3D Transesophageal Echocardiogram Research Articles

Use of a mini 3D transesophageal echocardiogram (TEE) probe in adult patients for outpatient TEE: initial experience in a national tertiary hospital

Abstract Background The mini 3D TEE probe, initially developed for pediatric patients, is now being utilized for adult patients due to its smaller size and clear 2D & 3-dimensional imaging and Doppler studies, potentially limiting anesthesia use and procedural complications. Purpose This study aimed to analyze the clinical profiles and outcomes of adult patients who underwent an outpatient TEE using a mini 3D TEE probe, including image quality and ease of use. Proper evaluation is vital for patient safety, and this initial study aims to determine the mini 3D TEE probe's applicability and safety in adults, potentially guiding future clinical practice. Methods This was a retrospective cross-sectional, and observational study. Medical records were reviewed, including demographic and clinical profiles, echocardiographic data, and procedural and safety outcomes. For each patient, two operators rated ease of use and all imaging modalities on a 5-point scale, from 1 (very difficult/poor) to 5 (very easy/good). Results Eight adult patients were included in the study to undergo a comprehensive TEE using a mini 3D TEE probe. Most patients were female (63%) with a median age of 28.5 years (IQR 5.13), with valvular heart diseases (38%), congenital heart diseases (38%), and heart failure (50%). Most patients had an ASA Physical Classification of Class II (38%) or III (38%). Indications for TEE were primarily suspected congenital heart disease with inadequate transthoracic echo (63%) and pre-intervention evaluation of valvular structures (63%). The probe insertion was rated very easy (100%), and handling was mostly very easy (87.5%). 2D, 3D, 2D color, continuous, and pulsed wave Dopplers were rated very good (100%), with 87.5% rating 3D color flow Doppler as very good. All patients received local pharyngeal anesthesia, with only half of the patients given low-dose intravenous midazolam. The median procedure time for a full study was 40 minutes (IQR 17). After the procedure, all patients were fully awake and recovered (median recovery time 4.5 minutes, IQR 1.88), with only minor post-TEE complications like pharyngeal irritation (13%) and hoarseness (13%). No major morbidities, GI bleeding, esophageal perforation, arrhythmia, respiratory compromise, or mortality occurred. All patients were discharged after recovery with a median outpatient length of stay of 47 minutes (IQR 15.25). Conclusion The mini 3D TEE probe demonstrates ease of use and excellent imaging quality for adult patients across all imaging modalities. It is safe to use and can be performed with local pharyngeal anesthesia alone or with mild intravenous sedation, with no significant post-procedural complications. This study supports the mini 3D TEE probe's applicability and safety in adult patients, suggesting its potential for broader clinical application in cardiovascular diagnostics. A larger scale prospective study is recommended to further confirm these preliminary findings.

Anatomical Significance of the Patent Foramen Ovale by Real-Time 3D TEE in Cryptogenic Stroke and Migraine.

The transesophageal echocardiogram (TEE) is the standard imaging modality for confirming the presence or absence of patent foramen ovale. PFO is a flap valve depending on the pressure change between the left and right atrium, which can help determine whether to open. 3D-TEE was shown to optimize the visualization of PFO. There is a causal association between PFO and unexplained stroke. It seems that 3D-TEE can present a high-risk PFO morphological feature, which seems to show more than just being easier to open. In total, 134 consecutive patients with cryptogenic stroke or migraine who had suspected PFO and underwent c-TCD, TTE, and c-TEE were included in this study. TEE confirmed the PFO. The right-to-left shunt (RLS) grade of PFO at rest and abdominal compression Valsalva maneuver was detected by c-TEE. The long diameter of FO (1.74 ± 0.3vs. 1.60 ± 0.4, p = 0.039), the short diameter of FO (1.12 ± 0.3vs. 1.00 ± 0.3, p = 0.036), perimeter of FO (4.62 ± 0.7vs. 4.22 ± 1.0, p = 0.026), and area (1.80 ± 0.8vs. 1.35 ± 0.8, p = 0.05) of the FO were significantly larger in the larger RLS group. In group of CS, a larger proportion of Eustachian valve or a Chiari's network (14.3%vs. 3.5%, p = 0.036), a larger proportion of in the left funnelform (55.1%vs. 16.3%, p < 0.001), a longer length of the PFO tunnel (13.4 ± 4.4vs. 7.8 ± 2.5, p < 0.001), a lower IVC-PFO angle (16.4 ± 3.4vs. 20.3 ± 7.7, p = 0.001), a higher proportion of LA multiple exits of the tunnel (46.9%vs. 14.3%, p < 0.001). Multivariate regression analysis showed that male gender (HR: 4.026, 95% CI: 0.883-18.361, p = 0.072), age (HR: 1.076, 95% CI: 1.002-1.155, p = 0.045), the left funnelform (HR: 7.299, 95% CI: 1.585-33.618, p = 0.011), a longer length of the PFO tunnel (HR: 1.843, 95% CI: 1.404-2.418, p < 0.001) and multiple exits of the tunnel of LA (HR: 8.544, 95% CI: 1.595-45.754, p = 0.012) increased the risk of cerebral infarction. The cut-off value calculated by ROC for the diagnosis of high-risk PFO was that the length of the PFO tunnel was 12mm and the left funnelform combined with multiple exits of the left atrial (sensitivity was 92%, specificity was 90%). The area under the curve of the combined index versus PoPE score (0.932 vs. 0.736) relative to the RoPE score was statistically significant. TEE has shown outstanding advantages in displaying the specific morphological characteristics of PFO. The left funnelform, a longer length of the PFO tunnel, and multiple exits of the tunnel of LA are associated with an increasing risk of CS in anatomical PFO respect.

Abstract 13392: 3D TEE Aids in Assessment of Embolic Stroke Due to Aortic Atherosclerotic Plaque

Case Presentation: A 69-year-old right-handed man presented with new left-sided weakness and recurrent ischemic strokes. His had history of coronary artery disease, diabetes mellitus, hypertension, dyslipidemia, chronic kidney disease stage 3, obstructive sleep apnea and obesity. Plasma low-density lipoprotein was 127 mg/dL. Brain MRI showed diffusion restriction in the left caudate head, left corona radiata, left anterior lentiform nucleus, and left periventricular white matter from acute to subacute infarction. CT angiogram showed diffuse atheromatous disease in the anterior and posterior circulation, bilateral mild cervical internal carotid artery stenosis, and calcifications in the aortic arch ( Figure 1 ). Transthoracic echocardiogram (TTE) showed mild generalized left ventricular hypokinesis (ejection fraction 45%) without thrombus. Transesophageal echocardiogram (TEE) showed complex mobile atherosclerotic plaques in the aortic arch ( Figure 2 ) after which Apixaban &amp; Clopidogrel were started and statins increased. At 1-year follow-up there was no recurrent stroke. Discussion: This case highlights the role of 3D TEE in the detection of complex aortic arch atherosclerotic plaque with mobile components as the etiology of recurrent embolic stroke. 2D TTE &amp; TEE and CT chest were unable to show mobile components in the aortic arch plaque. Many patients identified as having “cryptogenic stroke” after 2D TTE &amp; TEE may in fact have mobile aortic arch plaques which can only be delineated by 3D TEE, thus reducing the need for further workup and expediting appropriate treatment.

P161 INCIDENTAL FINDING OF QUADRICUSPID AORTIC VALVE IN A YOUNG ASYMPTOMATIC PATIENT

Abstract Background Quadricuspid aortic valve (QAV) is a rare congenital heart disease, eventually leading to aortic regurgitation (AR) and heart failure. In up to one–third of patients, QAV is associated with other coexisting cardiac defects, particularly aortic dilation and coronary arteries abnormalities. Case Report A 48–years old man without significant past medical history was referred to the Cardiologist for newly diagnosed arterial hypertension. The patient was asymptomatic and no abnormal findings were noticed on physical examination. Transthoracic echocardiography showed normal end–diastolic volume and diameter of the left ventricle and preserved systolic function. However, a mild dilation of the aortic root (40 mm) and ascending aorta (38 mm) with concomitant moderate–to–severe AR were described. Transoesophageal echocardiogram (TOE) was performed to better visualize the aortic valve anatomy and to define the exact mechanism of the AR. 2D–TOE revealed a QAV with equal–sized cusps (type A according to the Hurwitz–Roberts classification), with a central quadrangular coaptation defect and a moderate AR (vena contracta width: 4 mm) [Fig. 1–2]. The regurgitant jet conditioned a pseudo–prolapse of anterior mitral leaflet with consequent mild–to–moderate mitral regurgitation. 3D–TOE allowed a better characterization of valve morphology and the individuation of the sole left coronary artery ostium. A coronary artery computed tomography was requested to investigate a probable abnormal origin of the right coronary artery. The patients was subsequently addressed to a regular clinic and echocardiographic follow–up for the surveillance of AR and aortic dimensions and a prompt management of an eventual symptoms onset. Discussion We describe a rare case of type A QAV with moderate AR, mild dilation of aortic root and ascending aorta and suspected anomalous origin of the right coronary ostium. The broad diffusion of imaging techniques has recently led to an increase of incidental diagnosis, even in asymptomatic patients. The complex valve anatomy, with many possible morphologies of the supernumerary cusp, and the association with other congenital defects, particularly anomalous coronary ostia location, pose many technical issues in case of valve replacement. A multimodality imaging approach is essential for a clear description of valve morphology and coronary anatomy to avoid intraoperative complications in both surgical and percutaneous valve replacement procedures.

P103 LIBMAN–SACKS ENDOCARDITIS AND FIBROELASTOMA IN ANTYPHOSPHOLIPIDIC SYNDROME: A RARE COEXISTANCE

Abstract Background Libman–Sacks endocarditis (LSE) is the most common cardiac manifestation of the antiphospholipid antibody syndrome (APS), a systemic autoimmune disease characterized by the presence of arterial and venous thrombosis associated with the persistent presence of antiphospholipid antibodies (Sydney criteria). Cardioembolic events, mainly stroke, are important prognostic determinants of APS. Echocardiography, mostly transesophageal, is the main diagnostic tool to early identification and timely management of LSE. Case Summary we report a case of 33–year–old man, with no cardiovascular risk factors. In the last few months, he had a myocardial infarction without obstructive coronary artery disease, a femoral venous thrombosis and a cryptogenic stroke. After clinical and laboratory workout he received diagnosis of primary APS and started an anticoagulation therapy with warfarin. 2D and 3D transesophageal echocardiogram performed after stroke showed two vegetations of the mitral valve. The first one appeared as granular mass, attached to ventricular and atrial surface of the posterior leaflet, measuring 16 x 5 mm. The second one was a smaller, mobile, pedunculated and more hyperechogenic mass apposed on the anterior leaflet. Mitral valve had mild to moderate regurgitation. The patient underwent surgical vegetation excision due to the high embolic risk. Resected specimens revealed sterile fibrinous and verrucous vegetations referable to LSE and a papillary fibroelastoma. Discussion In this case we demonstrated a very rare coexistence of abacterial endocarditis and papillary fibroelastoma. We can assume a predisposing role of fibroelastoma by altering the morphology and structure of the mitral leaflets in LSE development.

Left atrial appendage perimeter ostium evaluation by cardiac CT utilizing 3mensio technology for watchman implantation

Abstract Background Left atrial appendage occlusion (LAAO) with Watchman device traditionally relies on accurate left atrial appendage ostium diameter measurement by 2D or 3D transesophageal echocardiogram (TEE). Alternate methods of ostium measurement including area-derived diameter and perimeter-derived diameter using cardiac computed tomography (CT) have been proposed. Methods We performed a retrospective analysis of 92 patients with atrial fibrillation (Afib) who underwent LAAO with WATCHMAN implantation with pre-procedural TEE and CT between May 2015 and December 2018. LAA characteristics including ostial or landing zone perimeter, minimum and maximum diameters were acquired utilizing 3mensio Structural Heart Imaging Program. Proposed device size was estimated utilizing ostium perimeter by CT and compared to the current standard utilizing ostium diameter by 2D-TEE. Both measurements were then compared to actual final device size that satisfying release criteria. Results CT had a very high correlation with the actual implanted device size (Pearson coefficient r=0.94, p&amp;lt;0.001), while TEE based sizing had a lower correlation (Pearson coefficient r=0.66, p&amp;lt;0.001). CT predicted size had a significantly higher agreement compared to standard TEE based sizing (93.4% vs 47.8%), and higher interrater agreement (Cohen's kappa = 0.91 vs Cohen's kappa = 0.32, p&amp;lt;0.001, p&amp;lt;0.001 respectively). Bland-Altman analysis also showed better correlation with CT-based sizing. Procedural complications were 0, and 0 patients had a leak recorded at 45-days post implant. Conclusion CCT LAA perimeter sizing is superior to the current standard TEE based Watchman sizing. Larger, multi-center studies may be necessary to further validate results. Funding Acknowledgement Type of funding sources: None. 3mensio after CT upload

Dynamic Shape Change of an Aortic Valve Cusp Perforation on 3D Transesophageal Echocardiogram

Dynamic Shape Change of an Aortic Valve Cusp Perforation on 3D Transesophageal Echocardiogram

P860 Multimodality imaging of multiple recurrent myxomas: the role of three dimensional echocardiography

Abstract A 33-year-old lady who underwent left atrial myxoma resection was found to have on a 3 years follow up transthoracic echocardiography (E) a multilobular mass in the right atrium. A 2D transesophageal echocardiogram (TEE) was performed. Two Multi-lobulated masses were seen in the right atrium(RA); one bigger attached by a peduncle to the atrial wall in between the interatrial septum (IAS) and the superior vena cava and one smaller attached to the inferior RA wall; a remnant likely a suture was seen on the right side of the fossa ovalis; another small mass was noted on the left atrial (LA) side of the IAS; a small mass attached close to the posteromedial commissure and P3 scallop of the mitral valve was also detected. The RA mass was partially protruding into the tricuspid valve during diastole with no significant obstruction to flow. Three dimensional TEE allows an anatomical imaging able to identify the peduncles of two right atrial masses and three LA masses that were confirmed at surgery and consistent with cardiac myxoma at histopathology : one close the previous resection area, one at the opening of the LAA (panel A, white arrow) and one close to the posterior commissure of mitral valve (panel B, yellow arrow) and that were not seen by 2D. Magnetic resonance imaging (MRI) with contrast identified and showed opacification of : two masses in the RA with the pedicles ; - one mass on the LA side of interatrial septum; - one mass close to mitral valve posterior commissure ; however it was not able to detect the small mass close to the LAA. In our case 2D Echocardiography and MRI were able to identify 4 of the 5 recurrences found at surgery. 3D TEE was the only technique able to identify all 5 lesions. MRI is considered the gold standard for detecting cardiac tumor masses; however, even after careful review, it was not possible to identify the presence of the mass close to LAA. In particular 3D TEE was able to image the left atrial masses by an "en face view" of the left atrium from above. In addition, the unique 2D planes in unconventional views allow a more clear identifications of the peduncles of the masses in the right atrium. The identification of the peduncles is mainstay for the diagnosis of recurrent myxomas and exclude other tumors like metastasis or sarcomas. In fact multiple recurrence are very rare in particular if we consider that are in the two atria. Genetic tests for Carney complex were negative. The MRI allowed to confirm the vascularization of the contrast and to identify the peduncles of two masses in the right atrium. A multimodality imaging is able to correctly detect recurrent myxomas by identifying the anatomical features and the vascularization and lead to the diagnosis ; 3DE was the only technique able to correctly identify all the recurrent myxomas and and its use has the potential for being considered the key adjunctive modality for the anatomy when advanced surgical plan is required. Abstract P860 Figure.

P306 Left ventricular volumes during 3D transesophageal echocardiography in comparison to those obtained by 3D transthoracic echocardiogram. A feasibility study

Abstract Background Three dimensional (3D) transthoracic echocardiogram (TTE) has been validated to have good agreement with cardiac magnetic resonance for the assessment of left ventricular ejection fraction (LVEF) with good interobserver reproducibility. Despite the increased use of perioperative transesophageal echocardiogram (TEE), TEE assessment of left ventricular (LV) function and volumes have never been validated against 3D TTE. Objective To evaluate whether 3D TEE measurement of LV function shows better agreement with 3DTTE, compared to 2DBiplane and X-plane TEE. Methods A total of 60 patients were included from a single large volume tertiary center, the mean age of 71.9 years, 40% were female; TTE and TEE studies were performed within one week. LV function parameters including LV EF, LV end-diastolic (LVEDV) and end systolic volumes (LVESV), stroke volumes (SV) were calculated with Qlab version 9, and 3DQ advanced software, with semi-automated endocardial contours for 3D TTE and 3D TEE. LV function parameters for 2D X-plane and Biplane TEE data sets were assessed using AGFA with manual endocardial contours. Mean differences were compared with paired, two-tail T-test, and limits of agreement were determined using the Bland-Altman analysis. Correlation between TTE and TEE values were tested using Pearson’s correlation test. Results 3D transthoracic LV EDV, ESV, SV, and EF respectively were 112± 46 ml, 57 ±32 ml, 55± 55 ml, and 51 ±11%. Comparisons and correlations between TTE and TEE for the four measures were: for EDV bias = 9.94 ml and 95% lower and upper limits of agreements being -68.7 and 88.5 ml, and r= 0.7; for ESV the bias was -0.3 ml with 95% lower and upper limits of agreements being -55 to 55 ml, and r = 0.7: for stroke volume bias= 0.2 with 95% lower and upper limits of agreements being -37 to 67 ml, and r = 0.2; for LVEF the bias was 2.7% with 95% lower and upper limits of agreements being -18.9% to 24.3%, and r= 0.7 (Fig) Conclusion Left ventricular volumetric assessments during 3D transesophageal echocardiography is not only feasible but also comparable to 3D transthoracic echocardiography obtained LV volumes and EF. Data from multicenter studies with a larger number of subjects are needed to corroborate our findings. Abstract P306 Figure. Fig. 3D LV volumes by 3D TEE vs. 3D TTE

P879 3D transoesophageal echocardiography to asses a case of a non-ebstein tricuspid valve congenital regurgitation

Abstract Introduction Due to the complexity of congenital heart disease and limitations of transthorathic echocardiogram (TTE), especially in adult patients, it is not unusual to need other image techniques to assess cardiac anatomy and function. The most common primary anomaly of tricuspid valve (TV) is Ebstein anomaly, but there are other much rarer primary anomalies of this valve consisting in prolapse, cord retraction.... without downward displacement of the leaflet, generally causing tricuspid regurgitation (TR) that can be severe and sometimes intervention is needed, preferably reparation. Due to anatomical issues, it is difficult to assess anatomy of TV in TTE, so sometimes 3D-TTE must be performed to clarify the mechanism and to measure orifice, but when transthoracic view is not enough, 3D transoesophageal echocardiogram (TOE) can be useful for this purpose. Case We report the case of a 15-year-old boy that was referred to our clinic because of shortness of breath and a systolic tricuspid murmur. TTE was performed and an image compatible with tricuspid valve prolapse with no apical displacement of any leaflets (Figure, A) causing severe TR (Figure, B) was noticed, as well as severely dilated right chambers, with good ejection fraction of both ventricles. It was not clear the mechanism so 2D TOE was done, showing a prolapse of a leaflet (Figure, C) causing severe TR (Figure, D). The mechanism was finally clarified by 3D TOE (figure E). This was a prolapse of lateral portion of posterior leaflet (asterisk) with restrictive movement of anterior (triangle) and septal (arrow) ones, causing a huge coaptation defect in systole leading to a very severe tricuspid insufficiency with signs of volume overload of right ventricle. There was no atrial septal defect and pulmonary drainage anomalies were ruled out by cardiac magnetic resonance. Patient was referred to surgery due to symptoms and great dilatation of right chambers. Conclusión: Due to anatomical complexity and limitations of echography, cross and multimodality cardiac imaging is usually needed in assessing congenital heart disease. Apart from Ebstein anomaly, other congenital entities of tricuspid valve such as prolapse and/or retraction can lead to severe tricuspid regurgitation. Due to limitations of 2D TTE in assessing tricuspid valve anatomy, 3D TTE has to be performed, but if it is not enough, 3D TOE can be an option to evaluate mechanism and directly see the orifice of regurgitation in congenital disease of tricuspid valve. Abstract P879 Figure

P247 Added value of 3D echo in diagnosing and monitoring transcatheter valve in mac procedure in a patient with severe mitral stenosis

Abstract INTRODUCTION Mitral annular calcification (MAC) is a chronic degenerative process involving calcification of the fibrous base of the mitral valve accounting for 12% to 26% of all mitral stenosis (MS) and eventually for significant mitral regurgitation. Calcification often extends to other parts of the mitral valve apparatus but, unlike rheumatic stenosis, does not produce commissural fusion. Surgical treatment carries a high mortality rate due to technical difficulties involving the heavily calcified annulus, advanced age and comorbidities of affected patients. In recent years, transcatheter mitral valve replacement using ballon expandable transcatheter aortic valves in severe MAC (valve-in-MAC) has been used with acceptable success rates. PURPOSE To describe the added value of 3D echo in the diagnostic work-up, decision making and monitoring during the interventional procedure of valve-in-MAC. CASE PRESENTATION Two years ago a 90-year-old female in sinus rhythm with hypertension and known coronary artery disease (CAD) was admitted with symptoms of pulmonary congestion (PC). At that time, a transthoracic 3D echocardiogram showed important MAC with a mitral valve area (MVA) estimated through 3D planimetry of 1.1 cm2, pulmonary artery pressure (PAP) of 53 mmHg, preserved biventricular function and left atrial enlargement. One year later, she was readmitted with unstable CAD and treated with percutaneous transluminal angioplasty. At that time a 3D transesophageal echocardiogram (3DTOE) showed worsening of the MVA now estimated in 0.6 cm2, a mean gradient of 19 mmHg and PAP of 88 mmHg. Albeit optimized medical therapy, her functional status worsened and less than a month later she was again readmitted in NYHA functional class III. Therefore decision making for valve-in-MAC was undertaken. Valve sizing was performed with computed tomography (CT) using the D-shape method with similar findings when compared with 3D TOE measurements. Both methods showed a favourable anatomy of the left ventricular outflow tract. Valve-in-MAC procedure was performed through transvenous transseptal access and an Edwards Sapien3-nr 29 balloon-expandable valve was deployed uneventfully, except for a residual interatrial septal defect measuring 2.2x0.8cm closed two weeks after, as she persisted with PC and pulmonary hypertension. During the procedure, 3DTOE showed a partial thrombosis involving one of the prosthesis leaflets with preserved transvalvular gradients despite anticoagulation. After that, PC resolved and PAP dropped dramatically. The patient was discharged under lifelong anticoagulation and remains asymptomatic until now. CONCLUSION Diagnosing and treating patients with severe MS due to MAC remains a challenge as traditional parameters and interventional procedures don’t apply for this population. Valve-in-MAC is a feasible alternative and 3DTOE may have a pivotal role in the diagnostic work-up and interventional monitoring of these cases. Abstract P247 Figure. 3D echo timeline valve in MAC

A workflow for patient-specific fluid–structure interaction analysis of the mitral valve: A proof of concept on a mitral regurgitation case

The mechanics of the mitral valve (MV) are the result of the interaction of different anatomical structures complexly arranged within the left heart (LH), with the blood flow. MV structure abnormalities might cause valve regurgitation which in turn can lead to heart failure. Patient-specific computational models of the MV could provide a personalised understanding of MV mechanics, dysfunctions and possible interventions. In this study, we propose a semi-automatic pipeline for MV modelling based on the integration of state-of-the-art medical imaging, i.e. cardiac magnetic resonance (CMR) and 3D transoesophageal-echocardiogram (TOE) with fluid–structure interaction (FSI) simulations. An FSI model of a patient with MV regurgitation was implemented using the finite element (FE) method and smoothed particle hydrodynamics (SPH). Our study showed the feasibility of combining image information and computer simulations to reproduce patient-specific MV mechanics as seen on medical images, and the potential for efficient in-silico studies of MV disease, personalised treatments and device design.

P3730Left atrial appendage perimeter measurement by cardiac CT is superior to transesophageal echocardiography for Watchman device sizing

Abstract Background Left atrial appendage occlusion with Watchman device traditionally relies on accurate left atrial appendage (LAA) ostium diameter measurement by 2D or 3D transesophageal echocardiogram (TEE). Alternate methods of ostium measurement including area-derived diameter and perimeter-derived diameter using cardiac computed tomography (CT) have been proposed. Purpose We aim to use CT technology with an advanced medical imaging application to measure LAA ostium perimeter for improved pre-procedural device sizing. Methods We performed a retrospective analysis of 92 patients with atrial fibrillation (Afib) who underwent Watchman implantation with pre-procedural TEE and cardiac CT between May 2015 and December 2018. LAA characteristics including ostial or landing zone perimeter, minimum and maximum diameters were acquired utilizing 3mensio Structural Heart Imaging Program. Proposed Watchman device size was estimated utilizing ostium perimeter by CT and compared to the current standard utilizing ostium diameter by 2D-TEE. Both measurements were then compared to actual implanted Watchman device size which met the P.A.S.S. criteria of position, anchor, size and seal. Results Watchman device sizing based on novel LAA landing zone perimeter size by CT had a very high correlation with the actual implanted Watchman size (Pearson coefficient r=0.94, p&lt;0.001). Traditional TEE based Watchman sizing only had a modest correlation with the implanted Watchman size (Pearson coefficient r=0.66, p&lt;0.001). CT predicted Watchman size had a significantly higher agreement compared to current standard TEE based sizing (93.4% vs 47.8%), inter-rater agreement was very high for CT based Watchman sizing compared to current standard TEE based sizing (Cohen's kappa = 0.91 vs Cohen's kappa = 0.32, p&lt;0.001, p&lt;0.001 respectively). Bland-Altman analysis also showed better correlation with CT based sizing compared to TEE (see Figure 1). Figure 1 Conclusion CT LAA perimeter sizing is superior to the current standard TEE based Watchman sizing. Larger, multi-center studies may be necessary to further validate our results.

OC02 AUTOMATIC 3D-ECHO AORTIC ANNULUS MEASUREMENT FOR A PRECISE PREOPERATIVE TAVI PLANNING: IS IT ALREADY FEASIBLE?

Background and aim: Transcatheter aortic valve implantation is a wide-spreading technique. The advent of recent softwares based on 3D transoesophageal echo is updating the role of ultrasound in the preoperative prosthesis sizing because of its potentiality to provide precise measurements of the aortic annulus avoiding X-ray and contrast material. Aim of this study is to verify the reliability of echo measurements. Methods: We enrolled 15 patients with severe aortic stenosis and 5 with healthy aortic valve. All patients underwent ECG-gated angio CT-scan and 3D transoesophageal echocardiogram. We blindly compared the two sets of data focusing on annulus and sinuses dimensions. Results: Statistically significant differences were found in aortic annulus diastolic maximum diameter and perimeter. Although not significant, the small differences highlighted in systole would have led to the choice of a different prosthesis size in 33% of the patients in case of CoreValve Evolut R, in 40% in case of Sapien 3 and in 60% in case of Lotus valve. Conclusions: Although not significant, the small differences between echo and CT measurements, if at the extremities of different size range, lead to a different transcatheter prosthesis size choice with potential relevant clinical effect.

The clot thickens: an incompletely ligated left atrial appendage

SummaryOur patient presented with known mechanical mitral valve endocarditis documented by 2D transesophageal echocardiogram (TOE) from a recent hospitalization at an outside facility. On admission to our center, there was no prior knowledge of an incompletely ligated left atrial appendage (LAA) according to patient- or family-reported history, review of outside records or the outside facility’s 2D TOE report. A 3D TOE performed at our center to assess her pathology, since a month had passed from her prior hospitalization, revealed a LAA ligation with evidence of communication to the left atrium and with clot present in the appendage. This case report highlights the common finding of incomplete closure of the LAA following surgical ligation, thus making it inadequate for stroke prevention in patients with atrial fibrillation, and that 3D TOE plays a valuable role in assessing the durability of LAA ligation.

The Value of 3D Printing Models of Left Atrial Appendage Using Real-Time 3D Transesophageal Echocardiographic Data in Left Atrial Appendage Occlusion: Applications toward an Era of Truly Personalized Medicine

Aims and Objectives: The objective of this study was to assess the clinical feasibility of generating 3D printing models of left atrial appendage (LAA) using real-time 3D transesophageal echocardiogram (TEE) data for preoperative reference of LAA occlusion. Background: Percutaneous LAA occlusion can effectively prevent patients with atrial fibrillation from stroke. However, the anatomical structure of LAA is so complicated that adequate information of its structure is essential for successful LAA occlusion. Emerging 3D printing technology has the demonstrated potential to structure more accurately than conventional imaging modalities by creating tangible patient-specific models. Typically, 3D printing data sets are acquired from CT and MRI, which may involve intravenous contrast, sedation, and ionizing radiation. It has been reported that 3D models of LAA were successfully created by the data acquired from CT. However, 3D printing of the LAA using real-time 3D TEE data has not yet been explored. Methods: Acquisition of 3D transesophageal echocardiographic data from 8 patients with atrial fibrillation was performed using the Philips EPIQ7 ultrasound system. Raw echocardiographic image data were opened in Philips QLAB and converted to ‘Cartesian DICOM' format and imported into Mimics® software to create 3D models of LAA, which were printed using a rubber-like material. The printed 3D models were then used for preoperative reference and procedural simulation in LAA occlusion. Results: We successfully printed LAAs of 8 patients. Each LAA costs approximately CNY 800-1,000 and the total process takes 16-17 h. Seven of the 8 Watchman devices predicted by preprocedural 2D TEE images were of the same sizes as those placed in the real operation. Interestingly, 3D printing models were highly reflective of the shape and size of LAAs, and all device sizes predicted by the 3D printing model were fully consistent with those placed in the real operation. Also, the 3D printed model could predict operating difficulty and the presence of a peridevice leak. Conclusions: 3D printing of the LAA using real-time 3D transesophageal echocardiographic data has a perfect and rapid application in LAA occlusion to assist with physician planning and decision making.

Transcatheter Mitral Valve Implantation: 30-day Outcome of First-in-Man Experience With an Apically Tethered Device.

A small number of transcatheter mitral valve implants (TMVIs) have been reported using devices designed to treat secondary mitral regurgitation (MR). However, MR has many etiologies, and patients have a broad spectrum of annular size, geometry, and lesions. There are a number of technical challenges for TMVI including left ventricular outflow tract obstruction and paravalvular MR. Thirty days' outcome of first-in-man implants with a novel TMVI device is reported. The Tendyne TMVI system consists of a porcine pericardial valve in a tethered nitinol frame. An apical tether fixed to an epicardial pad stabilizes the device. The device is fully repositionable and retrievable even after complete deployment. Preoperative assessment was performed with 3-dimensional (3D) transesophageal echocardiogram and multislice computed tomography to define annular dimensions, geometry, and guide surgical access. Three patients were deemed not to be candidates for conventional surgery or for treatment with any Conformitè Européenne-marked device by Heart Team Evaluation. They were a 68-year-old woman with prior coronary artery bypass grafts and severe functional MR; a 75-year-old man with prior coronary bypass grafts, significant renal dysfunction, and severe degenerative MR; and a frail 86-year-old man with severe degenerative MR. Each had a TMVI via a transapical approach through a left minithoracotomy. Apical tether tension was adjusted to optimize device position. Implantation was guided by 2D and 3D transesophageal echocardiogram. The apical pad facilitated LV apical closure. There were no procedural complications. No patient had hemodynamically significant residual MR or left ventricular outflow tract obstruction, and there was no significant mitral gradient. All patients were discharged to their own home (the third on the fifth postoperative day), all with significant improvement in their symptoms. All were alive and well 30 days after implant. Two patients with existing conduction abnormalities had cardiac resynchronisation therapy after the procedure, and one patient had para valvular leak (PVL) with evidence of hemolysis at 30 days, which reduced in severity with conservative treatment. The first-in-man experience with the Tendyne TMVI system is promising. Valve stabilization by an apical tether is a novel way to address some of the challenges of TMVI. The unique Tendyne design features may offer potential for its use across a wide range of mitral valve pathologies.

Plaque disruption during transcatheter aortic valve replacement

A 91-year-old man with a history of hypertension, hyperlipidaemia, coronary artery disease, and atrial fibrillation on chronic anticoagulation therapy presented with symptomatic aortic valve stenosis. The patient underwent a transcatheter aortic valve replacement (TAVR) using an 18-French delivery catheter. A live 3D transoesophageal echocardiogram (TOE) obtained during the procedure revealed an atherosclerotic plaque in the …

A general three-dimensional parametric geometry of the native aortic valve and root for biomechanical modeling

The complex three-dimensional (3D) geometry of the native tricuspid aortic valve (AV) is represented by select parametric curves allowing for a general construction and representation of the 3D-AV structure including the cusps, commissures and sinuses. The proposed general mathematical description is performed by using three independent parametric curves, two for the cusp and one for the sinuses. These curves are used to generate different surfaces that form the structure of the AV. Additional dependent curves are also generated and utilized in this process, such as the joint curve between the cusps and the sinuses. The model's feasibility to generate patient-specific parametric geometry is examined against 3D-transesophageal echocardiogram (3D-TEE) measurements from a non-pathological AV. Computational finite-element (FE) mesh can then be easily constructed from these surfaces. Examples are given for constructing several 3D-AV geometries by estimating the needed parameters from echocardiographic measurements. The average distance (error) between the calculated geometry and the 3D-TEE measurements was only 0.78±0.63mm. The proposed general 3D parametric method is very effective in quantitatively representing a wide range of native AV structures, with and without pathology. It can also facilitate a methodical quantitative investigation over the effect of pathology and mechanical loading on these major AV parameters.

Rotational angiography for preinterventional imaging in transcatheter aortic valve implantation

To evaluate the clinical value of 3D rotational angiography, as a tool for imaging and measuring 3D anatomy, coupled with transesophageal echocardiogram (TEE) as preinterventional imaging for transcatheter aortic valve implantation (TAVI) procedures. TAVI is a growing field in cardiology. An understanding of the 3D anatomy of the aortic root is crucial for patient selection and for the optimal planning and guidance of such procedures. Current techniques include 3D imaging (with MSCT MRI and 3D TEE) combined with multiplane TEE. Nevertheless, a gold standard of 3D imaging is yet not defined. 3D rotational angiography provides 3D anatomy information in the cathlab. Initially designed for nonmoving anatomical structures, one can adapt the protocol to temporarily minimize the heart anatomy motion during rotational angiography. Ninety-nine consecutive patients (61 females, 38 males, age 80.9 ± 5.2 years) with symptomatic aortic stenosis underwent 3D rotational angiography to assess the anatomical suitability of potential TAVI candidates. 3D rotational angiography with a C-Arm (Innova 3100(IQ) , GE Healthcare, Chalfont St Giles, UK) was performed to create the 3D anatomy of the aortic root. Coronary angiography and pelvic vessel angiography were performed during the same examination. Measurements of the aortic annulus and the sinotubular junction were made on the 3D cross-sections and were compared to TEE. Radiation dose to the patient was also monitored. In all 99 patients, 3D rotational angiography was performed successfully with good imaging of the aortic root and measurements of the aortic annulus. In patients scheduled for SAPIEN valve implantation, the distances from the annulus to the coronary ostia were also measured. Of 99 patients, 80 subsequently underwent successful implantation. There is a good correlation to the TEE in the measured aortic annulus (22.13 ± 2.09 mm in rotational angio, 21.58 ± 2.09 mm TEE, Spearman r = 0.88, 95% IC [0.83;0.92], P < 0.0001) and sinotubular junction (26.19 ± 2.71 mm in rotational angio, 26.22 ± 2.73 mm TEE, Spearman r = 0.83, 95% IC [0.75;0.88], P < 0.0001). The effective dose is a fraction of the X-ray dose required for multi-slice computed tomography. Given that this technology is available in the cathlab at reasonable dose levels, 3D rotational angiography has proven to be a suitable preinterventional 3D imaging modality for TAVI procedures. Together, the raw angiographic data and the reconstructed 3D volume provide all the necessary anatomical information necessary for this procedure, including the measurements.