Intraoperative three-dimensional transesophageal echocardiography for assessing the defect geometries of mitral prosthetic paravalvular leak during transcatheter closure

Three-dimensional transesophageal echocardiography-guided transcatheter closure of multiple mitral paravalvular leaks demonstrating real time avoidance of device-induced valve malfunction

Transcatheter closure of mitral paravalvular leaks has become an accepted alternative to surgical repair, especially in patients at high risk for reoperation. Device placement using three-dimensional (3D) transesophageal echocardiography (TEE) guidance allows en-face views of the valve and provides detailed information for device sizing and placement. We present a case demonstrating hybrid transapical transcatheter 3D TEE-guided closure of two mitral paravalvular leaks. We demonstrate real time 3D TEE guidance for device sizing and placement, and early real time recognition of mechanical mitral valve leaflet impairment during device deployment.

Usefulness of live/real time three/four-dimensional transesophageal echocardiography in the percutaneous closure of an iatrogenic aorto-right ventricular fistula

The development of an aorto-right ventricular fistula is a rare complication of cardiac surgery. The most common treatment is surgical closure of the fistula, but percutaneous closure of the fistula has become an attractive alternative option. We present a case of successful utilization of live/real time three/four-dimensional transoesophageal echocardiography (3/4DTEE) to select the correct device size for percutaneous closure of an adult patient presenting with an aorto-right ventricular (AO-RV) fistula following aortic valve replacement. To the best of our knowledge, this is the first case in which 3/4DTEE was used to select the device size and guide percutaneous closure of an iatrogenic AO-RV fistula.

Multi-Modality Imaging in the Evaluation and Treatment of Mitral Regurgitation

OPINION STATEMENT

Mitral regurgitation (MR) is frequent and associated with increased mortality and morbidity when severe. It may be caused by intrinsic valvular disease (primary MR) or ventricular deformation (secondary MR). Imaging has a critical role to document the severity, mechanism, and impact of MR on heart function as selected patients with MR may benefit from surgery whereas other will not. In patients planned for a surgical intervention, imaging is also important to select candidates for mitral valve (MV) repair over replacement and to predict surgical success. Although standard transthoracic echocardiography is the first-line modality to evaluate MR, newer imaging modalities like three-dimensional (3D) transesophageal echocardiography, stress echocardiography, cardiac magnetic resonance (CMR), and computed tomography (CT) are emerging and complementary tools for MR assessment. While some of these modalities can provide insight into MR severity, others will help to determine its mechanism. Understanding the advantages and limitations of each imaging modality is important to appreciate their respective role for MR assessment and help to resolve eventual discrepancies between different diagnostic methods. With the increasing use of transcatheter mitral procedures (repair or replacement) for high-surgical-risk patients, multimodality imaging has now become even more important to determine eligibility, preinterventional planning, and periprocedural guidance.

The Changing Paradigm in the Treatment of Structural Heart Disease and the Need for the Interventional Imaging Specialist

Percutaneous interventions in structural heart diseases are emerging rapidly. The variety of novel percutaneous treatment approaches and the increasing complexity of interventional procedures are associated with new challenges and demands on the imaging specialist. Standard catheterisation laboratory imaging modalities such as fluoroscopy and contrast ventriculography provide inadequate visualisation of the soft tissue or three-dimensional delineation of the heart. Consequently, additional advanced imaging technology is needed to diagnose and precisely identify structural heart diseases, to properly select patients for specific interventions and to support fluoroscopy in guiding procedures. As imaging expertise constitutes a key factor in the decision-making process and in the management of patients with structural heart disease, the sub-speciality of interventional imaging will likely develop out of an increased need for high-quality imaging.