultaneous rendering of 2D arrays in addition to accurately identifying spatial position of existing pathology in relation to the introduced devices, which may otherwise appear superimposed in 2D imaging modalities. The 3D en face view allows for precision in the centering of the wire, ensuring that it has not snared an existing leaflet, whereas the LV view more confidently identifies apical location, subvalvular structures, and appropriate device depth. If 3D imaging is unavailable or limited (reduced frame rate, artifact), simultaneous orthogonal 2D imaging also can be useful in precise positioning of the wire and delivery device.

Once the valve is positioned and deployed, a complete evaluation of the new prosthetic valve by 2D, 3D, and Doppler is necessary to evaluate for intravalvular regurgitation, paravalvular leaks, and prosthetic valve gradients (Video 3, Supplemental Digital Content 3, In addition, sparing of the papillary muscles and subvalvular apparatus should be confirmed by 2D TEE in the midesophageal views. As practitioners have gained experience and confidence with the devices, the off-label uses of TAVR have rapidly emerged and will likely continue to expand. The role of 3D TEE will assist in proper placement and may obviate the need for fluoroscopy with experience.

Clinician’s Key Teaching Points

By Nikolaos J. Skubas, MD, Massimiliano Meineri, MD, and Martin J. London, MD

  • Transcatheter valve-in-valve procedures are an alternative to surgical replacement of a failing bioprosthesis in high-risk surgical patients. The Edwards SAPIEN balloon-expandable valve is commonly used for a mitral valve-in-valve procedure. The transapical approach is most commonly used and requires real-time echocardiographic imaging.
  • Intraprocedural transthoracic or transesophageal echocardiography (TEE) plays a key role in prosthesis sizing, catheter guidance, valve positioning, and assessment of the final result.
  • In this case, the true left ventricular apex was located with transthoracic echocardiography and a guidewire was inserted. A real-time 3D TEE en face mitral valve view, from the atrial and the ventricular aspect, was used to confirm the positioning of the wire in the center of the stenotic bioprosthesis. The new valve was positioned inside the bioprosthesis sewing ring and adjusted so that its stent extended 3 to 5 mm superiorly into the left atrium, using 3D real-time, single-beat TEE, from a midesophageal long-axis view.
  • Three-dimensional TEE has been successfully used as the sole imaging modality for transcatheter valve-in-valve procedures. When used in combination with fluoroscopy, it allows significant reduction in radiation exposure and contract dye load. When 3D imaging is suboptimal, simultaneous orthogonal imaging can be effectively used to guide the procedure.


Name: Cory D. Maxwell, MD.

Contribution: This author helped write the manuscript.

Attestation: Cory D. Maxwell approved the final manuscript.

Name: Sean M. Daley, MD.

Contribution: This author helped write the manuscript.

Attestation: Sean M. Daley approved the final manuscript.

Name: Madhav Swaminathan, MD.

Contribution: This author helped write the manuscript.

Attestation: Madhav Swaminathan approved the final manuscript.

Name: Alina Nicoara, MD.

Contribution: This author helped write the manuscript.

Attestation: Alina Nicoara approved the final manuscript.

This manuscript was handled by: Martin London, MD.


1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM III, Thomas JDACC/AHA Task Force Members. ACC/AHA Task Force Members. . 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:2440–92
2. Wan B, Rahnavardi M, Tian DH, Phan K, Munkholm-Larsen S, Bannon PG, Yan TD. A meta-analysis of MitraClip system versus surgery for treatment of severe mitral regurgitation. Ann Cardiothorac Surg. 2013;2:683–92
3. Salizzoni S, Barbero C, Grosso Marra W, Moretti C, Rinaldi M. Transapical implantation of an Edwards SAPIEN XT in a degenerated mitral bioprosthesis without fluoroscopic landmarks. J Card Surg. 2014;29:625–7
4. Hahn RT, Gillam LD, Little SH. Echocardiographic imaging of procedural complications during self-expandable transcatheter aortic valve replacement. JACC Cardiovasc Imaging. 2015;8:319–36
5. Cheung A, Webb JG, Barbanti M, Freeman M, Binder RK, Thompson C, Wood DA, Ye J. 5-year experience with transcatheter transapical mitral valve-in-valve implantation for bioprosthetic valve dysfunction. J Am Coll Cardiol. 2013;61:1759–66
6. Wilbring M, Alexiou K, Tugtekin SM, Sill B, Hammer P, Schmidt T, Simonis G, Matschke K, Kappert U. Transapical transcatheter valve-in-valve implantation for deteriorated mitral valve bioprostheses. Ann Thorac Surg. 2013;95:111–7
7. D’Onofrio A, Zucchetta F, Gerosa G. Simultaneous transapical aortic and mitral valve-in-valve implantation for double prostheses dysfunction: case report and technical insights. Catheter Cardiovasc Interv. 2014;84:509–12
© 2015 International Anesthesia Research Society