A 55-year-old male underwent mitral and aortic valve replacement in the year 2005. He developed prosthetic valve infective endocarditis and underwent a re-double valve replacement with in a period of 45 days. The patient was re-admitted with pulmonary oedema in the year 2013. Transthoracic echocardiogram showed severe paravalvular mitral regurgitation (MR) and fluoroscopy showed a rocking movement of the Starr–Edward valve (Panels A and B, and Supplementary data online, Video S1). Intraoperative transoesophageal echocardiography (TEE) imaged in the three standard mid-oesophageal ventricular views: four-chamber (Panel C and Supplementary data online, Video S2 showing dehiscence in both 2 and 8 o'clock), two-chamber (Panels D and E, and Supplementary data online, Video S3 showing dehiscence at 4 o'clock) and long-axis (LAX) (Panel F and Supplementary data online, Video S4 demonstrating significant paravalvular space at 6 o'clock). From these views, it was evident that the prosthetic valve had a dehiscence of ∼50% of its circumference. The real-time three-dimensional (3D) TEE with zoom (iE33 x-MATRIX echo system; Philips Medical System, MA, USA) showed the full extent of prosthetic valve dehiscence. Only remaining attachment was at the level of aortic root (Panels G and H, and Supplementary data online, Video S5). The findings were confirmed at surgery (Panel I). Two-dimensional (2D) TEE uses sequential images to identify the location and extent of paravalvular MR by superimposing the face of a clock on the valve. The aortic valve is defined at the 12 o'clock position and the left atrial appendage lies in the 10 o'clock position. However, 2D TEE underestimated the severity of dehiscence and 3D TEE showed superior imaging quality for the assessment of severity of the dehiscence.
S. Kundan, Dr. Praveen Varma, and Koshy, T., “Real-time three-dimensional transoesophageal echocardiography for diagnosing the extent of dehiscence of Starr-Edward valve prosthesis in the mitral position.”, Eur Heart J Cardiovasc Imaging, vol. 15, no. 9, p. 1060, 2014.