
==== Front
Eur Heart J Imaging Methods Pract
Eur Heart J Imaging Methods Pract
ehjimp
European Heart Journal. Imaging Methods and Practice
2755-9637
Oxford University Press UK

10.1093/ehjimp/qyae049
qyae049
Image Focus
AcademicSubjects/MED00010
AcademicSubjects/MED00160
AcademicSubjects/MED00200
AcademicSubjects/MED00870
Eurheartj/31
Eurheartj/35
Eurheartj/34
Eurheartj/32
ECG-gated CT improves diagnosis in prosthetic valve degeneration
https://orcid.org/0000-0001-5611-8313
Fang Jonathan X Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA

Frisoli Tiberio M Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA

Giustino Gennaro Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA

Villablanca Pedro A Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA

Engel Gonzalez Pedro Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA

O’Neill Brian P Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA

Wang Dee Dee Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA

O’Neill William W Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA

Lee James C Center for Structural Heart Disease, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA

Corresponding authors. E-mail: jlee24@hfhs.org (J.C.L.); E-mail: fangjonathan@gmail.com (J.X.F.)
Conflict of interest: B.P.O. is a consultant to and receives research support from Edwards Lifesciences. T.M.F. is a proctor for Edwards Lifesciences, Abbott, Boston Scientific, and Medtronic. D.D.W. is a consultant for Edwards Lifesciences, Abbott, Neochord, and Boston Scientific and receives research grant support from Boston Scientific assigned to employer Henry Ford Health System. W.W.O. has served as a consultant for Abiomed, Edwards Lifesciences, Medtronic, Boston Scientific, Abbott Vascular, and St. Jude Medical and serves on the Board of Directors of Neovasc Inc. P.A.V. is a consultant for Edwards Lifesciences and Teleflex. The other authors had no conflicts to declare. The other authors have no potential conflict of interest to declare.

1 2024
21 5 2024
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2 1 qyae04912 6 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.
2024
https://creativecommons.org/licenses/by/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

echocardiogram
computed tomography
aortic valve replacement
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pmcAn 81-year-old woman with a prior valve-in-valve transcatheter implantation (TAVI) of a 23 mm CoreValve (Medtronic, USA) inside a 21 mm Carpentier (Edwards Lifesciences, USA) bioprosthesis 9 years ago and coronary artery bypass grafting 20 years ago presented dyspnoea and slow-rising pulse with an aortic area ejection-systolic murmur on physical examination. Transthoracic echocardiogram showed a left-ventricular ejection fraction of 59%, aortic transvalvular peak/mean gradients of 6.7/4.1 mmHg, aortic valve area (AVA) of 1.91 cm2, and no aortic regurgitation (Figure 1A). The valve was not well-visualized on parasternal view due to acoustic shadowing from the frame, and all standard did not reveal any significant gradient. Owing to discrepancy between clinical and echocardiographic finding, cardiac catheterization was pursued, which showed patent grafts but an aortic peak/mean gradient of 110/69 mmHg with an AVA of 0.37 cm2 (Figure 1B). Heart team evaluation for suspected bioprosthetic valve degeneration had computed tomography (CT) done as part of the workup (Figure 1C), showing a vertical-take-off aortic accentuated by the CoreValve, with predicted coaxial alignment of the valve achievable from a left subcostal view (Figure 1D). Transthoracic echocardiogram from this off-axis view showed aortic transvalvular peak/mean gradients of 116/81 mmHg, AVA of 0.28 cm2 (Figure 1E). The patient had prohibitive surgical risk and underwent a valve-in-valve TAVI with a 20 mm Sapien 3 valve (Edwards Lifesciences, USA) (Figure 1F) per heart-team decision. This case demonstrates the importance of multimodality approach integrating clinical, imaging, and catheterization findings in diagnosing bioprosthetic degeneration when each modality alone has limitation.

Figure 1

Consent

Patient consent has been obtained for educational use of material, including publication.

Funding

None declared.

Data availability

No new data were generated or analysed in support of this research.

Lead author biography

Jonathan X. Fang, MBBS, is currently the structural heart disease fellow at Henry Ford Hospital, Detroit, MI, USA. He obtained his medical degree and completed his training in internal medicine and cardiology at the University of Hong Kong. He then pursued further training in the USA including an Interventional Cardiology Fellow at Brigham and Women’s Hospital, Boston, USA, and his current structural heart disease fellowship. He has published articles in journals such as JACC: Cardiovascular intervention, Catheterization & Cardiovascular Interventions, and Heart Rhythm.
