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Intra-cardiac echocardiography in mitral valve repair: a novel use of a complimentary imaging modality in a difficult scenario
  1. N C Edwards1,2,
  2. M Griffiths3,
  3. R P Steeds2
  1. 1Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK
  2. 2Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
  3. 3Ultrasound, Biosense Webster, Wokingham, UK
  1. Correspondence to Dr Nicola Edwards, Clinical Lecturer, Department of Cardiovascular Medicine, University of Birmingham, Medical School, Birmingham B15 2TT, UK; n.c.edwards{at}bham.ac.uk

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A 75-year-old man underwent elective preoperative transesophageal echocardiography (TOE) in view of worsening symptomatic severe mitral regurgitation (MR). Intubation was uneventful but mid-oesophageal images were unexpectedly of poor quality. Prolapse of the P2 scallop of the posterior mitral valve (MV) was confirmed using two-dimensional and three-dimensional TOE (figure 1A,B, online supplementary video 1 and 2) with severe anteriorly directed MR (figure 1C,D, online supplementary video 3 and 4). However, transgastric views could not be obtained due to resistance on advancing the probe beyond 40 cm and the procedure was abandoned.

Figure 1

(A) Mid-oesophageal colour Doppler at 90° and 120° views of the mitral valve (MV) demonstrating severe eccentric mitral regurgitation (MR) directed anteriorly due to prolapse of the P2 scallop. (B) Live 3D image of the MV demonstrating prolapsed of the P2 scallop viewed from the left atrium. (C and D) Mid-oesophageal colour Doppler at 90° and 120° views of the MV demonstrating severe eccentric MR directed anteriorly due to prolapse of the P2 scallop (E) CT thorax at a high oesophageal level demonstrating the ‘double lumen’ of the oesophagus due to presumed intubation of the piriform fossa. (F) Water-soluble swallow demonstrating no oesophageal leak/perforation into the thorax.(G and H) Two-chamber view of the P2 scallop proplase with anteriorly directed MR performed in theatre, prerepair with intracardiac echo. (I and J) Intracardiac echo performed after successful repair and placement of MV annuloplasty ring.

Approximately 1 h following the procedure, the patient complained of severe retrosternal chest pain. An emergency CT thorax demonstrated an oesophageal dissection with a false lumen (figure 1E) but there was no evidence of perforation on a water-soluble swallow (figure 1F). The working diagnosis was that the piriform fossa or a diverticulum had been intubated, creating a false passage.

The patient was managed conservatively and supported with total parenteral nutrition feeding for 3 weeks before undergoing MV repair. In view of concerns about intraoperative TOE, intracardiac echo (AcuNav Ultrasound Catheter) was used via a right internal jugular approach. The P2 prolapse and anteriorly directed MR were visualised intraoperatively prerepair (figure 1G,H, online supplementary video 5 and 6). The MV was repaired successfully with Gortex cords to the free edges of P2 and a 34 mm Colvin-Galloway ring (figure 1I, online supplementary video 7) with no evidence of residual MR at the end of the procedure (figure 1J, online supplementary video 8). The patient made an uneventful recovery and was discharged one month after his original admission.

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Footnotes

  • Contributors NCE and RPS devised the manuscript. All authors were involved in the clinical case and approved the final manuscript.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data can be shared as requested.

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