Application Of Transesophageal Echocardiography Research Articles

Application of Transesophageal Echocardiography in Amplatzer Atrial Septal Defect Occluder for Percutaneous Closure of Large Patent Foramen Ovale.

Objective The Amplatzer patent foramen ovale (PFO) occluder is the most commonly used device for percutaneous closure of a large PFO. However, its use may predispose the patient to postoperative residual shunting. To reduce the incidence of residual shunting, we investigated the safety and effectiveness of the Amplatzer atrial septal defect (ASD) occluder for percutaneous closure of a large PFO measured by transesophageal echocardiography (TEE) and evaluated the value of TEE in this procedure. Methods Overall, 118 patients who were diagnosed with a large PFO (all with a ≥ 2 mm left atrial side height after the Valsalva maneuver (VM) excluding those with a small ASD) using contrast transthoracic echocardiography (c-TTE) and TEE underwent closure under TEE guidance at The First Affiliated Hospital of Xi'an Jiaotong University. An ASD device was used in 48 patients (group I) and a PFO device in 70 (group II). After the procedure, we verified the safety and efficacy of different devices using c-TTE, TTE, and TEE. Results In both groups, the preoperative TEE results showed a significantly increased left height of the PFO after VM compared with that at rest (all P < 0.01). Compared with the left height of the PFO measured using TEE after VM, the PFO-stretch diameter (SD) measured by TEE after the delivery sheath passed the PFO was higher (all P < 0.01). We selected the ASD occluder size according to this PFO-SD. In group II, most patients underwent the implantation of the larger PFO devices. Interventional treatment was successfully performed on all patients. The effective occlusion rate in group I at 12 months after the procedure was significantly higher than that in group II (93.7% vs. 78.6%, P < 0.05). The TEE results showed that 18 patients with a medium and large residual shunt at 12 months after the procedure exhibited an intradisc tunnel-like shunt. Conclusion The Amplatzer ASD device and Amplatzer PFO device are safe for large PFO closure, but the Amplatzer ASD device has a higher effective occlusion rate. TEE plays a crucial role in the use of the Amplatzer ASD occluder for percutaneous closure of a large PFO.

Cohen’s Comprehensive Thoracic Anesthesia

Cohen’s Comprehensive Thoracic Anesthesia

Transesophageal Ultrasound in Perioperative Hemodynamic Analysis of Off-Pump Coronary Artery Bypass Grafting

Transesophageal echocardiography (TEE) can directly, real-time, and visually monitor cardiac structure, function, and volume status, and effectively guide perioperative volumetric therapy and vasoactive drug use in critically ill patients to improve rehabilitation treatment and prognosis. Therefore, TEE is considered to be the most comprehensive monitoring technology. The characteristics of reliability, continuity, and repeatability of TEE-guided perioperative hemodynamic management make it have obvious advantages in clinical application, and have gradually developed into a technology that anesthesiologists must master. In this article, we carried out the application of transesophageal echocardiography in perioperative hemodynamic management, with a view to providing clinical research evidence for further promoting the clinical application of TEE and optimizing the quality of perioperative hemodynamic management in critical patients. The experimental results show that before and after cardiopulmonary bypass, there is a decrease after cardiopulmonary bypass, but it is not reflected in invasive pressure monitoring. It is considered that the volume change is small, and it has not yet caused the pressure change. In other words, the pressure is estimated to some extent. The load state sensitivity is poor and can not really reflect the change of the front load. Compared to the large number of applications to assess systolic function, there are few studies using estimated left ventricular diastolic function. In addition to the complexity of the diastolic process itself, the area curve is susceptible to clutter interference, and the poor readability of the time differential curve is directly related.

Perioperative Application of Transesophageal Echocardiography in Left Atrial Appendage Occlusion in an Elderly Patient with Mirror-Image Dextrocardia and Atrial Fibrillation

Mirror-image dextrocardia is non-life-threatening but not commonly diagnosed in the clinic. With the internal organs reversed, most of the patients with mirror-image dextrocardia have no clinical symptoms if the dextrocardia is not combined with other intracardiac malformations. Mirror-image dextrocardia is often discovered during other physical check or performing other examinations. In the present study, we reported a successful closure of a left atrial appendage in an 84-year-old patient with mirror-image dextrocardia with atrial fibrillation under the guidance of transesophageal echocardiography (TEE). Detailed perioperative steps of patient procedure description and TEE monitoring were described in this report.

The Application of Transesophageal Echocardiography in Mitral Valve Repair With Tendon Reconstruction.

Objective: To investigate whether tendon reconstruction during mitral valve repair can be effectively guided by transesophageal echocardiography (TEE), using the mid-esophageal bi-commissure view, bicaval view and the aortic valve–mitral valve transition short-axis view.Methods: A total of 40 patients that underwent mitral valve repair with artificial tendineae were recruited. Before the operation, conventional transthoracic echocardiography was used to determine whether mitral valve repair would be possible. Following intraoperative anesthesia, two-dimensional and three-dimensional TEE reconstructions were used to assess the state of the valve and tendon and to make a repair plan.Results: TEE accurately diagnosed single functional tendon rupture and predicted single artificial tendon implantation in 88% of cases (23/26). TEE accurately diagnosed single functional tendon rupture and predicted the implantation of two artificial tendons in 100% of cases (4/4). TEE accurately diagnosed two or more functional tendon ruptures and predicted the implantation of two artificial tendons in 100% of cases (5/5). The length of the tendon cord predicted by TEE (2.45 ± 0.15 mm) was not significantly different (P > 0.05) from the length of the cord that was actually implanted (2.31 ± 0.11 mm). TEE also accurately predicted the size of the annuloplasty ring in 86% of cases (33/38), with differences of 2 mm or less compared to the size of the ring that was actually implanted.Conclusion: Both the mid-esophageal bi-commissure view, bicaval view and the short-axis view of the aortic valve–mitral valve transition can reduce the difficulty of tendon reconstruction by helping to determine what length of tendon and what size of artificial annulus are required.

Application of Transesophageal Echocardiography in Observing Left Atrial and Left Atrial Appendage Before Radiofrequency Ablation in Patients with AF

Objective: To report and explain the significance of transesophageal echocardiography(TEE) in the observation of left atrium and left atrial appendage before radiofrequency ablation in patients with AF. Methods: 25 patients with AF were selected as the review objects who received echocardiography in our hospital during June 2018 to June 2019. They had routinely received transthoracic echocardiography (TTE) before preparing for radiofrequency ablation. Then TEE was selected to observe and compare the effect of two detection methods on left atrial and left auricular thrombosis. Results: TEE examinations were given to patients with atrial fibrillation before radiofrequency ablation. Compared with TTE examinations, the detection rate of left atrium and left atrial appendage thrombosis was significantly improved. The two detection methods are different and comparable(P&lt;0.05), which is of great significance in clinical application. Conclusion: The use of TEE has significantly improved the detection rate of left atrial and left atrial appendage thrombosis in patients with AF, and has become an important examination method before the implementation of radiofrequency ablation.

Application of transesophageal echocardiography, left atrial appendage angiography, cardiac computed tomography angiography, and three-dimensional reconstruction model in left atrial appendage occlusion

Objective: The objective was to evaluate the application of transesophageal echocardiography, left atrial appendage angiography, cardiac computed tomography angiography, and three-dimensional reconstruction model in the left atrial appendage occlusion. Methods: A total of 53 patients with persistent atrial fibrillation hospitalized from January 2015 to February 2019 were selected. Transesophageal echocardiography and cardiac computed tomography angiography were performed simultaneously before operation, and three-dimensional reconstruction of the left atrial appendage model was performed based on the cardiac computed tomography angiography findings. The morphology and size of the left atrial appendage were displayed by the left atrial appendage angiography during the operation. Results: Cardiac computed tomography angiography revealed filling defects in the left atrial appendage in four patients, whereas transesophageal echocardiography revealed thrombosis in two patients of the four patients. According to the cardiac computed tomography angiography results, the morphology of the left atrial appendage was classified into chicken wing–like, cauliflower-like, wind vane–like, and cactus-like. The diameters and depths of the left atrial appendage measured by cardiac computed tomography angiography and three-dimensional reconstruction model were found to be the greatest, and the orifice sizes and depths of the left atrial appendage measured by the left atrial appendage angiography were the smallest. Conclusion: Transesophageal echocardiography, left atrial appendage angiography, cardiac computed tomography angiography, and three-dimensional reconstruction model can evaluate the morphology and size of the left atrial appendage. The cardiac computed tomography angiography and three-dimensional reconstruction model could demonstrate the internal structure of the left atrial appendage more clearly.

Application of transesophageal echocardiography in high ventricular septal defect closure via the small intercostal incision with eccentric occluder in children

Objective To explore the value of transesophageal echocardiography (TEE) in high ventricular septal defect (VSD) occlusion via a left parasternal ultra-minimal intercostal incision (≤1 cm) with eccentric occluder in children. Methods Forty-eight children with high VSD underwent device occlusion via ultraminimal intercostal incision with eccentric occluder. The whole operation, including preoperative evaluation, intraoperative localization and guidance and postoperation evaluation were performed under the guidance of TEE. Results Forty-six children with high VSD underwent successfully device closure in all 48 cases and the operation success rate was 95.8%. The average size of high VSD was 2.2-6.0 (3.70±0.90)mm and the average size of eccentric occluder was 4-8 (5.48±1.12)mm. The average operation duration was 18-98 (49.80±16.71)min. There were 2 cases of peri-membranous high VSD and 44 cases of outlet-typle VSD, of which 10 cases of mild aortic valve prolapses (AVOP), including 5 cases of aortic valve regurgitation(AR). In addition, there was 1 case of replacement of device, 1 case of having septum below the margin of the defect and 1 case of using a dilator for a small defect. The 46 cases were followed up for 6 to 42 months, and the pericardial effusion occured in 3 cases and disappeared during follow-up. No other abnormal conditions were found. Conclusions During the surgery of high VSD device occlusion via ultraminimal intercostal incision with eccentric occluder, TEE has an important value in defect assessment, intraoperative localization and guidance, and immediate evaluation of efficacy, and can effectively guide the device occlusion of high VSD. Key words: Echocardiography, transesophageal; Ventricular septal defect; Minimal surgical procedures; Children

Application of transesophageal echocardiography in anesthesia management in modified morrow operation

Objective To evaluate the application of transesophageal echocardiography (TEE) in anesthesia management of obstructive hypertrophic cardiomyopathy (HOCM) during modified morrow operation and to evaluate the effect of TEE on surgical decision-making. Methods Twenty-one HOCM patients who were admitted into our hospital from March 2015 to March 2019 for TEE were selected. All patients underwent transesophageal ultrasound. The diameter of the narrowest left ventricular outflow tract, and subaortic interventricular septal thickness and length were recorded before and after operation. Continuous Doppler flow velocity was measured at the left ventricular outflow tract and the difference of transvalvular pressure was calculated. At point of mitral valve apex, peak velocity and atrial filling (A) and early filling (E) of mitral valve were recorded on four-chamber level of middle esophagus, E/A(mitral valve E peak velocity divided by A peak velocity ratio). Early diastolic (e′) phase of ventricular lateral wall of mitral annulus with tissue doppler, E/e′ (mitral valve E peak velocity divided by mitral annulus e′) were recorded. Results Intro-operative aerodynamics was stable and no malignant adverse events such as ventricular fibrillation occurred. There were 18 cases of auto-cardiac resuscitation (85%), 3 cases of temporary pacemaker use (15%), while 17 patients (81%) did not need to use positive inotropic drugs after rebound, but could successfully depart from cardiopulmonary bypass at low doses of deoxyepinephrine. The remaining four patients (19%) required low doses of milrinone or combined with deoxyepinephrine or norepinephrine. The cardiopulmonary bypass (CPB) time was (124±45) min and the aortic occlusion time was (85±21) min. The trans-valvular pressure of left ventricular outflow tract decreased to (68±8) mmHg (1 mmHg=0.133 kPa) to (16±6) mmHg by TEE after operation (P 14, and the lateral wall of ventricular septum e′ was<10 cm/s. Conclusions TEE plays an important role in anesthesia management, surgical decision-making and evaluation of operation. For patients with normal systolic function, TEE monitoring of transvalvular pressure through deep transgastric lax is consistent with intraoperative monitoring of transvalvular pressure through catheter. Key words: Transesophageal echocardiography; Modified morrow operation; Obstructive hypertrophic cardiomyopathy; Anesthesia management

Transoesophageal echocardiography current practice in France: A multicentre study

Few data are available on the application of transoesophageal echocardiography (TOE) recommendations in daily practice. To evaluate TOE practice based on echocardiography societies' guidelines, and to determine complication rates and factors associated with patient feelings. Between April and June 2017, we prospectively included all consecutive patients referred to 14 French hospitals for a transoesophageal echocardiogram (TOE). A survey was taken just after the examination, which included questions about pre-procedural anxiety, and any pain, unpleasant feeling or breathing difficulties experienced during the examination. Overall, 1718 TOEs were performed, mainly for stroke evaluation. A standardized operating procedure checklist was completed in half of the patients before the examination. TOE was unpleasant for 62.4% of patients, but was stopped for agitation or intolerance in 3.5 and 1.4% of cases, respectively. We observed one severe complication (pulmonary oedema). The mean TOE duration was short (9.2±4.6minutes), but was longer with residents than with more experienced physicians (11±4.7 vs. 8.8±4.7minutes for junior physicians [P=0.0027]; vs. 8.9±4.8minutes for senior physicians [P=0.0013]; and vs. 7.5±4.1minutes for associate professors/professors [P<0.0001]). The visual analogue scale (VAS) score after TOE was good (8.3±1.7 out of 10), and was better in patients with general anaesthesia (GA) than in those without GA (9.3±0.9 vs. 8.1±1.7; P<0.0001). In patients without GA, the VAS score was similar with and without local anaesthesia (8.1±1.7 vs. 8.2±1.6; P=0.19). After multivariable adjustment, absence of anxiety before TOE and greater operator experience were consistently associated with a higher VAS score. TOE is safe, with a low rate of complications and few stops for intolerance. A shorter TOE duration and better patient feelings were observed for experienced operators, highlighting the importance of the learning curve, and paving the way for teaching on a TOE simulator.

Application of transesophageal echocardiography in left atrial appendage closer with Amplatzer Cardiac Plug

Objective To assess the value of transesophageal echocardiography (TEE) in left atrial appendage (LAA) closer with Amplatzer Cardiac Plug (ACP). Methods Consecutive 32 atrial fibrillation patients (CHADS2≥1) with high risk bleeding underwent LAA occlusion with ACP LAA occlusion device under the guidance of TEE. Measurements of LAA anchoring area diameter (AAD) and LAA anatomical orifice diameter (AOD) including maximum, minimum values, and LAA depth on 2 dimentional TEE (2D TEE) were conducted before closer device implantation. The outcomes of LAA occlusion were analyzed. Results Among 32 patients, 27 cases achieved successful LAA occlusion, including 2 cases with peripheral leakage ≤5 mm, and 5 cases failed occlusion.Among 5 failed closed patients, 3 cases with LAA AAD≥ 30 mm, 1 case with LAA of short depth, and 1 case with anatomical variation of LAA of low position that access sheath could not be positioned in the LAA. LAA AAD maximum, minimum and LAA depth were (25.9±4.9)mm, (20.0±3.8)mm, (31.0±5.6)mm, respectively, and LAA AOD maximum, minimum diameters were (26.2±6.2)mm, (19.4±4.3)mm, respectively. Among 10 cases with LAA AAD≥30 mm, 7 cases achieved successful LAA occlusion, but 3 cases failed. The implanted device diameter was (26.4±3.8)mm, and device compression rate was (7.6±5.5)%. The coefficient of correlation between device diameter and large LAA AAD and AOD is 0.770 and 0.717, respectively. There was no complication but 1 case with pericardial effusion. Conclusions Two dimentional TEE measurements of LAA have clinical guiding significance in the selection of proper size of ACP LAA occluder. The AAD of 2D TEE has the good correlation with ACP occluder′s size, the AADs are important factors which affect the success of LAA occlusion. Key words: Echocardiography, transesophageal; Left atrial appendage; Occlusion; Amplatzer Cardiac Plug

Clinical research on the application of trans-esophageal echocardiography in monitoring Nuss surgery

To investigate the validity and safety of trans-esophageal echocardiography (TEE) in monitoring of Nuss surgery. A total of 140 patients with pectus excavatum from Sichuan Provincial People's Hospital underwent Nuss surgery from August, 2011 to Aμgust, 2013. Among them, 72 patients received TEE monitoring while 68 patients didn't. The injury of heart and large vessels by the introducer and Nuss steel bar was observed by intraoperative TEE monitoring under middle-esophageal four chamber view and middle-esophageal aortic short axis view. The operation in all patients had been performed successfully without any severe complications. Satisfactory TEE images were obtained in all patients. The procedure of inserting the inducer and Nuss steel bar behind sternum and steel bar overturn could be seen clearly. No injury in heart and large vessels was detected. Local streak-like hemorrhage in 3 patients was observed under intra-operative TEE screen, but no further new bleeding was found in postoperative TEE examination. The blood was absorbed and couldn't see under trans-thoracic echocardiography in 1 month after the operation. The TEE is a non-invasive monitoring method. It is sensitive to detect the status of the heart and large vessels and can prevent the severe complications due to Nuss surgery.

Transcatheter aortic valve implantation: Anesthetic experience of retrograde transfemoral approach with CoreValve ReValving System

ObjectivesValvular aortic stenosis (AS) is a major cardiac valvular disease in geriatric people. Conventional treatment for severe AS is aortic valve replacement through surgery. However, many geriatric patients are considered inoperable due to higher risks for surgery and anesthesia. Transcatheter aortic valve implantation (TAVI), a less invasive procedure, has rapidly developed in recent years as an alternative management option for high-risk AS patients. Herein, we describe our anesthetic experience in the TAVI procedure. MethodsWe included 11 patients who consecutively received transfemoral TAVI in the period from September 2010 to January 2011. All patients received general anesthesia with endotracheal intubation; arterial line placement and central venous catheter insertion were carried out for monitoring hemodynamics. Transesophageal echocardiography was applied for valve evaluation, hemodynamic monitoring, and intraoperative guidance. Patients were transferred to the intensive care unit for further care after surgery. The periprocedural events were recorded. ResultsThe mean age of these patients was 82 years. Morphology of the aortic valve in all patients was tricuspid, and the etiology of AS was degenerative calcification. During TAVI, all patients received bolus injections of 5–10 μg norepinephrine just before the rapid pacing stage in order to increase the mean arterial pressure. Only one patient needed continuous infusion of dopamine because of severe preoperative congestive heart failure, and another patient needed continuous infusion of norepinephrine due to relatively old age and suspected low systemic vascular resistance. After TAVI, all patients had the endotracheal tube extubated within 7 hours, except one because of preoperative ventilator dependence. Another male patient stayed in the intensive care unit for 8 days due to postoperative complete atrioventricular block, and he received permanent pacemaker implantation. There was no early mortality. ConclusionTAVI is another choice for AS patients who have a high perioperative risk. General anesthesia with endotracheal intubation and application of transesophageal echocardiography can facilitate the use of this new technique by cardiologists. Complete preprocedural evaluation and good intraprocedural cooperation are still the gold standards to achieve successful TAVI and patient safety.

CASE 12—2014Inferior Vena Cava Compression by Retroperitoneal Hematoma During Cardiopulmonary Bypass

From the *Cardiovascular and Thoracic Section, Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; †Division of Cardiac Surgery, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; ‡Division of Cardiothoracic Surgery, Department of Surgery, Aristotle University, Thessaloniki, Greece; §Division of Cardiac Surgery, Department of Surgery Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada. Address reprint requests to John G. Augoustides MD, FASE, FAHA, Anesthesiology and Critical Care, 680 Dulles, HUP, 3400 Spruce Street, Philadelphia, PA 19104-4283. E-mail: yiandoc@hotmail.com © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2013.10.020 CARDIOPULMONARY BYPASS (CPB) first was applied successfully in cardiac surgery by John H. Gibbon in 1953. Since that clinical milestone more than 60 years ago, CPB has evolved into a mainstream technique in contemporary cardiac surgery to facilitate openand closed-chamber procedures of all types, including specialized perfusion approaches such as deep hypothermic circulatory arrest. The safe conduct of CPB requires a vigilant and experienced team approach to minimize serious errors and to solve critical events when they occur. This conference presents a challenging case of major retroperitoneal hemorrhage that presented during CPB. The successful detection and management of this rare but serious complication is outlined, highlighting the principles of a team approach, vigilance, and creative applications of transesophageal echocardiography. The case conference begins with a description and discussion of the case, followed by 2 expert commentaries, the first from the cardiac surgeon’s perspective and the second from the cardiac anesthesiologist’s perspective.

Application of transesophageal echocardiography in min-invasive hybrid procedure for intracristal ventricular septal defects in children

Objective To evaluate the clinical outcome of transesophageal echocardiography(TEE) in guiding and monitoring min-invasive transthoracic hybrid procedure for intracristal ventricular septal defects (VSD) using eccentric occluders.Methods 13 patients with intacristal VSD successfully underwent the min-invasive hybrid procedure using eccentric occluders were analyzed retrospectively.They were all carefully examined by transthoracic echocardiography (TTE) preoperatively and were diagnosed as intracristal VSD.There were no obvious aortic valve prolapse and no severe regurgitation.The entire process was guided and monitored by TEE.The condition of VSD occlusion was assessed by immediate postoperative TEE.Results All cases were occluded successfully.The results of postoperative TEE showed that the occluder was coincided closely with the edge of VSD,no aortic valve regurgitation worsen.2 had tiny residual left-to-right shunt (＜1.5 mm),which disappeared 1 and 3 months respectively after operation.No occluder dislocated followed-up at 6 months to 2 years postoperatively,and no major complications occurred.Conclusions The min-invasive hybrid procedure for intracristal VSD using eccentric occluders guided and monitored by TEE is easy to manipulate,which is safe,less invasive,and has excellent early-term results. Key words: Echocardiograghy,transesophageal; Heart septal defect,ventricular; Eccentric occluder

Unicuspid Aortic Valve: Transesophageal Echocardiographic Features

A CONGENITAL MALFORMATION of the aortic valve is the most common cause of isolated aortic stenosis in adolescents and young adults. Usually the stenotic valve is found to be bicuspid, but not infrequently stenosis may result from a unicuspid aortic valve.1 The clinical presentations of unicuspid and bicuspid aortic valve stenosis are similar, and the distinction between these 2 entities before surgery can be difficult. The application of transesophageal echocardiography when properly performed potentially can make this distinction possible.

Intraoperative Assessment of Perivalvular Mitral Regurgitation: Utility of Three-Dimensional Echocardiography

THE APPLICATION OF transesophageal echocardiography (TEE) for the assessment of prosthetic valve function is considered a category II indication.1 Although direct surgical examination of the prosthetic mitral valve is considered the “gold standard,” TEE provides a “dynamic” assessment of the valve under varying loading conditions.2 Three-dimensional (3D) TEE imaging may provide additional information to improve the description of prosthetic valve function and the location of perivalvular leaks. The incorporation of color-flow Doppler information in the 3D image may also help visualize the complex and eccentric mitral regurgitation (MR) jets.

Application of transesophageal echocardiography in intraoperative device closure of secundum atrial septal defects

To evaluate the clinical value of transesophageal echocardiography (TEE) in guiding intraoperative device closure of secundum atrial septal defect (ASD). Fifty ASD patients, aged 40 +/- 18 (15-72), 34 with an ASD ranging from 30 to 40 mm and 16 with atrial septal aneurysm accompanied by double or more ASDs, underwent intraoperative device closure through a right minithoracotomy without cardiopulmonary bypass and fluoroscopy. Under general anesthesia, a probe was inserted into the esophagus, and TEE was conducted at different planes to observe the characteristics of the ASD. The size of implanted device was determined by TEE. Small parasternal incision was made in the right third or fourth intercostal space. A specially designed plastic sheath loaded with Amplatzer occlusion device was inserted through the purse-string sutures placed on the right atrium. Guided by transesophageal echocardiography, the Amplatzer occlusion device was advanced through the ASD into the left atrium and was deployed in place. The right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RVESV), right ventricular stroke volume (RVSV), right ventricular ejection fraction (RVSV), left ventricular end diastolic volume (LVEDV), left ventricular end systolic volume (LVESV), left ventricular stroke volume (LVSV), and left ventricular ejection fraction (LVEF) before and after the operation were calculated. The procedure was successful conducted in 48 patients. And the other two patients failing to receive this procedure, one having a large ASD that could not be occluded and the other with ASD accompanied by partial anomalous pulmonary venous connection, were shifted to operation with cardiopulmonary bypass. After the operation, the RVEDV was (94 +/- 32) ml, and the RVSV was (52 +/- 20) ml respectively, both significantly lower than those before the operation [(78 +/- 23) ml and (41 +/- 13) ml respectively, both P < 0.05]. The LVEDV and LVSV after operation were (73 +/- 19) ml and (50 +/- 11) ml respectively, both significantly higher than those before operation [(56 +/- 14) ml and (34 +/- 12) ml respectively, both P < 0.05]. TEE provides valuable information in further confirmation of diagnosis of ASD, selection of appropriate size of Amplatzer occluder, guidance of the deployment of occluder, observation of the effects of operation, and prompt detection of complication.

Extensive dehiscence of a stentless bioprosthesis with only mild paravalvular regurgitation after replacement of a degenerated bicuspid aortic valve

We report the case of a 54-year-old patient admitted for rehabilitation after implantation of a stentless bioprosthesis due to severe insufficiency of a degenerated bicuspid aortic valve. The patient could fully participate in a standard cardiac rehabilitation program without any signs of haemodynamic instability. Transthoracic echocardiography showed a small mobile subvalvular structure and only mild paravalvular reflux. Transesophageal echocardiography, however, revealed extensive dehiscence of the bioprosthesis with the need for urgent reoperation. We discuss the probable causes and encourage routine echocardiography after valve operations with generous application of transesophageal echocardiography in every suspicious case.

Fundamental Applications of Transesophageal Echocardiography: A Society of Cardiovascular Anesthesiologists Monograph on DVD.

Fundamental Applications of Transesophageal Echocardiography: A Society of Cardiovascular Anesthesiologists Monograph on DVD.