Thread by @dr_benoy_n_shah

**VALVE CASE OF THE MONTH**
@BrHeartValveSoc

Last case of 2021!

If EVER you needed an example of why not to judge a 3-dimensional structure with 2-dimensional imaging...this it it!

I think you'll like this one...😁

#echofirst #cardiotwitter #MedTwitter

Male, late 60s, underwent biological MVR (29mm) 11 yrs previously for
Severe MR. Has permanent AF & VVIR pacemaker

Admitted to local hospital with breathlessness

This is admission chest x-ray

Treated with diuretics, offloaded successfully

Rpt CXR after a week - nearly normal

First TTE after offloading...

AP4Ch with colour Doppler

@cardiacLucy @nat_echo @RobChamb87 @BiancaJudyC @vitormweaver @scrivsy85 @em_echo @boegel_kelly @CKFreeEcho @wess_jmm @LukshmiM @MCRImaging
@BSEcho

Mean MV gradient 13mmHg! Not tachycardic, well aligned CW Doppler

Admission with fluid overload
Very high gradient across 11yr old bioprosthesis

Could be SVD...so local hospital proceeds to TOE. Here are their 2D images

120degree view

One leaflet clearly fixed in this view, other leaflet moves well

Still a lot of turbulence on colour Doppler imaging

TOE MV mean gradient still high, above 10mmHg...

So, I'm sent images and asked what do I think. Patient stable & euvolaemic. Valve doesn't seem severely stenotic on 2D images (1 leaflet seems fixed). I wasn't convinced he needed urgent re-do surgery, but surgeons accepted transfer to our centre for more tests

So, we decide to repeat the TOE, this time with 3D imaging

Images here from our #echofirst heroine @EuniceOnwordi - great view of MVR from LA aspect

And here is key image from LV aspect...

So, you can see now that actually TWO leaflets are fused together and only one is moving freely

Took the dataset into 3DQ, used 3D-MPR for a 3D-planimetry MV area...which was 1.5cm2

So, you've seen 2D & 3D images, CW Doppler & clinical presentation

POLL! Does this patient need a mitral valve re-do operation?

@SCTSUK @BISMICS @ishahm
@EnochAkowuah1 @hatemsoliman
@mrjzacharias @DrMoritzWvB
@dralisonduncan

Well, the surgeons decided to go back to theatre and replace the valve

As 3D TOE revealed, they found 2 leaflets were fused together & fixed, whilst 1 leaflet moved freely

Patient opted for another bioprosthesis

Here is the post-op echocardiogram - mean MV gradient down to ~4mmHg!

I think it's a great reminder of the utility of 3D echocardiography especially for assessing prosthetic valves - the 2D images here didn't suggest that valve alone should cause MVG of >10mmHg

3D crucial here

That's it for 2021!

New case after Xmas! 😁

#echofirst #cardiotwitter #MedTwitter