Periprosthetic Leak Repair

In patients with symptomatic periprosthetic leak (PPL) following valve replacement, percutaneous transcatheter PPL closure is currently preferred to reoperation because of increased surgical morbidity and mortality and higher likelihood of recurrence associated with redo surgery. 3D TEE is critically important to guide closure of mitral PPL. Enface views of the mitral prosthesis from the left atrium provide a panoramic view of the mitral prosthesis bed including the entire sewing ring. Periprosthetic defect location(s) shape and size relative to fixed spatial coordinates and occluder hinges in the case of mechanical bileaflet prostheses can be communicated effectively to the interventional cardiologist. And, because wires and catheters can be seen in real time, 3D TEE plays a pivotal role in guiding catheter defect cannulation and positioning of the vascular occluder device(s). This includes confirming that the guide wire has crossed the defect rather than inadvertently being advanced through the prosthetic valve orifice, and together with 2D TEE to monitor for interference with prosthesis leaflet function by the vascular device(s) deployed. 3D TEE can also help guide the transseptal puncture when the tip of the transseptal needle is not well seen on 2D TEE. There is currently no role for 3D echocardiography to guide closure of aortic PPL.