title: Three-dimensional color Doppler transesophageal echocardiography for mitral paravalvular leak quantification and evaluation of percutaneous closure success.
abstract: BACKGROUND
  Three-dimensional (3D) color Doppler transesophageal echocardiography (TEE) enables accurate planimetry of the effective regurgitant orifice (ERO) of a mitral paravalvular leak (PVL). The aim of this study was to evaluate the usefulness of this method to quantify paravalvular regurgitation and to assess percutaneous PVL closure success, compared with 3D planimetry of PVLs without using color-flow images (3D anatomic regurgitant orifice [ARO]).
  
  
  METHODS
  Forty-six patients (59 mitral PVLs) who underwent 3D TEE to evaluate the indication of PVL closure procedure were retrospectively included. Receiver operating characteristic curves were compared to identify degree III and IV paravalvular regurgitation of 3D color ERO and 3D ARO measures. Forty patients underwent percutaneous PVL closure procedures; analysis was conducted to determine whether the undersizing of the closure devices according to 3D color ERO and 3D ARO measures was associated with PVL closure failure.
  
  
  RESULTS
  Three-dimensional ERO measures showed better areas under the curve than 3D ARO measures and correlated better with the degree of paravalvular regurgitation. Three-dimensional color ERO major diameter ≥ 0.65 cm showed a positive predictive value of 87.1% and a negative predictive value of 94% to diagnose degree III and IV paravalvular regurgitation. For the 40 patients who underwent PVL closure procedures, the immediate technical success rate was 76.9%, and 1-year estimated survival was 69.5%. Closure device undersizing according to 3D color ERO length, but not other PVL measurements, was significantly associated with PVL closure failure (P = .007).
  
  
  CONCLUSIONS
  Three-dimensional ERO was superior to 3D ARO at identifying the presence of degree III and IV paravalvular regurgitation. The undersizing of closure devices according to 3D color ERO length was associated with failed closure procedures. Confirmatory prospective studies are encouraged.
authors.affiliation: Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain. Electronic address: efranco@academiamir.com.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Franco
authors.affiliation: Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.
authors.forename: Carlos
authors.initials: C
authors.lastname: Almería
authors.affiliation: Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.
authors.forename: Jose Alberto
authors.initials: JA
authors.lastname: de Agustín
authors.affiliation: Paediatric Cardiology Department, Hospital Universitario La Paz, Madrid, Spain.
authors.forename: Viviana
authors.initials: V
authors.lastname: Arreo Del Val
authors.affiliation: Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.
authors.forename: José Juan
authors.initials: JJ
authors.lastname: Gómez de Diego
authors.affiliation: Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.
authors.forename: Miguel Ángel
authors.initials: MÁ
authors.lastname: García Fernández
authors.affiliation: Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.
authors.forename: Carlos
authors.initials: C
authors.lastname: Macaya
authors.affiliation: Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.
authors.forename: Leopoldo
authors.initials: L
authors.lastname: Pérez de Isla
authors.affiliation: Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.
authors.forename: Eulogio
authors.initials: E
authors.lastname: Garcia
mesh_terms: D018618:Echocardiography, Doppler, Color / Q000379:methods*; D019560:Echocardiography, Three-Dimensional / Q000379:methods*; D017548:Echocardiography, Transesophageal / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty / Q000379:methods*; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging* / Q000601:surgery*; D015588:Observer Variation; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D016896:Treatment Outcome
keywords: Effective regurgitant orifice; Paravalvular leak; Paravalvular mitral regurgitation; Percutaneous paravalvular leak closure procedure; Three-dimensional transesophageal echocardiography