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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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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
Post MVR AV High Velocity Jet
Case#: 4
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
41 y.o. male with history of an ASD repair 16 years ago ow presents with increasing SOB and DOE. He has a history of hypertension and mild renal insufficiency. The preoperative echocardiography exam showed severe MR and mild TR with a LVEF of 40%. The patient was scheduled for a minimally invasive mitral valve repair. Discuss the findings of the intraoperative echo and the post repair echo of the LVOT/AV. A high velocity jet was present after the repair that was not present on the preoperative echocardiography exam. What are the possible etiologies of the high velocity jet.

Case Discussion/CME Questions
The MV leaflets are thickened, especially at the leaflet edges. The MR is severe and is centrally located. No evidence of leaflet restriction or prolapse/flail could be found. The annulus is dilated. Therefore, the etiology of the MR was annular dilation.

The causes of post MVR high velocity jet in the LVOT or AV are the following:

  • SAM
  • IHSS
  • AS
  • MR
  • TR
  • Subaortic Membrane
  • Intraventricular Gradient

SAM (Systolic Anterior Motion) of the anterior leaflet which partially occludes the LVOT is the most common cause of a high velocity jet. Much less commonly, the posterior mitral valve leaflet can cause SAM.

The CWD scan line could be interrogating an MR or TR jet and misinterpretation of the location of the high velocity jet could occur.

IHSS could be present preoperatively but, because of the increased LV volume, IHSS is not diagnosed preoperatively. Postoperatively, the LV volume is decreased after the MVR and IHSS is uncovered.

In both SAM and IHSS the CWD profile is typically dagger shaped. The CWD in this case was not dagger shaped. Also, with a huge cleft in the anterior mitral valve leaflet, it would take both anterior leaflets to exhibit SAM to cause a significant gradient at the LVOT. The PISA formation at the origin of the LVOT did not show any SAM.

AS gradients are flow related so increased flow through the AV after a MVR would increase the gradient. However, the echo showed an AV that almost fully opened but the leaflets appeared to be caught in a turbulent wave. Also, a very nice PISA formation was present at the origin of the LVOT.

Given the PISA formation at the LVOT, the turbulent pattern in the LVOT, and the CWD profile indicating a static stenosis/obstruction, and the AV leaflets fluttering in a turbulent jet, and no evidence of SAM, we felt that the increased jet velocity was due to increased flow resulting in a high velocity jet. The PISA formation image shows that the LVOT diameter to be around 1 cm. The differential diagnosis would be a subaortic valve membrane but the preop CWD of the AV didn't show a turbulent pattern or a subaortic valvular gradient. An intraventricular gradient would also be unlikely given the location of the PISA formation and a non-daggar-shaped CWD profile.

On week later, a repeat echocardiographic exam showed no gradient or high velocity jet through the LVOT/AV apparatus.
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