Multimodality cardiac imaging for guidance of transapical transcatheter aortic valve implantation and mitral paravalvular leak closure

A 65-year-old man with a history of mechanical mitral valve replacement was admitted to our hospital for severe haemolytic anaemia and dyspnoea. Admission transthoracic echocardiography demonstrated severe aortic regurgitation and two mitral paravalvular leaks (PVLs), accompanied with dilated cardiac chambers and mild ventricular systolic dysfunction. Due to high risk of operation, the patient underwent transapical transcatheter aortic valve implantation (TAVI) and mitral PVL closure. Intraoperative transesophageal echocardiography (TEE) confirmed significant aortic regurgitation and PVLs (Panels A and B, Supplementary material online, Video S1). The location and size of PVLs were visualized in a surgeon’s view by three-dimensional TEE. One was at 9–10 o’clock (red arrow), and the other was at 6–7 o’clock (green arrow) (Panels C and D). Under the guidance of TEE and digital subtraction angiography (DSA), three guidewires (white arrow) advanced across one defect (Panels E and F, Supplementary material online, Video S2). After reorientation of the guidewire, three occludes were placed in the defect (Panel G). Subsequently, a fourth occlude was implanted (Panel H, Supplementary material online, Video S3). TEE showed a remarkable reduction in PVL (Panel I and J, Supplementary material online, Video S4). Transapical TAVI was performed successfully (Panels K and L, Supplementary material online, Video S5). Transapical TAVI and closure of PVLs were performed in one procedure. Combined monitoring of echocardiography and DSA increases procedural success and decreases procedure duration. Supplementary material is available at European Heart Journal online. Funding: The work was supported by National Natural Science Foundation of China (Grant No. 81727805), Health and Family Commission of Hubei Province Scientific Research Project (No. WJ2019M161), and Nature Science Foundation of Hubei Province (No. 2020CFB781). Conflict of interest: none declared.