Real-Time Three-Dimensional Transesophageal Echocardiography Outperforms Three-Dimensional Printing in Detecting Multiple Perivalvular Leaks after Mitral Valve Replacement：A Case Report and Literature Review

Real-Time Three-Dimensional Transesophageal Echocardiography Outperforms Three-Dimensional Printing in Detecting 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 Outperforms Three-Dimensional Printing in Detecting Multiple Perivalvular Leaks after Mitral Valve Replacement：A Case Report and Literature Review Zhirong Wang, Qiuxian Wan, Chengming Fan, Qi Ai, Hong You, Qin Wu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3826763/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 transesophageal echocardiography combined with 3D printing to complete transapical perivalvular closure. Additionally, we reviewed the literature to explore the advantages and disadvantages of multimodal imaging for perivalvular leaks.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 folding four years ago. She presented with shortness of breath and TTE revealed two PVLs. Real-time 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. The transapical occlusion was successfully performed under the guidance of 3D TEE.The patient also showed good recovery during postoperative follow-up.The combination of 3D ultrasound and color mapping is advantageous in identifying and describing multiple PVLs. The use of 3D TEE combined with 3D printing technology provides a "double protection" in closure of PVLs, allowing for more accurate and precise placement of closure devices. Multimodal imaging plays a critical role in the management of PVLs, providing clinicians with essential information for successful treatment. 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 can occur after valve replacement, which can cause various degrees of clinical consequences depending on the amount of turbulent blood flow. Complications such as infective endocarditis, hemolytic anemia, or heart failure may occur as a result [ 1 ] . Traditionally, the management of symptomatic patients with PVL has relied on redo surgery using cardiopulmonary bypass, which requires re-thoracotomy to suture the original PVL or even remove the original valve for re-suture. However, the extensive adhesion that occurs after the initial surgery can make reoperation challenging. Currently, transcatheter closure with implantation of the device provides a less invasive treatment strategy for symptomatic patients at high surgical risk. The ESC and ACC guidelines point out that this option should be considered depending on the number and morphology of leaks so as to maintain valve prosthesis function [ 2 – 3 ] . Therefore, multimodality imaging is essential for surgeons to identify the shape, size, and location of PVL. In this case, our structural heart team used three-dimensional transesophageal echocardiography (3D TEE) imaging and 3D printing to identify the PVL. We performed interventional closure of the mitral valve PVL through left ventricular apical access, and the operation was successfully completed under the guidance of TEE. 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 folding 4 years ago. She was readmitted to the hospital due to chest stuffiness, palpitations, and shortness of breath for over 2 months. On physical examination, a systolic murmur was heard at the auscultatory mitral area. She had not undergone regular echocardiography after discharge. Blood test and biochemical examination at admission revealed mild hemolytic anemia, with hemoglobin levels of 106 g/L 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 NYHA heart function was grade III. Troponin I levels were elevated at 0.29 ng/L, myoglobin levels were 95.1 ng/mL, and BNP levels were 1325 pg/mL, indicating myocardial injury. Color Doppler ultrasound of lower extremity blood vessels indicates poor blood vessel quality. TTE showed that the ejection fraction (EF) was 60%. The function of the mechanical mitral valve was normal, but there was a PVL at the posterior segment of the mitral valve annulus. To better evaluate the location and morphology of the PVL, a full-scale simulation 3D print model was created based on the patient's cardiac computed tomography angiography (CTA) data. The 3D printed model showed a single oval defect located at the 6 o’clock position from the surgeon’s view.By adjusting the CTA gray level several times, the small hole displayed on the 3D model are the same as the one in the same position before.However, during TEE, two defects were observed, with the size of the defects being 5mm and 4mm. In addition, multiple jets appeared on TEE (Fig. 1 ). To further evaluate the hemodynamic changes, a TEE was performed on the patient. Both two-dimensional (2D) and real-time three-dimensional (RT-3D) combined color-flow imaging were used to visualize the perivalvular leak. Surprisingly, the number of leaks observed on TEE was different from what was shown in the 3D model. Multiple jets were now visible on TEE as a result. RT-3D TEE from the left atrial view revealed two adjacent defects, which could either be a crescentic defect divided by a tight suture or fiber texture. The defects were mainly located at the posterior segment of the mitral valve annulus (6 o'clock position of mitrial annulus) and measured 5mm and 4mm in size, respectively. Interestingly, the motion of the sewing ring appeared to be stabilized (Fig. 2 ). Upon reviewing the cardiac computed tomography angiography (CTA) data, it was discovered that there was another small adjacent defect beside the original one that was previously missed. After adjusting the gray scale, the additional defect was visible (see Fig. 3 ). Considering the patient's rejection of a second thoracotomy operation and the poor quality of peripheral blood vessels, the decision was made to perform interventional closure through left ventricular apical access. The structural heart team of our institute engaged in a detailed discussion regarding the procedure based on the findings from the TEE. The procedure was performed in the operating room under TEE guidance using the EPIQ CVx ultrasound system by Phillips Healthcare in the Netherlands. The surgeon punctured the apical area with TEE guidance and directed the guide wire towards the perivalvular leakage position at the posterior segment of the mitral valve annulus. Once the guide wire passed smoothly through the large defect and entered the left atrium, a 7F delivery sheath was inserted 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 in China was placed along the sheath (Fig. 4 ). After the first device was deployed, a real time 3D True-Vue color doppler flow imaging revealed that another stream of regurgitation was still present next to the device. Therefore, a 7mm device was deployed in the same manner (Fig. 5 ). TEE showed that the second disk slightly overlapped with the first one. The stability and morphology of the devices were satisfactory without affecting the movement of the prosthetic leaflets (Fig. 6 ). Immediately after the surgery, a color 3D TEE evaluation demonstrated the normal opening of the mechanical leaflets and no residual reflux signal. The postoperative examination was uneventful.Through the follow-up of patient one month and half a year after operation, the symptoms of heart failure before operation did not recur. 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 through thoracotomy, or a less invasive plugging operation. For high-risk patients, interventional closure of PVL is considered a practical and less invasive alternative to alleviate symptoms and consequences [ 4 ] . The success of PVL occlusion depends on a comprehensive and accurate evaluation of the patient's condition, including the size, shape, and location of the PVL, as well as the stability of the artificial valve ring. A surgical plan based on these evaluation results is crucial. With advances in multimodality imaging, various diagnostic tools can diagnose PVL, and echocardiography and cardiac-computed tomography (CT) are often used as the primary diagnostic tools. Supplementary tools such as digital subtraction angiography (DSA), cardiac magnetic resonance (CMR), and intracardiac echocardiography (ICE) can also be utilized. Echocardiography is generally the preferred examination for evaluating PVL. 3D echocardiography provides accurate positioning and visualization of the PVL shape and offers critical insights into hemodynamics. RT-3D TEE combined with color Doppler provides informative structures for periprocedural assessment. In the 3D TEE view, the complex geometry of mitral PVL can be accurately depicted without disturbing acoustic shadowing. Meanwhile, 3D color mapping can be used for confirmation to avoid misdiagnosis. 3D imaging can comprehensively evaluate adjacent tissues, which provides important details for planning and guiding interventional occlusion [ 5 ] . Cardiac CT can be a valuable tool in evaluating perivalvular anatomical structures, especially in patients with limited echocardiographic image quality. It allows for complete cardiac imaging with excellent spatial and temporal resolution [ 6 ] . Recent advancements in CT technology have reduced beam hardening and motion artifacts, leading to better evaluation of prosthetic valves [ 7 ] . However, evaluating perivalvular leakage requires a high technical level and careful preparation and efficient equipment. Image acquisition parameters, such as cardiac phase, windowing, motion artifact, and slice thickness, must be optimized [ 8 ] . Additionally, CT cannot effectively assess cardiac function or the degree of perivalvular leakage reflux. It is vulnerable to artifacts caused by replacement prosthetic valves or valve calcification, leading to deviations in PVL size assessment [ 9 , 10 , 11 ] . 3D printing technology plays an essential role in some structural interventions. The 3D printed model can simulate the placement strategy for valve occlusion, enabling a fast and effective surgical plan without wasting time and resources. It can also predict device-related adverse events, such as residual leakage and valve leaflet obstruction [ 12 – 13 ] . However, 3D printing has limitations in displaying subtle structures and hemodynamics. The accuracy of the model depends on the choice of materials and printing techniques [ 14 ] . Additionally, the size of the valve primary ring changes during different heart cycles, requiring careful selection of the heart phase when creating and measuring the virtual ring, which increases the difficulty of designing the model [ 15 ] . As seen in this case, the process of adjusting CT data and model parameters is necessary but highly subjective. DSA is a traditional method used to guide PVL transcatheter closure. During the operation, DSA is used for localization and embolization based on the radioactive projection of the contrast agent. However, compared to echocardiography, DSA has certain limitations. Patients must remain still and hold their breath during the examination, and the accuracy of detection may be affected by various factors such as pain, interference, involuntary movement, or arrhythmia [ 16 – 17 ] . Moreover, DSA exposes both patients and inspectors to radiation risk, and it cannot clearly display subtle intracardiac structures or the hole in the heart cavity. CMR is a useful complement to evaluate functional and anatomical resolution. It can produce accurate blood flow imaging and volume-based measurements, which play a vital role in quantifying return flow for different types of valves [ 18 ] . All prosthetic valves can be imaged by CMR regardless of ejection fraction and valve morphology, and the regurgitant volume of various valve types can be measured. However, CMR has limitations in evaluating PVL accuracy when the PVL and prosthetic valve sizes are small. Additionally, the presence of arrhythmia or motion artifacts can affect the evaluation of PVL and limit its widespread use [ 19 ] . A new software tool called Echonavigator® from Philips Healthcare in the Netherlands is now available, which enables real-time image synchronization and fusion of 2D and 3D TTE with fluoroscopy images. This technology allows for the precise positioning of the percutaneous mitral valve on the fluoroscopic view and facilitates the accurate steering of the guide wire through the PLV. The safety and feasibility of this technology have been demonstrated in many structural heart diseases [ 20 ] . However, this type of procedure requires special equipment in the operating room. In cases where the above technology is not available, TEE can provide an advantage over 3D printing [ 21 ] . For example, in cases of multiple mitral PVLs, a new innovative diagnostic approach involves combining RT-3D TEE with a 3D printed model during surgery. This approach allows for the construction of a stereoscopic and intuitive image of the intracardiac structure based on 3D TEE. The advantages of this method include relatively accurate and real-time guidance to avoid damaging surrounding tissues during multiple PVLs plugging under the guidance of simple TEE. CONCLUSION The combination of 3D ultrasound and color mapping is particularly advantageous in accurately describing multiple PVLs during their occluding. In addition, the use of 3D TEE combined with 3D printing technology provides "double protection" in transcatheter closure procedures. This approach enables more accurate and efficient occluding of multiple PVLs and represents a promising new model for addressing complications following valve replacement. Therefore, the application of this combined approach is worthy of promotion in the clinical setting. 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. FUNDING This work was supported by the fund from Teaching Reform Project of Central South University (2021JGB094). CONFLICT OF INTEREST DISCLOSURE Authors have no conflict of interest to declare 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-3826763","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":265539577,"identity":"fb38e066-ff8b-41d7-b350-051d22ab6006","order_by":0,"name":"Zhirong Wang","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"prefix":"","firstName":"Zhirong","middleName":"","lastName":"Wang","suffix":""},{"id":265539578,"identity":"48145171-7540-4e9e-ae8d-1b0bea4b4386","order_by":1,"name":"Qiuxian Wan","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"prefix":"","firstName":"Qiuxian","middleName":"","lastName":"Wan","suffix":""},{"id":265539579,"identity":"3c1f18cd-f8a6-4a48-95bf-30ed449ac465","order_by":2,"name":"Chengming Fan","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"prefix":"","firstName":"Chengming","middleName":"","lastName":"Fan","suffix":""},{"id":265539580,"identity":"ec8a6657-74ca-4576-99cc-8fc8be7c35dd","order_by":3,"name":"Qi Ai","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"prefix":"","firstName":"Qi","middleName":"","lastName":"Ai","suffix":""},{"id":265539581,"identity":"ff2e24bf-82f9-48db-a494-bb6163e087c6","order_by":4,"name":"Hong You","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"You","suffix":""},{"id":265539582,"identity":"6af16c03-f5b1-43e1-9415-f6a91f335658","order_by":5,"name":"Qin Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIie3OsQrCMBCA4SuBuJx7iugzBAoVoeirKIVMDh3dFAS7iK6KPkTFwTVwg0sfoOIiFDo5CO5qcRRp6+aQnxsukA8OwGT60zSMRKsXTt4Pa1KNxJ4jUf9AwJqpQST6FYlM/B0FnKyDnaZ3BK8ZaZZdiokKaIXEOhvlNhCUE2nelkXETYaSUBCH85AzBBpEGrkoJ/nAKWb5Yc+qpK+ETBDyw3Q56cVZQKg9ac+Va2+l76yJu4XEDv39vf4Q42WN0tt11G0ujtOskOTJj52V/P8gJpPJZPrSC4WFSj6XNCeSAAAAAElFTkSuQmCC","orcid":"","institution":"Central South University","correspondingAuthor":true,"prefix":"","firstName":"Qin","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2024-01-01 03:29:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3826763/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3826763/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49388206,"identity":"bb017842-7e76-427c-9da5-d74688bbbbb0","added_by":"auto","created_at":"2024-01-09 20:52:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":152363,"visible":true,"origin":"","legend":"\u003cp\u003eAccording to the 3D printed model of the patient's cardiac CT, the aortic valve is located at 12 o'clock from surgeon’s view. A hole can be seen at 6 o'clock of the mitral valve annulus in 3D modeling diagram(A) and in 3D printing solid model (B)（shown in the red boxes）.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3826763/v1/2f7cc3737ecd818d7041f9aa.png"},{"id":49387925,"identity":"bc205290-348f-4f0e-9454-51ee50e66ee4","added_by":"auto","created_at":"2024-01-09 20:44:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":251883,"visible":true,"origin":"","legend":"\u003cp\u003eTwo adjacent perivalvular leakags were found in 3D TrueVue mode (A) and two streams of perivalvular regurgitation were shown in color doppler flow imaging (B) and in two dimensional section combined color doppler flow imaging(C).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3826763/v1/df5355feca87a7c24d5a3d3f.png"},{"id":49387923,"identity":"bad9cfc0-94eb-4ee9-861b-7447901832e1","added_by":"auto","created_at":"2024-01-09 20:44:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":95789,"visible":true,"origin":"","legend":"\u003cp\u003eReadjusted 3D modeling diagram showed two adjacent holes around the valve orifice from atrial view (A) and from ventricular view (B).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3826763/v1/998b748eada0bed58064ecaf.png"},{"id":49387928,"identity":"a15a42a9-c65c-432e-b8fc-562ee38c0295","added_by":"auto","created_at":"2024-01-09 20:44:36","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":239779,"visible":true,"origin":"","legend":"\u003cp\u003eGuide wire passed the left ventricle through one of the leakage hole to left atrium in real-time 3D image (A) . The first occluder was released and one hole was occluded. (B). Regurgitation was still visible along the edge of the first occluder in color doppler flow imaging (C).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3826763/v1/1ce15e2304af2a373cebbf3b.png"},{"id":49388207,"identity":"3c55eb7c-382f-4b60-9af1-d6b9649ebb75","added_by":"auto","created_at":"2024-01-09 20:52:36","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":207094,"visible":true,"origin":"","legend":"\u003cp\u003eUnder the guidance of real-time three dimensional tranesophageal echocardiography, guide wire repass the left ventricle through another hole adjacent to the first occluder in 3D view (A) and in 3D TrueVue view (B). The delivery sheath passed throuth the second hole along the guide wire and the second occluder was released (C).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3826763/v1/064859196dd62e6df61f9942.png"},{"id":49387926,"identity":"3854413c-27bd-4d79-b15e-ce1d1b08dcb1","added_by":"auto","created_at":"2024-01-09 20:44:36","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":179133,"visible":true,"origin":"","legend":"\u003cp\u003eThe two occluders overlapped slightly in 3D view (A) and no regurgitation were detected in real-time 3D color dopper flow imaging (B). The occluding effect is satisfactory.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-3826763/v1/98af481b21f519c0182419bf.png"},{"id":56516863,"identity":"e7eb9a9e-3a26-4589-9a4f-0505dc5419eb","added_by":"auto","created_at":"2024-05-15 07:59:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1372250,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3826763/v1/1c620914-6d84-4d54-a429-44ac7c69dbd3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Real-Time Three-Dimensional Transesophageal Echocardiography Outperforms Three-Dimensional Printing in Detecting 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 can occur after valve replacement, which can cause various degrees of clinical consequences depending on the amount of turbulent blood flow. Complications such as infective endocarditis, hemolytic anemia, or heart failure may occur as a result\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 redo surgery using cardiopulmonary bypass, which requires re-thoracotomy to suture the original PVL or even remove the original valve for re-suture. However, the extensive adhesion that occurs after the initial surgery can make reoperation challenging.\u003c/p\u003e \u003cp\u003eCurrently, transcatheter closure with implantation of the device provides a less invasive treatment strategy for symptomatic patients at high surgical risk. The ESC and ACC guidelines point out that this option should be considered depending on the number and morphology of leaks so as 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 for surgeons to identify the shape, size, and location of PVL.\u003c/p\u003e \u003cp\u003eIn this case, our structural heart team used three-dimensional transesophageal echocardiography (3D TEE) imaging and 3D printing to identify the PVL. We performed interventional closure of the mitral valve PVL through left ventricular apical access, and the operation was successfully completed under the guidance of TEE.\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 left atrial folding 4 years ago. She was readmitted to the hospital due to chest stuffiness, palpitations, and shortness of breath for over 2 months. On physical examination, a systolic murmur was heard at the auscultatory mitral area. She had not undergone regular echocardiography after discharge.\u003c/p\u003e \u003cp\u003eBlood test and biochemical examination at admission revealed mild hemolytic anemia, with hemoglobin levels of 106 g/L and hematocrit levels of 31.9%, and elevated levels of total bilirubin (37.7 \u0026micro;mol/L) and direct bilirubin (11.6 \u0026micro;mol/L). The patient's NYHA heart function was grade III. Troponin I levels were elevated at 0.29 ng/L, myoglobin levels were 95.1 ng/mL, and BNP levels were 1325 pg/mL, indicating myocardial injury. Color Doppler ultrasound of lower extremity blood vessels indicates poor blood vessel quality.\u003c/p\u003e \u003cp\u003eTTE showed that the ejection fraction (EF) was 60%. The function of the mechanical mitral valve was normal, but there was a PVL at the posterior segment of the mitral valve annulus. To better evaluate the location and morphology of the PVL, a full-scale simulation 3D print model was created based on the patient's cardiac computed tomography angiography (CTA) data. The 3D printed model showed a single oval defect located at the 6 o\u0026rsquo;clock position from the surgeon\u0026rsquo;s view.By adjusting the CTA gray level several times, the small hole displayed on the 3D model are the same as the one in the same position before.However, during TEE, two defects were observed, with the size of the defects being 5mm and 4mm. In addition, multiple jets appeared on TEE (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo further evaluate the hemodynamic changes, a TEE was performed on the patient. Both two-dimensional (2D) and real-time three-dimensional (RT-3D) combined color-flow imaging were used to visualize the perivalvular leak. Surprisingly, the number of leaks observed on TEE was different from what was shown in the 3D model. Multiple jets were now visible on TEE as a result. RT-3D TEE from the left atrial view revealed two adjacent defects, which could either be a crescentic defect divided by a tight suture or fiber texture. The defects were mainly located at the posterior segment of the mitral valve annulus (6 o'clock position of mitrial annulus) and measured 5mm and 4mm in size, respectively. Interestingly, the motion of the sewing ring appeared to be stabilized (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUpon reviewing the cardiac computed tomography angiography (CTA) data, it was discovered that there was another small adjacent defect beside the original one that was previously missed. After adjusting the gray scale, the additional defect was visible (see Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsidering the patient's rejection of a second thoracotomy operation and the poor quality of peripheral blood vessels, the decision was made to perform interventional closure through left ventricular apical access. The structural heart team of our institute engaged in a detailed discussion regarding the procedure based on the findings from the TEE.\u003c/p\u003e \u003cp\u003eThe procedure was performed in the operating room under TEE guidance using the EPIQ CVx ultrasound system by Phillips Healthcare in the Netherlands. The surgeon punctured the apical area with TEE guidance and directed the guide wire towards the perivalvular leakage position at the posterior segment of the mitral valve annulus. Once the guide wire passed smoothly through the large defect and entered the left atrium, a 7F delivery sheath was inserted 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 in China was placed along the sheath (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). After the first device was deployed, a real time 3D True-Vue color doppler flow imaging revealed that another stream of regurgitation was still present next to the device. Therefore, a 7mm device was deployed in the same manner (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e5\u003c/span\u003e). TEE showed that the second disk slightly overlapped with the first one. The stability and morphology of the devices were satisfactory without affecting the movement of the prosthetic leaflets (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImmediately after the surgery, a color 3D TEE evaluation demonstrated the normal opening of the mechanical leaflets and no residual reflux signal. The postoperative examination was uneventful.Through the follow-up of patient one month and half a year after operation, the symptoms of heart failure before operation did not recur.\u003c/p\u003e \u003cp\u003e \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 through thoracotomy, or a less invasive plugging operation. For high-risk patients, interventional closure of PVL is considered a practical and less invasive alternative to alleviate symptoms and 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 evaluation of the patient's condition, including the size, shape, and location of the PVL, as well as the stability of the artificial valve ring. A surgical plan based on these evaluation results is crucial. With advances in multimodality imaging, various diagnostic tools can diagnose PVL, and echocardiography and cardiac-computed tomography (CT) are often used as the primary diagnostic tools. Supplementary tools such as digital subtraction angiography (DSA), cardiac magnetic resonance (CMR), and intracardiac echocardiography (ICE) can also be utilized.\u003c/p\u003e \u003cp\u003eEchocardiography is generally the preferred examination for evaluating PVL. 3D echocardiography provides accurate positioning and visualization of the PVL shape and offers critical insights into hemodynamics. RT-3D TEE combined with color Doppler provides informative structures for periprocedural assessment. In the 3D TEE view, the complex geometry of mitral PVL can be accurately depicted without disturbing acoustic shadowing. Meanwhile, 3D color mapping can be used for confirmation to avoid misdiagnosis. 3D imaging can comprehensively evaluate adjacent tissues, which provides important details for planning and guiding interventional occlusion\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCardiac CT can be a valuable tool in evaluating perivalvular anatomical structures, especially in patients with limited echocardiographic image quality. It allows for complete 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 reduced beam hardening and motion artifacts, leading to better evaluation of prosthetic valves \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. However, evaluating perivalvular leakage requires a high technical level and careful preparation and efficient equipment. Image acquisition parameters, such as cardiac phase, windowing, motion artifact, and slice thickness, must be optimized \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Additionally, CT cannot effectively assess cardiac function or the degree of perivalvular leakage reflux. It is vulnerable to artifacts caused by replacement prosthetic valves or valve calcification, leading to deviations in PVL size assessment \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 some structural interventions. The 3D printed model can simulate the placement strategy for valve occlusion, enabling a fast and effective surgical plan without wasting time and resources. It can also 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 limitations in displaying subtle structures and hemodynamics. The accuracy of the model depends on the choice of materials and printing techniques \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Additionally, the size of the valve primary ring changes during different heart cycles, requiring careful selection of the heart phase when creating and measuring the virtual ring, which increases the difficulty of designing the model \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. As seen in this case, the process of adjusting CT data and model parameters is necessary but highly subjective.\u003c/p\u003e \u003cp\u003eDSA is a traditional method used to guide PVL transcatheter closure. During the operation, DSA is used for localization and embolization based on the radioactive projection of the contrast agent. However, compared to echocardiography, DSA has certain limitations. Patients must remain still and hold their breath during the examination, and the accuracy of detection may be affected by various factors such as 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. Moreover, DSA exposes both patients and inspectors to radiation risk, and it cannot clearly display subtle intracardiac structures or the hole in the heart cavity.\u003c/p\u003e \u003cp\u003eCMR is a useful complement to evaluate functional and anatomical resolution. It can produce accurate blood flow imaging and volume-based measurements, which play a vital role in quantifying return flow for different types of valves\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. All prosthetic valves can be imaged by CMR regardless of ejection fraction and valve morphology, and the regurgitant volume of various valve types can be measured. However, CMR has limitations in evaluating PVL accuracy when the PVL and prosthetic valve sizes are small. Additionally, the presence of arrhythmia or motion artifacts can affect the evaluation of PVL and limit its widespread use\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA new software tool called Echonavigator\u0026reg; from Philips Healthcare in the Netherlands is now available, which enables real-time image synchronization and fusion of 2D and 3D TTE with fluoroscopy images. This technology allows for the precise positioning of the percutaneous mitral valve on the fluoroscopic view and facilitates the accurate steering of the guide wire through the PLV. The safety and feasibility of this technology have been demonstrated in many structural heart diseases\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. However, this type of procedure requires special equipment in the operating room.\u003c/p\u003e \u003cp\u003eIn cases where the above technology is not available, TEE can provide an advantage over 3D printing\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. For example, in cases of multiple mitral PVLs, a new innovative diagnostic approach involves combining RT-3D TEE with a 3D printed model during surgery. This approach allows for the construction of a stereoscopic and intuitive image of the intracardiac structure based on 3D TEE. The advantages of this method include relatively accurate and real-time guidance to avoid damaging surrounding tissues during multiple PVLs plugging under the guidance of simple TEE.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe combination of 3D ultrasound and color mapping is particularly advantageous in accurately describing multiple PVLs during their occluding. In addition, the use of 3D TEE combined with 3D printing technology provides \"double protection\" in transcatheter closure procedures. This approach enables more accurate and efficient occluding of multiple PVLs and represents a promising new model for addressing complications following valve replacement. Therefore, the application of this combined approach is worthy of promotion in the clinical setting.\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\u0026nbsp;\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.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the fund from Teaching Reform Project of Central South University (2021JGB094).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCONFLICT OF INTEREST DISCLOSURE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have no conflict of interest to declare\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\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-3826763/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3826763/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 transesophageal echocardiography combined with 3D printing to complete transapical perivalvular closure. Additionally, we reviewed the literature to explore the advantages and disadvantages of multimodal imaging for perivalvular leaks.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 folding four years ago. She presented with shortness of breath and TTE revealed two PVLs. Real-time 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. The transapical occlusion was successfully performed under the guidance of 3D TEE.The patient also showed good recovery during postoperative follow-up.The combination of 3D ultrasound and color mapping is advantageous in identifying and describing multiple PVLs. The use of 3D TEE combined with 3D printing technology provides a \"double protection\" in closure of PVLs, allowing for more accurate and precise placement of closure devices. Multimodal imaging plays a critical role in the management of PVLs, providing clinicians with essential information for successful treatment.\u003c/p\u003e","manuscriptTitle":"Real-Time Three-Dimensional Transesophageal Echocardiography Outperforms Three-Dimensional Printing in Detecting Multiple Perivalvular Leaks after Mitral Valve Replacement：A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-09 20:44:31","doi":"10.21203/rs.3.rs-3826763/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":"January 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-15T07:51:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-09 20:44:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3826763","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3826763","identity":"rs-3826763","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}