what's the problem?

[ProRealDoc]

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[pgg]

Something stuck in the LVOT? Surely a prosthetic valve? But the AV is still there, so maybe a prosthetic mitral valve came loose and is jiggling around in the ventricle?

 

[lushmd]

So, mid-esophageal aortic valve long axis view showing, as pgg pointed out, something resembling a prosthetic valve in the LVOT. Perhaps a botched percutaneous aortic valve replacement? I guess this as the aortic valve appears calcified and stenotic and, in an open AVR, the native aortic valve would be removed prior to insertion of the new valve.

 

[ProRealDoc]

what else can you point to that tells you for sure there's a prosthetic valve in the LVOT?

 

[BLADEMDA]

For those who are not experts in TEE start with the basics. Look at the bottom of the picture. You will see what appears to be a valve opening into the lvot/aorta. Please notice that there is another structure just behind that valve. Remember the TEE probe has been rotated to 118 degrees.

Also, this is not "normal" anatomy as this patient had a prosthetic valve procedure. At the top of the picture you can see the Left Atrium. In addition, you can see a portion of the mitral valve (anterior leaflet adjacent to the aortic valve).

 

[BLADEMDA]

Long axis ascending aorta - 'ME AV LAX'

​

 

[geogil]

Long axis ascending aorta - 'ME AV LAX'

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Thanks, I wasn't sure how things were oriented.

 

[ProRealDoc]

For those who are not experts in TEE start with the basics. Look at the bottom of the picture. You will see what appears to be a valve opening into the lvot/aorta. Please notice that there is another structure just behind that valve. Remember the TEE probe has been rotated to 118 degrees.

Also, this is not "normal" anatomy as this patient had a prosthetic valve procedure. At the top of the picture you can see the Left Atrium. In addition, you can see a portion of the mitral valve (anterior leaflet adjacent to the aortic valve).

Blade, you may want to consult your community college RN grad, with online BSN and now MD-equivalent CRNA murse to make the call on this one.

 

[lushmd]

what else can you point to that tells you for sure there's a prosthetic valve in the LVOT?

There are two elements to this question:

(1) How do I know that this is a prosthetic valve: Again, the native mitral and aortic valves are in situ. Also, the prosthetic valve has a prominent annulus and seems to have a stented appearance.

(2) How do I know that this structure is in the LVOT? First, as Blade indicated, in this view the area of interest is the LVOT. Second, the anterior leaflet of the mitral valve is not able to open properly as its hitting this structure.

What am I missing? I've admittedly just started learning TEE a couple of months ago.

 

[ProRealDoc]

There are two elements to this question:

(1) How do I know that this is a prosthetic valve: Again, the native mitral and aortic valves are in situ. Also, the prosthetic valve has a prominent annulus and seems to have a stented appearance.

(2) How do I know that this structure is in the LVOT? First, as Blade indicated, in this view the area of interest is the LVOT. Second, the anterior leaflet of the mitral valve is not able to open properly as its hitting this structure.

What am I missing? I've admittedly just started learning TEE a couple of months ago.

The clue I was alluding to is the presence of struts inferior to the AML. Classic of bipprosthetic valves as you know. That's all. Good job.

 

[lushmd]

Thanks ProReal. So what's the rest of the story? How did this case present/situation occur?

 

[BLADEMDA]

There are two elements to this question:

(1) How do I know that this is a prosthetic valve: Again, the native mitral and aortic valves are in situ. Also, the prosthetic valve has a prominent annulus and seems to have a stented appearance.

(2) How do I know that this structure is in the LVOT? First, as Blade indicated, in this view the area of interest is the LVOT. Second, the anterior leaflet of the mitral valve is not able to open properly as its hitting this structure.

What am I missing? I've admittedly just started learning TEE a couple of months ago.

Good job. Be careful about making statements about the mitral valve as we need more views to ascertain function; however, we can see the struts and motion may be limited here. Again, I would want better Mitral valve views. You may be a natural at this.

Pro, what are the clinical symptoms? Patient? Case? Procedure? Other sign. TEE findings?

 

[periopdoc]

There was no restriction on mitral valve function although it may appear that way in this view.

- pod

 

[ProRealDoc]

This was not my pt. I got the image from a colleague but not sure of its origin. From the perc valves I have seen, it appears that they were attempting to do a perc AVR and they accidentaly deployed the valve-containing stent which may not have been fixed properly and ended up free floating in the LVOT. oops

 

[doctor712]

I saw one of these PAVR videos, not from the institution where I am, that had the Perc Valve LITERALLY pin-balling around the LV. Case was quickly converted to open. Quickly.

I feel this trial is at least SOME option for people who are in deep trouble otherwise. I wish I could comment on some of what I've seen in the cath lab with these cases, but that would be a nono. Severe AS has such a high mortality rate even 3-6 mos from diagnosis. I think if you look up the PARTNER trial on NIH (public info) you'll see an STS score (mortality parameters) of <10.0 is exclusionary. For fun, I did my own, with 1.1 Cr, 1st surgery, my age, weight, height, gave myself severe AS, EF 60%, stable angina) came to .4%. These are sick folks who don't have many options. Especially the transapical arm of the trial. Kudos to the teams doing these cases, including the Anesthesiologists of course! : )

D712