Spontaneous drainage of paravalvular abscess diagnosed by transesophageal echocardiography

Paravalvular abscesses, which occur in up to 30% of cases of native valve endocarditis, are being detected with increasing frequency with the use of transesophageal echocardiography. Abscesses of the mitral aortic intervalvular fibrosa have been described but only in association with native or prosthetic aortic valve endocarditis. We describe a patient with native mitral valve endocarditis complicated by an abscess in the fibrosa. A 51-year-old diabetic man presented with Staphylococcus aureus mitral valve endocarditis. A transesophageal echocardiographic study done 8 days after admission revealed two large masses at the base of the anterior mitral leaflet with extension into the fibrosa consistent with a paravalvular abscess that was not detected by precordial echocardiography. A repeat transesophageal echocardiographic study done 20 days after admission showed spontaneous drainage of the abscess and a subsequent fistula between the left atrium and left ventricle. This case highlights the important role that transesophageal echocardiography has in suspected and known cases of endocarditis. Its major advantage of delineating posterior cardiac structures allowed accurate diagnosis and serial evaluation of this previously unreported complication of endocarditis.     

Anomalous origin of the left coronary artery from the pulmonary artery accompanied by mitral valve prolapse and regurgitation: Surgical implication of dobutamine stress echocardiography.

A young woman with bileaflet mitral valve prolapse and anomalous left coronary artery arising from the pulmonary artery, accompanied by significant mitral regurgitation (MR), underwent dobutamine stress echocardiography to assess the effect of anomalous left coronary artery arising from the pulmonary artery on MR severity. On the basis of the dobutamine stress echocardiography-induced ischemia, which exacerbated the degree of MR, a revascularization operation sparing the mitral valve was performed, resulting in significant improvement of the MR. We suggest that dobutamine stress echocardiography could be used to assess the relative contribution of each syndrome to the pathophysiology of MR, directing the surgical procedure.     

Severe intermittent intraprosthetic regurgitation after mitral valve replacement with subvalvular preservation.

Preservation of the subvalvular apparatus during mitral valve replacement preserves left ventricular function and improves long-term survival. Complications of subvalvular preservation include left ventricular outflow tract obstruction and prosthesis impingement. We report a case of severe intermittent intraprosthetic mitral regurgitation detected by transesophageal echocardiography after mitral valve replacement by a bileaflet mechanical prosthesis with subvalvular preservation. Intravalvular prosthetic valve regurgitation was caused by remnants of the subvalvular apparatus, which were shown at reoperation to interfere with prosthetic leaflet motion and which were excised. Postoperative transesophageal echocardiography showed neither abnormal mitral regurgitation nor residual mass. The use of intraoperative transesophageal echocardiography could enable the detection of this rare complication.     

Accessory mitral valve in an adult population: the role of echocardiography in diagnosis and management.

Accessory mitral valve is a rare congenital abnormality and is an unusual cause for subvalvular left ventricular outflow tract (LVOT) obstruction. It is detected first in children and is very rarely noticed in adults. The most common clinical presentation is symptomatic LVOT obstruction. We present a case series of 5 adult patients with varying clinical presentations in which the accessory mitral valve was diagnosed using echocardiography. Three patients presented with varying degrees of symptomatic LVOT obstruction, one presented with recurrent transient ischemic attack and stroke, and one patient was incidentally diagnosed during echocardiography to exclude endocarditis. Accessory mitral valve should be suggested in patients with LVOT obstruction.     

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.     

The Mitral Valve by Three-Dimensional Echocardiography

A comprehensive evaluation of patients with mitral valve disease must include an echocardiographic examination of the mitral valve apparatus and resultant hemodynamic changes due to mitral pathology. Three-dimensional echocardiography has impacted on the diagnosis of mitral valve prolapse but has mostly existed in a research realm. After decades of development, three-dimensional echocardiography is now easily performed and readily incorporated in the assessment of mitral valve disease in daily clinical practice. Unique anatomic views of the mitral valve, accurate quantitative assessment of the mitral valve orifice area, and delineation of segmental prolapse are several advantages of three-dimensional echocardiography. Moreover, there is a wealth of data that can be derived from a three-dimensional volume, enabling more detailed analysis of mitral valve apparatus and valve annular dynamics. This review highlights current applications of three-dimensional echocardiography in the routine evaluation of mitral valve disease.     

Myxoma of the mitral valve: diagnosis by 2-dimensional and 3-dimensional echocardiography.

In this report we describe a 39-year-old patient who had left-sided hemiparesis. In search of a source of embolism, we performed transthoracic echocardiography, which did not show any abnormalities. Transesophageal echocardiography revealed a small tumor of the posterior mitral leaflet. Three-dimensional transesophageal echocardiography was subsequently performed and demonstrated more accurate information about the size, the morphology, and the attachment point of the tumor. Furthermore, the reconstruction provided excellent spatial visualization of the pathomorphology of the mitral valve and was a useful addition for optimal preoperative diagnostic management. The tumor was excised, and histologic examination confirmed the myxomatous character of the tumor. Mitral valve myxomas are rare. This is the first case reported of a mitral valve myxoma being visualized by 3D echocardiography.     

Intraoperative transesophageal echocardiographic assessment of acute prosthetic aortic valve regurgitation after mitral valve replacement: Value of the deep transgastric long-axis view

The transesophageal echocardiographic assessment of prosthetic aortic valve function is made more difficult by the presence of a mechanical mitral valve prosthesis because echocardiographic views conventionally used to assess the aortic valve function are obscured by acoustic shadowing and artifacts. We report the use of intraoperative transesophageal echocardiography in a patient who developed severe prosthetic aortic valve regurgitation after implantation of a mechanical mitral valve, in whom conventional multiplane midesophageal views failed to reveal aortic regurgitation owing to acoustic shadowing and artifacts from the prosthetic mitral valve. We report the value of the deep transgastric long-axis view of the aortic valve that provided an unobstructed view of the left-ventricular outflow tract, and clearly demonstrated severe aortic regurgitation as a result of interference with the prosthetic aortic valve mechanism by the implanted mitral valve prosthesis. This case also emphasizes the importance of a comprehensive intraoperative transesophageal examination, including that of surrounding structures, to detect iatrogenic complications during mitral valve replacement.     

彩色多普勒超声评价自制无支架带腱索生物二尖瓣功能

目的 评价自制无支架带腱索生物二尖瓣的临床应用效果。为无支架带腱索生物二尖瓣的推广应用提供理论依据。方法 用彩色多普勒超声心动图观察3例无支架带腱索生物二尖瓣替换术后心脏结构及血流动力学变化。结果 胸骨旁四腔心及左室短轴观极易观察到生物二尖瓣叶启闭运动，二尖瓣病变患者术后左房内径均较术前明显缩小，二尖瓣均无关闭不全‘；舒张期跨二尖瓣口峰值血流速度，平均血流速度，血流速度积分，峰值压差，平均压差和压力降半时间较术前明显改善，有效瓣口面积增加，但与自然瓣膜相比仍有差距。结论 无支架带腱索生物二尖瓣可维持人体二尖瓣生理功能，左室几何形状和血流动力学，彩色多普勒超声心动图在评价无支架带腱索生物二尖瓣替换术后的心脏结构和血流动力学方面有着较大的临床意义及实用价值。     

实时三维经食管超声心动图对二尖瓣成形术的指导意义

目的探讨实时三维经食管超声心动图（TEE）在二尖瓣脱垂患者外科手术治疗中对二尖瓣结构精细化诊断、成形环选择的意义及术后即刻疗效评估的价值。 方法选择2016年11月至2017年3月浙江大学附属第一医院经胸超声心动图诊断为二尖瓣脱垂,并进行外科手术治疗的19例患者。19例患者均在麻醉后体外循环之前行实时三维TEE检查。并在手术完成心脏复跳后即刻再次进行检查,实时显示并记录存储图像。整个检查过程中与外科医师、麻醉医师同时观察图像,直接交流并与术中所见相对照,以术中所见为标准。应用实时三维超声重建对19例中度以上二尖瓣脱垂患者进行检查测量,观察二尖瓣瓣膜与腱索,测量二尖瓣的瓣环、瓣膜长度及纤维三角的直径。 结果术中TEE检查可从任意角度清晰显示二尖瓣瓣膜、瓣环、腱索、乳头肌的解剖结构、运动情况。实时观察二尖瓣厚度、活动度、有无钙化及赘生物,腱索有无断裂,并能补充诊断有无血栓及卵圆孔未闭。本组19例患者TEE判断二尖瓣脱垂区域与术中基本一致,以后叶P2区最多见。检出病因：二尖瓣腱索断裂导致脱垂共15例,其中12例探查到2处腱索断裂,与术中一致,准确率100%。本组19例患者TEE测量后提供的成形环尺寸14例一致,准确率73.7%（4/9）,4例术中选择测瓣器size比TEE测值小一号,1例术中选择测瓣器size比TEE测值大一号。 结论应用实时三维超声重建可客观地反映二尖瓣脱垂的病因及病变情况,提供直观的立体图像,对制定手术方案具有重要参考价值。并能为选择成形环的大小提供依据,节约了手术时间,具有实际的临床指导意义。术后即刻评价自体成形瓣膜的功能,并实时了解室壁运动及左心室收缩功能,也可以监测左心气体,有助于麻醉医师术中监护,同时提高了手术的成功率。     

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。     

超声心动图在降落伞状二尖瓣畸形诊断中的应用价值

目的探讨超声心动图诊断降落伞状二尖瓣(PMV)的价值,并与术中结果进行对比分析.方法2002年1月-2005年6月应用常规经胸超声心动图(TTE)、经食管超声心动图(TEE)及经胸实时三维超声心动图(RT-3DE)诊断PMV共11例,进行回顾性分析,男7例,女4例,年龄1～64岁,平均21岁.结果超声诊断单纯PMV 3例(27.3%),合并其他心内畸形8例(72.7%).11例患者均有不同程度的二尖瓣狭窄,5例伴有二尖瓣反流.9例行手术治疗,术中所见和超声诊断一致,符合率100%.4例患者行二尖瓣置换术,1例行二尖瓣成形术,3例仅行室间隔修补术.结论常规TTE、TEE、RT-3DE均能诊断PMV,RT-3DE与传统的二维成像技术相比包含了更多的诊断信息,具有潜在的临床应用价值.     

二尖瓣腱索断裂的彩色多普勒超声心动图诊断

应用彩色多普勒超声心动图（ＣＤＥ）在已手术的６０１６例各种心血管疾病中检出５例二尖瓣腱索断裂（ＲＭＣＴ），ＣＤＥ诊断准确率１００％。本病的ＣＤＥ表现是两维超声心动图（２ＤＥ）显示腱索断裂的二尖瓣叶呈“枷样”或“甩鞭样”改变，彩色多普勒（ＣＤ）显示收缩期过二尖瓣五彩相间返流束血流信号。结果表明ＣＤＥ对本病有特异性诊断价值，可代替心血管造影检查。ＣＤＥ诊断本病需与二尖瓣脱垂（ＭＶＰ）和二尖瓣叶赘生物（ＭＶＶ）相鉴别。一旦确诊应及早手术治疗。     

Clinical and echocardiographic evaluation of mitral valve aneurysms: a retrospective,single center study

Mitral valve aneurysms (MVAs) are rarely encountered in echocardiography laboratories. Although they are commonly associated with endocarditis of the aortic valve, various mechanisms have been suggested for the etiopathogenesis of MVAs associated with non-infectious conditions. 5,887 patients who underwent transesophageal echocardiography (TEE) between 2007 and 2012 were evaluated retrospectively for MVA. Mitral valve aneurysm is defined as a localized saccular bulging of the mitral leaflet towards the left atrium with systolic expansion and diastolic collapse. The color flow Doppler image of a perforation was described as a high-velocity turbulent jet traversing a valve leaflet in systole. We found that 12 of 5,887 patients (0.204 %) had MVA in TEE examinations. The mean age of patients with MVA was 53 years (range 21–80 years), including four females and eight males. Nine patients presented with symptoms of endocarditis. On TEE, aneurysms were located in the anterior mitral leaflet in 11 patients, and in the posterior mitral leaflet in one patient. Eight patients had severe, three had moderate, and one had trace mitral regurgitation. Of the nine patients with perforated leaflets, eight patients had severe and one patient had moderate mitral regurgitation. Aortic regurgitation was present in nine patients, being severe in three, moderate in two, mild in two, and trace in two patients. Two patients without severe mitral regurgitation were followed-up conservatively, while nine patients underwent surgery. Two patients died from septic shock, one in the postoperative period and the other one prior to surgery. Although MVAs occur during the course of aortic valve endocarditis and, in particular, due to aortic regurgitation jet, it should be borne in mind that they may develop as an isolated valvular pathology and may be misdiagnosed as chordal rupture, other cardiac masses, or vegetation. Thus, MVAs may not be so infrequent as they are thought; they may justify to be considered in the differential diagnosis of masses seen on the mitral valve on echocardiographic examination.     

Mitral valve thrombus mimicking a primary tumor in the antiphospholipid syndrome.

Cardiac valvular abnormalities detected by echocardiography are relatively common in patients with the primary antiphospholipid syndrome. Valvular thickening with small vegetations are typical, but reports of lesion histology are rare. We report the case of a 50-year-old man presenting with thromboembolic phenomena who had a large (>2 cm), mobile, pedunculated, mass attached to the mitral valve that had the echocardiographic appearance of a primary valve tumor. Following surgical removal, histopathologic examination demonstrated pure fibrin thrombus and serological testing confirmed the antiphospholipid syndrome. This case highlights an unusual echocardiographic appearance of intracardiac thrombus in this syndrome.     

Nonbacterial thrombotic endocarditis demonstrated by repeat echocardiography

We report a case of nonbacterial thrombotic endocarditis (NBTE) in a patient with bladder cancer presenting with multiple cerebral infarctions. Initial transthoracic and transesophageal echocardiography did not show any abnormalities. However, repeat transthoracic and transesophageal echocardiography demonstrated a vegetation on the anterior leaflet of the mitral valve with mild mitral regurgitation and no evidence of leaflet destruction. Persistent high-grade fevers and leukocytosis were observed. The patient was suspected to have infective endocarditis. However, abdominal ultrasound and computed tomography scan revealed multiple metastatic masses, and serial blood cultures were negative. The patient was ultimately diagnosed with NBTE associated with multiple metastases of bladder cancer. This case suggests that even if echocardiography does not initially demonstrate any abnormalities in patients with embolism, it must be repeated at the recurrence of embolism, and that even if clinical signs of infection are documented, NBTE should be suspected in any cancer patient with thromboembolic events.     

Acquired right atrial blood cyst: a hitherto unrecognized complication of cardiac operation.

Blood-filled cysts within the heart are rare anomalies, usually congenital, and are seen predominately in infants. We report an unusual case of a 68-year-old woman with an acquired right atrial blood-filled cyst that developed after mitral and tricuspid valve operation and that was detected using 2-dimensional echocardiography. We propose that surgical trauma resulted in the formation of the cyst.     

Right upper lobe pulmonary edema after mitral valve replacement caused by paravalvular leakage recognized by bedside transesophageal echocardiography

OBJECTIVE: To describe an unusual case of right upper lobe pulmonary edema caused by acute paravalvular leakage that was identified by the use of bedside transesophageal echocardiography. DESIGN: Case report. SETTING: University-affiliated hospital. PATIENT: A 59-yr-old male patient underwent prosthetic mitral valve replacement (St. Jude valve) for severe mitral regurgitation and developed sudden onset of dyspnea and change in consciousness with blood pressure decreased to 70/30 mm Hg. Elevation of central venous pressure and images of transthoracic echocardiography led to the diagnosis of cardiac tamponade. CONCLUSION: Acute paravalvular leakage after mitral valvular replacement should be considered as one of the differential diagnoses for unilateral pulmonary edema. Physical findings of a holosystolic murmur and findings from bedside transesophageal echocardiography can confirm the diagnosis, avoiding delay in management.     

术中经食管彩色多普勒超声心动图实时评价二尖瓣成形术

本文报告用经食管彩色多普勒超声监测二尖瓣成形术ｌｌ例。１０例二尖瓣术前返流为４级或３级者，术后均降为０～１级；另一例成形术后发生严重狭窄，及时改作瓣膜替换术。作者认为本技术准确可靠，对二尖瓣成形术有指导意义。     

An unusual cause of diastolic mitral regurgitation as a result of sterile perforation of the mitral valve.

We report the case of a 50-year-old man in whom a supracristal ventricular septal defect led to aortic regurgitation and, thus, to consecutive sterile perforation of the anterior mitral leaflet, culminating in the development of severe systolic and diastolic mitral regurgitation. Aortic regurgitation as a result of valve prolapse caused by a supracristal (conal) ventricular septal defect is a well-known phenomenon. The same is true for the origin of mitral jet lesions in patients with infective endocarditis of the aortic valve. As of yet, there have been no reports about the acquisition of mitral valve perforations in patients without the history of vegetations. Moreover, the occurrence of diastolic mitral regurgitation is usually associated with atrioventricular pressure reversal, a phenomenon that was not present in our patient. The unique comorbidity was easy to detect with Doppler echocardiography, supported by transesophageal 2-dimensional and dynamic 3-dimensional echocardiography for preoperative surgical treatment.