20.09.2017 | Case image in cardiovascular ultrasound
Paravalvular leakages between sewing cuffs after the second surgery for double valve replacement: evaluation by three-dimensional color-Doppler transesophageal echocardiography
An 86-year-old woman was admitted for dyspnea on effort. She had previously undergone double valve replacement (DVR) at 57 years of age because of rheumatic valvular heart disease and re-do DVR at age 69 years. Her hemoglobin level was low (6.6 g/dl) and lactate dehydrogenase level was elevated (1692 IU/l). The 12-lead electrocardiogram showed atrial fibrillation. The chest radiograph revealed a 77% cardio-thoracic ratio. Transthoracic echocardiography (TTE) could not detect any paravalvular leakages (PVLs) because of the acoustic shadow of the mitral prosthesis (Fig. 1a, b). Although transesophageal echocardiography (TEE) could detect mitral regurgitation, we originally thought she had transvalvular leakage, which had seemed to be inside the mitral annulus (Fig. 1c, d). We found that a down-sized 25-mm St. Jude Medical (SJM) mechanical prosthesis had been inserted instead of a 27-mm Björk-Shiley (BS) mechanical prosthesis. The previous sewing cuff of the 27-mm BS mechanical prosthesis remained, and the 25-mm SJM mechanical prosthesis had been inserted inside it (Fig. 1e). Three-dimensional color-Doppler TEE finally detected PVLs between the sewing cuffs, which can cause hemolytic anemia and heart failure (Fig. 1f–h). Her condition was difficult to treat because of old age and frailty; she has been followed up with monthly blood transfusions.
Fig. 1
Imaging studies. a, b Transthoracic echocardiography cannot detect any paravalvular lesions because of the acoustic shadow of the mitral mechanical prosthesis. c, d Transesophageal echocardiography can detect mitral regurgitation, which seems to be derived from inside the mitral annulus (arrowheads). e Progress of mitral valve surgery. f–h Three-dimensional color-Doppler transesophageal echocardiography detects paravalvular leakage between the sewing cuffs (arrow) in the postero-lateral position as well as two small paravalvular leakages in the medial position (arrowheads)
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Paravalvular leakages between sewing cuffs after the second surgery for double valve replacement: evaluation by three-dimensional color-Doppler transesophageal echocardiography
verfasst von
Hideta Takushi Akihiro Hayashida Nobuyuki Kagiyama Misako Toki Atsushi Hirohata Keizo Yamamoto Kiyoshi Yoshida
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