Real-Time Three-Dimensional Transesophageal Echocardiography vs. Three-Dimensional Printing: Detection of Multiple Perivalvular Leaks after Mitral Valve Replacement - A Case Report and Literature Review

Real-Time Three-Dimensional Transesophageal Echocardiography vs. Three-Dimensional Printing: Detection of Multiple Perivalvular Leaks after Mitral Valve Replacement - A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Real-Time Three-Dimensional Transesophageal Echocardiography vs. Three-Dimensional Printing: Detection of Multiple Perivalvular Leaks after Mitral Valve Replacement - A Case Report and Literature Review Zhirong Wang, Qiuxian Wan, Chengming Fan, Qi Ai, Hong You, Tianli Zhao, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4970894/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract To report on a patient who developed multiple perivalvular leaks (PVLs) after a mechanical mitral valve replacement, and how clinicians successfully used real-time three-dimensional (RT-3D) transesophageal echocardiography (TEE) combined with three-dimensional (3D)printing to complete transapical perivalvular closure. Additionally, we reviewed the literature to explore the advantages and disadvantages of multimodal imaging for PVLs. The case is a 63-year-old female patient with a history of rheumatic heart disease underwent mitral mechanical valve replacement, tricuspid valvuloplasty, and left atrial reduction four years ago. She presented with shortness of breath and transthoracic echocardiography (TTE) revealed a PVL. RT-3D TEE combined with 3D printing technology was used to create a 3D model of the patient's heart, which allowed for precise identification of the PVLs. Ultimately, it was determined that the patient had two PVLs. The transapical occlusion was successfully performed with the guidance provided of 3D TEE. Postoperative follow-up indicated good recovery for the patient. The integration of 3D ultrasound with color Doppler mapping has demonstrated significant advantages in the identification and characterization of multiple PVLs. Furthermore, the synergistic application of RT-3D TEE and 3D printing technology facilitates superior precision and accuracy in PVLs closure, ensuring optimal positioning of occlusive devices. Utilizing multimodal imaging techniques is crucial for the effective management of PVLs, as it furnishes clinicians with vital data necessary to ensure the success of therapeutic interventions. Multiple perivalvular leaks Perivalvular leakage plugging surgery Real-time three-dimensional echocardiography 3D printing Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION Perivalvular leak (PVL) is a rare complication that may occur after valve replacement, leading to a spectrum of clinical consequences that can vary based on the volume of the leak and the degree of turbulent blood flow. Complications such as infective endocarditis, hemolytic anemia, or heart failure may arise as a consequence of the condition [ 1 ] . Traditionally, the management of symptomatic patients with PVL has relied on reoperative surgery using cardiopulmonary bypass, which involves re-thoracotomy to suture the leak associated with the original PVL, or in some cases, to remove and re-suture the original valve. However, the extensive postoperative adhesions that form after the initial surgery can pose significant challenges for reoperation. Currently, transcatheter closure with device implantation offers a less invasive treatment strategy for symptomatic patients who are at high risk for conventional surgical approaches. The guidelines from the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) highlight that this option should be considered based on the number, size, and morphology of the leaks, as these factors are critical in determining the feasibility and suitability of the transcatheter method to maintain valve prosthesis function [ 2 – 3 ] . Therefore, multimodality imaging is essential, enabling surgeons to accurately identify the shape, size, and location of PVL and to plan the intervention accordingly. In this case, our structural heart team utilized real-time three-dimensional (RT-3D) transesophageal echocardiography (TEE) imaging and three-dimensional (3D) printing technology to accurately identify the PVL. The interventional closure of the mitral valve PVL was successfully performed via left ventricular apical access, with the procedure completed successfully under the real-time TEE guidance. CASE PRESENTATION A 63-year-old woman with a history of rheumatic heart disease underwent mitral valve mechanical valve replacement, tricuspid valvuloplasty, and left atrial reduction 4 years ago. She had been experiencing chest stuffiness, palpitations, and shortness of breath for over 2 months prior to her readmission to the hospital. Upon physical examination, a systolic murmur was auscultated in the mitral area. It was noted that she did not receive regular echocardiographic follow-up after her initial discharge. Laboratory tests and biochemical analysis upon admission revealed mild hemolytic anemia, with hemoglobin levels of 10.6 g/dL and hematocrit levels of 31.9%, and elevated levels of total bilirubin (37.7 μmol/L) and direct bilirubin (11.6 μmol/L). The patient's New York Heart Association (NYHA) classification of cardiac function was class III. Elevated troponin I levels were found at 0.29 ng/mL, myoglobin levels were 95.1 ng/mL, and BNP levels were 1325 pg/mL, indicating myocardial injury. The color Doppler ultrasound indicates suboptimal quality of the lower extremity blood vessels. The TTE demonstrated an ejection fraction (EF) of 60%, which is indicative of well-preserved left ventricular systolic function. The mechanical mitral valve was found to be functioning normally. However, the 2D TTE detected a PVL at the posterior segment of the mitral valve annulus. To more accurately evaluate the PVL’s location and morphology, a full-scale anatomical 3D printed model was crafted, replicating the patient’s cardiac anatomy based on her cardiac computed tomography angiography (CTA) data. This 3D model revealed a single oval-shaped defect located at the 6 o’clock position of the mitral valve annulus, as viewed from the standard surgical perspective (Fig.1). To further evaluate the hemodynamic changes, a subsequent TEE examination was performed on the patient. Both 2D and RT-3D color-flow imaging were utilized to visualize the PVL. Unexpectedly, the TEE identified a different number of leaks compared to what was depicted in the 3D printed model. As a result, multiple jets were now apparent on the TEE. From the left atrial perspective, the RT-3D TEE revealed two adjacent defects, potentially representing a single crescentic defect bisected by a tight suture or fibrous tissue. These defects were primarily located at 6 o'clock position of the posterior segment of the mitral valve annulus and measured 5mm and 4mm in size, respectively. Unexpectedly, the motion of the prosthetic valve ring appeared to have stabilized (Fig. 2). Upon reviewing the cardiac CTA data, it was discovered that an additional small defect was adjacent to the original one, which had been previously missed. After several refinements of the CTA gray scale, the additional defect became visible. This consistently corresponds with the previous imaging studies, which provides valuable guidance for the surgical intervention (Fig. 3). The patient rejected the plan of a second thoracotomy operation. Considering that the transseptal approach was against the direction of blood flow of the perivalvular regurgitation, it posed certain difficulties for the guide wire to pass through the PVL orifice. In addition, our structural heart team, which has extensive experience in cardiac interventional procedures, typically relies solely on echocardiography for guidance. Therefore, the decision was made to perform interventional closure through the left ventricular apical approach to reduce operative time. We engaged in a detailed discussion about the procedure based on the TEE findings. The procedure was performed in the operating room under TEE guidance using the EPIQ CVx ultrasound system by Philips Healthcare in the Netherlands. Under TEE guidance, the surgeon punctured the apical area and directed the guide wire towards the PVL at the posterior segment of the mitral valve annulus. Once the guide wire had smoothly traversed through the larger defect and entered the left atrium, a 7F delivery sheath was advanced over it into the left atrium along the guide wire. The guide wire was then removed, and an 8mm symmetric VSD occluder from Shanghai Push Medical Device Co., Ltd., China, was deployed via the sheath (Fig.4). After the first device was deployed, RT-3D True-Vue color Doppler flow imaging revealed that another stream of regurgitation was still present next to the device. Consequently, a 7mm device was deployed in the same manner (Fig.5). TEE showed that the second occluder’s disk slightly overlapped with that of the first. The devices were stable, with satisfactory morphology and no impact on prosthetic leaflets motion (Fig.6). Immediately after the surgery, a postoperative 3D color TEE showed normal mechanical valve leaflets motion and no residual reflux signal. The postoperative examination was uneventful. Follow-up assessment at one month and six months postoperatively revealed no recurrence of preoperative heart failure symptoms. DISCUSSION Surgery has traditionally been the preferred treatment option for patients with PVL, as medical management has limited efficacy. PVL surgery may involve either replacing or repairing the prosthetic valve via thoracotomy, or a less invasive transcatheter plugging operation. For patients at high risk, interventional closure is considered a practical and less invasive alternative to surgery, effectively alleviating symptoms and mitigating consequences [ 4 ] . The success of PVL occlusion depends on a comprehensive and accurate assessment of the patient's condition. This includes evaluating the size, shape, and location of the PVLs, as well as the stability of the artificial valve ring. Formulating a surgical plan based on these assessment findings is essential. With advances in multimodality imaging, a variety of diagnostic tools are available for diagnosing PVL. Echocardiography and cardiac computed tomography (CT) are commonly utilized as primary diagnostic modalities. Additionally, supplementary diagnostic tools such as digital subtraction angiography (DSA), cardiac magnetic resonance (CMR), and intracardiac echocardiography (ICE) may also be employed. Echocardiography is generally the preferred method for evaluating PVLs. 3D echocardiography offers precise positioning and detailed visualization of the PVL’s shape, providing critical insights into hemodynamics. RT-3D TEE, when combined with color Doppler, furnishes informative structures that are invaluable for periprocedural assessment. In the 3D TEE view, the complex geometry of mitral PVLs can be accurately depicted without the interference of acoustic shadowing. Additionally, 3D color mapping can be employed for confirmation, helping to prevent misdiagnosis. Futhermore, 3D imaging allows for a comprehensive evaluation of adjacent tissues, offering essential details that are crucial for planning and guiding interventional occlusion procedures [ 5 ] . Cardiac CT is a valuable tool for evaluating perivalvular anatomical structures, particularly in patients with suboptimal echocardiographic image quality. It enables comprehensive cardiac imaging with excellent spatial and temporal resolution [ 6 ] . Recent advancements in CT technology have mitigated issues related to beam hardening and motion artifacts, thereby facilitating a more accurate evaluation of prosthetic valves [ 7 ] . However, the assessment of perivalvular leakage demands a high level of technical expertise and meticulous preparation, as well as efficient equipment. Parameters for image acquisition, such as the cardiac phase, windowing, motion artifact control, and slice thickness, must be meticulously optimized [ 8 ] . Furthermore, CT has limitations in effectively assessing cardiac function or the severity of PVL reflux. It is also susceptible to artifacts from replacement prosthetic valves or valve calcification, which can lead to inaccuracies in the assessment of PVL size [ 9 , 10 , 11 ] . 3D printing technology plays an essential role in certain structural interventions. A 3D printed model can simulate the placement strategy for valve occlusion, facilitating a rapid and efficient surgical plan without the waste of time and resources. It also has the potential to predict device-related adverse events, such as residual leakage and valve leaflet obstruction [ 12 – 13 ] . However, 3D printing has its limitations, particularly in accurately representing subtle structures and hemodynamics. The fidelity of the model hinges on the selection of materials and the printing techniques employed [ 14 ] . Furthermore, the size of the valve's primary ring fluctuates throughout different cardiac cycles, necessitating a careful selection of the cardiac phase when creating and measuring the virtual ring. This requirement adds to the complexity of designing the model [ 15 ] . As demonstrated in this case, the process of adjusting CT data and model parameters is not only necessary but also highly subjective. DSA is a traditional method used to guide transcatheter closure of PVL. During the procedure, DSA is utilized for localization and embolization, relying on the radioactive projection of a contrast agent. However, compared to echocardiography, DSA has certain limitations. Patients are required to remain still and hold their breath during the examination, and the accuracy of detection may be compromised by various factors, including pain, interference, involuntary movement, or arrhythmia [ 16 – 17 ] . Furthermore, DSA exposes both patients and medical staff to the risk associated with radiation, and it may not clearly delineate subtle intracardiac structures or the orifice of a cardiac defect. CMR is a valuable adjunct for evaluating both functional and anatomical details. It is capable of generating precise blood flow images and performing volume-based measurements, which are crucial for quantifying regurgitant flow associated with various types of valves [ 18 ] . CMR can image all prosthetic valves, irrespective of ejection fraction and valve morphology, allowing for the measurement of the regurgitant volume across different valve types. However, CMR has limitations when assessing PVL with high accuracy, particularly when the sizes of the PVL and the prosthetic valve are small. Additionally, the presence of arrhythmia or motion artifacts can impede the evaluation of PVL and may limit the widespread use of CMR in the context [ 19 ] . A novel software tool called Echonavigator® from Philips Healthcare in the Netherlands is now accessible. It facilitates real-time image synchronization and fusion of 2D and 3D TTE with fluoroscopy images. This technology enables precise positioning of the percutaneous mitral valve on the fluoroscopic view and aids in the accurate guidance through the PVL. The safety and feasibility of this technology have been established in the context of numerous structural heart diseases [ 20 ] . However, procedures of this nature necessitate specialized equipment in the operating room. In instances where advanced technology is not accessible, TEE can offer advantages over 3D printing [21] . For instance, in cases involving multiple mitral PVLs, a innovative diagnostic approach combines RT-3D TEE with a 3D printed model during surgery. This method facilitates the creation of a stereoscopic and intuitive image of the intracardiac structures, leveraging the capabilities of 3D TEE. The benefits of this technique include the provision of relatively accurate and real-time guidance, which is crucial for avoiding damage to surrounding tissues during the plugging of multiple PVLs, especially when guided by conventional TEE alone. CONCLUSION The integration of 3D ultrasound with color mapping is particularly advantageous for accurately delineating multiple PVLs during their occlusion. Furthermore, the use of 3D TEE in conjunction with 3D printing technology offers a "double safeguard" in transcatheter closure procedures. This combined approach allows for more precise and efficient occlusion of multiple PVLs and presents a promising new paradigm for managing complications that arise following valve replacement. Consequently, the application of this integrated method is highly recommended for broader use in clinical practice. Declarations DATA AVAILABILITY STATEMENT The original contributions presented in the study have been included in the article and supplementary material. For further inquiries, please contact the corresponding authors. ETHICS STATEMENT Ethical review and approval were not required for the study involving human participants, as it was conducted in accordance with the local legislation and institutional requirements. Written informed consent was obtained from each participant, including their consent for the publication of any potentially identifiable images or data included in this article.Clinical trial number: not applicable. FUNDING This work was supported by the fund from Hunan Provincial Health Commission Research Project (202204023391) and Hunan Innovative Province Construction Special Project of the Hunan Provincial Department of Science and Technology (2022ZK4107). CONFLICT OF INTEREST DISCLOSURE Authors have no conflict of interest to declare.Consent to Publish declaration: not applicable Author Contribution （A）Zhirong Wang: Drafted the manuscript and was resiponsible for the review and interpretation of imaging findings. (B)Qiuxian Wan: Contributed to drafting and revising the manuscript.（C）Chengming Fan: Reviewed and revised the manuscript.(D)Hong You and(E) Qi Ai: Handled the collection and editing images, as well as revising the manuscript.(F)Tianli Zhao: Provided 3D printed images, participated in formulating the interventional surgery plan, and performed the surgery on the patient.(G)Shijun Hu: Performed the surgery on the patient, reviewed the manuscript, and offered valuable suggestions during the initial drafting phase of the manuscript. (H）Qin Wu: Responsible for the comprehensive review, revision and polishing of the entire manuscript, as well as for addressing the reviewers' inquiries.All authors have contributed to the work, have read the manuscript, and approved the submitted version. References Thomas F Lüscher, MD, FESC, Mitral valve disease: news from the frontier in valvular heart disease, European Heart Journal , Volume 39, Issue 15, 14 April 2018, Pages 1211–1214. Writing Committee Members, Otto C M, Nishimura R A, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[J]. Journal of the American College of Cardiology, 2021, 77(4): e25-e197. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)[J]. European heart journal, 2022, 43(7): 561-632. Cruz-Gonzalez I, Rama-Merchan J C, Rodríguez-Collado J, et al. Transcatheter closure of paravalvular leaks: state of the art[J]. Netherlands Heart Journal, 2017, 25: 116-124. Furukawa K, Kamohara K, Itoh M, Furutachi A, Mukae Y, Morita S.Real‐time three‐dimensional transesophageal echocardiography is useful for the localization of a small mitral paravalvular leak. Ann Thorac Surg. 2011;91:e72‐e73 Aziz M U, Manapragada P, Singh S P. Non coronary applications of cardiac computed tomography: A review[J]. Journal of Medical Imaging and Radiation Sciences, 2021, 52(3): S51-S64. Ghersin E , Martinez CA , Singh V , Fishman JE , Macon CJ , Runco Ther- rien JE . ECG-gated MDCT after aortic and mitral valve surgery. AJR Am J Roentgenol . 2014;203(6):W596–W604 O’Neill, A.C.; Martos, R.; Murtagh, G.; Ryan, E.R.; McCreery, C.; Keane, D.; Quinn, M.; Dodd, J.D. Practical tips and tricks for assessing prosthetic valves and detecting paravalvular regurgitation using cardiac CT. J. Cardiovasc. Comput. Tomogr. 2014, 8, 323–327. Hascoet S, Smolka G, Bagate F, et al. Multimodality imaging guidance for percutaneous paravalvular leak closure: Insights from the multi-centre FFPP register[J]. Archives of Cardiovascular Diseases, 2018, 111(6-7): 421-431. Quail MA, Nordmeyer J, Schievano S, Reinthaler M, Mullen MJ, Taylor AM. Use of cardiovascular magnetic resonance imaging for TA VR assessment in patients with bioprosthetic aortic valves: comparison with computed tomography. Eur J Radiol. 2012;81:3912–7. .Numata S, Tsutsumi Y , Monta O, Yamazaki S, Seo H, Y oshida S, et al. Mechanical valve evaluation with four-dimensional computed tomography. J Heart V alve Dis. 2013;22:837–42. Balzer J, Zeus T, Veulemans V, et al. Hybrid imaging in the catheter laboratory: real-time fusion of echocardiography and fluoroscopy during percutaneous structural heart disease interventions. Interv Cardiol 2016; 11: 59–64. Lau I, Sun Z. Three‐dimensional printing in congenital heart disease: A systematic review[J]. Journal of medical radiation sciences, 2018, 65(3): 226-236. Ciobotaru V, Tadros VX, Batistella M, Maupas E, Gallet R, Decante B, Lebret E, Gerardin B, Hascoet S. 3D-Printing to Plan Complex Transcatheter Paravalvular Leaks Closure. J Clin Med. 2022 Aug 15;11(16):4758. Ooms J F, Wang D D, Rajani R, et al. Computed tomography–derived 3D modeling to guide sizing and planning of transcatheter mitral valve interventions[J]. Cardiovascular Imaging, 2021, 14(8): 1644-1658. Yamamoto M, Okura Y, Ishihara M, et al. Development of digital subtraction angiography for coronary artery[J]. Journal of digital imaging, 2009, 22(3): 319-325 Nejati M, Pourghassem H. Multiresolution image registration in digital X-ray angiography with intensity variation modeling. J Med Syst. 2014;38:10. Zoghbi WA, Asch FM, Bruce C, et al. Guidelines for the evaluation of valvular regurgitation after percutaneous valve repair or replace-ment: a report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Angiography and Interventions, Japanese Society of Echocardio-graphy, and Society for Cardiovascular Magnetic Resonance. J A m Soc Echocardiogr. 2019;32:431‐475. Suchá D, Symersky P, Tanis W, et al. Multimodality imaging as-sessment of prosthetic heart valves. Circ Cardiovasc Imaging. 2015;8:e003703. Ciobotaru V, Tadros V X, Batistella M, et al. 3D-Printing to Plan Complex Transcatheter Paravalvular Leaks Closure[J]. Journal of clinical medicine, 2022, 11(16): 4758. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4970894","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":352372571,"identity":"891eb60a-ceb0-46a9-bbff-d2412838287d","order_by":0,"name":"Zhirong Wang","email":"","orcid":"","institution":"the Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Zhirong","middleName":"","lastName":"Wang","suffix":""},{"id":352372572,"identity":"fe40a0df-f3b4-4297-907e-64766f427fb4","order_by":1,"name":"Qiuxian Wan","email":"","orcid":"","institution":"the Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Qiuxian","middleName":"","lastName":"Wan","suffix":""},{"id":352372573,"identity":"ebcee4bb-d709-4185-acd1-a9ac482350fb","order_by":2,"name":"Chengming Fan","email":"","orcid":"","institution":"the Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Chengming","middleName":"","lastName":"Fan","suffix":""},{"id":352372574,"identity":"2d048836-9889-424a-827a-a103e1813796","order_by":3,"name":"Qi Ai","email":"","orcid":"","institution":"the Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Qi","middleName":"","lastName":"Ai","suffix":""},{"id":352372575,"identity":"82ba6010-963b-4427-b0fb-5f970a1731f5","order_by":4,"name":"Hong You","email":"","orcid":"","institution":"the Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"You","suffix":""},{"id":352372578,"identity":"b808bc9f-1ee7-4cc2-8feb-d43403b96492","order_by":5,"name":"Tianli Zhao","email":"","orcid":"","institution":"the Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Tianli","middleName":"","lastName":"Zhao","suffix":""},{"id":352372579,"identity":"e1bc6e0d-dd96-46c7-ab50-a1bda2adf18b","order_by":6,"name":"Shijun Hu","email":"","orcid":"","institution":"the Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Shijun","middleName":"","lastName":"Hu","suffix":""},{"id":352372581,"identity":"9c2eb15e-6465-45cd-a02c-0a10bd10862b","order_by":7,"name":"Qin Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIie3OsQrCMBCA4SuBuJx7iugzBAoVoeirKIVMDh3dFAS7iK6KPkTFwTVwg0sfoOIiFDo5CO5qcRRp6+aQnxsukA8OwGT60zSMRKsXTt4Pa1KNxJ4jUf9AwJqpQST6FYlM/B0FnKyDnaZ3BK8ZaZZdiokKaIXEOhvlNhCUE2nelkXETYaSUBCH85AzBBpEGrkoJ/nAKWb5Yc+qpK+ETBDyw3Q56cVZQKg9ac+Va2+l76yJu4XEDv39vf4Q42WN0tt11G0ujtOskOTJj52V/P8gJpPJZPrSC4WFSj6XNCeSAAAAAElFTkSuQmCC","orcid":"","institution":"the Second Xiangya Hospital of Central South University","correspondingAuthor":true,"prefix":"","firstName":"Qin","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2024-08-25 01:51:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4970894/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4970894/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":70973286,"identity":"c14f9b84-734a-4cab-8e1f-058348dc7394","added_by":"auto","created_at":"2024-12-09 18:27:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":170438,"visible":true,"origin":"","legend":"\u003cp\u003eBased on\u003cstrong\u003e \u003c/strong\u003ethe 3D printed model derived from the patient's cardiac CT scan, the aortic valve is located at 12 o'clock from the surgeon’s perspective. A hole is visible at the 6 o'clock position of the mitral valve annulus, as depicted in both the 3D modeling diagram (A) and the 3D printed solid model (B) (as highlighted in the red boxes).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4970894/v1/013acaddab9bba8299e58ad4.png"},{"id":70973289,"identity":"f88c6a6a-d038-45f5-b1a0-9295cc97b5f3","added_by":"auto","created_at":"2024-12-09 18:27:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":709391,"visible":true,"origin":"","legend":"\u003cp\u003eTwo adjacent PVLs were identified using 3D TrueVue mode, highlighted in the red box. The larger hole is indicated by the green arrow, while the smaller one is indicated by the white arrow (A) . The regurgitation flows associated with these PVLs were visualized in color Doppler flow imaging (B) and were further depicted in a two-dimensional section combined color Doppler flow imaging(C).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4970894/v1/a3e72d10b90776b29227479f.png"},{"id":70973288,"identity":"e206b2c0-faa5-476e-b81f-1d96b25becc1","added_by":"auto","created_at":"2024-12-09 18:27:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":144917,"visible":true,"origin":"","legend":"\u003cp\u003eThe readjusted 3D modeling diagram reveals two adjacent perforations around the valve orifice as viewed from the atrial perspective (A) and the ventricular perspective (B) (as highlighted in the red boxes).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4970894/v1/da1e01505809daed094c46e0.png"},{"id":70973290,"identity":"3c32b9c8-b63e-4bc8-b961-e86a23fe8422","added_by":"auto","created_at":"2024-12-09 18:27:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":673331,"visible":true,"origin":"","legend":"\u003cp\u003eA guide wire navigated through one of the leakage holes from the left ventricle to the left atrium in the RT-3D image (as indicated by the green arrow in the red box) (A). The first occluder was deployed, successfully occluding one of the holes (as indicated by the red arrow) (B). However, regurgitation was still evident along the edge of the first occluder in the color Doppler flow imaging (as indicated by the yellow arrow) (C).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4970894/v1/244f82623fa9058dce330040.png"},{"id":70973291,"identity":"8b9ab76f-b599-4e2a-9657-3717e71ad772","added_by":"auto","created_at":"2024-12-09 18:27:28","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":618955,"visible":true,"origin":"","legend":"\u003cp\u003eUnder the guidance of RT-3D TEE, a guide wire was passed through another adjacent hole in the left ventricle, near to the first occluder, as visualized in the 3D view (A) and the 3D TrueVue view (as indicated by the red arrow) (B). Subsequently, a delivery sheath (as indicated by the red arrow) was navigated through the second hole over the guide wire, adjacent to the first occulder (as indicated by the green arrow in the X-plane image)(C). Finally, the second occluder was successfully deployed.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4970894/v1/65495415914c788b29bb8343.png"},{"id":70973476,"identity":"bd38f5c4-da6c-4d94-b557-9ececbd7fe3d","added_by":"auto","created_at":"2024-12-09 18:35:27","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":305280,"visible":true,"origin":"","legend":"\u003cp\u003eThe two occluders were observed to slightly overlap in the 3D view (A), and no regurgitation was detected in the RT-3D color Dopper flow imaging (B). The occluding effect is deemed satisfactory.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-4970894/v1/397b2dce5779f1d6148b2334.png"},{"id":98774662,"identity":"8042dc33-aec0-42d2-a719-899dc9567686","added_by":"auto","created_at":"2025-12-22 12:08:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3749219,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4970894/v1/98c238f8-5f43-4edb-be07-5c33ed587ad4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Real-Time Three-Dimensional Transesophageal Echocardiography vs. Three-Dimensional Printing: Detection of Multiple Perivalvular Leaks after Mitral Valve Replacement - A Case Report and Literature Review","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePerivalvular leak (PVL) is a rare complication that may occur after valve replacement, leading to a spectrum of clinical consequences that can vary based on the volume of the leak and the degree of turbulent blood flow. Complications such as infective endocarditis, hemolytic anemia, or heart failure may arise as a consequence of the condition\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTraditionally, the management of symptomatic patients with PVL has relied on reoperative surgery using cardiopulmonary bypass, which involves re-thoracotomy to suture the leak associated with the original PVL, or in some cases, to remove and re-suture the original valve. However, the extensive postoperative adhesions that form after the initial surgery can pose significant challenges for reoperation.\u003c/p\u003e \u003cp\u003eCurrently, transcatheter closure with device implantation offers a less invasive treatment strategy for symptomatic patients who are at high risk for conventional surgical approaches. The guidelines from the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) highlight that this option should be considered based on the number, size, and morphology of the leaks, as these factors are critical in determining the feasibility and suitability of the transcatheter method to maintain valve prosthesis function\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Therefore, multimodality imaging is essential, enabling surgeons to accurately identify the shape, size, and location of PVL and to plan the intervention accordingly.\u003c/p\u003e \u003cp\u003eIn this case, our structural heart team utilized real-time three-dimensional (RT-3D) transesophageal echocardiography (TEE) imaging and three-dimensional (3D) printing technology to accurately identify the PVL. The interventional closure of the mitral valve PVL was successfully performed via left ventricular apical access, with the procedure completed successfully under the real-time TEE guidance.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 63-year-old woman with a history of rheumatic heart disease underwent mitral valve mechanical valve replacement, tricuspid valvuloplasty, and\u0026nbsp;left atrial reduction 4 years ago. She had been experiencing chest stuffiness, palpitations, and shortness of breath for over 2 months prior to her readmission to the hospital. Upon physical examination, a systolic murmur was auscultated in the mitral area. It was noted that she did not receive regular echocardiographic follow-up after her initial discharge.\u003c/p\u003e\n\u003cp\u003eLaboratory tests and biochemical analysis upon admission revealed mild hemolytic anemia, with hemoglobin levels of 10.6 g/dL and hematocrit levels of 31.9%, and elevated levels of total bilirubin (37.7 \u0026mu;mol/L) and direct bilirubin (11.6 \u0026mu;mol/L). The patient\u0026apos;s New York Heart Association (NYHA) classification of cardiac function was class III. Elevated troponin I levels were found at 0.29 ng/mL, myoglobin levels were 95.1 ng/mL, and BNP levels were 1325 pg/mL, indicating myocardial injury. The color Doppler ultrasound indicates suboptimal quality of the lower extremity blood vessels.\u003c/p\u003e\n\u003cp\u003eThe TTE demonstrated an ejection fraction (EF) of 60%, which is indicative of well-preserved left ventricular systolic function. The mechanical mitral valve was found to be functioning normally. However, the 2D TTE detected a PVL at the posterior segment of the mitral valve annulus. To more accurately evaluate the PVL\u0026rsquo;s location and morphology, a full-scale anatomical 3D printed model was crafted, replicating the patient\u0026rsquo;s cardiac anatomy based on her cardiac computed tomography angiography (CTA) data. This 3D model revealed a single oval-shaped defect located at the 6 o\u0026rsquo;clock position of the mitral valve annulus, as viewed from the standard surgical perspective (Fig.1).\u003c/p\u003e\n\u003cp\u003eTo further evaluate the hemodynamic changes, a subsequent TEE examination was performed on the patient. Both 2D and RT-3D color-flow imaging were utilized to visualize the PVL. Unexpectedly, the TEE identified a different number of leaks compared to what was depicted in the 3D printed model. As a result, multiple jets were now apparent on the TEE. From the left atrial perspective, the RT-3D TEE revealed two adjacent defects, potentially representing a single crescentic defect bisected by a tight suture or fibrous tissue. These defects were primarily located at 6 o\u0026apos;clock position of the posterior segment of the mitral valve annulus and measured 5mm and 4mm in size, respectively. Unexpectedly, the motion of the prosthetic valve ring appeared to have stabilized (Fig. 2).\u003c/p\u003e\n\u003cp\u003eUpon reviewing the cardiac CTA data, it was discovered that an additional small defect was adjacent to the original one, which had been previously missed. After several refinements of the CTA gray scale, the additional defect became visible. This consistently corresponds with the previous imaging studies, which provides valuable guidance for the surgical intervention (Fig. 3).\u003c/p\u003e\n\u003cp\u003eThe patient rejected the plan of a second thoracotomy operation. Considering that the transseptal approach was against the direction of blood flow of the perivalvular regurgitation, it posed certain difficulties for the guide wire to pass through the PVL orifice. In addition, our structural heart team, which has extensive experience in cardiac interventional procedures, typically relies solely on echocardiography for guidance. Therefore, the decision was made to perform interventional closure through the left ventricular apical approach to reduce operative time. We engaged in a detailed discussion about the procedure based on the TEE findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe procedure was performed in the operating room under TEE guidance using the EPIQ CVx ultrasound system by Philips Healthcare in the Netherlands. Under TEE guidance, the surgeon punctured the apical area and directed the guide wire towards the PVL at the posterior segment of the mitral valve annulus. Once the guide wire had smoothly traversed through the larger defect and entered the left atrium, a 7F delivery sheath was advanced over it into the left atrium along the guide wire. The guide wire was then removed, and an 8mm symmetric VSD occluder from Shanghai Push Medical Device Co., Ltd., China, was deployed via the sheath (Fig.4). After the first device was deployed, RT-3D True-Vue color Doppler flow imaging revealed that another stream of regurgitation was still present next to the device. Consequently, a 7mm device was deployed in the same manner (Fig.5). TEE showed that the second occluder\u0026rsquo;s disk slightly overlapped with that of the first. The devices were stable, with satisfactory morphology and no impact on prosthetic leaflets motion (Fig.6).\u003c/p\u003e\n\u003cp\u003eImmediately after the surgery, a postoperative 3D color TEE showed normal mechanical valve leaflets motion and no residual reflux signal. The postoperative examination was uneventful. Follow-up assessment at one month and six months postoperatively revealed no recurrence of preoperative heart failure symptoms.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSurgery has traditionally been the preferred treatment option for patients with PVL, as medical management has limited efficacy. PVL surgery may involve either replacing or repairing the prosthetic valve via thoracotomy, or a less invasive transcatheter plugging operation. For patients at high risk, interventional closure is considered a practical and less invasive alternative to surgery, effectively alleviating symptoms and mitigating consequences\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe success of PVL occlusion depends on a comprehensive and accurate assessment of the patient's condition. This includes evaluating the size, shape, and location of the PVLs, as well as the stability of the artificial valve ring. Formulating a surgical plan based on these assessment findings is essential. With advances in multimodality imaging, a variety of diagnostic tools are available for diagnosing PVL. Echocardiography and cardiac computed tomography (CT) are commonly utilized as primary diagnostic modalities. Additionally, supplementary diagnostic tools such as digital subtraction angiography (DSA), cardiac magnetic resonance (CMR), and intracardiac echocardiography (ICE) may also be employed.\u003c/p\u003e \u003cp\u003eEchocardiography is generally the preferred method for evaluating PVLs. 3D echocardiography offers precise positioning and detailed visualization of the PVL\u0026rsquo;s shape, providing critical insights into hemodynamics. RT-3D TEE, when combined with color Doppler, furnishes informative structures that are invaluable for periprocedural assessment. In the 3D TEE view, the complex geometry of mitral PVLs can be accurately depicted without the interference of acoustic shadowing. Additionally, 3D color mapping can be employed for confirmation, helping to prevent misdiagnosis. Futhermore, 3D imaging allows for a comprehensive evaluation of adjacent tissues, offering essential details that are crucial for planning and guiding interventional occlusion procedures\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCardiac CT is a valuable tool for evaluating perivalvular anatomical structures, particularly in patients with suboptimal echocardiographic image quality. It enables comprehensive cardiac imaging with excellent spatial and temporal resolution\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Recent advancements in CT technology have mitigated issues related to beam hardening and motion artifacts, thereby facilitating a more accurate evaluation of prosthetic valves\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. However, the assessment of perivalvular leakage demands a high level of technical expertise and meticulous preparation, as well as efficient equipment. Parameters for image acquisition, such as the cardiac phase, windowing, motion artifact control, and slice thickness, must be meticulously optimized\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Furthermore, CT has limitations in effectively assessing cardiac function or the severity of PVL reflux. It is also susceptible to artifacts from replacement prosthetic valves or valve calcification, which can lead to inaccuracies in the assessment of PVL size\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e3D printing technology plays an essential role in certain structural interventions. A 3D printed model can simulate the placement strategy for valve occlusion, facilitating a rapid and efficient surgical plan without the waste of time and resources. It also has the potential to predict device-related adverse events, such as residual leakage and valve leaflet obstruction\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. However, 3D printing has its limitations, particularly in accurately representing subtle structures and hemodynamics. The fidelity of the model hinges on the selection of materials and the printing techniques employed\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Furthermore, the size of the valve's primary ring fluctuates throughout different cardiac cycles, necessitating a careful selection of the cardiac phase when creating and measuring the virtual ring. This requirement adds to the complexity of designing the model\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. As demonstrated in this case, the process of adjusting CT data and model parameters is not only necessary but also highly subjective.\u003c/p\u003e \u003cp\u003eDSA is a traditional method used to guide transcatheter closure of PVL. During the procedure, DSA is utilized for localization and embolization, relying on the radioactive projection of a contrast agent. However, compared to echocardiography, DSA has certain limitations. Patients are required to remain still and hold their breath during the examination, and the accuracy of detection may be compromised by various factors, including pain, interference, involuntary movement, or arrhythmia\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Furthermore, DSA exposes both patients and medical staff to the risk associated with radiation, and it may not clearly delineate subtle intracardiac structures or the orifice of a cardiac defect.\u003c/p\u003e \u003cp\u003eCMR is a valuable adjunct for evaluating both functional and anatomical details. It is capable of generating precise blood flow images and performing volume-based measurements, which are crucial for quantifying regurgitant flow associated with various types of valves\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. CMR can image all prosthetic valves, irrespective of ejection fraction and valve morphology, allowing for the measurement of the regurgitant volume across different valve types. However, CMR has limitations when assessing PVL with high accuracy, particularly when the sizes of the PVL and the prosthetic valve are small. Additionally, the presence of arrhythmia or motion artifacts can impede the evaluation of PVL and may limit the widespread use of CMR in the context\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA novel software tool called Echonavigator\u0026reg; from Philips Healthcare in the Netherlands is now accessible. It facilitates real-time image synchronization and fusion of 2D and 3D TTE with fluoroscopy images. This technology enables precise positioning of the percutaneous mitral valve on the fluoroscopic view and aids in the accurate guidance through the PVL. The safety and feasibility of this technology have been established in the context of numerous structural heart diseases\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. However, procedures of this nature necessitate specialized equipment in the operating room.\u003c/p\u003e \u003cp\u003eIn instances where advanced technology is not accessible, TEE can offer advantages over 3D printing\u003csup\u003e[21]\u003c/sup\u003e. For instance, in cases involving multiple mitral PVLs, a innovative diagnostic approach combines RT-3D TEE with a 3D printed model during surgery. This method facilitates the creation of a stereoscopic and intuitive image of the intracardiac structures, leveraging the capabilities of 3D TEE. The benefits of this technique include the provision of relatively accurate and real-time guidance, which is crucial for avoiding damage to surrounding tissues during the plugging of multiple PVLs, especially when guided by conventional TEE alone.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe integration of 3D ultrasound with color mapping is particularly advantageous for accurately delineating multiple PVLs during their occlusion. Furthermore, the use of 3D TEE in conjunction with 3D printing technology offers a \"double safeguard\" in transcatheter closure procedures. This combined approach allows for more precise and efficient occlusion of multiple PVLs and presents a promising new paradigm for managing complications that arise following valve replacement. Consequently, the application of this integrated method is highly recommended for broader use in clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study have been included in the article and supplementary material. For further inquiries, please contact the corresponding authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical review and approval were not required for the study involving human participants, as it was conducted in accordance with the local legislation and institutional requirements. Written informed consent was obtained from each participant, including their consent for the publication of any potentially identifiable images or data included in this article.Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the fund from Hunan Provincial Health Commission Research Project (202204023391) and Hunan Innovative Province Construction Special Project of the Hunan Provincial Department of Science and Technology (2022ZK4107).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST DISCLOSURE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have no conflict of interest to declare.Consent to Publish declaration: not applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e（A）Zhirong Wang: Drafted the manuscript and was resiponsible for the review and interpretation of imaging findings. (B)Qiuxian Wan: Contributed to drafting and revising the manuscript.（C）Chengming Fan: Reviewed and revised the manuscript.(D)Hong You and(E) Qi Ai: Handled the collection and editing images, as well as revising the manuscript.(F)Tianli Zhao: Provided 3D printed images, participated in formulating the interventional surgery plan, and performed the surgery on the patient.(G)Shijun Hu: Performed the surgery on the patient, reviewed the manuscript, and offered valuable suggestions during the initial drafting phase of the manuscript. (H）Qin Wu: Responsible for the comprehensive review, revision and polishing of the entire manuscript, as well as for addressing the reviewers' inquiries.All authors have contributed to the work, have read the manuscript, and approved the submitted version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThomas F L\u0026uuml;scher, MD, FESC, Mitral valve disease: news from the frontier in valvular heart disease, \u003cem\u003eEuropean Heart Journal\u003c/em\u003e, Volume 39, Issue 15, 14 April 2018, Pages 1211\u0026ndash;1214.\u003c/li\u003e\n\u003cli\u003eWriting Committee Members, Otto C M, Nishimura R A, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[J]. Journal of the American College of Cardiology, 2021, 77(4): e25-e197.\u003c/li\u003e\n\u003cli\u003eVahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)[J]. European heart journal, 2022, 43(7): 561-632.\u003c/li\u003e\n\u003cli\u003eCruz-Gonzalez I, Rama-Merchan J C, Rodr\u0026iacute;guez-Collado J, et al. Transcatheter closure of paravalvular leaks: state of the art[J]. Netherlands Heart Journal, 2017, 25: 116-124.\u003c/li\u003e\n\u003cli\u003eFurukawa K, Kamohara K, Itoh M, Furutachi A, Mukae Y, Morita S.Real‐time three‐dimensional transesophageal echocardiography is useful for the localization of a small mitral paravalvular leak. Ann Thorac Surg. 2011;91:e72‐e73 \u003c/li\u003e\n\u003cli\u003eAziz M U, Manapragada P, Singh S P. Non coronary applications of cardiac computed tomography: A review[J]. Journal of Medical Imaging and Radiation Sciences, 2021, 52(3): S51-S64.\u003c/li\u003e\n\u003cli\u003eGhersin E , Martinez CA , Singh V , Fishman JE , Macon CJ , Runco Ther- rien JE . ECG-gated MDCT after aortic and mitral valve surgery. AJR Am J Roentgenol . 2014;203(6):W596\u0026ndash;W604 \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Neill, A.C.; Martos, R.; Murtagh, G.; Ryan, E.R.; McCreery, C.; Keane, D.; Quinn, M.; Dodd, J.D. Practical tips and tricks for assessing prosthetic valves and detecting paravalvular regurgitation using cardiac CT. J. Cardiovasc. Comput. Tomogr. 2014, 8, 323\u0026ndash;327.\u003c/li\u003e\n\u003cli\u003eHascoet S, Smolka G, Bagate F, et al. Multimodality imaging guidance for percutaneous paravalvular leak closure: Insights from the multi-centre FFPP register[J]. Archives of Cardiovascular Diseases, 2018, 111(6-7): 421-431.\u003c/li\u003e\n\u003cli\u003eQuail MA, Nordmeyer J, Schievano S, Reinthaler M, Mullen MJ, Taylor AM. Use of cardiovascular magnetic resonance imaging for TA VR assessment in patients with bioprosthetic aortic valves: comparison with computed tomography. Eur J Radiol. 2012;81:3912\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003e.Numata S, Tsutsumi Y , Monta O, Yamazaki S, Seo H, Y oshida S, et al. Mechanical valve evaluation with four-dimensional computed tomography. J Heart V alve Dis. 2013;22:837\u0026ndash;42.\u003c/li\u003e\n\u003cli\u003eBalzer J, Zeus T, Veulemans V, et al. Hybrid imaging in the catheter laboratory: real-time fusion of echocardiography and fluoroscopy during percutaneous structural heart disease interventions. Interv Cardiol 2016; 11: 59\u0026ndash;64.\u003c/li\u003e\n\u003cli\u003eLau I, Sun Z. Three‐dimensional printing in congenital heart disease: A systematic review[J]. Journal of medical radiation sciences, 2018, 65(3): 226-236.\u003c/li\u003e\n\u003cli\u003eCiobotaru V, Tadros VX, Batistella M, Maupas E, Gallet R, Decante B, Lebret E, Gerardin B, Hascoet S. 3D-Printing to Plan Complex Transcatheter Paravalvular Leaks Closure. J Clin Med. 2022 Aug 15;11(16):4758.\u003c/li\u003e\n\u003cli\u003eOoms J F, Wang D D, Rajani R, et al. Computed tomography\u0026ndash;derived 3D modeling to guide sizing and planning of transcatheter mitral valve interventions[J]. Cardiovascular Imaging, 2021, 14(8): 1644-1658.\u003c/li\u003e\n\u003cli\u003eYamamoto M, Okura Y, Ishihara M, et al. Development of digital subtraction angiography for coronary artery[J]. Journal of digital imaging, 2009, 22(3): 319-325\u003c/li\u003e\n\u003cli\u003eNejati M, Pourghassem H. Multiresolution image registration in digital X-ray angiography with intensity variation modeling. J Med Syst. 2014;38:10.\u003c/li\u003e\n\u003cli\u003eZoghbi WA, Asch FM, Bruce C, et al. Guidelines for the evaluation of valvular regurgitation after percutaneous valve repair or replace-ment: a report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular\u003c/li\u003e\n\u003cli\u003eAngiography and Interventions, Japanese Society of Echocardio-graphy, and Society for Cardiovascular Magnetic Resonance. J A m Soc Echocardiogr. 2019;32:431‐475.\u003c/li\u003e\n\u003cli\u003eSuch\u0026aacute; D, Symersky P, Tanis W, et al. Multimodality imaging as-sessment of prosthetic heart valves. Circ Cardiovasc Imaging. 2015;8:e003703.\u003c/li\u003e\n\u003cli\u003eCiobotaru V, Tadros V X, Batistella M, et al. 3D-Printing to Plan Complex Transcatheter Paravalvular Leaks Closure[J]. Journal of clinical medicine, 2022, 11(16): 4758.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multiple perivalvular leaks, Perivalvular leakage plugging surgery, Real-time three-dimensional echocardiography, 3D printing","lastPublishedDoi":"10.21203/rs.3.rs-4970894/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4970894/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTo report on a patient who developed multiple perivalvular leaks (PVLs) after a mechanical mitral valve replacement, and how clinicians successfully used real-time three-dimensional (RT-3D) transesophageal echocardiography (TEE) combined with \u0026nbsp;three-dimensional (3D)printing to complete transapical perivalvular closure. Additionally, we reviewed the literature to explore the advantages and disadvantages of multimodal imaging for PVLs. The case is a 63-year-old female patient with a history of rheumatic heart disease underwent mitral mechanical valve replacement, tricuspid valvuloplasty, and left atrial reduction four years ago. She presented with shortness of breath and transthoracic echocardiography (TTE) revealed a PVL. RT-3D TEE combined with 3D printing technology was used to create a 3D model of the patient's heart, which allowed for precise identification of the PVLs. Ultimately, it was determined that the patient had two PVLs. The transapical occlusion was successfully performed with the guidance provided of 3D TEE. Postoperative follow-up indicated good recovery for the patient. The integration of 3D ultrasound with color Doppler mapping has demonstrated significant advantages in the identification and characterization of multiple PVLs. Furthermore, the synergistic application of RT-3D TEE and 3D printing technology facilitates superior precision and accuracy in PVLs closure, ensuring optimal positioning of occlusive devices. Utilizing multimodal imaging techniques is crucial for the effective management of PVLs, as it furnishes clinicians with vital data necessary to ensure the success of therapeutic interventions.\u003c/p\u003e","manuscriptTitle":"Real-Time Three-Dimensional Transesophageal Echocardiography vs. Three-Dimensional Printing: Detection of Multiple Perivalvular Leaks after Mitral Valve Replacement - A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 18:27:23","doi":"10.21203/rs.3.rs-4970894/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"17d3648f-cf6e-4ed8-8f3e-75df9eb1b14f","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-21T14:45:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-09 18:27:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4970894","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4970894","identity":"rs-4970894","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}