The value of transesophageal echocardiography in the investigation of acute prosthetic valve dysfunction

Improved Assessment of Pathological Regurgitation in Patients with Prosthetic Heart Valves by Multiplane Transesophageal Echocardiography

The aim of this study was to evaluate the diagnostic increment of individually optimized axes in the assessment of pathological prosthetic valve regurgitation. Forty-two patients with pathologically regurgitant prostheses in the aortic (n = 21), mitral (n = 15), and tricuspid (n = 6) positions were examined by multiplane transesophageal echocardiography. The investigation was performed utilizing the transverse axis first, the longitudinal axis second, and the intermediate axes afterwards. The presence of regurgitation, the differentiation between trans- and perivalvular origin, and the localization of perivalvular leakages at the sewing ring were evaluated. Findings in the biplane and intermediate axes were compared to surgery or autopsy in all patients. There was slightly higher detection rate for aortic prosthetic regurgitation using the intermediate axes than the biplane axes. The intermediate axes revealed significantly fewer differences to the morphological control than the biplane axes with regard to the differentiation of peri- and transprosthetic aortic regurgitation and to the localization of a periprosthetic aortic regurgitant origin. The intermediate axes provided significantly better agreement to surgery/autopsy than the biplane axes regarding the localization of the origin of mitral periprosthetic regurgitation. Morphological visualization of the perivalvular gap adds important information on the precise localization of the regurgitant origin. The pathological gap was visualized significantly more often using the intermediate than the biplane axes in all types of prostheses. The data in this study therefore suggest that multiplane transesophageal echocardiography is superior to biplane transesophageal echocardiography in the assessment of pathologic prosthetic regurgitation.

Bioprosthetic mitral valve thrombosis: clinical profile, transesophageal echocardiographic features, and follow-up after anticoagulant therapy

Cardiac bioprosthetic valve thrombosis is frequently found on pathologic examination, but preoperative diagnosis is rarely performed. Four hundred six patients with mitral porcine xenograft bioprostheses were examined by transthoracic echocardiography. Transesophageal echocardiography (TEE) was performed in 161 of the patients, with clinical or echocardiographic criteria of prosthetic malfunction. Fairly homogeneous and echodense masses, attached to the ventricular surface of the mitral bioprosthetic cusps, were detected by TEE in 15 patients. Only 10 patients, in whom diagnosis of bioprosthetic thrombosis was confirmed, are included in this study. After TEE, two patients underwent prosthetic replacement and eight patients received anticoagulants. A new TEE was performed 85.6 +/- 29.8 days after anticoagulation in these eight patients. Clinical follow-up was continued for 13.6 +/- 8.6 months, and one additional patient underwent surgery during the follow-up. Pathologic examination of removed grafts (three cases) identified these masses as being thrombotic tissue. TEE examination after therapeutic anticoagulation demonstrated complete disappearance of the echogenic masses on bioprosthetic cusps and normal mobility of all leaflets in six cases. In the other two cases, cusp masses were notably reduced, but partially restrictive mobility of affected leaflets persisted, suggesting incomplete resolution of thrombi. Mitral valve prosthetic mean gradient decreased from 11.8 +/- 4.5 to 7.6 +/- 3.7 mm Hg (p < 0.001), and mitral valve area increased from 1.13 +/- 0.3 to 1.72 +/- 0.6 cm2 (p < 0.001). Long-term symptomatic improvement after anticoagulation was obtained in seven patients. Thus this study shows that mitral bioprosthetic thrombosis is a relatively frequent cause of valve dysfunction, TEE is useful for detecting thrombus in relation to mitral bioprosthetic valves, and oral anticoagulation is effective in resolving thrombosis on bioprostheses.

Refractory hemolytic anemia secondary to perivalvular leak diagnosed by transesophageal echocardiography

Transesophageal echocardiography (TEE) has become increasingly important in the assessment of mitral valve prosthetic dysfunction. We report on three patients who developed medically refractory hemolytic anemia after St. Jude mitral valve replacement secondary to perivalvular mitral prosthetic regurgitation. Two of the three cases had corrective surgical intervention that resolved the hemolytic process. Careful transesophageal echocardiographic evaluations of the perivalvular area proved diagnostic and resulted in appropriate management decisions.

Detection of acute thrombosis of mitral tilting disk prosthesis by transesophageal echocardiography

Acute thrombosis is a very severe complication in the replacement of mechanical prostheses and most often fatal if immediate treatment is not implemented. We describe a case in which an acute thrombosis of a mitral tilting disk prosthesis was adequately diagnosed by transesophageal echocardiography and immediate surgical replacement of the dysfunctioning device was possible without catheterizing the patient.