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Eccentric paraprosthetic leak on Starr-Edwards mitral valve and pannus on the valve

Authors : Dr. Julia Grapsa, Dr. Andreas Kalogeropoulos, Dr. Grigorios Karamasis, Mr. David Dawson, Prof. Petros Nihoyannopoulos

Hammersmith Hospital, Imperial College NHS Trust

Contact : Julia Grapsa,
EACVI ambassador for Greece

On behalf of the EACVI club 35 for Greece


 

Description

  • 37 years old woman with a Starr-Edwards mitral valve replacement 9 years ago.
  • Admitted with shortness of breath, raised JVP, signs of heart failure

Clinical case information

Parasternal long axis :Moderately dilated left ventricle with severe global systolic impairment. The right ventricle is not dilated but it function is moderately impaired. Starr Edwards MVR. There is an echogenic mass on the posterior aspect of the sewing ring with mobile part that looks like thrombus.

Parasternal long axis with colour :Aortic valve: bicuspid. Fusion of commissure between RCC/LCC. Moderate stenosis. Moderate central AR (50% of LVOT).

Parasternal short axis view with colour on the prosthetic mitral valve: There is an eccentric paraprosthetic leak from the posteromedial aspect of the ring.

Parasternal short axis of the left ventricle at the level above the mitral papillary muscles. There is severe left ventricular global impairment.

Apical four chamber view : Both left and right atria are severely dilated. Moderately dilated left ventricle. Severe global left ventricular systolic impairment. Moderately impaired right ventricle. Starr Edwards MVR. There is an echogenic mass on the posterior aspect of the sewing ring.

Apical two chamber view : Zoom on the mitral valve. Moderate prosthetic valve obstruction and moderate to severe paraprosthetic regurgitation.

Apical four chamber view : focus on the right ventricle. Moderately impaired right ventricle. Moderate tricuspid regurgitation.

 

Apical five chamber view : Continuous wave of aortic valve: Continuous wave of aortic valve: Vmax: 4 m/sec, peak pressure gradient 63 mmHg, mean 31 mmHg.

Apical five chamber view:Pulsed wave of left ventricular outflow tract: Vmax: 0.94 m/sec, PPG 4 mmHg, MPG 2 mmHg, VTI 18 cm.

Transesophageal echocardiogram: mid oesophageal. Mid oesophageal 4 chamber 0-20°. Assessment of the prosthetic mitral valve. Starr Edwards MVR. There is an echogenic mass on the posterior aspect of the sewing ring with mobile parts.

Assessment of the prosthetic mitral valve. Transesophageal echocardiogram: mid oesophageal 4 chamber 0-20°. Assessment of the prosthetic mitral valve.

Transesophageal echocardiogram : Mid oesophageal long axis 151° Assessment of the mitral valve: A2/P2 scallops. There is an eccentric paraprosthetic leak from the posteromedial aspect of the ring Moderate to severe mitral regurgitation.

Real time 3D transoesophageal echocardiography: Surgical view from the left atrium towards the left ventricle: Colour Doppler : There is an eccentric paraprosthetic leak from the posteromedial aspect of the ring (4 o clock on the 3D colour).

Real time 3D transoesophageal echocardiography: Real time 3D transoesophageal echocardiography: surgical view from the left atrium towards the left ventricle: moderate prosthetic valve obstruction

Conclusion

  • The patient had to undergo surgical operation and repair of the tricuspid valve.
  • His postoperative period was uncomplicated and his symptoms of heart failure resolved.