The present study shows that transesophageal echoin mitral valve endocarditis. In 2 of our patients, transesophageal echocardiography was unable to properly visu- cardiography is an important complementary technique in the study of aortic valve disease with some advantages alize the aortic valve. In all of these patients, a mitral over precordial echocardiography. It is particularly use prosthesis was present. Therefore, an important limitation in visualizing the aortic valve with transesophageal ful in the visualization of the posterior aspect of the aortic echocardiography is the presence of a concomitant pros- valve, annulus and root, and should be performed any thetic mitral valve. One must conclude that transesopha- time a periannular abscessor perivalvular leak is suspectgeal and transthoracic echocardiography are comple- ed. In addition, some patients were managed based on mentary and not exclusive in the study of aortic valve transesophageal findings only, without bemg subject to disease. The recent introduction of biplane probes with the extra risk and cost of cardiac catheterization. Howthe ability to obtain 2 perpendicular scan planes may ever, the present study also shows some limitations of increase the diagnostic yield of transesophageal echocar- transesophageal echocardiography, especially the presdiography in the study of the aortic valve. Further studies ence of concomitant mitral prostheses, owing to the shadare necessary using this approach. owing of the left ventricular outflow tract and the valve In the setting of infective endocarditis, Taams et al2 itself. Transesophageal echocardiography is indicated recently showed that transesophageal echocardiography when transthoracic echocardiography does not provide is superior to the precordial approach. In their study, adequate information; both should be considered compleprecordial echocardiography did not show vegetations in mentary techniques in the evaluation of aortic valve disany of 12 patients with prosthetic valve endocarditis (in- ease. cluding 10 patients with prosthetic valves in the aortic position), whereas transesophageal echocardiography showed vegetation in 4. They concluded that transesoph1. Nellemen U, Schnittger I. Appleton CP, Masuyama T, Bolger AF, Fischell ageal echocardiography is the best diagnostic approach TA, Tye T, Popp RL. Tramesophageal twodimensional echocardiography and when infective endocarditis is suspected in patients with color Doppler flow velocity mapping in the evaluation of cardiac valve prostheses. Circulation 1988;78:848-855. either native or prosthetic valves. 2. Taams MA, Gussenhoven El, Bos B, de Jaegere P, Rcelandt JRTC, SutherThe present study is a retrospective analysis; there land GR, Born N. Enhanced morphological diagnosis in infective endocarditis by fore, some minor clinical information may have been tramesophageal echocardiography. Er Heart J 1990;63:109-113. 3. Beward JB, Khanderia BK, Oh JK, Abel MD, Hughes RW, Edwards WD, overlooked in some patients. In addition, surgery was Nichols BA, Freeman WK, Tajik AJ. Tramesophageal echocardiography: techperformed in only 13 patients, although relevant clinical nique, anatomic correlation, implementation and clinical applications. Mayo Ch follow-up was accomplished in all. Transthoracic studies Pnx 1988;63:649-680. Gussenhoven EJ, van Herwerden LA, Roelandt J, Bcs E, de Jong N. Detailed were performed before transesophageal ones; thus, the 4.analysis of aortic valve endocarditisz comparison of precordiil, esophageal and patient cohort is necessarily biased, because patients were epicardial two-dimensional echocardiography with surgical findings. J Clin Ulrraselected based on the transthoracic results. However, in sound 1986;14:209-211. Polak PE, Gussenhoven WJ. Roelandt JR. Tramesophageal cross-sectional routine cliical practice, transthoracic studies always pre- 1.echocardiographic recognition of an aortic valve ring abscess and a subannular cede transesophageal echocardiography and should be mymtic aneurysm. Eur Hear1 J 1987;8:664-666. Dittrich HC, McCann HA, Walsh TP, Blanchard DG, Oppcnheim GE, seen as complementary. The use of singleplane probes is 6.Waack TC, DonagheyLB, WheelerK. Tramesophagealechocardiographyin the also a limitation. Further studies using bi- or omniplane evaluation of prosthetic and native aortic valves. Am J Cardiol 1990;66:758-761. probes may enhance our ability to diagnose aortic valve 7. Daniel WG, Miigge A, Martin RP, Lindert 0, Hauamann D, Nonnast-Daniel B, Laas J, Lichtlen PR. Improvement in the diagnosis of abscesses associated with abnormalities, particularly in patients with concomitant endocarditis by tramesophageal echocardiography. N Eng/ J A4ed 1991;324: mitral valve prosthesis. 795-800.
Localization of Mitral Periprosthetic Leaks by Transesophageal Echocardiography Luigi Meloni, MD, Giorgio M. Aru, MD, Pietro A. Abbruzzese, MD, Gabriele Cardu, MD, Valentino Martelli, MD, and Angelo Cherchi, MD visualization of mitral regurgitant jets, and 0from theptimal absence of acoustic shadowing in the left atrium prosthetic material account for the increasing use of transesophageal echocardiography (TEE) in evaluating mitral prostheses in the outpatient clinic,1-3 as well as in the operative room.3-5 This study was undertaken to evalFrom the Istituto di CardioIogia, Univeraita’ di Cagliari, and the Divisione di Cardiochirurgia, Ospedale San Michele, Cagliiri, Italy. Dr. Meloni’s address is: Istituto di Cardiologla, Universita’ degli Studi, Via San Giorgio 12,09124 Cagliari, Italy. Manuscript received Janwry 25, 1991; revised manuscript received and accepted September 17,199l.
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uate the accuracy of TEE in predicting the surgical location of mitral periprosthetic leakage. From November 1988 to December 1990,d patients (3 men and 3 women, aged 46 to 67 years, mean age 56) were studied with TEE for mitral valve prosthesis dehiscence (Carpentier-Edwards, n = 2; Bjork-Shiley, n = 2; Starr-Edwards, n = I; Medtronic-Hall, n = I) (Table I). Five of these patients were referred to our institution for newly developed mitral regurgitant murmurs, as well asfor signs and symptoms of congestive heart failure. At the time of the study, the prosthetic valves were in place from 4 months to 14 years (mean 85 months). TEE was JANUARY
15. 1992
performed on awake patients to contrm a previous diagnosis obtained by transthoracic echocardiography (2 cases), or because of technically inadequate transthoracic imaging (3). In 1 of the Spatients (no. 5), endocarditic vegetation was demonstrated at the valve sewing ring by 2-dimensional TEE, but not by 2-dimensional transthoTABLE
I Location
of Mitral
qrosthetic
Dehiscence
racic echocardiography. Cardiac catheterization was performed in all patients but I and confirmed the diagnosis of periprosthetic leak. In the remaining patient (no. 6), the periprosthetic leak was discovered by routine intraoperative TEE immediately after mitral valve replacement with a Med-
by Transesophageal
Echocardiography Dehiscence
Pt.
Age (yr) & Sex
NYHA Class
1 2 3 4
57F 64M 49M 6OF
5 6
6OF 53M
Ill IV IV Ill IV III
Prosthesis (type) Carpentier-Edwards Starr-Edwards Bjork-Shiley Bjork-Shiley Carpentier-Edwards Medtronic-Hall
TEE-2D (quadrant) Posterior Anterior, medial Medial, posterior Posterior -
and During
Surgery
in Six Patients
Location
TEE-CFI (quadrant) Medial, posterior Lateral Anterior, medial Medial, posterior Posterior Lateral
Operative Procedure
Surgery 2-5 6-9 9-l
o’clock o’clock o’clock 2-5 o’clock 3-5 o’clock 7 o’clock
Valve rereplacement Leak closure Valve rereplacement Leak closure Valve rereplacement Leak closure
CFI = Doppler color flow imaging; NYHA = New York Heart Association; TEE = transesophageal echocardiography; 2D = Z-dimensional.
B
BRIEF
REPORTS
277
tronic-Hall prosthesis. This wasthe only case in which a periprosthetic leak was detected by intraoperative TEE in a series of 38 consecutive patients who had undergone surgery for mitral valve replacement. The prosthetic valve was replaced in 3 patients and resutured in the other 3. TEE with Doppler color flow imaging was performed with a Hewlett-Packard ultrasound system (Sonos 500 or 100) using a 5 MHz phased-array transducer (model 21362A). All TEE studies were well-tolerated, and no complications were observed. Visualization of the prosthetic mitral valves and regurgitant jlow was obtained in the 4- and j-chamber views with the transducer positioned behind the left atrium. Regurgitant jets were considered to be periprosthetic when they originated outside the valvular sewing ring. To clearly define the origtn and the spatial extension of the periprosthetic jets, the echocardiographic mitral annulus was divided in 4 conventional quadrants similar to those used in surgery (i.e., anterior, 9 to 12 o’clock; medial, I2 to 3; posterior, 3 to 6; lateral, 6 to 9)
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(Figure I). Beginning at the I-chamber view, each quadrant was carefully scanned by manipulating the probe up and down behind the left atrium. The location of the leak was considered medial or posterior, or both, when periprosthetic jetsjlowed along the interatrial septum or the
JANUARY
15. 1992
free wall of the left atrium, or both, respectively, in the 4chamber view. The location of the leak was considered anterior or lateral, or both, when periprosthetic jets flowed along the aortic root or free wall of the lef atrium, or both, respectively, in the j-chamber view. Table I lists the clinical characteristics of the patients, and the location of the mitral prosthetic dehiscence identified by TEE and during surgery. Representative echocardiograms are shown in Figures 2 through 5. Compared with the transthoracic approach, TEE offers important advantages in evaluating patients with mitral valve prostheses.’ Because the probe is positioned behind the posterior wall of the left atrium, reverberations from the mitral prosthesis are projected into the left ventricle and do not mask the color flow imaging of the left atrium. In addition, the close proximity of the esophageal transducer to the left atrium, and the parallel orientation of the ultrasound beam to the flow moving away from the mitral valve provide high quality imaging of the atria1 side of the prosthesis, as well as of the regurgitant flow into the left atrium. In this study, all the mitral periprosthetic jets exhibited multicolored mosaic patterns corresponding to high velocity and turbulent flows, tilling large areas of the left atrium. In addition, TEE with Doppler color flow imaging was more sensitive than 2dimensional TEE alone in detecting periprosthetic leaks. In fact, periprosthetic jets were present without any visible gap related to valve dehiscence in 2 patients. The mitral annulus was conventionally subdivided in 4 quadrants to establish common reference points for the cardiologist and the surgeon. Although the landmarks used by the cardiologist in defining each quadrant differ slightly from those used by the surgeon, there was always a strict correspondence between the quadrants indicated by TEE and those visualized by the surgeon. Our findings demonstrate that in all 6 patients localization of the mitral periprosthetic jets correlated precisely with the fmdings at surgery. Therefore, the search for a dehiscence with a probe is unnecessary and, furthermore, potentially dangerous in a weak annulus. With the information ob tained by TEE, the surgeon can now direct his attention to a well-defined portion of the suture line. Aekno~ We thank Achi Ludomirsky, MD, for helpful comments, and Jan S. Radakovich, MS, Ed, for assistance in editing the manuscript.
1. van den Brink RBA, Visser CA, Basart DCG, Duren DR. de Jong AP, Dunning AJ. Comparison of transthoracic and tramesophageal color Doppler flow imaging in patients with mechanical prostheses in the mitral valve position. Am J Cardiol 1989;63:1471-1474. 2. Taams MA, Gussenhoven EJ, Cahalan MK, Roelandt JRTC, van Herwerden
LA, The HK, Born N, de Jong N. Tramesophageal Doppler color flow imaging in the detection of native and Bjork-Shiley mitral valve regurgitation. J Am Co/l Cardiol 1989;13:95-99. 3. Alam M, Serwin JB, Rosman HS, Sheth M, Sun I, Silverman NA, Goldstein S. Tramesophageal color flow Doppler and echocardiographic features of normal and regurgitant St. Jude Medical prostheses in the mitral position. Am J Cardiol 1990;66:871-873. 4. Sheikh KH, de Bruijn NP, Rankin JS, Clements FM, Stanley T, Wolfe WG, Kisslo J. The utility of tramesophageal echocardiography and Doppler flow imaging in patients undergoing cardiac valve surgery. J Am Coil Cardiol 1990,15: 363-372. 5. Abhruz.zese P, Meloni L, Nap&one A, Cardu G, Cherchi A, Martelli V. lntraoperative transcsophageal echocardiography and periprosthetic leak. J Thorac Cardiooasc Surg 1991;101:556-557.
BRIEF REPORTS 279
Localization of Mitral Periprosthetic Leaks by Transesophageal Echocardiography Luigi Meloni, MD, Giorgio M. Aru, MD, Pietro A. Abbruzzese, MD, Gabriele Cardu, MD, Valentino Martelli, MD, and Angelo Cherchi, MD visualization of mitral regurgitant jets, and 0from theptimal absence of acoustic shadowing in the left atrium prosthetic material account for the increasing use of transesophageal echocardiography (TEE) in evaluating mitral prostheses in the outpatient clinic,1-3 as well as in the operative room.3-5 This study was undertaken to evalFrom the Istituto di CardioIogia, Univeraita’ di Cagliari, and the Divisione di Cardiochirurgia, Ospedale San Michele, Cagliiri, Italy. Dr. Meloni’s address is: Istituto di Cardiologla, Universita’ degli Studi, Via San Giorgio 12,09124 Cagliari, Italy. Manuscript received Janwry 25, 1991; revised manuscript received and accepted September 17,199l.
276
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
69
uate the accuracy of TEE in predicting the surgical location of mitral periprosthetic leakage. From November 1988 to December 1990,d patients (3 men and 3 women, aged 46 to 67 years, mean age 56) were studied with TEE for mitral valve prosthesis dehiscence (Carpentier-Edwards, n = 2; Bjork-Shiley, n = 2; Starr-Edwards, n = I; Medtronic-Hall, n = I) (Table I). Five of these patients were referred to our institution for newly developed mitral regurgitant murmurs, as well asfor signs and symptoms of congestive heart failure. At the time of the study, the prosthetic valves were in place from 4 months to 14 years (mean 85 months). TEE was JANUARY
15. 1992
performed on awake patients to contrm a previous diagnosis obtained by transthoracic echocardiography (2 cases), or because of technically inadequate transthoracic imaging (3). In 1 of the Spatients (no. 5), endocarditic vegetation was demonstrated at the valve sewing ring by 2-dimensional TEE, but not by 2-dimensional transthoTABLE
I Location
of Mitral
qrosthetic
Dehiscence
racic echocardiography. Cardiac catheterization was performed in all patients but I and confirmed the diagnosis of periprosthetic leak. In the remaining patient (no. 6), the periprosthetic leak was discovered by routine intraoperative TEE immediately after mitral valve replacement with a Med-
by Transesophageal
Echocardiography Dehiscence
Pt.
Age (yr) & Sex
NYHA Class
1 2 3 4
57F 64M 49M 6OF
5 6
6OF 53M
Ill IV IV Ill IV III
Prosthesis (type) Carpentier-Edwards Starr-Edwards Bjork-Shiley Bjork-Shiley Carpentier-Edwards Medtronic-Hall
TEE-2D (quadrant) Posterior Anterior, medial Medial, posterior Posterior -
and During
Surgery
in Six Patients
Location
TEE-CFI (quadrant) Medial, posterior Lateral Anterior, medial Medial, posterior Posterior Lateral
Operative Procedure
Surgery 2-5 6-9 9-l
o’clock o’clock o’clock 2-5 o’clock 3-5 o’clock 7 o’clock
Valve rereplacement Leak closure Valve rereplacement Leak closure Valve rereplacement Leak closure
CFI = Doppler color flow imaging; NYHA = New York Heart Association; TEE = transesophageal echocardiography; 2D = Z-dimensional.
B
BRIEF
REPORTS
277
tronic-Hall prosthesis. This wasthe only case in which a periprosthetic leak was detected by intraoperative TEE in a series of 38 consecutive patients who had undergone surgery for mitral valve replacement. The prosthetic valve was replaced in 3 patients and resutured in the other 3. TEE with Doppler color flow imaging was performed with a Hewlett-Packard ultrasound system (Sonos 500 or 100) using a 5 MHz phased-array transducer (model 21362A). All TEE studies were well-tolerated, and no complications were observed. Visualization of the prosthetic mitral valves and regurgitant jlow was obtained in the 4- and j-chamber views with the transducer positioned behind the left atrium. Regurgitant jets were considered to be periprosthetic when they originated outside the valvular sewing ring. To clearly define the origtn and the spatial extension of the periprosthetic jets, the echocardiographic mitral annulus was divided in 4 conventional quadrants similar to those used in surgery (i.e., anterior, 9 to 12 o’clock; medial, I2 to 3; posterior, 3 to 6; lateral, 6 to 9)
278
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
69
(Figure I). Beginning at the I-chamber view, each quadrant was carefully scanned by manipulating the probe up and down behind the left atrium. The location of the leak was considered medial or posterior, or both, when periprosthetic jetsjlowed along the interatrial septum or the
JANUARY
15. 1992
free wall of the left atrium, or both, respectively, in the 4chamber view. The location of the leak was considered anterior or lateral, or both, when periprosthetic jets flowed along the aortic root or free wall of the lef atrium, or both, respectively, in the j-chamber view. Table I lists the clinical characteristics of the patients, and the location of the mitral prosthetic dehiscence identified by TEE and during surgery. Representative echocardiograms are shown in Figures 2 through 5. Compared with the transthoracic approach, TEE offers important advantages in evaluating patients with mitral valve prostheses.’ Because the probe is positioned behind the posterior wall of the left atrium, reverberations from the mitral prosthesis are projected into the left ventricle and do not mask the color flow imaging of the left atrium. In addition, the close proximity of the esophageal transducer to the left atrium, and the parallel orientation of the ultrasound beam to the flow moving away from the mitral valve provide high quality imaging of the atria1 side of the prosthesis, as well as of the regurgitant flow into the left atrium. In this study, all the mitral periprosthetic jets exhibited multicolored mosaic patterns corresponding to high velocity and turbulent flows, tilling large areas of the left atrium. In addition, TEE with Doppler color flow imaging was more sensitive than 2dimensional TEE alone in detecting periprosthetic leaks. In fact, periprosthetic jets were present without any visible gap related to valve dehiscence in 2 patients. The mitral annulus was conventionally subdivided in 4 quadrants to establish common reference points for the cardiologist and the surgeon. Although the landmarks used by the cardiologist in defining each quadrant differ slightly from those used by the surgeon, there was always a strict correspondence between the quadrants indicated by TEE and those visualized by the surgeon. Our findings demonstrate that in all 6 patients localization of the mitral periprosthetic jets correlated precisely with the fmdings at surgery. Therefore, the search for a dehiscence with a probe is unnecessary and, furthermore, potentially dangerous in a weak annulus. With the information ob tained by TEE, the surgeon can now direct his attention to a well-defined portion of the suture line. Aekno~ We thank Achi Ludomirsky, MD, for helpful comments, and Jan S. Radakovich, MS, Ed, for assistance in editing the manuscript.
1. van den Brink RBA, Visser CA, Basart DCG, Duren DR. de Jong AP, Dunning AJ. Comparison of transthoracic and tramesophageal color Doppler flow imaging in patients with mechanical prostheses in the mitral valve position. Am J Cardiol 1989;63:1471-1474. 2. Taams MA, Gussenhoven EJ, Cahalan MK, Roelandt JRTC, van Herwerden
LA, The HK, Born N, de Jong N. Tramesophageal Doppler color flow imaging in the detection of native and Bjork-Shiley mitral valve regurgitation. J Am Co/l Cardiol 1989;13:95-99. 3. Alam M, Serwin JB, Rosman HS, Sheth M, Sun I, Silverman NA, Goldstein S. Tramesophageal color flow Doppler and echocardiographic features of normal and regurgitant St. Jude Medical prostheses in the mitral position. Am J Cardiol 1990;66:871-873. 4. Sheikh KH, de Bruijn NP, Rankin JS, Clements FM, Stanley T, Wolfe WG, Kisslo J. The utility of tramesophageal echocardiography and Doppler flow imaging in patients undergoing cardiac valve surgery. J Am Coil Cardiol 1990,15: 363-372. 5. Abhruz.zese P, Meloni L, Nap&one A, Cardu G, Cherchi A, Martelli V. lntraoperative transcsophageal echocardiography and periprosthetic leak. J Thorac Cardiooasc Surg 1991;101:556-557.
BRIEF REPORTS 279
