title: Intraoperative three-dimensional transesophageal echocardiography for assessing the defect geometries of mitral prosthetic paravalvular leak during transcatheter closure.
abstract: BACKGROUND
  Paravalvular leaks (PVLs) are a common complication of prosthetic valve replacement. Use of the transcatheter intervention technique is a suitable alternative in high-risk patients who may not tolerate repeat surgery. Common reasons for failure of this demanding intervention include poor imaging quality and unsuitable anatomy. The purpose of this study was to assess the usefulness and the incremental value of real-time three-dimensional (RT 3D) transesophageal echocardiography (TEE) over two-dimensional (2D) TEE findings in the evaluation of the geometry and track of mitral PVLs during transcatheter closure.
  
  
  METHODS
  Five patients with six mitral PVLs at high risk for repeat surgery underwent transcatheter leak closure. Intraoperative RT 3DTEE was used to assess the location, shape, number, and size of the defects. Transapical approaches were used in all cases with fluoroscopic and RT 3D TEE guidance of the wire and catheter, device positioning, and assessment of residual leak after the procedure.
  
  
  RESULTS
  In all of the cases, defects with irregular crescent shapes and distorted tracks were clearly delineated by RT 3D TEE. This was compared to those results obtained through 2D TEE, which was unable to characterize the defects. Three cases showed small leaks, which were completely occluded with a patent ductus arteriosus (PDA) device in two cases, and a muscular ventricular septal defect (mVSD) occluder combined with coil devices in one case. One case involved a large leak and early device embolization of the muscular VSD occluder, which was removed surgically, and demonstrated a crescent-shaped defect. One patient had two releaks 2 months subsequent to the procedure due to two new extended leaks at the tails of the crescent-shaped defect.
  
  
  CONCLUSIONS
  RT 3D TEE can clearly delineate the geometries of defects in their entirety, including shape, size, and location of the defect and track canal. It would also appear that RT 3D TEE is superior to 2D TEE in the process of guiding the wire through the difficult canal anatomy, facilitating the overall procedure. The small mitral PVLs can be completely occluded, but subsequent complications occurred with large defect closures because of embolization or releak. Therefore, transcatheter closure of PVLs seems to be an attractive alternative for these patients, but newer occluder designs that better conform to leak geometry will be required to improve outcomes.
authors.affiliation: Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC.
authors.forename: Jeng
authors.initials: J
authors.lastname: Wei
authors.affiliation: Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC.
authors.forename: Wei-Hsian
authors.initials: WH
authors.lastname: Yin
authors.affiliation: Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC.
authors.forename: Yung-Tsai
authors.initials: YT
authors.lastname: Lee
authors.affiliation: Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC.
authors.forename: Ming C
authors.initials: MC
authors.lastname: Hsiung
authors.affiliation: Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC. Electronic address: ch9198@chgh.org.tw.
authors.forename: Shen-Kou
authors.initials: SK
authors.lastname: Tsai
authors.affiliation: Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC.
authors.forename: Yi Cheng
authors.initials: YC
authors.lastname: Chuang
authors.affiliation: Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC.
authors.forename: Ching-Huei
authors.initials: CH
authors.lastname: Ou
authors.affiliation: Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC.
authors.forename: Yi-Pen
authors.initials: YP
authors.lastname: Chou
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006328:Cardiac Catheterization; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D016343:Monitoring, Intraoperative
keywords: mitral prosthetic paravalvular leak; occluder; real-time 3D TEE; transapical approach; transcatheter closure technique