Title: 3D echocardiography as diagnostic tool in a dysfunction of a mechanical mitral valve prosthesis during the intraoperative period

Author(s):

Miralles Bagán J., Cegarra-Sanmartín V., Maestre Hittinger M.L., Paniagua Iglesias P., Díaz Jover R., Galán Serrano J.
	
Institute(s): Hospital Sant Pau Barcelona, Dept of Anaesthesiology, Barcelona, Spain

Background:

Intraoperative use of echocardiography can often dramatically influence a patient's management during cardiac surgery. Transesophageal echocardiography (TEE) is a valuable adjunct in the intraoperative assessment of heart valve surgery for adults patients without contraindications, and should be used in all valvular procedures to confirm the normal valve motion, proper seating of the prosthesis within the native valve annulus, and normal blood flow pattern through the valve1. Three-dimensional (3D) echocardiography has made it possible to obtain images in real time, without the need for off-line reconstruction2 and has become an essential tool for intraoperative assesstment in cardiac surgery.

Case report: 

We present a case of a 62 years- old man who received mitral mechanical valve replacement with a On-X 25 mm valve placed on anti-anatomic position because a severe mitral insufficiency . In 2005 he had an acute miocardial infarction complicated with a septal ventricular rupture, and underwent closure with two amplatzers. After mechanical valve implantation and during weaning  off of cardiopulmonay bypass (CPB) the 2D echocardiography showed a mild transvalvular mitral insufficiency with apparently correct movement of the two valve hemi-discs, but the 3D images shown an incomplete closure of the inferior hemi-disc in systole due to an interposition of a ventricular amplatzer between the inferior hemi-disc and the closure plane of the valve. The problem could be solved by re-entry in CPB and rotation of the valve to an anatomic position.

Discussion: 

This case is an example that we ought to be attentive to the possibility of an early valve malfunction and be able to recognize this potential life-threatening complication by echocardiography. 3D TEE is an essential tool for the assessment of the dysfunction of a prothesic valve, and can make an estructural diagnosis with more precision than 2D images. Anesthesiologist should integrate this new skills in their current practice during the TEE exam in the context of cardiac surgery. 

References

1. Albert, C. (2008). A practical approach to Transesophageal Echocardiography. Philadelphia, PA: Lippincott Williams & Wilkins.

2. Solis, J. Three-Dimensional Echocardiography. New Possibilities in Mitral Valve Assessment. Rev Esp Cardiol. 2009;62:188-98.

Learning points: 
3D images improves the quality of the 2D TEE exam and should be considered in all heart valve procedures.

3D transesophageal echocardiography as diagnostic tool in mechanical mitral valve prosthesis dysfunction during the intraoperative period