3D Transesophageal Echo in Percutaneous Correction of Paraprosthetic\nRegurgitation
Male patient, aged 76, assisted in August 2010, complaining of progressive dyspnea on\nexertion for two years, which had worsened one month before, accompanied by episodes of\npresyncope. The patient was diagnosed with severe aortic stenosis and, in January 2011,\nhe underwent surgery for aortic valve replacement with a bioprosthesis and was\ndischarged on the seventh postoperative day, which was uneventful.\nIn April 2011, he was hospitalized with fever, dysarthria and ejection systolic murmur\nin the aortic area. The hypothesis of infective endocarditis was confirmed by\ntransesophageal echocardiography that showed an image of an abscess near the anterior\nannulus and prosthetic vegetations, and severe mitral regurgitation and mild left\nventricular systolic dysfunction. Blood cultures were positive for S.\naureus and brain computed tomography scan showed left front hypodense lesion\n(probably septic embolism). The patient received treatment with vancomycin, gentamicin\nand rifampicin. He underwent further surgery with implantation of bioprostheses in\naortic and mitral positions. He was discharged after two months of hospitalization.\nAfter four months, the patient underwent transthoracic echocardiography that revealed\nbioprostheses with anatomically normal leaflets and the presence of severe mitral\nparaprosthetic regurgitation. This finding was confirmed by 3DTEECHO, which found the\nlocation of the leak and measured the dimensions of the defect ().\nDue to the high surgical risk, percutaneous correction of the paraprosthetic\nregurgitation was chosen on November 30, 2011. The procedure was performed under general\nanesthesia and started with the puncture of the right femoral vein and left femoral\nartery. Subsequently, transseptal puncture was performed with the aid of\nechocardiography, which helped find the catheter in position in order to allow access to\nthe mitral valve. Paraprosthetic regurgitation was then found by 3DTEECHO and measured\nin its length and diameter to plan the number and size of devices to be deployed.\nSubsequently, the interventionist tried to cross the defect assisted by 3DTEECHO. At\nthis time, the echocardiography was crucial, since the natural tendency of the catheter\nis to cross the prosthesis through its center hole. Once the catheterization of the\ndefect was confirmed by 3DTEECHO, two therapeutic catheters were separately introduced\nand two AmplatzerTM Vascular Plugs III were implanted. 3DTEECHO guided as to\nthe correct position and release of the prostheses. At the end, it was demonstrated that\nthe paraprosthetic regurgitation had completely disappeared (). The procedure was uneventful. The patient was extubated\nin the catheterization laboratory and remained under observation for about two hours and\ntaken to the infirmary.\nThe patient underwent control transthoracic echocardiography after two days, which\nrevealed normal bioprostheses and no mitral regurgitation. He was discharged on the same\nday.