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.
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.” 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. 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.
Declaration of patient consent
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Gürsoy MO, Güner A, Kalçık M, Bayam E, Özkan M. A comprehensive review of the diagnosis and management of mitral Paravalvular leakage. Anatol J Cardiol 2020;24:350-60
2. Kronzon I, Sugeng L, Perk G, Hirsh D, Weinert L, Garcia Fernandez MA, et al. Real-time 3-dimensional transesophageal echocardiography in the evaluation of post-operative mitral annuloplasty ring and prosthetic valve dehiscence. J Am Coll Cardiol 2009;53:1543-7