Picture Of A Leaky Valve On Peds Echo

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Fig. 38. A 72-yr-old man 2 wk after coronary artery bypass graft mitral valve repair, left ventricle aneurysm resection.

Panus Mitral

Fig. 39. Prosthetic mitral valve: paravalvular leak. Prosthetic mitral valve dysfunction leading to prosthetic mitral regurgitation can occur secondary to thrombus formation or pannus ingrowth that can interfere with normal valve closure. This is most often seen with mechanical valves compared to bioprosthetic valves. The most common type of regurgitation following mitral valve replacement is owing to a paravalvular leak which occurs outside the sewing ring. The nature and severity of the paravalular regurgitation can be detected on transthoracic echocardiography, but transesophageal echocardiography is necessary to map the extent of the dehiscence, which may be crescent-shaped and guide surgical repair. (Please see companion DVD for corresponding video.)

Fig. 39. Prosthetic mitral valve: paravalvular leak. Prosthetic mitral valve dysfunction leading to prosthetic mitral regurgitation can occur secondary to thrombus formation or pannus ingrowth that can interfere with normal valve closure. This is most often seen with mechanical valves compared to bioprosthetic valves. The most common type of regurgitation following mitral valve replacement is owing to a paravalvular leak which occurs outside the sewing ring. The nature and severity of the paravalular regurgitation can be detected on transthoracic echocardiography, but transesophageal echocardiography is necessary to map the extent of the dehiscence, which may be crescent-shaped and guide surgical repair. (Please see companion DVD for corresponding video.)

Mitral Valve Ring Leak

Fig. 40. Prosthetic mitral valve: normal signature regurgitation. Midesophageal two-chamber view showing St. Jude bileaflet prosthesis during systole at omniplane 80°. Normal leaflet appearance in closed position (arrows, A) with normal acoustic shadow pattern and reverber-tion seen within left ventricular cavity. St. Jude valve with leaflets in open position is show in insert A. The two tiny jets of mitral regurgitation (arrows, B) seen at in this midesophageal two-chamber view are "signature MR" of normal functioning St. Jude mitral valve prosthesis. Other prosthetic valves have their own normal signature mitral regurgitations. They do not indicate prosthetic valve dysfunction.

Fig. 40. Prosthetic mitral valve: normal signature regurgitation. Midesophageal two-chamber view showing St. Jude bileaflet prosthesis during systole at omniplane 80°. Normal leaflet appearance in closed position (arrows, A) with normal acoustic shadow pattern and reverber-tion seen within left ventricular cavity. St. Jude valve with leaflets in open position is show in insert A. The two tiny jets of mitral regurgitation (arrows, B) seen at in this midesophageal two-chamber view are "signature MR" of normal functioning St. Jude mitral valve prosthesis. Other prosthetic valves have their own normal signature mitral regurgitations. They do not indicate prosthetic valve dysfunction.

These images illustrate a common complication after mitral valve surgery. Transthoracic images and subsequent transesophageal images confirm moderate to severe MR because of a paravalvular leak and dehiscence of a bioprothetic valve. Color flow doppler now illustrate that some of the regurgitation occurs outside of the struts of the porcine mitral valve. Superimposed on a central jet of MR is the regurgitant jet resulting from a paravalvular leak with dehiscence.

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case presentation 7: mitral regurgitation endocarditis

This 72-yr-old man had coronary artery bypass surgery, mitral valve repair and LV aneurysm resection. Fourteen days after surgery, he was still in the intensive care unit with signs of heart failure and low-grade temperatures, despite no evidence of bacteremia (Fig. 38).

Transthoracic images demonstrate a mitral regurgitant jet that appears to originate from outside the ring annulus. Transesophageal images reveal a thick mass on the anterior mitral leaflet. When this patient was brought back to the operating room, the sutures were noted to be incompetent. No vegetations were seen. The ring, coiled and loosened from its original points of attachment, resulted in a mass-like appearance on the anterior mitral valve leaflet, and MR.

case presentation 8: status-post mitral valve replacement

This 56-yr-old man had mitral valve replacement 1 yr earlier, but was discovered to have a new MR murmur (Fig. 39; please see companion DVD for corresponding video).

Mitral valve mapping has an important application in the evaluation of prosthetic valves. Mapping of the regurgitant jet on TEE revealed a crescent-shaped dehiscence. Prosthetic valves normally demonstrate a small jet(s) that are characteristic of each model (Fig. 40). Such "signature" regurgitations are clinically insignificant.

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