CASE 11000 Published on 10.08.2013

Paravalvular mitral leak diagnosed by coronary artery Computed Tomography

Section

Cardiovascular

Case Type

Clinical Cases

Authors

Romagnoli A, Fusco A, Costanzo E, Di Trapano R, Girardi V, Simonetti G.

University of Rome Tor Vergata,
Department of Diagnostic and Interventional Radiology,
Molecular Imaging and Radiotherapy;
Viale Oxford 81, Rome, Italy;
Email:arfus@libero.it

Patient

65 years, female

Categories

Area of Interest Cardiac ; Imaging Technique CT-Angiography

Procedure Complications ; Special Focus Prostheses ;

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Clinical History

A 65-year-old obese woman (BMI= 34.71) with history of mechanical mitral valve transplantation presented a pansystolic cardiac murmur. She also reported the presence of recurrent retro-sternal pain and hyperlipidaemia.

Imaging Findings

The patient first underwent a transthoracic echocardiography (TTE) and no abnormalities were detected. She refused to undergo transesophageal ecocardiograpy (TEE). Due to her retro-sternal pain and hyperlipidaemia she was introduced to a coronary artery computed tomography evaluation (CACT). No abnormalities were detected at the coronary artery evaluation. A 1.5 cm paravalvular leak between left cardiac atrium and ventricle was detected. At the CACT contrast medium acquisition, performed by electrocardiographic retrospective synchronisation protocol, an image of hyperdensity through the leakage both in systolic and diastolic phase was observed. The left atrio-ventricular leakage was confirmed by surgery.

Discussion

Paravalvular leak (PVL) complicating mechanical or bioprosthetic surgical valve replacement may be seen in 2-12% of patients after mitral valve replacement (MVR) [1, 2].
Risk factors for PVL in the surgical population include mechanical valve implantation, annular calcification, infectious endocarditis, and previous valve surgery, all of which can result in inadequate suturing of the valve to de native cardiac tissue [3]. In patients undergoing transcatheter valve replacement, risk factors include annular calciﬁcation and incorrect pre-procedural valve sizing [4].
With mild or moderate paravalvular leakage, patients may be asymptomatic and may have only a mild haemolytic anaemia (13–47% of patients within the ﬁrst year after MVR [5, 6]) so they can be observed carefully with serial echocardiographic examinations [7]. Patients with severe paravalvular leakage usually have symptoms of heart failure (85% of patients) or severe anaemia and should be treated with surgical repair or replacement of the valve [5, 8].
Multimodality imaging using transthoracic (TTE) and transoesophageal echocardiography (TEE) usually provides the initial diagnosis of PVL, and procedural guidance often requires the aid of 2D and 3D TEE, intracardiac echocardiography (ICE), ﬂuoroscopy/angiography, and more recently the combination of computed tomography (CT) and ﬂuoroscopy [9].
CT study permitted to diagnose the paravalvular leak and to well define its dimensions not invasively. Cardiac MRI study can be performed for diagnosis, to determine leak dimensions and flow quantification [10].
Delineation of normal prosthetic valve function is usually possible with TTE. Transthoracic Doppler echocardiography provides important haemodynamic information with regard to prosthetic valve pressure gradients and is extremely useful in long-term follow-up [7]. However, exclusion of an incompetent valve is often quite difficult, especially for prosthetic valves in the mitral position [9].
TEE is the imaging modality of choice when the TTE is suboptimal or when there are borderline findings on the TTE in a patient whom there is a strong clinical suspicion of malfunction [11].
The sensitivity for the detection of paravalvular leaks for mitral valve by TTE was 25% whereas by TEE it was 100% [12].
TTE and TEE are usually limited by severe acoustic shadowing caused by the prosthetic valve itself, resulting in an incomplete evaluation.
In recent years, multi-detector-row CT (MDCT) has been used to provide more precise diagnostic information in prosthetic heart valve evaluation, and several studies have used MDCT with encouraging results [13].
According to a recent study the concordance of MDCT for diagnosing and localising prosthetic valve disorders and the surgical findings was 100% [14].

Differential Diagnosis List

Mitral para-valvular leak

Mitral regurgitation

Mitral annulus calcification

Mitral valve infectious endocarditis

Final Diagnosis

Mitral para-valvular leak

References

[1] Jindani A, Neville EM, Venn G, Williams BT (1991) Paraprosthetic leak: A complication of cardiac valve replacement. J Cardiovasc Surg 32: (PMID: 1864881)

[2] Ionescu A, Fraser AG, Butchart EG (2003) Prevalence and clinical signiﬁcance. Heart 89: 1316 – 1321. (PMID: 14594888)

[3] Amar Krishnaswamy, MD; Samir R. Kapadia, MD; E. Murat Tuzcu, MD. (2013) Percutaneous Paravalvular Leak Closure – Imaging, Techniques and Outcomes. Circ J 77: 19 – 27 (PMID: 23258128)

[4] Jilaihawi H, Kashif M, Fontana G, Furugen A, Shiota T, Friede G, (2012) Cross-sectional computed tomographic assessment improves accuracy. J Am Coll Cardiol 59: 1275 – 1286 (PMID: 22365424)

[5] M, Franzen D, Vogt P, Seifert B, Jenni R, Kunzli A,Niederhauser U, Turina M (2000) Paravalvular leakage after mitral valve replacement: Improved longterm. Eur J Cardiothorac Surg 17: 14 – 19 (PMID: 10735406)

[6] Cicco G, Russo C, Moreo A, Beghi C, Fucci C, Gerometta P (2006) Mitral valve periprosthetic leakage: Anatomical observations in 135 patients from a multicentre study. Eur J Cardiothorac Surg : 887 – 891 (PMID: 17081767)

[7] Foster E, Stainback RF (1995) Transesophageal Echocardiography In Cardiology. Edited by: Parmley WW, Chatterjee K. Philadelphia: J. B

[8] Dave R (2002) Clinical Vignette. CHF and Severe Mitral Regurgitation. Proceedings of UCLA healthcare

[9] Suriya Jayawardena, Danushan Sooriabalan, Olga Burzyantseva and (2008) Paravalvular mitral valve leakage presenting as congestive heart failure, missed by TTE but diagnosed by TEE: a case report. Cases Journal 1:216 (PMID: 18838002)

[10] Westenberg JJ, Doornbos J, Versteegh MI, Bax JJ, van der Geest RJ, de Roos A, Dion RA, Reiber JH (2004) Accurate quantitation of regurgitant volume with MRI in patients selected for mitral valve repair. Eur J Cardiothorac Surg 27(3):462-6 (PMID: 15740956)

[11] Khandheria BK (1993) Transesophageal echocardiography in the evaluation of prosthetic valves. Cardiol Clin 11:427-36 (PMID: 7795374)

[12] Mansour K, Salam AE, Attia I (1998) Prosthetic valve malfunction.Intraoperative findings as the verifying indices to the preoperative diagnosis and predictors of the surgical outcome. Egypt Heart J 50:131-143

[13] Leborgne L, Renard C, Tribouilloy C (2006) Usefulness of ECG-gated multidetector computed tomography for the diagnosis of mechanical prosthetic valve dysfunction. Eur Heart 27:2537 (PMID: 16613933)

[14] I-Chen Tsai, Yung-Kai Lin (2009) Correctness of multi-detector-row computed tomography for diagnosing mechanical prosthetic heart valve disorders using operative findings as a gold standard. Eur Radiol 19: 857–867 (PMID: 19037643)

Case information

URL:	https://www.eurorad.org/case/11000
DOI:	10.1594/EURORAD/CASE.11000
ISSN:	1563-4086

Figure 1

Mitralic leak MPR reconstruction

Coronary artery CT (350-550 mA; 120KV; thickness 0.6mm; retrospective ECG synchronisation; ASIR 40%): MPR reconstruction shows the atrio-ventricular leak in the four chambers long axis in diastolic phase (red arrow).

Heart atrio-ventricular long axis CT-MPR reconstruction in diastolic phase; it is possible to observe two bulgings in the context of the leak (red arrow) .

Heart atrio-ventricular long axis CT-MPR reconstruction in systolic phase; it is possible to observe two bulgings in the context of the leak that increase their dimension in this phase (red arrow).

Figure 2

Mitralic leak and coronary artery relationship

Coronary artery CT VR reconstruction (350-550 mA; 120KV; thickness 0.6mm; retrospective ECG synchronisation) well demonstrate the presence of the atrio-ventricular leak (arrow).

Coronary artery CT: VR reconstruction (350-550 mA; 120KV; thickness 0.6mm; retrospective ECG synchronisation) well demonstrate the relationship between atrio-ventricular leak and left coronary artery.