Left ventricular outflow tract to left atrium fistula as a complication of aortic root repair

Left ventricular outflow tract obstructions (LVOTOs) encompass a series of stenotic lesions starting in the anatomic left ventricular outflow tract (LVOT) and stretching to the descending portion of the aortic arch (Figure 1). Obstruction may be subvalvar, valvar, or supravalvar. These obstructions to forward flow may present alone or in concert, as in the frequent association of a bicuspid aortic valve with coarctation of the aorta. All of these lesions impose increased afterload on the left ventricle and, if severe and untreated, result in hypertrophy and eventual dilatation and failure of the left ventricle. LVOTOs are congenital in the vast majority of individuals younger than 50 years in the United States; some variants of subaortic obstruction are the exception. It is imperative to consider all patients with LVOTO at a high risk for developing infective endocarditis, and one should always institute appropriate measures for prophylaxis. The present article is intended as a contemporary review of the causes, manifestations, treatments, and outcomes of LVOTO; it will not address LVOTO in the pediatric population or genetic hypertrophic cardiomyopathy but will focus strictly on congenital malformations in the adult. Figure 1. Artist’s rendering of the LVOTO lesions in sequence as viewed from a superolateral orientation. A, Gradient echo cardiac MR image as viewed from the frontal projection demonstrating flow acceleration at a site of supravalvar aortic stenosis (white arrow) in a patient with Williams syndrome. The black arrow identifies the level of the unrestricted aortic valve. B, Classic radiological signs of coarctation of the aorta: rib notching (white arrows) as seen on a posteroanterior chest x-ray in a patient with coarctation of the aorta. The rib notching is caused by erosion of the inferior rib margins by dilated pulsatile posterior intercostals collateral arteries. The black arrow points to the Figure 3 silhouette that …

During the last few decades, the use of intraoperative echocardiography has become increasingly evident as anesthesiologists, cardiologists, and surgeons continue to appreciate its potential application as an invaluable tool for monitoring cardiac performance and diagnosing pathology in patients undergoing cardiac surgery (1,2). The essential information provided by intraoperative echocardiography regarding hemodynamic management, cardiac valve function, congenital heart lesions, and great vessel pathology has contributed to its widespread popularity. In fact, perioperative echocardiography has been shown to influence cardiac anesthetic and surgical management in as many as 50% of cases (3). The publication of guidelines describing the indications for performing intraoperative echocardiography based on reviews of the literature and expert opinion of task force members from the Society of Cardiovascular Anesthesiologists (SCA), American Society of Anesthesiologists, and American Society of Echocardiography (ASE) has also facilitated the growth of this important diagnostic tool (4,5). Despite its overwhelming popularity and favorable influence on perioperative clinical decision-making and outcomes (1,2,6), the transesophageal echocardiographic (TEE) approach to a comprehensive echocardiographic examination has some limitations. For example, TEE imaging of the distal ascending aorta and aortic arch may be impaired by the interposition of the trachea and main bronchi (7–9). In addition, a TEE probe may occasionally be difficult or impossible to advance into the esophagus or, in patients with significant gastroesophageal pathology, TEE probe placement may even be contraindicated (10). Furthermore, TEE may be rarely associated with perioperative morbidity from oropharyngeal and gastroesophageal injury (e.g., dysphagia, gastrointestinal hemorrhage, gastroesophageal rupture) (10,11). Thus, an experienced echocardiographer must be familiar with other imaging approaches to conduct a comprehensive perioperative echocardiographic examination. More than a decade before the introduction of TEE, epicardial echocardiography was already in use as a diagnostic imaging modality to assist cardiac surgeons, anesthesiologists, and cardiologists with clinical decision-making (12). A comprehensive epicardial echocardiographic examination can be performed efficiently and safely (13), and may be the most practical intraoperative imaging technique when a TEE probe cannot be inserted or when probe placement is contraindicated. Epicardial echocardiography may be superior to TEE because it can provide more optimal image resolution when using higher frequency probes (14). In addition, epicardial echocardiography may offer better windows for imaging anterior cardiac structures including the aorta, aortic valve (AV), pulmonic valve, and pulmonary arteries, and, therefore, may have a favorable influence on perioperative surgical decision-making (15,16). However, epicardial imaging requires direct access to the anterior surface of the heart, and consequently cannot be performed without a sternotomy. Furthermore, the epicardial approach does not permit continuous monitoring, and requires interruption of the surgical procedure for imaging. The most recent recommendations by the ASE and SCA Task Force Guidelines for Training in Perioperative Echocardiography include epicardial and epiaortic imaging as core components of advanced training (5). Thus, the following guidelines for performing a comprehensive epicardial echocardiographic examination have been developed by the ASE Council for Intraoperative Echocardiography to establish requirements for training, and to standardize a comprehensive epicardial examination using a set of 7 reliably obtained views. TRAINING GUIDELINES The epicardial approach is unique among the readily used echocardiographic imaging windows in that it requires a collaborative effort with the cardiac surgeon to either allow the echocardiographer to guide them in obtaining images, or alternatively permit the echocardiographer to have direct access to the epicardial surface within the operative field. Experience in epicardial echocardiography is an important component of advanced, rather than basic perioperative echocardiographic training as defined by the ASE and SCA Task Force Guidelines for Training in Perioperative Echocardiography (5). Epicardial echocardiographic training should include the study of 25 epicardial examinations of which five are personally directed under the supervision of an advanced echocardiographer, before a trainee should pursue independent interpretation and application of the information to perioperative clinical decision-making. EPICARDIAL PROBE PREPARATION Epicardial echocardiography is performed by placing the ultrasound transducer on the epicardial surface of the heart to acquire 2-dimensional, color flow, and spectral Doppler images in multiple planes. Because of the proximity of the probe to the heart, epicardial echocardiography typically uses higher frequency probes (5–12 MHz). The probe is placed in a sterile sheath along with sterile acoustic gel or saline to optimize acoustic transmission. Two sheaths may also be used in an attempt to increase sterility. Warm sterile saline can be poured into the mediastinal cavity to further enhance acoustic transmission from the probe to the epicardial surface. The depth setting and the depth of transmit focus is then adjusted to visualize the near field. If a multifrequency probe is used, the frequency is increased to obtain the highest resolution image possible. Epicardial images may only be obtained by an operator who is wearing a sterile gown and gloves, and uses sterile technique within the operative field as described in these guidelines. This task may be performed either by a diagnosing physician with advanced perioperative echocardiography training or, alternatively and perhaps more practically, by a cardiac surgeon under the direct guidance of an advanced echocardiographer. Interpretation of epicardial echocardiographic images for the purpose of directing intraoperative surgical and anesthesia decision-making should only be performed by a physician with advanced perioperative echocardiography training. IMAGING PLANES The following proposed guidelines describe 7 epicardial echocardiographic imaging planes consistent with the ASE recommendations for transthoracic echocardiograph (TTE) nomenclature (17). We recognize that placement of the transducer directly on the heart provides views that can be slightly different than those obtained by TTE. These views will be identified as "modified" views. Individual patient characteristics, anatomic variations, or time constraints may limit the ability to obtain every component of the recommended comprehensive epicardial echocardiographic examination. Furthermore, there may be certain clinical situations where additional views may be necessary to address specific anatomic or pathologic questions. However, the 7 recommended views should permit the completion of a comprehensive 2-dimensional and Doppler echocardiographic evaluation in the vast majority of cardiac surgical cases, and should be obtainable in 5–10 min (13). Epicardial AV Short-Axis View (TTE Parasternal AV Short-Axis Equivalent) The ultrasound transducer is placed on the aortic root above the AV annulus, with the ultrasound beam directed toward the AV in a short-axis (SAX) orientation to obtain the epicardial AV SAX view (Fig. 1A). Appropriate transducer alignment and orientation is critical and requires the orientation marker (indentation) on the transducer to face toward the patient's left. The transducer typically has to be rotated approximately 30 degrees clockwise to develop this view. The right coronary cusp will be at the top of the monitor screen, the left coronary cusp will be on the right, and the noncoronary cusp will be on the left side of the screen adjacent to the interatrial septum (Fig. 1B). By slowly moving the transducer, the coronary ostia can be visualized. The area of the AV can also be measured in this view using planimetry.Figure 1.: Epicardial aortic valve (AV) short-axis (SAX) view (transthoracic echocardiographic parasternal AV SAX equivalent). A, Porcine anatomic specimen demonstrating ultrasound transducer oriented above AV annulus so that ultrasound beam can be aligned in SAX plane to AV. B, When orientation marker (indentation) on transducer is pointed toward patient's left, right coronary cusp (R) will be at top of monitor screen, left coronary cusp (L) will be on right, and noncoronary cusp (N) will be on left side of screen adjacent to interatrial septum. PA, Pulmonary artery.Epicardial AV Long-Axis View (TTE Suprasternal AV Long-Axis Equivalent) The epicardial AV long-axis (LAX) view is obtained from the epicardial AV SAX view by positioning the probe upward along the right-sided surface of the aortic root with the orientation marker slightly rotated clockwise and directed to the patient's left. The ultrasound beam is directed posteriorly to visualize the left ventricular (LV) outflow tract (LVOT) and AV (Fig. 2). This view can be used to determine LVOT, aortic annulus, and sinotubular junction diameters. Furthermore, the LAX orientation provided by this view permits optimal alignment of a continuous wave and pulse wave Doppler ultrasound beam, to measure pressure gradients across the AV and LVOT. Similarly, color flow Doppler interrogation of the AV can be used to grade the degree of aortic insufficiency.Figure 2.: Epicardial aortic (AO) valve (AV) long-axis (LAX) view (transthoracic echocardiographic suprasternal AV LAX equivalent). A, Porcine anatomic specimen demonstrating ultrasound transducer oriented along AO root, and directing ultrasound beam posteriorly to visualize left ventricular outflow tract (LVOT) and AV. B, AV and LVOT are well visualized. PA, Pulmonary artery.Epicardial LV Basal SAX View (TTE Modified Parasternal Mitral Valve Basal SAX Equivalent) The epicardial LV basal SAX view is obtained from the epicardial AV SAX position by moving the probe toward the apex along the right ventricle (RV) with the transducer orientation marker again directed toward the patient's left (Fig. 3A). This view will approximate what will be achieved with a right parasternal TTE imaging plane, and shows more of the RV and tricuspid valve than the standard left parasternal TTE orientation (Fig. 3B). The RV will be on top in the near field and the LV below it in the far field of the ultrasound beam sector. The mitral valve (MV) annulus is well visualized in this view with its typical "fish mouth" appearance. The MV anterolateral commissure will be on the right and the posteromedial commissure will be on the left of the screen. The anterior leaflet will appear on the top of the screen and the posterior leaflet will be underneath. The epicardial LV basal SAX view can be used to evaluate the anterior and posterior leaflets of the MV in 2-dimensional imaging. Color flow Doppler can also be used to determine the origin of mitral regurgitation jets and obtain an estimate of the regurgitant orifice area. Finally, basal LV regional wall motion can be assessed using the same LV wall orientation as seen in the epicardial LV mid-SAX view discussed below.Figure 3.: Epicardial left ventricle (LV) basal short-axis (SAX) view (transthoracic echocardiographic modified parasternal mitral valve [MV] basal SAX equivalent). A, Porcine anatomic specimen demonstrating proper probe positioning for developing epicardial LV basal SAX view. B, MV annulus is well visualized with its typical "fish mouth" appearance. MV anterior leaflet (AL) appears on top of screen and posterior leaflet (PL) is underneath. When transducer orientation marker is directed toward patient's left, MV anterolateral commissure will be on right and posteromedial commissure will be on left of screen. RV, Right ventricle.Epicardial LV Mid-SAX View (TTE Parasternal LV Mid-SAX Equivalent) Repositioning or angulating the probe inferiorly and to the left from the epicardial LV basal SAX view in an apical direction along the RV myocardial surface allows visualization of the RV and LV in SAX at the level of the papillary muscles and the LV apex (Fig. 4A). When the transducer orientation marker faces the patient's left, the anterolateral papillary muscle will be on the right side of the display and the posteromedial papillary muscle will be on the left side. The septal wall of the LV will be displayed on the left followed by the anterior, lateral, and inferior walls, respectively, in a clockwise rotation (Fig. 4B). The RV can be evaluated similarly by moving the transducer further toward the patient's right. LV and RV areas, global LV function, and LV regional wall motion can all be evaluated with this view.Figure 4.: Epicardial left ventricle (LV) mid short-axis (SAX) view (transthoracic echocardiographic parasternal LV mid-SAX equivalent). A, Porcine anatomic specimen demonstrating proper epicardial probe positioning toward right ventricle apex for developing epicardial LV mid-SAX view. B, With transducer orientation marker directed toward patient's left, LV anterolateral papillary muscle will be on right and posteriomedial papillary muscle will be on left of ultrasound sector displayed on monitor. Septal (S) wall of LV is displayed on left followed by anterior (A), lateral (L), and inferior (I) walls, respectively, in clockwise rotation.Epicardial LV LAX View (TTE Parasternal LAX Equivalent) From the epicardial LV mid-SAX view, the ultrasound beam can be angled superiorly and rotated toward the patient's right shoulder to generate the epicardial LV LAX view as depicted in Figure 5A. This view allows visualization of the inferolateral and anteroseptal walls of the LV and the RV, left atrium (LA), LVOT, AV, and MV (Figs. 5B and C). Color Doppler interrogation of the AV and MV is possible in this view. A rightward orientation of the beam allows evaluation of the right atrium and tricuspid valve (not shown). Further probe manipulation also permits spectral Doppler of the tricuspid valve. Hence, this view is useful for diagnosing and quantifying aortic, mitral, and tricuspid regurgitation. The interventricular septum can also be evaluated for ventricular septal defects, LVOT obstruction, or systolic anterior motion of the MV.Figure 5.: Epicardial left ventricle (LV) long-axis (LAX) view (transthoracic echocardiographic parasternal LAX equivalent). A, Porcine anatomic specimen demonstrating proper probe positioning with ultrasound beam angled superiorly and toward patients left shoulder to obtain epicardial LV LAX view. B, Porcine anatomic specimen with resected anterior ventricular wall demonstrating visualization of LV and right ventricle (RV), left atrium (LA), LV outflow tract (LVOT), interventricular septum (IVS), aortic valve (AV), and mitral valve (MV). C, Corresponding epicardial LV LAX echocardiographic view.Epicardial 2-Chamber View (TTE Modified Parasternal LAX Equivalent) From the epicardial LV LAX view, movement of the probe toward the anterior surface of the LV and further rotation of the transducer clockwise from the parasternal LAX view as described above will develop the epicardial 2-chamber view, permitting evaluation of the LA, LA appendage, MV, and LV (Fig. 6). Pathology that can be assessed in this view includes LA masses, and abnormalities in LA size, MV anatomy, and MV leaflet motion. Finally, regional wall motion of the basal and mid segments of the anterior and inferior LV walls can also be obtained. This view is the most difficult to consistently obtain unless the LV is dilated.Figure 6.: Epicardial 2-chamber view (transthoracic echocardiographic modified parasternal long-axis [LAX] equivalent). A, Porcine anatomic specimen demonstrating proper probe positioning with ultrasound transducer rotated 90 degrees from epicardial left ventricle (LV) LAX view to obtain epicardial 2-chamber view. B, Porcine anatomic specimen with resected anterior ventricular wall demonstrating left atrium (LA), mitral valve (MV), and LV. To completely eliminate right ventricle, transducer must be place directly on LV, which is possible only in patients with severe LV dilation (not shown). C, Corresponding epicardial 2-chamber echocardiographic image in patient with LV dilation.Epicardial RV Outflow Tract View (TTE Parasternal SAX Equivalent) The epicardial RV outflow tract view is developed by moving the transducer over the RV outflow tract and directing the ultrasound beam toward the patients left shoulder (Fig. 7). The RV outflow tract, pulmonic valve, and proximal main pulmonary artery can be visualized. Orienting a spectral Doppler beam parallel to blood flow permits the evaluation of chamber pressures and quantification of pulmonic stenosis. Color flow Doppler can also be used to evaluate pulmonic regurgitation or stenosis. Finally, this view is also useful for diagnosing a proximal pulmonary embolism or assisting with positioning a pulmonary artery catheter.Figure 7.: Epicardial right ventricular (RV) outflow tract (RVOT) view (transthoracic echocardiographic parasternal short-axis equivalent). A, Porcine anatomic specimen with resected anterior ventricular wall demonstrating proper probe positioning for developing epicardial RV inflow tract/RVOT view. B, RVOT, pulmonic valve (PV), proximal main pulmonary artery, and aortic valve (AV) can be visualized.CONCLUSION As the population of patients with complex cardiac surgical conditions and increasing comorbidity becomes more prevalent, there will be a greater and perhaps more important role for experienced perioperative echocardiographers, who should assume the responsibility of acquiring advanced echocardiographic cognitive and technical skills. The most recent recommendations by the ASE and SCA Task Force Guidelines for Training in Perioperative Echocardiography state that advanced training includes the "ability to acquire or direct the acquisition of all necessary echocardiographic data including epicardial and epiaortic imaging" (5). Although intraoperative epicardial echocardiography was introduced into clinical practice in the early 1970s for the evaluation of open MV commissurotomy, its use has declined during the last decade because of the increasing availability and improved technologic design of TEE probes. The epicardial approach to a comprehensive echocardiographic examination does present certain potential limitations and disadvantages compared with TEE. Nonetheless, a fundamental understanding of the skills required to obtain and interpret images as suggested in these guidelines for performing a comprehensive epicardial examination may be an advantageous adjunct or even a substitute when TEE probe insertion is contraindicated or cannot be performed. Epicardial echocardiography may also provide the best balance between safety and the efficient acquisition of vital information necessary to optimize the perioperative treatment of patients who are critically ill.

Short-term outcomes of a simple and effective approach to aortic root and arch repair in acute type A aortic dissection

Guidelines for Performing a Comprehensive Epicardial Echocardiography Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

A 73-year-old man was scheduled for aortic valve (AV) replacement for severe aortic regurgitation (AR). Preoperative transthoracic echocardiography revealed severe AR due to flail of the right coronary cusp (RCC). No vegetation was observed on the valve and surrounding tissues, inflammatory responses were within normal limits, and preoperative blood cultures were negative. Written informed consent was obtained from the patient for publication of this report and any accompanying images. Intraoperative transesophageal echocardiography (TEE) was performed using a 3-dimensional (3D) echocardiographic matrix-array probe (X7-2t transducer; Philips Healthcare, Andover, MA). The midesophageal (ME) 4-chamber view demonstrated a saccular structure in the left ventricular (LV) outflow tract (LVOT), and color flow Doppler (CFD) analysis revealed a severe regurgitant jet from nearby, although from a different site on the structure (Video 1, see Supplemental Digital Content 1, https://links.lww.com/AA/A517). An ME AV short-axis view showed a tricuspid AV with a large and deformed RCC (Video 2, see Supplemental Digital Content 2, https://links.lww.com/AA/A519). With slight advancement of the probe, 2 masses with an echo-free center were scanned at the LVOT, appearing at diastole and disappearing at systole, while CFD demonstrated mosaic blood flow throughout diastole from 1 of the 2 masses (Video 2, https://links.lww.com/AA/A519). On scanning with the ME AV long-axis (LAX) view, the RCC of the AV was seen to be perforated, with severe AR (Video 2, https://links.lww.com/AA/A519). The X-plane mode (Philips Healthcare) was used to assess orthogonal views of each structure in the LVOT. With this, a perforated aneurysm was seen on the RCC (Fig. 1A). Another view seemed to depict an AV aneurysm of the RCC that protruded into the LVOT, with expansion during diastole and collapse during systole (Fig. 1B). A 3D echocardiographic view was constructed from the full-volume mode with 4-beat estimation based on the aortic and LV perspectives.1 From the aortic perspective, 2 circular echo-free areas were seen on the RCC (Fig. 2A) (Video 3, see Supplemental Digital Content 3, https://links.lww.com/AA/A518). To obtain the view from the LV perspective, the image was rotated by approximately 180 degrees, so that the RCC remained at the bottom. Once again, 2 echo-free areas were seen on the RCC and a regurgitant jet was revealed at the site of perforation on the RCC by CFD, while there was no regurgitant jet from the nonperforated aneurysm (Video 3, https://links.lww.com/AA/A518). The other valves, including the mitral valve (MV) and surrounding structures had a normal morphology. During the surgery, the surgeon inspected the AV and confirmed the presence of 2 AV aneurysms on the RCC, one of which was perforated (Fig. 2B). These findings were consistent with those of intraoperative TEE examinations.Video 1: Two-dimensional echocardiographic analysis of the aortic valve aneurysms in the midesophageal 4-chamber (ME 4ch) view. First part: Saccular structure (yellow arrow) in the left ventricular outflow tract. Second part: Color flow Doppler (CFD) identified a regurgitant jet from a different site on the saccular structure (yellow arrow). LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.Video 2: Two-dimensional echocardiographic analysis of the aortic valve aneurysms in the midesophageal aortic valve short-axis (ME AV SAX) view and ME AV long-axis (LAX) view. First part: Deformed right coronary cusp (RCC) in the ME AV SAX view. Second part: Slight advancement of the transesophageal echocardiographic probe from the ME AV SAX view revealed 2 masses with an echo-free center in the left ventricular outflow tract (yellow arrow). Third part: Mosaic blood flow with color flow Doppler (CFD) in 1 of the 2 structures (yellow arrow). Fourth part: Perforated AV aneurysm on the RCC in the ME AV LAX view. Fifth part: Severe aortic regurgitation (AR) through the AV aneurysm in the ME AV LAX view with CFD. LA = left atrium; LV = left ventricle.Figure 1: Two-dimensional X-plane analysis of the aortic valve aneurysms. A, Orthogonal views of a perforated aneurysm (red arrow) on the right coronary cusp (RCC), based on the cursor line in the left panel. B, Orthogonal views of nonperforated aneurysm (yellow arrow) based on the cursor line in the left panel. The aneurysm was thin walled and round shaped in diastole. The bottom of the aneurysm was not delineated because of echo dropout (right panel). LV = left ventricle; LA = left atrium.Figure 2: Three-dimensional echocardiographic view of the aortic valve aneurysms and resected surgical specimen of the right coronary cusp (RCC). A, The aortic perspective view revealed 2 aortic valve aneurysms on the RCC, both of which were indicated as masses with an echo-free center. The red arrow indicates the perforated aneurysms. B, Resected surgical specimen of the RCC. Two aneurysms were identified on the RCC, one of which was perforated. LCC = left coronary cusp; NCC = noncoronary cusp.Video 3: Three-dimensional echocardiographic analysis of the aortic valve (AV) aneurysms. First part: Aortic perspective view of the 2 AV aneurysms on the right coronary cusp (RCC). Second part: Left ventricular (LV) perspective view of the 2 AV aneurysms. Third part: LV perspective view with color flow Doppler of the 2 AV aneurysms. The red and yellow arrows indicate the perforated and nonperforated aneurysms, respectively. LCC = left coronary cusp; NCC = noncoronary cusp; LV = left ventricle; LA = left atrium; PAC = pulmonary artery catheter.The AV was replaced with a bioprosthetic AV, the patient was successfully weaned off cardiopulmonary bypass, and he recovered with an uneventful postoperative course. DISCUSSION An AV aneurysm is defined as a localized bulge of the AV cusp toward the LVOT. Although infective endocarditis is a common cause of AV aneurysms,2,3 rheumatoid arthritis4 and bicuspid AVs5 are other possible etiologic factors. Irrespective of the etiology, perforation of the aneurysmal cavity into the LVOT can lead to severe AR. In previous reports, transthoracic echocardiography and TEE for AV aneurysm revealed a mass with an echo-free center in the LVOT, just below the AV.2–4 Careful observation indicated a saccular aneurysm of the AV, originating from the aortic cusp. It was shown to expand and protrude into the LVOT during diastole and collapse during systole, as was seen in our case as well. In case of aneurysms due to infective endocarditis, MV aneurysms form via spread of infection along the mitral-aortic intervalvular fibrosa or injury to the anterior mitral leaflet via contact with an aortic vegetation. In contrast to AV aneurysms, MV aneurysms are seen to bulge into the left atrium in systole and collapse in diastole.6 Perforation of the aneurysm is usually identifiable during CFD by visualization of a regurgitant jet passing through the perforation.2,3 In our case, 2 masses with an echo-free center were revealed in the LVOT, at the scanning level of which continuity between the masses and cusps of the AV could not be clearly scanned. Both of the masses were scanned with 2D orthogonal LAX views, which confirmed their origin from the RCC. Although slight clockwise or counterclockwise rotation of the TEE probe while scanning the standard 2D LAX view made longitudinal scanning of both the aneurysms possible, the X-plane mode facilitated accurate and detailed visualization of both aneurysms and their associations with surrounding tissues. The X-plane mode enabled scanning of simultaneous orthogonal views by fine and real-time scans by means of the cursor line and by fixing the short-axis view of the 2 simultaneously scanned structures. Furthermore, the 3D en face view allows visualization of the entire AV complex in motion throughout the cardiac cycle, providing additional information on its spatial relationship with surrounding structures.1 In this case, the relationship between the RCC and the 2 aneurysms during diastolic expansion could be displayed in a single view from the aortic and LV perspective. However, whether or not the aneurysms were perforated could not be confirmed, because both aneurysms were seen as masses with an echo-free center. The information about blood flow through the aneurysms provided by CFD was useful for distinguishing whether or not the aneurysms were perforated, because both 2D and 3D images were unable to scan the bottom of the round and thin wall of the nonperforated aneurysm. Echo dropout led to an apparent defect in the bottom of the aneurysm, as seen in Figures 1B and 2A. Instead, the perforation was obvious in the morphologic view. The X-plane mode with CFD, 3D, and color 3D modes had limitations associated with low frame rate and poor temporal resolution, although the 3D image was reconstructed in full volume with 4-beat estimation. AV aneurysms need to be distinguished from other causes of aneurysmal formations presenting in the LVOT.7 The differential diagnosis is displayed in Table 1. Detailed scanning of their appearance, origin, and changes in TEE appearance during the cardiac cycle would help differentiation of the different etiologies.Table 1: Differential Diagnosis of Aortic Valve AneurysmIn conclusion, detailed 2D, X-plane, and 3D TEE analyses complement each other in analyzing the morphologic features of AV aneurysms, and CFD analysis with both 2D and 3D TEE is useful for diagnosing whether or not the aneurysms are perforated. DISCLOSURES Name: Masataka Kuroda, MD, PhD. Contribution: This author helped with design of the study, conduct of the study, data collection, data analysis, and preparation of the manuscript. Attestation: Masataka Kuroda approved the final manuscript. Name: Akihito Takemae, MD. Contribution: This author helped prepare the manuscript. Attestation: Akihito Takemae approved the final manuscript. Name: Toshikazu Takahashi, MD. Contribution: This author helped prepare the manuscript. Attestation: Toshikazu Takahashi approved the final manuscript. Name: Norikatsu Mita, MD. Contribution: This author helped prepare the manuscript. Attestation: Norikatsu Mita approved the final manuscript. Name: Shin Kagaya, MD, PhD. Contribution: This author helped prepare the manuscript. Attestation: Shin Kagaya approved the final manuscript. Name: Sohtaro Miyoshi, MD, PhD. Contribution: This author helped prepare the manuscript. Attestation: Sohtaro Miyoshi approved the final manuscript. Name: Yuji Kadoi, MD, PhD. Contribution: This author helped prepare the manuscript. Attestation: Yuji Kadoi approved the final manuscript. Name: Shigeru Saito, MD, PhD. Contribution: This author helped prepare the manuscript. Attestation: Shigeru Saito approved the final manuscript. This manuscript was handled by: Martin J. London, MD.

The art of aortic valve repair

Aortic root repair in acute type A aortic dissection: Neomedia or no neomedia

Echocardiographic assessment of systolic anterior motion of the mitral valve.

Isolated Bicuspid Aortic Valve Repair With Double Annuloplasty: How I Teach It

The origin of the left main coronary artery (LMCA) from the pulmonary artery (PA), known as Bland-White-Garland syndrome (BWGS), is a rare anomaly with mortality of 90% during infancy (1). If collateral circulation between right and left coronary systems ensues, BWGS patients may reach adulthood (1,2). However coronary flow directs preferentially into the lower pressure PA, away from the left ventricle (LV) creating “coronary steal,” and left-to-right shunt. Mitral regurgitation (MR) is further common in BWGS most likely due to multiple factors (3). Surgical correction of BWGS is strongly recommended, even in asymptomatic patients, because of the high risk of developing heart failure, myocardial infarction, ventricular arrhythmias, and sudden death (1,2). A 44-yr-old man presented with recent onset of fatigue and atrial fibrillation. Transthoracic echocardiography demonstrated severe MR with a posterior-directed jet, mild anterior mitral leaflet prolapse, a dilated mitral annulus, enlarged left atrium (5.8 cm), preserved global LV function, a moderately dilated right ventricle with moderate tricuspid regurgitation, and estimated right ventricle systolic pressure of 60 mm Hg. Because of the patient’s occasional chest pain, a persantine–thallium study was performed demonstrating a significant perfusion defect of the anterior LV wall. Cardiac catheterization revealed the absence of the LMCA in the left sinus of Valsalva. Contrast dye injected into the right coronary artery (RCA) filled the main branches of the LMCA with anomalous drainage through the LMCA into the PA. The patient was referred for mitral valve (MV) repair and correction of anomalous LMCA. Intraoperative transesophageal echocardiography (TEE) mostly confirmed the preoperative echocardiography findings but now demonstrated a large RCA (17 mm of diameter) that was identified at the right sinus of Valsalva. Color flow Doppler examination showed that the LMCA passed close to the left sinus of Valsalva with no connection to the aortic root. The LMCA origin was identified as arising from the PA, 18 mm distal to the pulmonic valve with retrograde flow into the PA (Figs. 1 and 2; please see video clip available at www.anesthesia-analgesia.org).Figure 1.: Preoperative multiplane transesophageal echocardiography (TEE), mid-esophageal aortic valve long axis view. The large orifice of the right coronary artery can be seen with laminar diastolic antegrade flow demonstrated by Color Doppler mapping. (LA, left atrium; MV, mitral valve; LVOT, left ventricle outflow tract, IVS, interventricular septum; AoV, aortic valve; AO, ascending aorta; RCA, right coronary artery.)Figure 2.: Preoperative multiplane transesophageal echocardiography (TEE), modified mid-esophageal aortic valve short axis view. The ascending aorta just above the aortic valve can be recognized. Color Doppler shows the left main coronary artery (LMCA) passing close to the left sinus of Valsalva however with no identified connection to the Aortic root. (LA, left atrium; RA, right atrium; IAS, interatrial septum; AO, ascending aorta.)The patient underwent uncomplicated reimplantation of the LMCA into the aortic root and MV repair. The postoperative TEE showed LMCA orifice reimplanted into the left sinus of Valsalva, and the MV annuloplasty ring with mild MR (Fig. 3).Figure 3.: Postoperative multiplane transesophageal echocardiography (TEE), mid-esophageal aortic valve short axis view. The LMCA orifice now reimplanted into the left sinus of Valsalva can be seen. (LA, left atrium; RA, right atrium; IAS, interatrial septum; LCC, left coronary cusp; RCC, right coronary cusp; NCC, noncoronary cusp; LMCA, left main coronary artery.)Identification of the coronary orifices and normal coronary flow pattern is an important part of a TEE examination. Young adults with no risk factors for coronary disease may present with MR and unrecognized BWGS. In the presence of a single enlarged RCA orifice, BWGS should be considered.

Left Atrial Dissection Associated with Pulmonary Vein Cannulation

Intraoperative transesophageal echocardiography for pediatric patients with congenital heart disease.

Short- and long-term outcomes of aortic root repair and replacement in patients undergoing acute type A aortic dissection repair: Twenty-year experience

To identify which rest phase (systolic or diastolic) is optimum for assessing or measuring cardiac structures in the setting of three-dimensional (3D) whole-heart imaging in congenital heart disease (CHD). The study was approved by the institutional review board; informed consent was obtained. Fifty children (26 male and 24 female patients) underwent 3D dual-phase whole-heart imaging. Cardiac structures were analyzed for contrast-to-noise ratio (CNR) and image quality. Cross-sectional measurements were taken of the aortic arch, right ventricular (RV) outflow tract (RVOT) and pulmonary arteries. Normally distributed variables were compared by using paired t tests, and categorical data were compared by using Wilcoxon signed-rank test. Mean CNR and image quality were significantly (all P < .05) greater in systole for the right atrium (CNR, 8.9 vs 7.5; image quality, 438 vs 91), left atrium (CNR, 8.0 vs 5.3; image quality, 1006 vs 29), RV (CNR, 10.6 vs 8.2; image quality, 131 vs 23), LV (CNR, 9.4 vs 7.7; image quality, 125 vs 28), and pulmonary veins (CNR, 6.2 vs 4.9; image quality, 914 vs 32). Conversely, diastolic CNR was significantly higher in the aorta (9.2 vs 8.2; P = .013) and diastolic image quality was higher for the left pulmonary artery (238 vs 62; P = .007), right pulmonary artery (219 vs 35; P < .001), and for imaging of an area after an arterial stenosis (164 vs 7; P < .001). All aortic arch and RVOT cross-sectional measurements were significantly (P < .05) greater in systole (narrowest point of arch, 70 vs 53 mm(2); descending aorta, 71 vs 58 mm(2); transverse arch, 293 vs 275 mm(2); valvar RVOT, 291 vs 268 mm(2); supravalvar RVOT, 337 vs 280 mm(2); prebifurcation RVOT, 329 vs 259 mm(2)). Certain structures in CHD are better imaged in systole and others in diastole, and therefore, the dual-phase approach allows a higher overall success rate. This approach also allows depiction of diameter changes between systole and diastole and is therefore preferable to standard single-phase sequences for the planning of interventional procedures.

Stroke volume (SV) and aortic valve area calculations require the left ventricular (LV) outflow tract (LVOT) or aortic annular area calculations that involve squaring the respective diameters. Area calculation errors became evident with transcatheter aortic valve replacement where areas were underestimated due to an elliptical annulus. We hypothesized that LVOT and annular shape are more elliptical in patients with greater relative LV wall thickness (RWT) leading to underestimation of SV index using 2D Doppler echocardiography. We studied 203 consecutive patients referred to an outpatient noninvasive laboratory for Doppler echocardiograms which included acceptable 3-dimensional images. 3-dimensional assessment of the LVOT at 3-5mm from the valve insertion, at the site of valve insertion, and at the sinus of Valsalva (SOV) was performed with assessment of the minor axis (MN), major axis (MJ), and areas at mid-systole. SV index was calculated from LVOT and annular diameters obtained from 2-dimensional echo and from 3-dimensional LVOT areas. An inverse relation of RWT with MN/MJ at mid-systole for the LVOT (r=0.5812, P<0.0001) and annulus (r=0.6865, P<0.0001) was noted. LVOT and annulus areas were similar among groups at mid-systole. SV index calculated from 2D LVOT dimensions was significantly smaller than using 3D LVOT areas (35.6±8.9 vs 53.6±16.1mL, P<0.0001). There is an inverse relation between MN/MJ and RWT at the LVOT and aortic annulus despite the LVOT and annular areas being similar across most geometries resulting in SV index underestimation calculated using LVOT diameters vs 3D LVOT areas.