Three-dimensional transesophageal echocardiogram provides real-time guidance during percutaneous paravalvular mitral repair.

A 65-year-old woman with severe paravalvular mitral regurgitation and chronic hemolytic anemia was referred for surgical consultation. Her medical history included rheumatic heart disease with mitral valve replacement in 1977, aortic valve replacement in 1988, and repeat mechanical mitral valve replacement in 2002. Predominant symptoms were New York Heart Association function class III dyspnea and fatigue. The patient was considered at high risk for surgical complication because of the 3 previous valve surgeries and significant pulmonary hypertension (systolic pulmonary pressure, 70 mm Hg). The Figure demonstrates repair of the significant paravalvular regurgitation using antegrade transcutaneous catheterbased deployment of a patent ductal occluder device (Amplatzer, AGA Medical Corp, Plymouth, Minn) into the paravalvular mitral annular defect. Two-dimensional transesophageal echocardiographic (TEE) color Doppler (panel A) demonstrates a significant paravalvular defect (white arrow). Real-time 3D color Doppler TEE (“surgeon’s view” from the left atrium) demonstrates a crescent of systolic paravalvular flow along the anterolateral region of the prosthetic annulus (panel B; Movie I). This en-face view suggests more severe regurgitation than appreciated by 2D 2-chamber images (compare with panel A). Catheter placement through the paravalvular defect was confirmed by fluoroscopy (panel C). Live 3D TEE confirmed the occluder (blue triangle) and catheter position immediately before occluder deployment (panel D; Movie II). Fluoroscopy confirmed complete deployment of the paravalvular occluder device (inset, panel E). Live 3D TEE demonstrated en-face “surgeon’s view” of the deployed occluder and mechanical leaflets during diastole (panel F). Both live 3D TEE and