Bicaval View Research Articles

Efficacy and safety of pulmonary artery catheterization with combined transesophageal echocardiography and pressure waveform: A prospective observational study

ObjectiveThis study investigated whether pulmonary artery catheter placement method with combined transesophageal echocardiography and pressure waveform measurement improve the placement success rate within 5 min and reduce the incidence of arrhythmia during pulmonary artery catheter placement compared to conventional pulmonary artery catheter placement with pressure waveform measurement only. MethodsThis single center prospective observational study included 129 patients scheduled for cardiac surgery. Patients were divided into two groups. In the conventional group, the pulmonary artery catheter was placed by monitoring the pressure waveform and the length of placement; in the combination group, not only were the pressure waveform and the length monitored but also the following transesophageal echocardiography images: “mid esophageal bicaval view,” " mid esophageal modified bicaval view,” a mirror image of “mid esophageal 4 chamber view,” “mid esophageal right ventricular inflow-outflow view,” and “mid esophageal ascending aortic short axis view." ResultsA 1:1 propensity score matching was used to adjust for confounding factors. The success rates of pulmonary artery catheter placement within 5 min in the conventional and combination groups were 85.5 % vs. 97.8 % (p = 0.032) before matching, and 73.7 % vs. 100 % (p = 0.001) after matching. The incidences of arrhythmias in the conventional and combination groups were 28.9 % vs. 17.4 % (p = 0.20) before matching, and 28.9 % vs. 18.4 % (p = 0.42) after matching. ConclusionPulmonary artery catheter placement with transesophageal echocardiography had a significantly higher rate of successful placement within 5 min, but no significant differences were observed in the incidences of arrhythmias.

Impact of interatrial septal thickness and interatrial conduction time on cryoballoon ablation outcome

Abstract Introduction Interatrial septal thickness (IAST) is an indirect measure of interatrial septal fat which is anatomic extension of epicardial fat. Interatrial conduction time (IACT) reflects altered conduction between atria. Both parameters are associated with left atrial (LA) fibrosis and atrial fibrillation (AF). However, limited data exist regarding the influence of IAST and IACT on the outcomes of cryoballoon ablation (CBA). In this study, we aimed to analyze possible effect of IAST and IACT on atrial tachyarrhythmia (ATA) free survival after CBA. Methods and results Sixty five patients (34/65, 52.3% male, 53.3±11.0 years old) undergoing first time CBA for pulmonary vein isolation were enrolled. Pre-procedural TEE images were analyzed and bicaval view was used to visualize SVC rim for IAST measurement (Figure 1). IACT was measured from the onset of surface P wave to atrial EGM recorded by distal coronary sinus electrode. After 3 months blanking period all anti-arrhythmic drugs were discontinued. Clinical endpoint was ATA recurrence including AF, flutter or tachycardia lasting more than 30 seconds. After 11.2±4.1 months of follow-up 8 patients (12.3%) had ATA recurrence. IAST (4.4±1.1 vs 3.3±0.6 mm, p=0.007) and LA volume index (37.4±8.0 vs 30.1±12.4 mL/m2, p=0.03) were greater in patients with ATA recurrence than those without. In contrast, patients with and without had similar IACT (85.8±31.1 vs 62.2±23.9 ms, p=0.10). Conclusion Pre-procedural measurement of IAST using TEE may provide prognostic information in CBA patients. Increased IAST was found to be associated with ATA recurrence after CBA based PVI and warrants further study.Interatrial septal thickness measurement

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

High-Velocity Systolic Color Doppler Flow Into the Superior Vena Cava

•An unconventional bi-caval view during mid esophageal transesophageal echocardiography of a child undergoing intracardiac repair detected by chance a high velocity systolic flow into the superior vena cava. The underlying etiology for the origin of the flow raised interesting possibilities.

MODIFIED DEEP TRANSGASTRIC TRANSESOPHAGEAL ECHOCARDIOGRAPHY IMAGING OF SUPERIOR VENA CAVA

<h3>Background</h3> Superior vena cava is usually interrogated intraoperatively by a standard bi-caval view as suggested by American Society of Echocardiography. A modified deep transgastric transesophageal echocardiography view is suggested that will superior interrogation of the superior vena cava intraoperatively. <h3>Objective</h3> Evaluation of a modified deep transgastric imaging of superior vena cava in patients undergoing cardiac surgery. <h3>Methods and material</h3> A modified deep transgastric imaging of superior vena cava was performed in children undergoing cardiac surgery. The deep transgastric interrogation with color Doppler blood flow map showed the venous return pattern. A pulse wave Doppler signal analysis was also feasible. The position of the tip of a central venous catheter tip that was inserted through the internal jugular vein could be seen. An agitated saline contrast injected into the left upper limb could exclude the presence of a left superior vena cava. In patients undergoing a undergoing a bi-directional Glenn shunt, considerable length of superior vena cava was visualized. In a child with a partial anomalous pulmonary venous drainage and a superior sinus venosus ASD, a point of the pulmonary vein joining the superior vena cava could be identified as it was possible to interrogate a considerable length of superior vena cava compared to the standard mid esophageal bi-caval view. The deep transgastric TEE interrogation of superior vena cava revealed a residual gradient in the superior vena cava following a sinus venosus atrial septal defect repair that was corrected at the same sitting. A color Doppler blood flow map across the superior vena cava following removal of a directly inserted venous cannula showed turbulence and a continuous-wave Doppler signal analysis revealed a residual gradient that was immediately corrected by the surgeon in another patient. <h3>Conclusion</h3> In conclusion, the deep transgastric TEE view of the superior vena cava is clinically useful. The doppler alignment is parallel to SVC flow (less than 20 degree) which is superior to bi caval view, where the doppler alignment is almost perpendicular to the flow. The probable difficulties that may be encountered that would interfere with proper visualization are: (i) poor contact of the probe with cephalad aspect of the stomach, (ii) air in the stomach, (iii) use of inadequate contact jelly, and (iv) lack of experience. There is a deep learning curve that can be a practical impediment but once honed, it could be a really useful adjunct to our routine trans-esophageal views.

Confirmation of Dual Lumen Cannula Position Before Extracorporeal Membrane Oxygenation Initiation Using a Microbubbles Contrast Technique.

Dual lumen cannulas (DLCs) for venovenous extracorporeal membrane oxygenation (ECMO) therapy are introduced in the right internal jugular vein, passing through the superior vena cava and the right atrium (RA) down to the inferior vena cava. The correct placement is challenging and needs careful positioning to limit mechanical complications. The outflow port needs to be located in the RA and directed toward the tricuspid valve (TV) to optimize therapy and reduce recirculation rate. Transesophageal echocardiography (TEE) is considered the standard to monitor insertion and optimal placement of this type of cannula. In addition to TEE 2D imaging, confirmation of optimal positioning is possible after ECMO initiation using color Doppler in a bicaval view to visualize the reinfusion jet located in the RA and pointing toward the TV. We present an example of DLC implantation where correct positioning was confirmed before ECMO initiation using a microbubbles contrast technique. Using TEE 2D imaging, in a bicaval (Figure 1, A and B) and modified bicaval view (Figure 1, C and D), we depict the contrast obtained while flushing the reinjection port of the DLC with saline, simulating the reinfusion jet adequately directed toward the TV (arrows in Figure 1, B and D). We use a 50 cc catheter tip syringe (conical tip) with 0.9% saline to rapidly flush the DLC. The turbulences and bubbles created provide sufficient contrast.Figure 1.: A: Bicaval view and (C) modified bicaval view without contrast; (B) bicaval and (C) modified bicaval view with contrast. DLC, dual lumen cannula; IVC, inferior vena cava; RA, right atrium; SVC, superior vena cava; TV, tricuspid valve.The authors believe that this technique helps to ensure immediate optimal efficiency of venovenous ECMO and avoid further correction of cannula position after ECMO initiation (See Video, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A878).

Transesophageal echocardiographic imaging of the coronary sinus: a retrospective analysis of mid-esophageal views and a novel transgastric view

BackgroundTransesophageal echocardiographic imaging plays an important role in assessing coronary sinus anatomy prior to placement of a retrograde cardioplegia cannula. The coronary sinus can be imaged in the long axis by advancing the TEE probe from the mid-esophageal 4-chamber view or using a modified mid-esophageal bicaval view, while a short axis view can be obtained in the mid-esophageal 2-chamber view. While use of a transgastric view is only briefly mentioned in the literature as an alternative to mid-esophageal views, the authors commonly include it in our comprehensive transesophageal echocardiographic exam of the coronary sinus. This study examines the various imaging strategies. We hypothesize that the transgastric view offers comparable coronary sinus imaging to the mid-esophageal views.MethodsAfter approval by our institutional review board, the intraoperative transesophageal echocardiographic exams for 50 consecutive elective cardiac surgical patients with a comprehensive echocardiographic assessment of the coronary sinus were retrospectively reviewed and analyzed to evaluate imaging of the coronary sinus in the various views. For each view, we noted and recorded if the coronary sinus and coronary sinus cannula were visualized. Statistical analysis required pairwise comparisons between each of the 4 views. P values were calculated using McNemar’s Exact test.ResultsBoth the coronary sinus and coronary sinus cannula were visualized a majority of the time for each view. There was no statistically significant difference between each view in its ability to visualize the coronary sinus, nor was there a statistically significant difference between each view in its ability to visualize the coronary sinus cannula.ConclusionsUse of a transgastric window provides the echocardiographer with an effective alternate modality for imaging the coronary sinus when mid-esophageal views are limited.

Interrogation of Superior Vena Cava by Deep Transgastric Transesophageal Echocardiography Imaging

ABSTRACTThe advantages of intraoperative deep transgastric interrogation by transesophageal echocardiography (TEE) of the superior vena cava (SVC) in comparison to the standard bicaval view was studied in pediatric cardiac surgical cases. The view was found to be helpful in obtaining additional data in pediatric cardiac surgical patients.

Should we include bicaval view in the study of the fetal heart?

Should we include bicaval view in the study of the fetal heart?

Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography

BackgroundTo assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard.MethodsA prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients.ResultsAs per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view.ConclusionsThe concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

Third Atrial Chamber

A 10-MONTH-OLD BOY (weight: 5.8 kg; height: 66 cm; body mass index: 13) was taken to the cardiac catheterization laboratory before the creation of a bidirectional Glenn shunt. At 4 days of age, transthoracic echocardiography done for the evaluation of persistent cyanosis revealed heterotaxy (left atrial isomerism), situs ambiguous with levocardia, bilateral superior vena cava, atrial septal defect (9 mm), partial anomalous right pulmonary venous return to the morphologic right atrium, discordant atrioventricular connection and concordant ventriculoarterial connection, with a hypoplastic right ventricle. The child underwent stenting of the patent ductus arteriosus and balloon atrial septostomy on the 11th day of life. Pulmonary artery banding was done at the age of 1 month. During the current admission, a computerized tomography scan revealed the complex connections of the great vessels (Fig 1). A 4-chamber transesophageal echocardiography view displayed the morphologic left atrium, which was on the right side, and multiple coronary artery fistulae opening into an enlarged chamber located superiorly (Fig 2; Video 1). The atrial septal defect could be visualized in the bicaval view (Fig 3; Video 2). A modified midesophageal 4-chamber view displayed a large superior chamber, as well as the atrial septal defect (Fig 4). Agitated saline was injected into a right upper extremity vein. The agitated saline appeared first in the right internal jugular vein and then appeared in the upper atrial chamber, right side atrium (morphologic left atrium), followed by an appearance in the right ventricle (Fig 5, A-D; Video 3). Slight retraction of the probe from the 4-chamber view displayed a right superior vena cava on the right side that was moving into close juxtaposition with the morphologic left atrium (Fig 6; Video 4). Correlation with computerized tomography findings revealed the identity of the structure seen by transesophageal echocardiography into which the right superior vena cava and the coronary artery fistulae were draining. What is the diagnosis? Fig. 2(A) Midesophageal 4-chamber 2-dimensional transesophageal echocardiography image with (B) color Doppler displaying an enlarged chamber (white query sign) with multiple coronary artery fistulae opening into the chamber. mLA, morphologic left atrium; RV, right ventricle; TV, tricuspid valve View Large Image Figure Viewer Download Hi-res image Fig. 3Bicaval midesophageal transesophageal echocardiography view displaying the atrial septal defect. View Large Image Figure Viewer Download Hi-res image Fig. 4Midesophageal 4-chamber 2-dimensional transesophageal echocardiography image with color-flow Doppler displaying the atrial septal defect and a large upper chamber marked by white query sign. View Large Image Figure Viewer Download Hi-res image Fig. 5Midesophageal 4-chamber 2-dimensional transesophageal echocardiography image displaying (A) the agitated saline echo contrast injected into an upper limb vein entering the right superior vena cava, (B) the coronary sinus and the morphologic right atrium on the right side, (C) the morphologic left atrium on the right side, and (D) the right ventricle. View Large Image Figure Viewer Download Hi-res image Fig. 6Midesophageal 4-chamber 2-dimensional transesophageal echocardiography image displaying the right superior vena cava and morphologic right atrium in close proximity. ASD, atrial septal defect; LAA, morphologic left atrial appendage; mLeft atrium, morphologic left atrium; mR, morphologic right atrium; RSVC, right superior vena cava; RV, right ventricle; TV, tricuspid valve. View Large Image Figure Viewer Download Hi-res image

Estimation of pulmonary artery pressure with transesophageal echocardiography: An observer-blinded test accuracy study.

With the declining use of the pulmonary artery catheter (PAC), transesophageal echocardiography (TEE) has become an appealing alternative to obtain pulmonary artery pressure non-invasively using the simplified Bernoulli equation. The validation of this method in the perioperative setting has been scarce with no clear recommendations about which view is the most accurate to estimate right ventricular systolic pressure (RVSP).Therefore, we performed a prospective, observer-blinded, diagnostic test accuracy study to assess the difference in systolic pulmonary artery pressure (sysPAP) measuring both, invasively sysPAP and estimated RVSP with TEE in 3 different views: the mid-esophageal (ME) 4Chamber, the ME right ventricular (RV) inflow-outflow and the ME modified bicaval view.To show a clinically significant difference of at least 10% in RVSP, we included 40 cardiac surgical patients divided into 3 subgroups: Patients with mild to moderate tricuspid regurgitation (TR) and mean PAP <25 mm Hg, patients with mild to moderate TR and mean PAP≥ 25 mm Hg, and patients with severe TR.For the whole cohort, bias of estimated RVSP compared to measured sysPAP was 5.27 mm Hg, precision was 7.96 mm Hg, limits of agreement were −10.66 to 21.19 mm Hg. The best agreement between the 2 methods was found in patients with severe TR and in the ME RV inflow-outflow and the modified bicaval view. Good Doppler signals were available in 35% and 46% in these views, and in 20% in the ME 4 chamber view.The estimation of the sysPAP by TEE cannot be considered reliable in the clinical perioperative setting. Only measurements that provide a full Doppler envelope show sufficient precision to provide accurate estimations.

Is That a Real Tumor?

A 58-year-old man (height, 165 cm; weight, 54 kg) presented with dysarthria, tinnitus, and transient numbness of the hands. A chest radiograph and a carotid ultrasound were normal. Cranial magnetic resonance imaging revealed multiple cerebral infarctions. Electrocardiography showed sinus bradycardia (48 beats/min), whereas Holter electrocardiography showed multiple episodes of sinus arrest lasting between four and ten seconds. Computed tomography showed a 2.5 × 5-cm mass in the right atrium (Fig 1). The patient was taken to the operating room for resection of the tumor. Intraoperative transesophageal echocardiography (TEE) showed a 2.5 × 5-cm mass extending from the right atrium to the superior vena cava (Fig 2; Video 1). What is the diagnosis? Fig 2The midesophageal bicaval view on intraoperative transesophageal echocardiography showed a mass (2.5 × 5 cm, arrow) extending from the right atrial wall to the superior vena cava. LA, left atrium; RA, right atrium; SVC, superior vena cava. View Large Image Figure Viewer Download Hi-res image

Comparison of pulmonary vein sizing by transesophageal echocardiogram and by direct angiogram

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary vein (PV) anatomy and sizing is important to know before performing PV isolation. This information is conventionally obtained by angiography or by CT scan. Aim We undertook this study to identify and measure the PVs during TEE studies and validate these against angiography. Method 17 consecutive patients due to undergo PV isolation for paroxysmal atrial fibrillation were analysed. Using TEE, the PVs were visualised (Upper panel) as follows: i) From the mid-esophageal four chamber view, the chamber probe was turned to the right at 110-130º for the bicaval view, where the RSPV was seen entering the left atrium adjacent to the SVC. ii) At 0º the SVC was imaged in its short axis, and the probe advanced till the interatrial septum was seen. The angle was changed to 30º to visualise the right inferior PV (RIPV). iii) From the two chamber view (70-90º), the probe was turned to the left and withdrawn to display the left superior PV (LSPV) entering the left atrium parallel to the appendage.iv) Keeping the LSPV in focus, the angle was changed to 135º and the probe advanced till the AV groove, where the left inferior PV (LIPV) was visualised. After transseptal puncture, each PV was cannulated. The PV angiograms were performed in several projections to obtain the best PV profile (lower panel). Using electronic callipers, each PV was measured within 1 cm of its entry into the left atrium, after having received all tributaries. Those PVs were considered for analysis which were measured by both TEE and angiography. The paired ‘T’ test was used to compare the PV diameters by TEE and angiography and the Bland Altman analysis was done to see the level of agreement. Results Of a total of 68 PVs, 62 could be adequately visualised by TEE and 50 by angiography. These 50 PVs were measured using both methods. The diameters of the PVs measured by TEE and angiography were not statistically different by the paired t test; LSPV14 ± 1.8 mm v/s 14.4 ± 2.1 mm; RSPV 13 ± 1.8 mm v/s 14.6 ± 3.5 mm; LIPV 11.9 ± 2.1 vs 13.2 ± 2.8 mm and RIPV 10.5 ± 2.7 vs 12.1 ± 2.9 mm. Bland Altman analysis showed most PV sizes estimated by TEE and angiography lay within limits of agreement. Conclusions A majority of PVs can be visualised by TEE using a defined protocol. TEE is a good technique to visualise and assess the size of PVs, avoiding the need for contrast medium and radiation. Abstract Figure. TEE and angiographic images of PVs

TEE Midesophageal bicaval view. Wire in the correct position passing through the right atrium and entering in the superior vena cava

TEE Midesophageal bicaval view. Wire in the correct position passing through the right atrium and entering in the superior vena cava

TEE Midesophageal bicaval view dual color of a two stage venous cannula in a correct position during systemic perfusion.

TEE Midesophageal bicaval view dual color of a two stage venous cannula in a correct position during systemic perfusion.

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.

An Intriguing Right Atrial Object in a Child With Ventricular Septal Defect

A nine-month-old-boy (weight, 5.8 kg; height, 70 cm) was taken to the operating room for surgical repair of a ventricular septal defect. Transthoracic echocardiography reported situs solitus (S,D,S) with atrioventricular and ventriculoarterial concordance, a moderate-size (8 mm) perimembranous ventricular septal defect with left-to-right shunt (pressure gradient: 60 mmHg), a dilated left atrium (left atrial indexed diameter Z-score: 2.07, left atrium/aorta ratio: 2.5 and left atrial volume index: 40 mL/m2), and left ventricle with a normal-sized coronary sinus (Fig 1). The midesophageal aortic valve short-axis view by transesophageal echocardiography revealed a circular structure in the right atrium adjacent to the superior aspect of the interatrial septum (white arrow, Fig 2, video clip 1). Following the forward rotation of the transducer angle to about 30°, the structure was slightly elongated (Fig 3). Slight retroflexion of the probe in the midesophageal four-chamber view revealed a normal-sized coronary sinus that appeared separate from the structure (Fig 4, video clip 2). The midesophageal bicaval view showed a prominent crista terminalis (white arrow) (Fig 5). Agitated saline was injected into the left upper arm vein and the contrast was found to enter the right atrium after opacifying the saccular structure (Fig 6, video clip 3). In the midesophageal bicaval view, the agitated saline entered the right atrium and there was no communication with the left atrium (Fig 7, video clip 4). Agitated saline contrast injected into the distal lumen of the central venous catheter demonstrated the contrast in the right atrium without opacification of the right atrial structure (Fig 8, video clip 5). What is this structure? Fig 2The midesophageal aortic valve short-axis view by transesophageal echocardiography revealed a circular structure in the right atrium (white arrows). View Large Image Figure Viewer Download Hi-res image Fig 3The midesophageal aortic valve short-axis view by transesophageal echocardiography with transducer plane rotated to 30° showing the saccular structure. View Large Image Figure Viewer Download Hi-res image Fig 4The midesophageal four-chamber view by transesophageal echocardiography showing the coronary sinus in the usual position. View Large Image Figure Viewer Download Hi-res image Fig 5The midesophageal bicaval view by transesophageal echocardiography displaying a prominent crista terminalis View Large Image Figure Viewer Download Hi-res image Fig 6The midesophageal aortic valve short-axis view by transesophageal echocardiography demonstrating opacification of the saccular structure following injection of agitated saline into the left upper arm vein. View Large Image Figure Viewer Download Hi-res image Fig 7The midesophageal bicaval view by transesophageal echocardiography, showing the agitated saline entering the right atrium and with no communication with the left atrium. View Large Image Figure Viewer Download Hi-res image Fig 8The midesophageal aortic valve short-axis transesophageal echocardiography view showing the agitated saline contrast injected into the distal lumen of the central venous catheter did not opacify the right atrial structure. View Large Image Figure Viewer Download Hi-res image

The feasibility of measurement of different right ventricular systolic function parameters by intraoperative trans-esophageal echocardiography and their interchangeability with transthoracic echocardiography in pediatric patients undergoing cardiac surgery- interim results from an ongoing study

Introduction All the parameters recommended for functional assessment of right ventricle (RV) in children are based on transthoracic echocardiographic (TTE) measurements¹. Intraoperative echocardiography during pediatric cardiac surgery is, however, mainly dependent on trans-esophageal echocardiography (TEE). We planned to determine the feasibility of measurement of different RV systolic function parameters by intraoperative TEE and their interchangeability with TTE in pediatric patients undergoing cardiac surgery. Methods This ongoing single-centre, observational study has been registered (CTRI/2019/06/019743) after Institutional Ethics Committee clearance. After written, informed, parental consent, pediatric patients (1-18 years) undergoing corrective surgery for congenital heart diseases- are included. TEE transducer is inserted after induction of general anaesthesia. TTE examination is performed using Apical four-chamber (A4C) view. TEE examination is performed within 10 minutes of performing TTE, while keeping heart rate, mean arterial pressure and central venous pressure within 10% of that during performing TTE. Mid-esophageal four-chamber RV-focused (ME4C) view, Mid-esophageal modified bicaval view (MBC), Transgastric RV inflow view (TGRVI), Deep transgastric RV view (DTG-RV)- are used. All the recorded images/clips are analysed offline later, using Echopac-113 (GE) software. Fractional Area Change (FAC), Tricuspid annular plane systolic excursion (TAPSE), Tricuspid annular systolic velocity by pulsed-wave tissue Doppler (RV S’), Right ventricular index of myocardial performance (RIMP) (by tissue Doppler), Right ventricular free wall strain (RVFWS)- are measured. Feasibility is assessed as ability to acquire an image/loop deemed readable during the examination. Readable image/loop is defined as ability to completely delineate the endocardial border of the RV and tricuspid annulus in 2D-mode, to obtain completely traceable lines in M-mode (MM) and Angled M- mode (AMM), to obtain optimally aligned and completely traceable envelopes of pulsed wave Tissue-Doppler velocities. Agreement between TTE and TEE measured parameters are assessed by Bland-and-Altmann analysis. Results 42 patients has been recruited and analysed so far. The Mean±SD age of the patients was 6.5±4.6 years. Feasibility of measuring all the studied parameters was > 85% in all the TEE views (Table 1). There was good Intra- and Inter-observer reliability (Intra-class Correlation Coefficient > 0.8) of measurements of all the parameters in all the views (Both TTE and TEE) utilised. In comparison to TTE measurements, there were low bias in TEE measured parameters in: AMM measured TAPSE in ME4C and MBC views, FAC in ME4C view, RIMP in DTG-RV and TGRVI views, RVFWS in all the utilised views (Table 1). The limits of agreements, however, were wide (Table 1). Discussion Despite high feasibility, wide limits of agreement prevents intraoperative TEE measured RV function parameters to be used interchangeably with those measured by TTE for individual pediatric cardiac surgical patients.

Nontraditional Transesophageal Echocardiographic Views to Evaluate Hepatic Vasculature in Orthotopic Liver Transplantation and Liver Resection Surgery

Background.Utilization of intraoperative transesophageal echocardiography (TEE) during orthotopic liver transplantation (OLT) is expanding annually in high-volume transplant centers. During OLT intraoperative TEE is used to gather real-time information on cardiovascular function and intravascular volume status. Although standardized TEE views exist, there are nontraditional views described in the literature which have the potential to diagnose evolving pathology and define normal variants of hepatic vasculature.Methods.A literature review was completed utilizing the PubMed database for English-only, peer-reviewed publications discussing nontraditional use of intraoperative TEE during OLT and hepatic vascular-related surgeries from 2009 to 2019. Both case reports and review articles were considered.Results.The PubMed literature search offered 8 publications for analysis, including 7 case reports and 1 article review, revealing several nontraditional TEE views not included in a comprehensive transesophageal echocardiographic examination. These nontraditional views were generally obtained using modifications to the transgastric and bicaval views to visualize liver vasculature. We present the various techniques for obtaining these views from the 8 articles identified.Conclusions.At high-volume transplant centers, TEE use during OLT is increasing. Intraoperative TEE is a valuable tool to assess hepatic vascular structures critical to allograft/organ function without interruption of the surgical procedure. Nontraditional use of TEE to diagnose intraoperative noncardiac pathology in OLT appears underutilized and underreported. The modified hepatic and modified transgastric views we describe can be used to evaluate hepatic vasculature, influence surgical decision-making and ultimately improve patient care.