State-of-the-Art Review

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Journal of Structural Heart Disease, April 2016, Volume 2, Issue 2:61-66
DOI: 10.12945/j.jshd.2016.002.14

State-of-the-Art Periprocedural 3D Transesophageal Echocardiography during Transcatheter Mitral Valve-in-Valve Implantation

Jason N. Dungu, PhD, BSc, MBBS, MRCP*, Nilesh Sutaria, MBChB, FRCP, MD, Ben Ariff, MRCP, FRCR, PhD, Angela Frame, Jonathan Cousins, FRCA, MBBS, BSc, John R. Anderson, MBChb, FRCS, Andrew Chukwuemeka, MBBS, MD, FRCS, Ghada Mikhail, BSc, MBBS, MD, MRCP, Iqbal S. ­Malik, MBBCh, MA, FRCP, PhD

Cardiovascular Department, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK


An 88 year old lady, with a previous 25 mm ­Carpentier-Edwards 6900 Perimount pericardial ­mitral bio prosthesis in 2007 for severe mitral regurgitation, presented in September 2013 with shortness of breath on mild exertion with NYHA class 3 heart failure. ­Transthoracic and transoesophageal echocardiography, demonstrated good biventricular systolic function but significant transvalvular mitral prosthesis regurgitation and severe restriction of the leaflets. She was reviewed by the cardiothoracic surgeons and turned down for re-do mitral valve surgery due to frailty. The mitral MDT recommended transcatheter mitral ­valve-in-valve ­implantation.

A temporary pacing wire was inserted via the right internal jugular vein. The procedure was performed via transapical access with a 6F sheath. A standard J-wire crossed the mitral valve easily with the aid of a pigtail catheter. The TAVI delivery sheath was positioned across the mitral valve prosthesis, guided by 2D and real time 3D TOE and fluoroscopy. A 26 mm Edwards XT Ascendra Transcatheter Valve (Edwards Lifesciences, Irvine, California) was deployed successfully under rapid pacing within the bioprosthetic ring. A good position was seen on fluoroscopy and 2D and 3D TOE showed only minimal paravalvular leak. A significant increase in mitral valve area and reduction in ­transmitral ­gradient was observed. The patient was discharged on day 6 and remains well at 6 months review.

Valve-in-valve implantation, a new technology only possible with state-of-the-art imaging, is a viable treatment option for degenerative tissue bioprosthesis ­disease in high risk surgical patients.


  • Video 1

    Real time 3D zoom (left ventricular view) pre intervention demonstrating severely restricted bioprosthetic leaflet opening

  • Video 2

    Full volume 3D colour Doppler pre intervention demonstrating severe transvalvular regurgitation and turbulent diastolic flow due to severe mitral bioprosthesis stenosis

  • Video 3

    Live 3D TOE-guided positioning of TAVI in mitral position

  • Video 4

    Live 3D left ventricular view post TAVI in mitral position

  • Video 5

    3D full volume left atrial view post intervention

  • Video 6

    2D TOE colour compare post intervention demonstrating good TAVI in mitral position function

  • Video 7

    Full volume 3D colour Doppler post intervention (left atrial view)


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Cite this article as: Dungu JN, Sutaria N, Ariff B, Frame A, Cousins J, Anderson JR, Chukwuemeka A, Mikhail G, Malik IS. State-of-the-Art Periprocedural 3D Transesophageal Echocardiography during Transcatheter Mitral Valve-in-Valve Implantation. Structural Heart Disease 2016;2(2):61-66. DOI: 10.12945/j.jshd.2016.002.14

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