ABC | Volume 110, Nº3, March 2018

Image Partial Prosthetic Mitral Valve Dehiscence: Transapical Percutaneous Closure Catarina Ruivo, 1 José Ribeiro, 2 Alberto Rodrigues, 2 Luís Vouga, 2 Vasco Gama 2 Centro Hospitalar de Leiria, Leiria – Portugal 1 Centro Hospitalar Vila Nova de Gaia, Espinho – Portugal 2 Mailing Address: Catarina Ruivo • Rua das Olhalvas 2410, Pousos, Leiria E-mail: catarina.ruivo.cardio@gmail.com, catarinaruivo10@gmail.com Manuscript received March 30, 2017, revised manuscript April 28, 2017, accepted April 28, 2017 Keywords Endocarditis; Mitral Valve Insufficiency; Aortic Valve Insufficiency; Echocardiography,Transesophageal DOI: 10.5935/abc.20180028 An 80-year-old woman with a history of mitral and aortic prosthesis replacement with biological prostheses due to endocarditis presented worsening dyspnea. A transthoracic echocardiogram demonstrated a paravalvular regurgitation between the left ventricle and left atrial appendage. Given her high-risk surgery (EuroSCORE-II: 38%), a percutaneous approach was performed for definitive closure. Transesophageal echocardiography (TEE) peri-procedure allowed the visualization of a partial dehiscence of the mitral prosthesis (Panel A, Figure 1). Through the 3D images, a tunneled defect with wall dissection measuring 12.5 mm of maximum diameter (Panel B, Figure 1) was observed. Using a transapical pathway and collecting three-dimensional (3D) images in real time, a 12 mm Amplatzer septal prosthesis was positioned, occluding the entire defect. The TEE 3D image demonstrated savings of adjacent structures and absence of pericardial effusion during closure. Coronary angiography demonstrated no arterial compromise. A slight residual flow was detected after device implantation (C-F Panels Figure 1). Paravalvular regurgitation may result from suture dehiscence of the mitral prosthesis. Symptoms of heart failure are an indication for closure. A transapical approach allows direct access to the defect, providing good technical support. The TEE 3D image is essential for guiding the guidewire through the defect, confirming the correct position of the device and relating it to critical structures. The anatomy of the defect and the surrounding structures make this case a challenge, on both imaging acquisition and percutaneous technique. Author contributions Conception and design of the research and Writing of the manuscript: Ruivo C; Acquisition of data: Ruivo C, Ribeiro J; Analysis and interpretation of the data: Ruivo C, Ribeiro J, Rodrigues A; Critical revision of the manuscript for intellectual content: Ribeiro J, Rodrigues A, Vouga L, Gama V. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. 295