Degradation of bioprosthetic aortic valves can eventually lead to both paravalvular and intravalvular regurgitation. However, differentiating between the two may be difficult in the case of multiple lesions in close proximity or highly eccentric jets. Whereas such exact distinction may be of little procedural significance in open cardiac surgery, it is of crucial importance when approaching such lesions in the catheterization laboratory or hybrid operating room. Interventions on one lesion often have a significant effect on the other. For example, guidewires may damage new bioprosthetic valve leaflets and dislodge vascular plugs. Even more concerning is the possibility of undergoing a lengthy and risky procedure on a lesion that does not truly exist. Fortunately, the use of three-dimensional Doppler echocardiography can expand our vision beyond the single imaging plane of a standard two-dimensional examination, allowing extensive manipulation of cutting planes and a wider field of view. Regurgitant jets can thus be tracked in a way that may be otherwise impossible, better quantifying their true origins. Here the authors present a unique case of misdiagnosis after surgical aortic valve degradation, where the use of intraoperative three-dimensional echocardiography significantly altered the preoperative plan and reduced operative time.
Keywords: 3D TEE; TAVR; aortic regurgitation; paravalvular leak; transcatheter aortic valve replacement; transesophageal echocardiography; valve-in-valve.
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