Wei-Hsian Yin

Atrial Septal Occluder Device Embolization to an Iliac Artery: A Case Highlighting the Utility of Three-Dimensional Transesophageal Echocardiography during Percutaneous Closure

Percutaneous closure of secundum atrial defects has become an accepted treatment in part because it is minimally invasive and relatively low risk. Despite recent advances in implantation technique and device improvements, complications occur. Here, we report a case of device embolization during percutaneous repair of an atrial septal defect (ASD) with multiple fenestrations. We highlight the value of using live/real time three‐dimensional transesophageal echocardiography to help plan the percutaneous procedure and detect complications.

Quantitative Analysis of Mitral Valve Morphology in Mitral Valve Prolapse Using Real-Time Three-Dimensional Echocardiography: Importance of Annular Saddle-Shape in Pathogenesis of Mitral Regurgitation

Background— Few data exist on the relation of the 3-dimensional morphology of mitral valve and degree of mitral regurgitation (MR) in mitral valve prolapse. Methods and Results— Real-time 3-dimensional transesophageal echocardiography of the mitral valve was acquired in 112 subjects, including 36 patients with mitral valve prolapse and significant MR (≥3+; MR+ group), 32 patients with mitral valve prolapse but no or mild MR (⩽2+; MR− group), 12 patients with significant MR resulting from nonprolapse pathologies (nonprolapse group), and 32 control subjects. The 3-dimensional geometry of mitral valve apparatus was measured with dedicated quantification software. Compared with the normal and MR− groups, the MR+ group had more dilated mitral annulus (P<0.0001), a reduced annular height to commissural width ratio (AHCWR) (P<0.0001) indicating flattening of annular saddle shape, redundant leaflet surfaces (P<0.0001), greater leaflet billow volume (P<0.0001) and billow height (P<0.0001), longer lengths from papillary muscles to coaptation (P<0.0001), and more frequent chordal rupture (P<0.0001). Prevalence of chordal rupture increased progressively with annulus flattening (7% versus 24% versus 42% for AHCWR >20%, 15%–20%, and <15%, respectively; P=0.004). Leaflet billow volume increased exponentially with decreasing AHCWR in patients without chordal rupture (r2=0.66, P<0.0001). MR severity correlated strongly with leaflet billow volume (r2=0.74, P<0.0001) and inversely with AHCWR (r2=0.44, P<0.0001). In contrast, annulus dilatation but not flattening occurred in nonprolapse MR patients. An AHCWR <15% (odds ratio=7.1; P=0.0004) was strongly associated with significant MR in mitral valve prolapse. Conclusion— Flattening of the annular saddle shape is associated with progressive leaflet billowing and increased frequencies of chordal rupture and may be important in the pathogenesis of MR in mitral valve prolapse.Background— Few data exist on the relation of the 3-dimensional morphology of mitral valve and degree of mitral regurgitation (MR) in mitral valve prolapse.nnMethods and Results— Real-time 3-dimensional transesophageal echocardiography of the mitral valve was acquired in 112 subjects, including 36 patients with mitral valve prolapse and significant MR (≥3+; MR+ group), 32 patients with mitral valve prolapse but no or mild MR (≤2+; MR− group), 12 patients with significant MR resulting from nonprolapse pathologies (nonprolapse group), and 32 control subjects. The 3-dimensional geometry of mitral valve apparatus was measured with dedicated quantification software. Compared with the normal and MR− groups, the MR+ group had more dilated mitral annulus ( P 20%, 15%–20%, and <15%, respectively; P =0.004). Leaflet billow volume increased exponentially with decreasing AHCWR in patients without chordal rupture ( r 2=0.66, P <0.0001). MR severity correlated strongly with leaflet billow volume ( r 2=0.74, P <0.0001) and inversely with AHCWR ( r 2=0.44, P <0.0001). In contrast, annulus dilatation but not flattening occurred in nonprolapse MR patients. An AHCWR <15% (odds ratio=7.1; P =0.0004) was strongly associated with significant MR in mitral valve prolapse.nnConclusion— Flattening of the annular saddle shape is associated with progressive leaflet billowing and increased frequencies of chordal rupture and may be important in the pathogenesis of MR in mitral valve prolapse.nn# Clinical Perspective {#article-title-34}

Valve-In-Valve Therapy

Transcatheter valve-in-valve implantation is feasible in failing bioprostheses and offers an alternative to reoperative surgical valve replacement for many high-risk patients.

Complications of Interventional Procedures

Interventions serve an alternative to surgical replacements for severe, symptomatic structural heart disease in high risk patients. Intraprocedural transesophageal echocardiography provides real-time imaging guidance throughout the procedure and allows for instant and accurate assessment of complications and procedural results, which can significantly lower patients’ morbidity and mortality.

Percutaneous Closure of Congenital and Acquired Cardiac Defects

Even if many transcatheter closure techniques are closely associated, atrial septal defects, ventricular septal defects, and patent ductus arteriosus each involve unique approaches. Similarly, aortic pseudoaneurysms and iatrogenic fistulas are discussed separately. Most closure techniques are improvisations of methods applied in more commonly encountered congenital defects. There is no standard approach to either of these conditions because the location and relation to surrounding structures varies significantly.

Coronary Artery Diseases

This chapter, Coronary Artery Disease, covers ischemic MR, LV apex akinesis having Dor’s procedure, and a post myocardial infarction VSD.

Diseases of the Aortic Valve

This chapter described AV prolapse, bicuspid AV, rheumatic heart disease, and AS received proper treatments including aortic repair, replacement, or transcatheter AV implantation.

Tumors and Mass Lesions

This chapter deals with tumors and mass lesions. Cases of thrombus, myxomas, and thymoma are described.

Diseases of the Tricuspid and Pulmonary Valve

Right-sided vlavular disorders are discussed in this chapter, including cases of TV prolapse, tricuspid prosthesis restenosis, subvalvular PS, and carcinoid syndrome.

Diseases of the Mitral Valve

In this chapter, cases of mitral leaflets prolapse, flail, annulus calcification, rheumatic heart disease, and systolic anterior motion received mitral repair or replacement are presented.