Tayyar Gökdeniz, Emre Ertürk, M. Ali Astarcıoğlu, Sabahattin Gündüz, A. Çağrı Aykan, A. Emrah Oğuz, Zübeyde Bayram, Mustafa Yıldız, N.

Transcription

1 Tayyar Gökdeniz, Emre Ertürk, M. Ali Astarcıoğlu, Sabahattin Gündüz, A. Çağrı Aykan, A. Emrah Oğuz, Zübeyde Bayram, Mustafa Yıldız, N. Ekşi Duran, Mehmet Özkan

2 Introduction The incidence of development of paravalvular leak (PVL) 15 years after mitral valve operation is nearly 17% and is a serious complication that may require intervention when it appears. Hammermeister K, et al. JACC 2000;36: Jindani A, et al. J Cardiovasc Surg 1991;32:503-8 Lonescu A, et al. Heart 2003;89:

3 Introduction PVL is most commonly seen in commissural regions and posterior annulus. Sutures may seperate easly since the region involving the posterior anulus is longer than the anterior region and posterior region is more affected by anular dilatation. Genoni M, et al. J Heart Valve Dis 2001;10: De Cicco G, et al. E. J. Of Cardio-thoracic Surgery 2006;30:

4 Introduction PVL typically cause mitral regurgitation and symptoms secondary to it. It may cause deterioration of functional capacity and hemolysis in varying degrees. Patel AR, et al. Echocardiography 2000;17:275-83

5 Introduction 2-D TEE is significantly superior to 2-D TTE in terms of accurate estimation of regurgitation. Though differential diagnosis of pathologies responsible for PVL including separation of sutures, fistulas, perivalvular abcess, and dehiscence is possible by 2-D TEE, PVL origin and the lenght of defect can not be shown anatomically. RT-3D-TEE makes it possible to obtain cross-sectional visualization of the mitral valve and PVL origin, which are not possible with 2-D TEE. Consequently the size of the defect which is a key guide in the treatment plan of PVL can directly be measured. Kronzon I, et al. JACC 2009;53: Singh P, et al. Echocardiography 2009;26: Sade LE, et al. Eur J Echcardiography 2008;9:82-3 Yildiz M, et al. Arc Turk Soc Cardiol 2009;37(6):

6 Aim of the study In this study, we investigated the comparison of two dimensional and real-time three-dimensional transesophageal echocardiography in the assessment of prosthetic mitral PVL location and size.

7 Study design The study included 53 pts (38 female, 15 male; mean age 41.6±13.0 years) who developed PVL within a mean of 9.03±3.1 years following mechanical prosthetic MVR.

8 Study design Each patient was assessed with 3D matrix-array TEE transducer with IE33 ultrasound system (Phillips Medical Systems, Andover, USA). Images were evaluated offline with QLAB software (Phillips Medical System). Real-time 3D TEE was performed immediately after detection of PVL on 2D TEE examination.

9 Study design Full volume: This modality is used for Analyzing structures (Parallel imaging for optimizing the anatomical structures, ECG gated image collection, analysis of 3D images, rotation,cropping for inspection inside structures)

10 Study design Volume measurements (Parallel imaging for optimization, ECG gated image collection, segment analysis, parametric Imaging) Color full volume images (Color Doppler image of flow at valves or other structures, parallel imaging for optimization, ECG gated image collection analysis of the color flow in 3D, relating the flow to anatomical structures)

11 Study design For the localization of PVL, aort was set as anteriorly at lower side (clockwise, 06) of the image. PVL were classified into four zones according to this position. Image gride method: According to the image size, image window is automaticaly divided into squares sizing 2mm or 5mm. By the help of this squares the size of the image could be measured.

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13 Results Paravalvular leak was mild, moderate and severe in 12, 10, 31 pts, respectively. The mean PVL width measured by 2D TEE was 3.7±1.02 mm. The mean lenght of dehiscence was 11.30±7.9 mm, and the mean width was 3.88 ±1.80 mm on RT-3D TEE.

14 Results The PVLs were localized between hours (zone-i) (n=19, 30.0%), hours (zone-ii) (n=22, 34.9%), hours (zone-iii) (n=8, 12.6%) and hours (zone-iv) (n=14, 22.2%) on RT-3D TEE, respectively. The PVLs were localized mainly at zone I and zone II. Among 53 pts, multiple PVL were detected in 10 (18.95%) pts only by RT-3D TEE.

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16 Results Twenty-eight pts (52.8%) had atrial fibrillation. Seventeen pts (32.1%) had hemolysis.

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22 Discussion In this study, anatomical description of leak origin was clearly shown by RT-3D-TEE in patients diagnosed as PVL with 2D-TEE.

23 Discussion 2D echocardiography shows endocardial and epicardial borders and other anatomical structures directly without geometrical assumptions. Sugeng L, et al. Circulation 2006;114: Van den Bosch AE, et al. JASE 2006;19:815-21

24 Discussion Full volume, biplane and triplane images could be obtained in the same cardiac cycle with 3D echocardiography which use matrix array transducers. Hence, detailed information about left ventricular and valvular functions may be obtained. Sugeng L, et al. Circulation 2006;114: Van den Bosch AE, et al. JASE 2006;19:815-21

25 Discussion Perfect images of mechanical mitral valve may be obtained with both left ventricular and atrial views but in compared to left atrial view, mechanical mitral valve scores are probabaly lower because of acustic shadowing in left ventricular view. Sugeng L, et al. Circulation 2006;114: Van den Bosch AE, et al. JASE 2006;19:815-21

26 Discussion PVL associated with mitral valves will be especially important in percutaneous and surgical interventions because it provides perfect spatial delination about dehisence and associated structures. Dynamics of prosthetic valve or annuloplasty may be measured and association with other cardiac structures could be assessed. Sugeng L et al. JASE 2008;21: Mor-Avi V et al. Circulation;2009:119: Kronzon I et al. JACC;2009:53:1543-7

27 Discussion Like native aort and tricuspid valves, prosthetic valves in this location could not be clearly visulalized with RT-3D-TEE and it is assumed to be associated with relative distance to transducer and oblique angle of ultrasound wave. Hence, for ideal clinical use of 3D-TEE evaluation of aortic valve and prosthetic valves in these two locations advenced technological reserachs are necessary.

28 Conclusion Real-time 3D TEE is clearly superior to 2D TEE in localizing and measuring the size of PVLs that develop following prosthetic MVR. PVL was mostly observed in zone-i and zone-ii.