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\begin{document}

\title{Demonstration of a Rocking Prosthetic Mitral Valve Using 3-Dimentional
Echocardiography and Live Surgical Imaging}



\author[1]{Sean Baskin}%
\author[2]{Rece Laney}%
\author[2]{Senthil Nathan}%
\author[1]{Feroze Mahmood}%
\author[1]{J. Michael Haering}%
\affil[1]{Beth Israel Deaconess Medical Center Harvard Medical School}%
\affil[2]{Beth Israel Deaconess Medical Center}%


\vspace{-1em}



  
  \date{June 02, 2024}


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\selectlanguage{english}
\begin{abstract}
Prosthetic valve endocarditis is a complication of bacteremia which can
cause damage to the prosthetic valve or the tissue to which it was sewn.
Extensive tissue damage can result in a loss of anchoring and allow for
abnormal valvular motion. Dehiscence can lead to excessive motion of the
valve which is termed rocking. Through advances in imaging technology,
live 3-dimentional (3-D) transesophageal echocardiography can allow for
precise identification of the location of, and amount of dehiscence. We
present a 37-year old male with a rocking prosthetic valve demonstrated
on 3-D echocardiography and correlated to surgical manipulation.%
\end{abstract}%



\sloppy


Article Title: Demonstration of a Rocking Prosthetic Mitral Valve Using
3-Dimentional Echocardiography and Live Surgical Imaging. Sean M Baskin,
DO, MA\textsubscript{1}; Rece Laney, MD, MS\textsubscript{2};
Venkatachalam Senthilnathan, MD\textsubscript{2}; Feroze Mahmood, MD,
FASE\textsubscript{1}; James Michael Haering MD\textsubscript{1}1:
Department of Anesthesia, Critical Care and Pain Medicine. Beth Israel
Deaconess Medical Center, Harvard Medical School; Boston, MA. 2:
Department of Cardiovascular Surgery. Beth Israel Deaconess Medical
Center, Boston, MA Name, mailing address, phone number, and e-mail
address of the corresponding author. James Michael Haering, MD Feldberg
440 1 Deaconess Road; CC-470; Boston, MA 02215 617-754-2101 Email:
mhaering@bidmc.harvard.edu Financial Disclosures: None Conflicts of
interest: None Abstract word count - 95

List each author's individual contribution to the manuscript:

Sean Baskin- This author prepared the manuscript and obtained the
procedural video Rece Laney- This author edited the manuscript and
provided surgical correlation Venkatachalam Senthilnathan- This author
edited the manuscript and performed the surgery Feroze Mahmoud- This
author obtained the echocardiographic images, and helped with manuscript
editing. James Michael Haering- This author edited the manuscript

MeSH keywords:

Transesophageal echocardiography

Endocarditis

Mitral Valve Replacement

Dehiscence

Abstract:

Prosthetic valve endocarditis is a complication of bacteremia which can
cause damage to the prosthetic valve or the tissue to which it was sewn.
Extensive tissue damage can result in a loss of anchoring and allow for
abnormal valvular motion. Dehiscence can lead to excessive motion of the
valve which is termed rocking. Through advances in imaging technology,
live 3-dimentional (3-D) transesophageal echocardiography can allow for
precise identification of the location of, and amount of dehiscence. We
present a 37-year old male with a rocking prosthetic valve demonstrated
on 3-D echocardiography and correlated to surgical manipulation. This
manuscript adheres to the applicable EQUATOR guidelines.

Glossary of Terms:

3-D=3-dimensional; 2-D=2-dimensional; TEE=transesophageal
echocardiography; MVR=mitral valve replacement;
MSSA=methicillin-susceptible Staphylococcus aureus; TTE=transthoracic
echocardiography

Background:

Prosthetic valve endocarditis is a complication of bacteremia with
destruction of the annular tissue and occurs in 0.1-1.3\% of cases and
can result in partial or complete prosthetic valvular
dehiscence\textsubscript{1}. Valvular dehiscence results in positional
instability and the prosthetic valve demonstrates motion that is
independent of the cardiac motion. The extent of this motion is
determined by the degree of dehiscence of the prosthesis and ranges from
subtle to frank ``rocking'' motion. Rocking motion of the valve implies
extreme instability and impending dislodgment\textsubscript{2}.
Diagnosis of prosthetic valve dehiscence requires demonstration of the
valve ring motion independent of cardiac motion. Over the years,
fluoroscopy has been replaced with two-dimensional (2D) echocardiography
for assessment of prosthetic valve function and now three-dimensional
(3D) transesophageal echocardiography (TEE) has further enhanced our
understanding. We present a case of dehiscence of a prosthetic valve in
mitral position with the classic rocking motion as seen with live
3-dimensional transesophageal echocardiography (TEE). Written HIPAA
authorization has been obtained from the patient.

Case Report

A 37year-old male with a prior mitral valve replacement due to infective
endocarditis secondary to intravenous drug use presented with recurrent
bacteremia and was found to have multiple prosthetic vegetations,
(largest 14 mm x7 mm) by echocardiography. Despite an antibiotic regimen
and demonstrating clearance of bacteremia, he developed new onset
shortness of breath and chest pain. A repeat TEE identified posterior
dehiscence of the mitral valve prosthesis and he was admitted for urgent
re-do sternotomy and redo MVR. On the day of surgery, after uneventful
induction of general anesthesia an intraoperative TEE examination was
performed using an Epiq Ultrasound System using an X7-2t TEE probe
(Philips Medical Systems Andover MA). A comprehensive 2D examination was
performed and the preoperative findings were confirmed (Figure 1).
Posteriorly, there was a large area of valve dehiscence with
communication between the left ventricle and left atrium (Figure 2). The
prosthetic valve ring demonstrated significant independent motion. Next,
an R-wave gated 3D full-volume acquisition was performed in the
mid-esophageal position after optimizing the region of interest
(prosthetic valve) in the lateral and elevational planes. After
appropriate cropping and image adjustment, the ``rocking'' motion of the
prosthetic valve could be visually appreciated from multiple
perspectives (Video 1). It could also be visually appreciated that more
than fifty percent of the circumference of the prosthetic valve ring had
dehisced. This finding was also confirmed on direct surgical examination
of the valve on cardiopulmonary bypass (video 2). The prosthetic valve
was excised, and a 33 On-X mechanical mitral valve (NW Kennesaw GA USA)
was placed. The rest of the clinical course was uneventful and he was
subsequently discharged on the 11\textsuperscript{th} postoperative day
to a rehabilitation facility.

Discussion

One of the earliest published descriptions of rocking motion, in 1979 by
Schipira and colleagues described a hinge like motion of the partially
secured aortic prosthesis as it changed position throughout the cardiac
cycle. This motion was identified using 2-dimensional echocardiography
and was compared with the expected normal motion of a well seated
prosthesis\textsubscript{3}. Since then, rocking remains in the lexicon
of echocardiographers to describe the prototypical movement of a
prosthetic valve that has dehisced at least 50\% from the annulus to
which it was sewn. Clinical availability of 2D echocardiography marked a
significant advancement over the use of m-mode echocardiography or
fluoroscopy. 2D imaging allowed for better visualization and
characterization of prosthetic valves both at the time of repair and
during follow-up\textsubscript{3}. Recent work has shown that
computerized tomography can have near 100\% concurrence with surgical
findings and be assistive in surgical planning\textsubscript{4}.
Availability of real-time 3D echocardiography has further enhanced our
understanding of prosthetic valve function and pathology and prior
authors have shown prosthetic aortic valvular pathology using 2-D and
3-D echocardiography\textsubscript{5,6}. We however present a mechanical
mitral prosthesis where 3-dimentional echocardiography confirmed the
requisite extent of dehiscence to allow for rocking motion.

Our case demonstrates that 3D imaging provides unique insight into the
mechanism of ``rocking'' motion of a dehisced prosthetic valve. Also,
the temporal sequence of events in our patient implies that development
of dehiscence was associated with sudden appearance of symptoms and
clinical deterioration. Based on the 3D imaging it can also be visually
appreciated that there is more than 50\% of circumferential dehiscence
of the ring which provides the fulcrum and the hinge point of the
rocking motion seen. This characteristic back and forth motion of the
prosthetic ring generates greater mechanical sheering forces that
ultimately may completely dislodge the prosthetic valve. Therefore,
rapid progression of symptoms consistent with heart failure should raise
the suspicion of dehiscence. As can be seen in videos 1 and 2, the
extent of dehiscence identified was significant, and posed a significant
risk for further detachment and catastrophic cardiovascular collapse.
Initial 2-dimentional imaging provided initial assurance of valvular
pathology, and 3-dimentional live imaging was utilized to establish the
diagnosis, and to further identify the specific dehisced region of the
mitral prosthesis. Real-time surgical imaging as seen in video 2
confirmed the echocardiographic findings.

Conclusion:

New onset symptoms consistent with regurgitant valvular lesions should
prompt significant concern from providers, especially in patients with
pre-existing valvular prostheses as this could signify partial
dehiscence. When dehiscence exceeds 50\% of the attached circumference,
rocking motion is highly probable. Rocking motion represents excessive
motion of the prosthesis independent of the annulus and can lead to
catastrophic sequela. Echocardiographers should promptly assess any
areas of paravalvular regurgitation to evaluate the region, extent and
severity of detachment. 3-Dimentional TEE may provide highly useful
images for both diagnosis and possible interventional planning. If
rocking motion is identified, prompt surgical intervention should be
considered.

References:

\begin{enumerate}
\tightlist
\item
  Baddour LM et al for the Committee on Rheumatic Fever, Endocarditis,
  and Kawasaki Disease., Council on Cardiovascular Disease in the
  Young., Councils on Clinical Cardiology, Stroke, and Cardiovascular
  Surgery and Anesthesia., American Heart Association., Infectious
  Diseases Society of America. Circulation. 2005 Jun 14;
  111(23):e394-434
\item
  Tominaga R, Kurisu K, Ochiai Y, Tomita Y, Masuda M, Morita S, Yasui H.
  A 10-year experience with the Carbomedics Cardiac Prosthesis. Ann
  Thorac Surg. 2005; 79: 784-789
\item
  Schapira, N; Martin RP; Fowles, RE; et al. Two dimensional
  echocardiographic assessment of patients with bioprosthetic valves. Am
  J Cardiol, 1979;43(3)510-519
\item
  Tsai IC, Lin YK, Chang Y, Fu YC, Wang CC, Hsieh SR, Wei HJ, Tsai HW,
  Jan SL, Wang KY, Chen MC, Chen CC. Correctness of multi-detector-row
  computed tomography for diagnosing mechanical prosthetic heart valve
  disorders using operative findings as a gold standard. Eur Radiol.
  2009 Apr;19(4):857-67.
\item
  Gonzalez-Ferrer JJ, Fernandez-Jimenez R, Perez de Isla L, Rocafort AG,
  Zamorano JL. Rocking Aortic Valve Prosthesis: A 3-Dimentional
  Transesophageal Echocardiography View. J Am Coll Cardiol. 2010 Apr,
  55(17) e135
\item
  Gerstein NS, Bhamidipati CM, Schulman PM. Near-Complete aortic
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  Echocardiography 2018 Jun; 35(6):872-875
\item
  Figures: Figure 1: Midesophageal 4-chamber view in mid-systole showing
  rocking of the posterior portion of the mitral prosthesis during
  ventricular systole. LA: Left Atrium, LV: Left Ventricle. RA: Right
  Atrium. Arrow: Area of prosthetic mitral valve dehiscence. Star:
  Prosthetic mitral valve oriface Figure 2: Mid-esophageal Long Axis in
  mid-systole showing severe regurgitation through the posterior
  dehiscence of the mitral prostethesis. Ao: Ascending Aorta LV: Left
  ventricle. RV: Right ventricle. Star: Area of prosthetic dehiscence.
  Arrows (multiple): Flow of regurgitant jet through the area of
  dehiscence Videos: Video 1: 3-D reconstruction of rocking motion Video
  2: Side-by-side of 3-D reconstruction showing rocking motion with
  direct surgical visualization.
\end{enumerate}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1-S-Baskin-et-al-new-label/Figure-1-S-Baskin-et-al-new-label}

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\end{figure}\selectlanguage{english}
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