Mitral Prosthetic Valve Dehiscence: Role of Three-Dimensional Transesophageal Echocardiogram in Management

A 36-year-old female had mitral valve replacement for severe rheumatic mitral valve disease with bi-leaflet mechanical prosthesis valve (25 mm ON –X valve, On-X Life Technologies Inc, Austin, Texas, USA). Six months after surgery, she presented with a 10 days history of significant breathing difficulty and features of heart failure. Transthoracic echocardiogram showed normal prosthetic disc mobility with the significant mitral regurgitant flow by the side of valve annulus suggestive of paravalvular leak (PVL), there was mild tricuspid regurgitation (TR) severe pulmonary hypertension [Figure 1a-f and Video 1]. The team explored the possibility of transcatheter closure of the PVL. Transesophageal echocardiogram (TEE) clearly showed significant large mitral PVL, mainly to the left lateral region. There was another jet seen anteriorly in the aortomitral curtain. The rocking movement of the mitral prosthesis was not explainable by two jets [Figure 2a-d and Video 2]. Enface three-dimensional (3D). TEE revealed the lesion as dehiscence of the mitral prosthesis of more than 50% of the mitral annular region, mainly the lateral half of the annulus. The 3D TEE demonstrated the dehiscence very clearly in multiple views and also showed the extent of dehiscence in 3D color Doppler [Figure 3a-f and Video 3]. The idea of possible percutaneous intervention was dropped, and she was shifted to an operation theater complex from the echocardiography laboratory. She underwent redo mitral valve replacement on the same day. Surgical findings were similar to those described in the echocardiogram. She had an uneventful recovery and is doing well in follow-up.

Figure 1: Transthoracic echocardiogram in four chamber view (a) with colour Doppler (b and c) Good mitral mechanical prosthesis disc movement, paravalvularleak from lateral annular region (yellow arrow) and mild tricuspid regurgitation, Gradient 73 mmHg (f). Parasternal long-axis view with colour Doppler (d and e) showing the paravalvularleak in the aorto-mitral curtain region and lateral annular region (arrow). RA: Right atrium, LA: Left atrium, LV: Left Ventricle, Ao: Aorta

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Figure 2: Transesophageal echocardiogram in two dimensional (a) and color Doppler (b) showing rocking mitral mechanical prosthesis movement, paravalvularleak from lateral annular region (green arrow). In the long-axis view with color Doppler (c) and bi-chamber view (d) showing the paravalvularleak in the aortomitral curtain region (yellow arrow) and posterior annulus (Sky blue arrow). LA: Left atrium, LV: Left Ventricle, Ao: Aorta

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Figure 3: Three dimensional transesophageal echocardiogram enface view from left atrial aspect in systole (a) and diastole (b) and grayscale without color Doppler (c) showing good moment of the mitral prosthetic leaflets, dehiscence of the mechanical prosthesis involving more than 50% of the mitral annular circumference in the poster- lateral region (white arrow). Rocking movement of the sewing ring seen. The same features are visible from the left ventricular site view in systole (d) and diastole (e). Three-dimensional enface color Doppler (f) confirming large mitral paravalvular regurgitant jet from the dehisced valve region in the lateral annular region (red arrow)

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Mitral PVL is seen after 2.2% of mitral valvular surgery, the grade of the PVL is usually defined by the circumference of the annular ring involvement. A small PVL involves less than 10% of the circumference of the valve annular ring, whereas 10%–20% circumference involvement is termed moderate and more than 20% involvement is called severe PVL. A leak involving more than 25% of the circumference of valve annulus with rocking movement of the prosthesis is called “dehiscence.”^[1] It is very important to diagnose the exact anatomical detail of PVL in terms of site and size of the leak, amount of circumference of annulus involvement as well as the involvement of adjacent structure and added lesion-like vegetation. This information helps in decision-making on the nature of treatment, conservative with medication versus intervention which could be transcatheter or surgical. The traditional transthoracic echocardiogram is not adequate for proper anatomical diagnosis. The real-time 3D TEE (RT-3D TEE) can display the whole of the prosthetic valve enface and show the exact site of the PVL and can quantify the leak. The PVL can be confirmed by 3D color flow.^[2] The TEE with 3D evaluation was very helpful in the diagnosis of the index case communicating to the surgical team the exact anatomy of the lesion and proper management.

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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.