Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2022 Feb 16;4(4):241-246.
doi: 10.1016/j.jaccas.2021.12.021.

Unearthing the Tunnel

Yaser Nemshah  1   2 , Anjali Sharma  1 , Nadira Hamid  1 , Hussein Rahim  1 , Vivian Ng  1 , Isaac George  1 , Tamim Nazif  1 , Torsten Vahl  1 , Susheel Kodali  1 , Rebecca Hahn  1 , Omar Khalique  1
Affiliations
Case Reports

Unearthing the Tunnel

Yaser Nemshah et al. JACC Case Rep. .

Abstract

We present a unique case of a paravalvular leak through a periannular channel around a bioprosthetic mitral valve. The role of multimodality imaging, in addition to novel technology, helped uncover the complex course of the jet, including its origin and direction, which translated into excellent procedural success. (Level of Difficulty: Advanced.).

Keywords: 2D, 2-dimensional; 3D; 3D, 3-dimensional; AVP II, Amplatzer Vascular Plug II; CT, computed tomography; PVL, paravalvular leak; TEE, transesophageal echocardiogram; channel; echocardiography; mitral regurgitation; paravalvular leak; percutaneous closure.

PubMed Disclaimer

Conflict of interest statement

Dr Nemshah has received an educational scholarship from King Fahad Medical City through the Saudi Arabian Cultural Mission in Washington, DC. Dr George has received consulting fees from W.L. Gore & Associates, Vdyne, Cardiomech, Mitremedical, and Atricure. Dr Nazif has received consulting fees for or honoraria from Edwards Lifesciences, Medtronic, Venus Medtech, and Boston Scientific. Dr Vahl has received institutional funding to Columbia University Irving Medical Center from Boston Scientific, Edwards Lifesciences, JenaValve, Medtronic, and Siemens Healthineers; and has received consulting fees from Abbott Vascular, Boston Scientific, and Siemens Healthineers. Dr Kodali has served as a consultant for and received honoraria from Admedus, Meril Lifesciences, JenaValve, and Abbott Vascular; has reported membership on the scientific advisory boards and equity in Dura Biotech, MicroInterventional Devices, Thubrikar Aortic Valve Inc, Supira, and Admedus; and has received institutional funding to Columbia University and/or the Cardiovascular Research Foundation from Edwards Lifesciences, Medtronic, Abbott Vascular, Boston Scientific, and JenaValve. Dr. Hahn has received speaker fees from Abbott Structural, Edwards Lifesciences, and Philips Healthcare; has received institutional consulting contracts with Abbott Structural, Boston Scientific, Edwards Lifesciences, and W.L. Gore & Associates; has received equity in Navigate; and is the Chief Scientific Officer for the Echocardiography Core Laboratory at the Cardiovascular Research Foundation for multiple industry-sponsored trials, for which she receives no direct industry compensation. Dr Khalique has received consulting fees from Abbott Structural and Boston Scientific; and has received Speakers Bureau fees from Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Preprocedural Transesophageal Echocardiogram (A) Baseline 2-dimensional (2D) and color Doppler transesophageal echocardiogram in the commissural view demonstrating the paravalvular leak (PVL). (B to E) Baseline 3-dimensional (3D) transesophageal echocardiogram rendering in en face view showing the jet entrance (blue arrow), the periannular channel (yellow arrows), and the jet exit site (red arrows). (F) Paravalvular jet demonstration in en face view using multislice automated cropping (arrows as in B to E). Ao = aorta.
Figure 2
Figure 2
Preprocedural Cardiac Computed Tomography Cardiac computed tomography in the short axis at the level of the mitral annulus showing the entrance and exit point of the paravalvular leak jet across the channel.
Figure 3
Figure 3
Sizing of the Paravalvular Leak Defect by Cardiac Computed Tomography Preprocedural cardiac computed tomography with multiplanar reconstruction and analysis of the periannular channel at the junction with the left atrium. The crosshairs show the paravalvular leak channel in the (A and B) long axis and (C) short axis. (C) Cross-sectional image of the paravalvular leak channel with measurement (9.3 × 4.7 mm). A 12-mm Amplatzer Vascular Plug II (Abbott) device was selected for the procedure. AO = aorta; AV = aortic valve; LA = left atrium; LV = Left ventricle; Max = maximum; Min = minimum.
Figure 4
Figure 4
Intraprocedural Imaging (A) Intraprocedural 3-dimensional transesophageal echocardiogram in the surgeon’s view showing the guide catheter across the channel. The red dotted line shows the course of the wire as it travels through the channel. (B) Fluoroscopy showing the wire traveling through the periannular channel.
Figure 5
Figure 5
Postprocedural 3-Dimensional Transesophageal Echocardiogram Postprocedure 3-dimensional photorealism rendering Amplatzer Vascular Plug II (AVP II, Abbott) device (yellow arrow) and the residual trace paravalvular leak jets.
Figure 6
Figure 6
Postprocedural Cardiac Computed Tomography Follow-up cardiac computed tomography showing the Amplatzer Vascular Plug II (AVP II, Abbott) device (red dotted circle) in (A) the 2-chamber view and (B) the short-axis view at the level of the mitral prosthetic sewing ring. Abbreviations as in Figure 3.
See this image and copyright information in PMC

References

    1. Noble S., Jolicoeur E.M., Basmadjian A., et al. Percutaneous paravalvular leak reduction: procedural and long-term clinical outcomes. Can J Cardiol. 2013;29:1422–1428. - PubMed
    1. Giblett J.P., Rana B.S., Shapiro L.M., Calvert P.A. Percutaneous management of paravalvular leaks. Nat Rev Cardiol. 2019;16:275–285. - PubMed
    1. Ruiz C.E., Hahn R.T., Berrebi A., et al. Clinical trial principles and endpoint definitions for paravalvular leaks in surgical prosthesis: an expert statement. J Am Coll Cardiol. 2017;69:2067–2087. - PubMed
    1. Vairo A., Marro M., De Ferrari G.M., Rinaldi M., Salizzoni S. Use of a photo-realism 3D rendering technique to enhance echocardiographic visualization of the anatomical details during beating-heart mitral valve repair. Echocardiography. 2019;36:2090–2093. - PubMed
    1. Karagodin I., Addetia K., Singh A., et al. Improved delineation of cardiac pathology using a novel three-dimensional echocardiographic tissue transparency tool. J Am Soc Echocardiogr. 2020;33:1316–1323. - PMC - PubMed

Publication types

LinkOut - more resources