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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Loop Text Key  
Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Periprosthetic Leak
Case#: 18
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
65 you WM S/P PTCA, CABG 8 years ago. He has a Hx of HTN, NIDDM, COPD, MI. He presents with SEMI and CP. Cath shows LVEF 55%, RCA 100%, RIMA -> RCA OK, LAD 70%, LIMA -> LAD 70%. Mild to Moderate MR.

What is your assessment of the mitral valve?
What is your assessment of the IntraopPostOp loops of the mitral valve?
Please discuss the outcomes of periprosthetic leak in the mitral valve position.

Case Discussion/CME Questions
The echo shows A2 and A3 prolapse of the mitral valve with a LVEF 50-60%. The MR is eccentrically directed and is severe.  Mild to moderate pulmonary regurgitation is also present. After the mitral valve replacement a leak is present in the anterolateral aspect of the mitral valve. The leak is mild and borders on moderate.

O'Rourke looked at small or trivial periprosthetic leak (PPL) in the aortic and mitral valve position and found an incidence of PPL of 22.6% for the mitral valve. As these patients were followed with TTE postoperatively, he found that the PPL resolved or remained unchanged in the vast majority of patients. Older age, smaller body size, degenerative valve disease, or the use of a bioprosthetic valve increased the risk of a PPL. 1 patient (0.9%) required reoperation for a PPL.

The natural history of small or trivial PPL in two other studies indicated that small or trivial PPL does not progress. Patients with small or trivial PPL had either no change or resolution of the PPL on followup.

When a PPL does occur it most likely is going to occur in the anterolateral or the posteromedial aspect of the mtiral valve annulus which may indicate that these areas are more techinically demanding areas of the mitral valve.

Please answer the following questions correctly to obtain your CME.
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