Thrombosis of a bileaflet prosthetic mitral valve: a real-time three-dimensional transesophageal echocardiography perspective

Rheumatic mitral valve disease being common in India, valve replacement and hence thrombosis of prosthetic heart valves (PHV) are not uncommon. The diagnosis is commonly established by increased gradients across PHV during transthoracic echo and restricted leaflet movement during transesophageal echo or fluoroscopy. We demonstrated both the leaflets of a thrombosed PHV,of which one was stuck in closed position by real-time three-dimensional transesophageal echocardiography.     

经食管三维超声心动图评价人工二尖瓣瓣周反流

目的 探讨经食管三维超声心动图评价人工二尖瓣术后瓣周反流的可行性、准确性.方法 2007年12月至2011年8月本心脏中心因二尖瓣置换术后瓣周反流行再次心脏手术的病例24例,男17例.女7例,年龄30~65岁,平均(48±9)岁,24例均术前行经胸二维超声检查,ll例行经食管二维超声检查.9例行经食管三维超声检查.以外科术中所见为金标准,分别对比经胸二维超声、经食管二维超声、经食管三维超声评价瓣周反流存在与否、位置、程度及病因的准确性.结果 经胸二维超声、经食管二维超声、经食管三维超声评价瓣周反流存在与否准确性分别为87.5%(21/24),100%(11/11),100%(9/9);判断瓣周反流位置准确性:经胸二维超声62.5%(15/24),经食管二维超声81.8%(9/11),经食管三维超声100%(9/9);判断反流程度准确性:经胸二维超声70.8%(17/24),经食管二维超声72.7%(8/11),经食管三维超声100%(9/9);判断病因准确性:经胸二维超声54.2%(13/24),经食管二维超声63.6%(7/11),经食管三维超声88.8%(8/9).结论 经食管三维超声心动图能实时提供人工二尖瓣瓣周立体信息,在评价二尖瓣置换术后瓣周反流存在与否、位置、程度、病因中起到重要作用,具有更高的准确性.     

Detection of prosthetic mitral valve leak: a comparative study using transesophageal echocardiography, transthoracic echocardiography, and auscultation

Paravalvular leakage is a major complication of prosthetic valve dysfunction. Sixty-one subjects with valvular heart disease who had received prosthetic mitral valve replacement 5 months to 5 years before (43 received a porcine prosthesis and 18 received Bjork-Shiley valve prostheses) were evaluated for this complication. Careful auscultation was performed by two experienced cardiologists followed by transthoracic and transesophageal echocardiography. Physiologic leaks were detected in all Bjork-Shiley valves, but in only 30% of porcine valves using transesophageal echocardiography. These regurgitant jets were flame-like, with mean low velocities of 50 +/- 12.3 cm/sec and 48 +/- 18.2 cm/sec in the two types of valves. Neither transthoracic echocardiography nor auscultation could detect physiological regurgitant jets. Ten cases with paravalvular leak were detected by transesophageal echocardiography and subsequently demonstrated by left ventriculography (7 porcine, 3 Bjork-Shiley valves). Pathologic regurgitant jets were seen as high-velocity, systolic-retrograde turbulent flow across the prosthesis. However, only 6 cases of prosthetic valve dysfunction were detected by transthoracic echocardiography, 4 cases of mild paravalvular leakage went undetected. Thirteen of the 61 subjects had an apical systolic murmur and suspected prosthetic valve leakage; in 10 of the 13 cases the findings corresponded to those obtained by transesophageal echocardiography. In 3 cases of double valve replacement with Bjork-Shiley valves the magnitude of the leakage was overestimated by auscultation.     

经食管超声心动图在二尖瓣修复术中的应用

目的　探讨经食管超声心动图 (TEE)在二尖瓣反流性病变修复术中的指导作用。方法　对 19例二尖瓣反流 (MR)患者 ,体外循环 (CPB)前及修复术后 ,应用TEE评价二尖瓣结构的异常。在相同的仪器条件和相近的血流动力学状态下 ,以实时目测法估测MR。结果　CPB前TEE检查纠正术前诊断 1例。CPB前MR(3 .4± 0 .5 )级 ,修复后残余MR(1.2± 1.0 )级 (P <0 .0 0 0 1)。 2例因残余MR 3级 ,再次转机行二尖瓣替换术。17例修复术患者出院前经胸超声心动图 (TTE)示残余MR与术中TEE残余反流量无显著性差异 [(0 .9± 0 .7)级vs (0 .9± 0 .8)级 ,P >0 .0 5 ]。后叶病变修复效果明显优于前叶。结论　TEE在二尖瓣修复术前后提供了较为可靠的二尖瓣结构和血流的信息 ,以指导手术治疗。实时目测法半定量评估MR是术中可靠且实用的方法     

Quantification of mitral valve stenosis by three-dimensional transesophageal echocardiography

The aim of this study was the evaluation of the diagnostic potentials of transesophageal 3D-echocardiography in the determination of mitral valve stenosis. 54 patients were investigated by transthoracic and multiplane transesophageal echocardiography. In 41 patients cardiac catheterization was performed. 3D-echocardiographic data acquisition was performed by automatic transducer rotation at 2° increments over a span of 180°. The transesophageal probe was linked to an ultrasound unit and to a 3D-workstation capable of ECG- and respiration gated data acquisition, postprocessing and 2D/ 3D image reconstruction. The mitral valve was visualized in sequential cross-sectional planes out of the 3D data set. The spatial position of the planes was indicated in a reference image. In the cross-sectional plane with the narrowest part of the leaflets the orifice area was measured by planimetry. For topographic information a 3D view down from the top of the left atrium was reconstructed. Measurements were compared to conventional transthoracic planimetry, to Doppler-echocardiographic pressure half time and to invasive data. The mean difference to transthoracic planimetry, pressure half time and to invasive measurements were 0.3 ± 0.1 cm², 0.2 ± 0.1 cm² and 0.1 ± 0.1 cm², respectively. Remarkable differences between the 3D- echocardiographic and the 2D- or Doppler- echocardiographic methods were observed in patients with severe calcification or aortic regurgitation. In 22% of the patients the 3D data set was not of diagnostic quality. New diagnostic information from a 3D view of the mitral valve could be obtained in 69% of the patients. Thus, although image quality is limited, 3D- echocardiography provides new topographic information in mitral valve stenosis. It allows the use of a new quantitative method, by which image plane positioning errors and flow-dependent calculation is avoided.     

Quantitative assessment of mechanical prosthetic valve area by 3-dimensional transesophageal echocardiography.

OBJECTIVE: The goal of this study was to assess the geometric orifice area of mechanical valve prostheses by transesophageal 3-dimensional echocardiographic planimetry. METHODS AND RESULTS: Currently used Doppler methods for prosthetic assessment (orifice area-Doppler) were compared with 3D planimetry for orifice area (orifice area-3D) and with manufacturer's values (orifice area-manufacturer) for the corresponding prosthesis types and sizes and with historical controls provided by Doppler literature (orifice area-literature). Twenty-four mechanical valve prostheses (in 22 patients) were studied: 13 in mitral position and 11 in aortic position. Orifice area-manufacturer, orifice area-Doppler, orifice area-literature, and orifice area-3D were 3.6 +/- 1.1 cm(2), 2.3 +/- 0.9 cm(2), 2.4 +/- 0.9 cm(2), and 2.6 +/- 0.7 cm(2), respectively. Orifice area-manufacturer values were significantly larger. Correlation coefficients between orifice area-3D and orifice area-manufacturer, and between orifice area-3D and orifice area-Doppler and orifice area-literature were 0.83, 0.90, and 0.73, respectively (all P < .0001). CONCLUSION: Three-dimensional transesophageal echocardiography is feasible and has good correlation with orifice area-Doppler (in aortic position) and good correlation with orifice area-manufacturer (in aortic and mitral positions) methods.     

术中经食管超声心动图在全机器人二尖瓣修复术中的作用

目的 探讨术中经食管超声心动图(TEE)在全机器人二尖瓣修复术(MVR)中的作用.方法 对24例因重度退行性二尖瓣反流(MR)行全机器人MVR的患者行术中TEE检查.应用TEE在体外循环(CPB)转机前明确MR病变原因及病变部位;建立外周CPB时,引导下、上腔静脉插管及升主动脉内心脏停搏液灌注针的置放;心脏复跳后.即刻评价有无残余MR及有无手术相关并发症.结果 以外科所见为标准,TEE诊断退行性MR病变原因及病变部位均有较高的准确性,分别为93.1%和98.6%;TEE引导下,所有患者下、上腔静脉插管及升主动脉内灌注针均放置于适当位置.TEE引导置管成功率为100%;TEE证实所有患者手术均获成功.无残余MR及手术相关并发症.结论 术中TEE在全机器人MVR术中必不可少.     

经食管超声心动图在急诊二次瓣膜置换术中的应用

目的 急诊二次瓣膜置换是挽救人工瓣膜功能急性障碍患的唯一方法，本探讨多平面经食管超声心动图(MTEE)在急诊二次瓣膜置换术中监测及疗效评价。方法 经胸超声心动图(TTE)分别诊断为二尖瓣位机械瓣环撕裂伴大量瓣周漏1例、主动脉瓣位人工机械瓣卡瓣1例患，在急诊二次换碍手术中，作用MTEE进行术前、术中及术后监测，总结MTEE特点及应用。结果 全麻后MTEE检查，1例为主动脉瓣位机械瓣急性狭窄伴关闭不全，CW估测跨主动脉瓣收缩期压差110mmHg，彩色多普勒血流显像(CDFI)示重度主动脉瓣反流，为人工金属主动脉瓣卡瓣51例为二尖瓣位机械瓣环与前叶根部见1．6cm的回声缺失，为人工金属二尖瓣撕裂伴大量瓣周漏。在二次瓣膜置换术、心脏复跳后进行MTEE检查，瓣膜功能良好后关闭胸腔。2例二次急诊瓣膜置换均成功。结论 与Tm比较，术前MTEE检查可更正确判断人工瓣膜功能急性障碍病变的性质和程度；闭胸前进行叮rEE检查可及时、正确判断瓣膜手术效果，不干扰手术视野、避免再次开胸。建议在急诊瓣膜置换术中，常规进行叮rEE监测，以确保疗效。     

Obstructed bi‐leaflet prosthetic mitral valve imaging with real‐time three‐dimensional transesophageal echocardiography

Real‐time three‐dimensional transesophageal echocardiography (RT3D‐TEE) can provide unique visualization and better understanding of the relationship among cardiac structures. Here, we report the case of an 85‐year‐old woman with an obstructed mitral prosthetic valve diagnosed promptly by RT3D‐TEE, which clearly showed a leaflet stuck in the closed position. The opening and closing angles of the valve leaflets measured by RT3D‐TEE were compatible with those measured by fluoroscopy. Moreover, RT3D‐TEE revealed, in the ring of the prosthetic valve, thrombi that were not visible on fluoroscopy. RT3D‐TEE might be a valuable diagnostic technique for prosthetic mitral valve thrombosis. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43 :64–67, 2015     

The vegetation that was not a vegetation: excusable misinterpretation of transesophageal echocardiography findings in late infective endocarditis of a prosthetic mitral valve.

The echocardiographic detection of a valvar mobile mass with independent mobility is one of the major Duke criteria for diagnosing infective endocarditis.(1) We report a case in which a mobile mass seen by transesophageal echocardiography on a prosthetic mitral valve with proven endocarditis was not a vegetation but pannus. This is an important clinical message for the interpretation of mobile masses on artificial valves.     

Intraoperative transesophageal echocardiography accurately predicts mitral valve anatomy and suitability for repair.

Mitral valve (MV) repair is the procedure of choice for MV prolapse or flail. However, valve repair is more technically demanding and requires a precise definition of MV morphology to determine the timing, complexity, and feasibility of repair. We prospectively examined 170 consecutive patients with MV prolapse or flail referred for MV repair. The MV valve was systematically assessed by intraoperative transesophageal echocardiography. MV anatomy was independently assessed at the time of operation. Accuracy of transesophageal echocardiography in identifying MV segments ranged from 90% to 97%, and was best for the middle segment/scallop of either anterior or posterior leaflet. MV repair was successful in 91% of patients. Success rate was the lowest (78%) in the presence of extensive bileaflet disease involving at least 2 segments of each leaflet. Independent predictors of unsuccessful repair were central jet of mitral regurgitation, calcification or severe dilatation of the mitral annulus, and extensive leaflet disease with involvement of at least 3 segments.     

经食管实时三维超声心动图检测二尖瓣对合指数的临床应用研究

目的应用经食管实时三维超声心动图对比分析正常与缺血性二尖瓣反流(IMR)患者二尖瓣对合指数,探讨二尖瓣对合指数的临床意义。方法慢性IMR患者11例与无瓣膜疾病且无瓣膜反流的正常对照组12例,均行经食管三维超声心动图检查,应用定量分析软件Qlab7.0对三维数据进行后处理分析。应用以下公式计算二尖瓣对合指数=〔(舒张早期二尖瓣面积-收缩末期二尖瓣面积)/舒张早期二尖瓣面积〕×100%。结果正常对照组二尖瓣对合指数(23.0±7.9)%。慢性IMR患者二尖瓣对合指数(12.6±6.9)%。慢性IMR患者二尖瓣对合指数明显小于正常对照组(P0.05)。结论三维定量分析软件Qlab7.0可以对经食管实时三维超声心动图三维数据进行定量分析得到二尖瓣对合指数。应用二尖瓣对合指数这一指标能够判定二尖瓣对合程度,揭示IMR的发生机制。     

经食管实时三维超声心动图在诊断二尖瓣脱垂中的价值

目的探讨经食管实时三维超声心动图(RT3D-TEE)诊断二尖瓣脱垂的价值。方法 20例二尖瓣脱垂患者于术前1周内行RT3D-TEE检查,判断瓣膜病变的类型、部位、病因,并与手术结果对照。结果 20例患者中18例RT3D-TEE检查发现的二尖瓣瓣膜及腱索的病变与术中探查相符,准确率为90%。瓣膜脱垂部位诊断符合率为90%,其中对于单发病变部位的准确性为100%。结论 RT3D-TEE能实时动态显示瓣膜病变类型、部位、程度,为手术方式、方案的设计提供重要信息。     

经食管实时三维超声心动图在二尖瓣病变中的应用价值

目的初步探讨经食管实时三维超声心动图（RT3D—TEE）在二尖瓣病变术前诊断、术中监测及术后评价中的临床应用价值。方法应用RT3D—TEE对31例二尖瓣病变患者进行术前、术中及术后检查,并与外科手术结果对比。结果RT3D—TEE清晰显示23例风湿性瓣膜病变患者的二尖瓣病变情况、累及瓣膜情况,并指导手术成功完成;准确显示7例二尖瓣脱垂患者的病变部位并量化病变情况;准确诊断1例二尖瓣人工机械瓣置换术后再狭窄患者的病因。31例患者均获得满意的RT3D—TEE图像。结论RT3D—TEE能在二尖瓣病变术前、术中及术后提供真实准确的评价信息。     

实时三维经食管超声心动图在二尖瓣成形术中的应用价值

目的 初步探讨实时三维经食管超声心动图在二尖瓣成形术中的临床应用价值.方法 采用Philips IE33 超声诊断仪、X7-2t探头.应用实时三维经食管超声心动图对6例二尖瓣脱垂患者二尖瓣成形术前、术后进行评价,并与心外科手术结果对照.结果 实时三维经食管超声心动图能准确评价和真实显示二尖瓣脱垂的形态、部位、范围、空间关系及并发症,与心外科视野和手术结果一致,在二尖瓣成形术前的决策中起重要作用.结论 实时三维经食管超声心动图为二尖瓣成形术提供了快速而准确的评价手段.     

实时三维经食管超声心动图对二尖瓣脱垂的诊断价值

目的比较实时三维经食管超声心动图（RT-3D-TEE）与二维经胸超声心动图（2D-TTE）、二维经食管超声心动图（2D-TEE）对二尖瓣脱垂的诊断价值。 方法回顾性分析2018年1月至2020年12月于武汉亚洲心脏病医院因二尖瓣脱垂行外科手术治疗,并在术前进行了2D-TTE、2D-TEE和RT-3D-TEE的患者共370例。以术中诊断为“金标准”,计算3种检查方法对二尖瓣脱垂瓣叶定位、腱索及赘生物形成的诊断效能,对3种检查方法的敏感度、特异度及准确性进行比较,并采用Kappa检验分别对3种方法诊断结果与术中诊断结果的一致性进行分析。 结果370例患者中,术前2D-TTE诊断出二尖瓣脱垂361例,检出率97.5%;术前2D-TEE诊断368例,检出率99.4%;而RT-3D-TEE检出率达100%。RT-3D-TEE对瓣叶脱垂的分区定位的敏感度、特异度和准确性均高于2D-TTE（P均＜0.05）,对腱索断裂诊断的敏感度和准确性亦高于2D-TTE,差异有统计学意义（P均＜0.05）,且RT-3D-TEE对脱垂分区定位的准确性高于2D-TEE（P均＜0.05）。一致性分析结果显示,RT-3D-TEE各项指标与术中诊断均具有良好的一致性（Kappa值均＞0.75,P均＜0.05）。 结论RT-3D-TEE较2D-TTE、2D-TEE对二尖瓣脱垂区域的定位及相关病变的识别更准确,可为手术医师提供更为直观、精准的影像信息,帮助制定个性化治疗方案。     

Heparin-triggered release of camouflaged tissue plasminogen activator for targeted thrombolysis

A targetable, heparin-triggered release system for tissue plasminogen activator (tPA) was designed to prevent the excessive ‘lytic’ state associated with the current tPA therapy for acute thrombotic conditions, such as myocardial infarction (MI). The strategy is, upon target accumulation, to trigger tPA release from a prodrug construct by a usual heparin dose. A relatively inactive form of tPA was constructed by conjugating tPA with low-molecular weight heparin followed by complexation with albumin-protamine conjugate, termed ‘camouflage’. The modified tPA was ~ 97% as active as native tPA. The prodrug construct of tPA significantly masked the enzymatic activity, which was fully recovered upon heparin addition. The camouflaged tPA was stable in human blood for at least 30 min and was able to trigger enzyme activation in vitro at heparin level of 0.4 U/mL. In vivo studies on jugular vein rat thrombosis model showed that the clot lysis of the heparin-triggered camouflaged tPA group was equivalent to the tPA + heparin group without prolongation of activated partial thromboplastin time (aPTT) before and after the treatment. This proof-of-principle study suggests that the activity of the tPA prodrug construct can be triggered at the thrombus site at therapeutic heparin concentration conjunctively used for MI with reduced bleeding risk.     

Successful thrombolysis of a partially obstructed bileaflet prosthetic heart valve in the mitral position

We describe the case of a woman who presented with dyspnea of abrupt onset and who had recently undergone replacement of the mitral valve with a bileaflet mechanical prosthesis. Transthoracic echocardiographic examination with spectral Doppler recording of transvalvular blood flow revealed a velocity spectrum consistent with obstruction. Transesophageal echocardiography demonstrated partial obstruction of the prosthetic valve due to immobilization of 1 hemidisc in the closed position. This immobilization was apparently caused by a small mass whose appearance was consistent with that of a thrombus. The patient was successfully treated by intravenous administration of a thrombolytic agent. This case demonstrates the value of transesophageal echocardiography in the selection of candidates for thrombolytic treatment in cases of thrombosis of a left-sided valve prosthesis.