Usefulness of intraoperative real-time three-dimensional transesophageal echocardiography for pre-procedural evaluation of mitral valve cleft: a case report
A 38-year-old woman planned to undergo open heart surgery to surgically correct a known severe MR. She had a history of undergoing percutaneous balloon valvuloplasty due to rheumatic mitral stenosis (MS) during a previous pregnancy 10 years before. At the preoperative evaluation employing 2D TTE, a tearing of the tip of a mid part of the thickened anterior mitral valve leaflet (AML) was suggested to be the main reason for a coaptation defect producing severe MR; two-chambered views using color Doppler showed a severe central MR jet projecting into an enlarged left atrium (, and ). MVR to install a bioprosthetic valve was planned preoperatively considering the technical difficulties and worse outcome of a patch repair of a large defect on the free margin of the AML.\nAfter induction of anesthesia, a 3D-TEE probe (X7-2t transducer; Philips Healthcare, Andover, MA, USA) was placed and connected to a TEE console (iE33™, Philips Healthcare, Andover, MA, USA) and intraoperative 2D and 3D TEE examinations were performed. The 2D TEE images in the midesophageal commissural and long axis views also supported the preoperative diagnosis regarding a severe MR and systolic coaptation defect between the AML and posterior mitral leaflet (PML) (, and ). However, intraoperative real time 3D TEE provided more detailed spatial information on the MR pathology, which was entirely different from that suggested by the preoperative TTE; the "en face view" in the left atrial perspective showed a cleft in the middle of the PML, a ruptured chordae attached to the P3 scallop moving toward the left atrium during systole, and fusion of both ends of the MV commissures producing mild MS (, ). Interestingly, the defect or cleft in the AML, which had been suggested, was not observed.\nThe feasibility of MVRep was reevaluated considering this new and different intraoperative diagnosis. Finally, after confirming a cleft in the P2 scallop by direct observation through atriotomy, MVRep, consisting of posterior mitral valvuloplasty with patch closure and lifting posterior annuloplasty, was successfully performed.\nPost-procedural TEE evaluation including the RT 3D TEE view and post-operative TTE showed a satisfactory surgical outcome with sufficient diastolic opening greater than 3.5 cm2 without any residual MR (, ).