3Dechocardiography
the art of defining cardiac morphology

Assessing Paravalve leak by 3D Echocardiography: transcatheter interventions

Imaging is the corner stone of cardiac interventions. The main objective of imaging is to identify the following aspect

  • Severity of the paravalve leak, its anatomic location, size and dimensions.
  • Course and extent of the lesion with clear delineation of the exit and entrance points.
  • Proximity of the leak to vital structures and assessment of possible impact of intervention on these structures.
  • Predict suitability for device closure, suggest appropriate device and guide through the intervention, while evaluating for any potential complications.

The following specific aspects are looked for in dealing with Aortic para prosthetic leak

  • Length of the track,Proximity to the coronaries and conduction tissue
  • It is also important to differentiate paravalve leak from fistulous openings

Mitral paravalve leaks are usually multiple due to friability of the valve tissue. There is an increased risk of haemolysis. Often the access to intervention is done through trans-septal approach which can be aided by 3D TOE. In complex cases and lesions which are medialy located, a trans-apical approach (hybrid) is more appropriate.

Tricuspid paraprosthetic leak is uncommon, as the need for intervention in a low pressure chamber is often not necessary. When there is a need for prosthetic valve insersion, the access to the tricuspid valve and visualization for surgical procedure is direct and para prosthetic leak is extremely uncommon. Even when paravalve leak ocures unless there is significant haemodynamic insufficiency need for intervention is infrequent.

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2D colour images showing mitral para-prosthetic leak

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3D assessment: zoom mode is used for evaluating the para-valve leak. For the purpose of standardised description of the defects, the display is reformated in such a way that the aorta is at the 12'O clock poistion and the left atrial appendage is in the 9'O clock position as illustrated in the image above and below..

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The 3D imade of para-valve leak: Demonstrating the fallacy of measuring in 3D plane due to parallax error.

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Illustration of colour 3D MPR for accurate measurement of paravalve leak

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Severe paravalve leak in a symptomatic patient with partially dehesed prosthetic valve unsuitable for trans-catheter intervention. When surgical replacement is called for, the 3D visualization may not add much towards an emergency intervention.

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Paraprosthetic leak adjacent to a tissue mitral prosthesis

A trifoliate tissue mitral valve prosthesis in a 65 year old with para valve leak.

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The 3D images are visualized in anatomic planes with Left atrial appendage (LAA) at 9 O' clock position and Aorta at 12 O'clock position. The image is then rotated to view from the LV aspect. The gain is reduced to reveal the para prosthetic leak. Quantification regurgitant orifice is better assessed by colour 3D MPR as shown below.

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