Transesophageal Doppler Echocardiography Research Articles

Two Posterior Mitral Leaflets or a Feature of Degenerative Valve Disease That Contributes to Mitral Regurgitation?

A 79-year-old, 77 kg, 170 cm man with ischemic cardiomyopathy, hypertension, hyperlipidemia, type 2 diabetes mellitus, and chronic renal insufficiency presented to the authors’ institution after his son and daughter reported that their father's activity level had decreased and he was observed to be more fatigued. The patient disagreed with this assessment of his condition, denying chest pain or pressure, dyspnea at rest or on exertion, exercise intolerance, fatigue, malaise, or peripheral swelling, but his children commented that he often intentionally minimized his symptoms. The patient suffered an anterior wall myocardial infarction two years before the current admission. Three stents were placed in the left anterior descending coronary artery during this previous hospitalization. The physical examination was notable for a grade III of VI systolic murmur heard best at the apex that radiated into the axilla. Transthoracic echocardiography suggested the presence of severe mitral regurgitation. Transesophageal echocardiography (TEE) was performed as part of the diagnostic evaluation and the following images were obtained (Figure 1, Figure 2; video clips 1 and 2). What is the diagnosis? Figure 2Midesophageal four-chamber color Doppler TEE view View Large Image Figure Viewer Download Hi-res image

REPLY: Reply to Kumar and colleagues.

The author reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.In their recent letter to the Editor, Kumar and colleagues1Kumar N. Flores A.S. Hussain N. Ganapathi A.M. Whitson B.A. Essandoh M.K. et al.Ensuring pulmonary artery patency in donor-recipient size mismatch: a collaborative challenge.J Thorac Cardiovasc Surg Tech. 2022; 15: 206-207Scopus (4) Google Scholar provided an important suggestion for additional evaluation of the pulmonary artery anastomosis after lung transplantation with transesophageal echocardiography (TEE) in the operating room. We thank Yokoyama and colleagues2Yokoyama Y. Chen-Yoshikawa T.F. Nakajima D. Ohsumi A. Date H. Various techniques for anastomosis of pulmonary arteries with size mismatch during lung transplantation.J Thorac Cardiovasc Surg Tech. 2021; 9: 192-194Scopus (7) Google Scholar for their previous article on anastomotic techniques that again highlight the importance of a technically optimal operation, which includes an unobstructed pulmonary artery anastomosis. The routine nature of thoracic transplantation might allow a suboptimal pulmonary artery anastomosis after heart or lung transplantation to go undetected as a potential cause of pulmonary graft dysfunction or donor heart right ventricular dysfunction.Kumar and colleagues' suggestion of TEE Doppler interrogation of the flow characteristics across the anastomosis after lung transplantation could provide early evidence of a technical problem. If TEE is not routinely used for lung transplant operations, the anticipation of important pulmonary artery size disparity should at least stimulate consideration with our anesthesia colleagues for insertion of a TEE probe for anastomotic examination. The author reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The author reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. In their recent letter to the Editor, Kumar and colleagues1Kumar N. Flores A.S. Hussain N. Ganapathi A.M. Whitson B.A. Essandoh M.K. et al.Ensuring pulmonary artery patency in donor-recipient size mismatch: a collaborative challenge.J Thorac Cardiovasc Surg Tech. 2022; 15: 206-207Scopus (4) Google Scholar provided an important suggestion for additional evaluation of the pulmonary artery anastomosis after lung transplantation with transesophageal echocardiography (TEE) in the operating room. We thank Yokoyama and colleagues2Yokoyama Y. Chen-Yoshikawa T.F. Nakajima D. Ohsumi A. Date H. Various techniques for anastomosis of pulmonary arteries with size mismatch during lung transplantation.J Thorac Cardiovasc Surg Tech. 2021; 9: 192-194Scopus (7) Google Scholar for their previous article on anastomotic techniques that again highlight the importance of a technically optimal operation, which includes an unobstructed pulmonary artery anastomosis. The routine nature of thoracic transplantation might allow a suboptimal pulmonary artery anastomosis after heart or lung transplantation to go undetected as a potential cause of pulmonary graft dysfunction or donor heart right ventricular dysfunction. Kumar and colleagues' suggestion of TEE Doppler interrogation of the flow characteristics across the anastomosis after lung transplantation could provide early evidence of a technical problem. If TEE is not routinely used for lung transplant operations, the anticipation of important pulmonary artery size disparity should at least stimulate consideration with our anesthesia colleagues for insertion of a TEE probe for anastomotic examination. Ensuring pulmonary artery patency in donor-recipient size mismatch: A collaborative challengeJTCVS TechniquesVol. 15PreviewThe vascular anastomoses of lung transplantation are a growing area of interest. Anastomosing the donor and recipient pulmonary artery (PA) segments is among the most delicate aspects of the surgery, and proper surgical technique is critical to allograft and patient survival. Obstruction of blood flow through the PA may cause graft ischemia, refractory hypoxemia, right ventricular dysfunction, and even death in affected patients.1 However, the importance of the PA anastomoses has yet to be critically examined in the lung transplant literature. Full-Text PDF Open Access

Correlation between Doppler Echocardiography and Right Heart Catheterization Assessment of Systolic Pulmonary Artery Pressure in Patients with Mitral Regurgitation: A Prospective Observational Study.

Pulmonary hypertension (PH) is common in patients with left-side valvular diseases, especially with mitral regurgitation (MR). Measurement using pulmonal artery catheter (PAC) is the gold standard to asses pulmonary vascular pressures. During mitral valve surgery echocardiography is routinely used for valvular management and to evaluate pulmonary hemodynamic. The accuracy of echocardiographic measurements is controversial in the literature. We aimed to evaluate the reliability and accuracy of the noninvasive measurement for systolic pulmonary artery pressure (SPAP) using Doppler echocardiography compared to the invasive measurement using PAC in patients presenting with MR undergoing surgery. This prospective observational study evaluated 146 patients with MR undergoing cardiac surgery between 09/2020 and 10/2021. All patients underwent simultaneous SPAP assessment by PAC and transesophageal echocardiography at three different time points: before heart-lung-machine (HLM), after weaning from HLM and at the end of surgery. Mean patients' age was 61 11.5 years, and 51 (35%) patients were female. Most of patients presented with severe MR (n = 126; 86.3%) or endocarditis (n = 18; 12.3%). Patients underwent either isolated mitral valve surgery (n = 65; 44.5%) or mitral valve surgery combined with other surgeries (n = 81; 55.5%). Mean SPAP was underestimated by transesophageal echocardiographic measurement in comparison to PAC measurement before HLM (41.9 13.1 mmHg vs. 44.8 13.8 mmHg, p 0.001), after weaning from HLM (37.6 9.3 mmHg vs. 42.4 10.1 mmHg, p 0.001), and at the end of surgery (35.6 9.1 mmHg vs. 39.9 9.9 mmHg, p 0.001). This difference remained within the sub-analysis in patients presented with moderate or severe PH during all the time points. Bland-Altman analysis showed that transesophageal echocardiographic measurement underestimate SPAP in comparison to PAC as these two approaches are significantly different from one another. In patients presented with MR, transesophageal Doppler echocardiography could asses the presence of PH with high probability. This assessment is however underestimated and the use of PAC in those patients to diagnose, classify and monitor the therapy of PH remains recommended if required.

Pulse Wave Analysis Using the Pressure Recording Analytical Method to Measure Cardiac Output in Pediatric Cardiac Surgery Patients: A Method Comparison Study Using Transesophageal Doppler Echocardiography as Reference Method.

Cardiac output (CO) is a key determinant of oxygen delivery, but choosing the optimal method to obtain CO in pediatric patients remains challenging. The pressure recording analytical method (PRAM), implemented in the MostCareUp system (Vygon), is an invasive uncalibrated pulse wave analysis (PWA) method to measure CO. The objective of this study is to compare CO measured by PRAM (PRAM-CO; test method) with CO simultaneously measured by transesophageal Doppler echocardiography (TEE-CO; reference method) in pediatric patients. In this prospective observational method comparison study, PRAM-CO and TEE-CO were assessed in pediatric elective cardiac surgery patients at 2 time points: after anesthesia induction and after surgery. The study was performed in a German university medical center from March 2019 to March 2020. We included pediatric patients scheduled for elective cardiac surgery with arterial catheter and TEE monitoring. PRAM-CO and TEE-CO were compared using Bland-Altman analysis accounting for repeated measurements per subject, and the percentage error (PE). We included 52 PRAM-CO and TEE-CO measurement pairs of 30 patients in the final analysis. Mean ± SD TEE-CO was 2.15 ± 1.31 L/min (range 0.55-6.07 L/min), and mean PRAM-CO was 2.21 ± 1.38 L/min (range 0.55-5.90 L/min). The mean of the differences between TEE-CO and PRAM-CO was -0.06 ±0.38 L/min with 95% limits of agreement (LOA) of 0.69 (95% confidence interval [CI], 0.53-0.82 L/min) to -0.80 L/min (95% CI, -1.00 to -0.57 L/min). The resulting PE was 34% (95% CI, 27%-41%). With a PE of <45%, PRAM-CO shows clinically acceptable agreement with TEE-CO in hemodynamically stable pediatric patients before and after cardiac surgery.

Abstract 117: Contrast-enhanced Transcranial Doppler Ultrasonography Versus Transesophageal Echocardiography As Screening Tool In Embolic Stroke

Introduction: Right-to-left (RtL) intracardiac and intrapulmonary shunts are associated with embolic stroke. Although contrast-enhanced transcranial doppler ultrasonography (ceTCD) and transesophageal echocardiography (TEE) are used in embolic stroke work up, there are no standardized guidelines as to which test should be considered as ‘gold standard’. Our objective is to evaluate the sensitivity of contrast-enhanced TCD and TEE in detecting right-to-left shunt to determine respective utilities as screening tools. Methods: Electronic medical records of subjects presenting with acute neurological symptoms who had ceTCD and TEE were evaluated. Sensitivity and specificity were calculated. Based on the respective prevalence of intracardiac and intrapulmonary shunts, positive predictive value, negative predictive value, and test accuracy were determined for ceTCD and TEE. Social Science Statistics was used for data analysis. Results: From June 2016 to August 2021, of 7,498 ischemic stroke patients, 260 patients were suspected of having strokes related to right to left shunts and underwent ceTCD and TEE for detection of cardioembolic sources for stroke. A positive right-to-left shunt was detected in 83 subjects. Detection by ceTCD was confirmed by the operator for 81 patients while 2 were considered false positive results (delayed sporadic High Intensity Transient Signals (HITS)). Sensitivity of ceTCD was 97.65% (95% CI [91.76%, 99.71%]). No safety concerns were identified in patients undergoing ceTCD. Of those with positive ceTCD (68.57%, n=35) were detected by Valsalva, and all of those 35 patients had negative TEE. TEE had sensitivity of 70.34% (95% CI [61.23%, 78.39%]). Conclusion: Contrast-enhanced TCD has superior sensitivity, is cost-effective, practical, and a safe alternative to TEE in identifying intracardiac or intrapulmonary shunts. Screening superiority of ceTCD may lie in ability to elicit shunts during Valsalva maneuvers. To our knowledge this is the largest single center series confirming ceTCD as a gold standard tool for screening of right to left shunts.

Orifice Areas of Balloon-Expandable Transcatheter Heart Valves: A Three-Dimensional Transesophageal Echocardiographic Study

Accurate expected effective orifice area (EOA) values for balloon-expandable (BE) transcatheter heart valves (THV) are crucial for preventing patient-prosthesis mismatch (PPM) and assessment of THV function. Currently published reference EOAs, however, are based on transthoracic echocardiography (TTE), which may be subject to left ventricular outflow tract diameter underestimation and/or suboptimal THV Doppler interrogation. The objective of this study was to establish reference EOA values for BE THVs on the basis of Doppler and three-dimensional (3D) transesophageal echocardiography (TEE). Two hundred twelve intraprocedural transesophageal echocardiographic examinations performed during BE THV implantation with optimal postimplantation Doppler and 3D imaging were retrospectively reviewed. Continuity equation-derived EOAs were compared with geometric orifice areas by 3D planimetry (GOA3D). Performance indices (i.e., EOA normalized to valve size) and PPM rates were determined. TTE-based EOAs obtained within 30days were also calculated in a subset of 170 patients. The average EOA for all BE THV valves (77% SAPIEN 3) was 2.3±0.5cm2, while the average EOA was 1.6±0.2cm2 for 20-mm, 2.0±0.2cm2, for 23-mm, 2.5±0.3cm2 for 26-mm, and 3.0±0.3cm2 for 29-mm THV size (P<.001). Bland-Altman analysis demonstrated very good agreement between EOA and GOA3D (bias -0.04±0.15cm2). There were strong correlations between annular area and TEE-based EOA (R=0.84) and GOA3D (R=0.87). The mean performance index was 47±5% and was similar for all THV sizes (P=.21). EOAs based on TTE were smaller compared with those based on TEE, while the correlation with annular area (R=0.67) and agreement with GOA3D (bias -0.26±0.43cm2) was not as strong. The overall PPM rate was 2% in the TEE cohort and 12% in the TTE cohort. EOAs for BE THVs based on intraprocedural Doppler and 3D TEE suggest that previously published TTE-based reference values for EOA are underestimated, while PPM rates may be overestimated. Our findings have important clinical implications for preimplantation decision-making and for the evaluation of THV hemodynamics and function during follow-up.

Dilated Coronary Sinus: The Usual Persistent Left Superior Vena Cava or a Less Common Etiology?

AN 84-YEAR-OLD MAN, 70 kg, 183 cm, with hypertension and left ventricular hypertrophy, presented to the authors’ institution with a history of progressive shortness of breath and abdominal distention. A large amount of ascites was present, necessitating biweekly paracentesis. The patient's functional capacity had significantly deteriorated. He described severe dyspnea associated with bending forward and standing from a sitting position. The physical examination was notable for cachexia, a grade- 3 holosystolic murmur heard best at the lower left sternal border, and a pulsating right upper quadrant. Relevant laboratory findings included a BNP level of 687 pg/mL. Transesophageal echocardiography (TEE) was performed as part of the diagnostic evaluation, and the following images were obtained (Fig. 1, 2, and 3; video clips 1 and 2). What is the diagnosis? Fig 2Midesophageal 2-chamber transesophageal echocardiography view. View Large Image Figure Viewer Download Hi-res image Fig 3Modified midesophageal 4-chamber color Doppler transesophageal echocardiography image. View Large Image Figure Viewer Download Hi-res image

Left Atrial Appendage Function Assessment by Tissue Doppler Transesophageal Echocardiography in Acute Ischemic Stroke Patients

Background: Strokes due to Cardioembolic causes are the most severe in ischemic stroke subtypes. LAA flow patterns and function could be assessed accurately by TEE. The study aimed to present the importance of Transesophageal echocardiography in the assessment of LAA function and its relation to cardioembolic stroke. Methods: 120 patients were enrolled in the study and were subdivided into 3 subgroups, each group included 40 patients. Group A; patients had a stroke with normal sinus rhythm, Group B; patients had a stroke with atrial fibrillation, and Group C; normal control subjects. The study participants were evaluated by medical history, physical examination, standard 12-leads electrocardiogram, a transesophageal echocardiographic detailed evaluation of the LAA, and brain CT and/or MRI for patients with stroke. Results: both stroke patients with AF and sinus rhythm had significantly higher LAA mean orifice diameter and higher LAA length than control patients, significantly lower mean LAA medial wall tissue Doppler upward and downward motion velocities than control patients and that patients with stroke and AF had significantly lower mean LAA pulsed wave emptying and filling velocities than both patients with stroke and sinus rhythm and control patients. Presence of LAA thrombi, spontaneous echo contrast, and stroke recurrence were higher in stroked AF patients than stroke patients with sinus rhythm. Conclusion: increased LAA orifice diameter, LAA length, and reduced filling and emptying velocities and upward and downward motion velocities of the medial wall of LAA as detected by TEE are associated with stroke and cardio embolization.&#x0D;

Partial Annuloplasty Rings in the Repair of Functional Ischemic Mitral Regurgitation.

BackgroundAcute myocardial infarction (MI) is the leading cause of worldwide cardiac morbidities and mortalities. Mitral regurgitation (MR) is a common complication of MI. The severity of ischemic MR (IMR) can range widely, both clinically and hemodynamically. Mitral valve (MV) repair by lifting annuloplasty is a surgical procedure used to correct the pathology of IMR. The immediate outcomes of this technique have not yet been determined. The present study, therefore, evaluated the immediate results of MV annuloplasty performed to complement MV repair in patients with IMR.MethodologyAll adult patients with IMR who underwent lifting posterior mitral annuloplasty (LPMA) plus concomitant coronary artery bypass grafting (CABG) were included. Immediate outcomes were evaluated by transesophageal color Doppler echocardiography. The frequency of successful outcomes was compared in patients with different baseline characteristics.ResultsPosterior mitral annuloplasty was successful in 93.1% of patients, including in 92.8% of men and 94.1% of women. The percentages of successful immediate outcomes differed significantly in patients with and without diabetes and hypertension, and in patients with two- and three-vessel disease.ConclusionLPMA resulted in a high percentage of successful immediate outcomes in patients with IMR. Further studies should compare rates of immediate, intermediate, and late outcomes of this technique.

Validation of Semiautomated Quantification of Mitral Valve Regurgitation by Three-Dimensional Color Doppler Transesophageal Echocardiography

The aim of this study was to evaluate the accuracy of mitral regurgitation (MR) volume quantified on three-dimensional (3D) color Doppler transesophageal echocardiography (TEE) using new semiautomated software compared with conventional two-dimensional (2D) proximal isovelocity surface area (PISA) transthoracic echocardiography (TTE) and TEE and cardiac magnetic resonance imaging (CMR). Fifty-one patients (mean age, 63±16years; 35 men) prospectively underwent TTE, TEE, and CMR for MR evaluation. Regurgitant volume (RVol) by 3D MR flow quantification was compared with 2D TTE, TEE, and CMR, and the accuracy of evaluation of severe MR by 3D MR flow quantification was compared against guideline criteria by TEE. Twenty-nine patients had severe MR, 16 had moderate MR, and six had mild MR. Three-dimensional MR flow quantification was feasible in all patients, including prolapse (n=37), restriction (n=9), functional MR (n=5), and eccentric or multiple jects (n=41). RVol on 3D MR flow quantification correlated well with RVol on 2D PISA TTE (interclass correlation coefficient [ICC]=0.75, P<.001), quantitatively estimated RVol (ICC=0.74, P<.001), and 2D PISA TEE (ICC=0.79, P<.001). Three-dimensional MR flow quantification agreed better with CMR (ICC=0.86, P<.001) than did RVol on 2D PISA TTE (ICC=0.66, P<.001) and 2D PISA TEE (ICC=0.69, P<.001), with narrower limits of agreement on Bland-Altman analysis. Three-dimensional MR flow quantification had high accuracy for diagnosing severe MR using TEE (area under the curve=0.85, 95% CI 0.74-0.96, P<.001) or CMR (area under the curve=0.95; 95% CI, 0.89-1.00; P<.001) as the criterion. The new software enabled semiautomated 3D MR flow quantification in complex MR with multiple and eccentric jets and showed better agreement with CMR than 2D PISA TTE or TEE, suggesting that this method is more accurate than conventional 2D PISA TTE and TEE.

Diagnostic Value of 3-Dimensional Vena Contracta Area for the Quantification of Residual Mitral Regurgitation After MitraClip Procedure

ObjectivesThe authors sought to define the feasibility and performance of 3-dimensional (3D) vena contracta area (VCA) measurement in evaluating total residual mitral regurgitation (MR) following percutaneous edge-to-edge clip (E-EC) mitral valve repair. BackgroundResidual MR severity after percutaneous repair is not only a determinant of procedural success, but also a major prognostic factor. To date, no single echocardiographic method has been recommended for post-procedural MR quantification, with the evaluation currently relying on a complex, multiparametric appraisal. MethodThe authors performed a retrospective study of patients undergoing the E-EC procedure, for which baseline and post-repair 3D color Doppler transesophageal echocardiogram datasets were available. Total VCA was recorded as the sum of individual VCAs (if more than 1) and compared with an expert multiparametric appraisal of MR severity as the reference standard. Receiver-operating characteristic analysis was performed. Results155 patient studies were available for review. Total VCA correlated with hemodynamic parameters and was significantly reduced after E-EC. Receiver-operating characteristic analysis demonstrated a VCA threshold of 0.27 cm2 for identification of ≥moderate MR, with good diagnostic accuracy (area under the curve 0.81) and a negative predictive value of 92%. Smaller VCA was associated with clinical New York Heart Association functional class improvement at 30-day follow-up. ConclusionsMeasurement of VCA is feasible using 3D color Doppler transesophageal echocardiography and provides reliable quantification of MR following E-EC transcatheter mitral valve repair.

Noninvasive Determination of Vortex Formation Time Using Transesophageal Echocardiography During Cardiac Surgery.

Trans-mitral blood flow produces a three-dimensional rotational body of fluid, known as a vortex ring, that enhances the efficiency of left ventricular (LV) filling compared with a continuous linear jet. Vortex ring development is most often quantified with vortex formation time (VFT), a dimensionless parameter based on fluid ejection from a rigid tube. Our group is interested in factors that affect LV filling efficiency during cardiac surgery. In this report, we describe how to use standard two-dimensional (2D) and Doppler transesophageal echocardiography (TEE) to noninvasively derive the variables needed to calculate VFT. We calculate atrial filling fraction (β) from velocity-time integrals of trans-mitral early LV filling and atrial systole blood flow velocity waveforms measured in the mid-esophageal four-chamber TEE view. Stroke volume (SV) is calculated as the product of the diameter of the LV outflow track measured in the mid-esophageal long axis TEE view and the velocity-time integral of blood flow through the outflow track determined in the deep transgastric view using pulse-wave Doppler. Finally, mitral valve diameter (D) is determined as the average of major and minor axis lengths measured in orthogonal mid-esophageal bicommissural and long axis imaging planes, respectively. VFT is then calculated as 4 × (1-β) × SV/(πD3). We have used this technique to analyze VFT in several groups of patients with differing cardiac abnormalities. We discuss our application of this technique and its potential limitations and also review our results to date. Noninvasive measurement of VFT using TEE is straightforward in anesthetized patients undergoing cardiac surgery. The technique may allow cardiac anesthesiologists and surgeons to assess the impact of pathological conditions and surgical interventions on LV filling efficiency in real time.

Correlation between plasma brain natriuretic peptide levels and left atrial appendage flow velocity in patients with non-valvular atrial fibrillation and normal left ventricular systolic function.

The left atrial appendage (LAA) flow velocity is an important factor for thrombus formation in patients with non-valvular atrial fibrillation (NV-AF). Recently, the relation of plasma brain natriuretic peptide (BNP) levels and thromboembolism has been reported in patients with NV-AF. The aim of this study was to determine whether the plasma BNP is predictive of lower LAA flow velocity in patients with NV-AF and normal left ventricular (LV) systolic function. A total of 184 patients with NV-AF (132 men; 65±12years, LV ejection fraction; 65±10%) underwent transthoracic echocardiography, transesophageal echocardiography (TEE), and measurement of plasma BNP. The LAA flow velocity was obtained by pulsed Doppler TEE. Multivariate logistic regression analysis demonstrated that plasma BNP levels, left atrial volume index (LAVI), LV mass index (LVMI), and the CHADS2 score were independent predictors of lower LAA flow velocity (<20cm/s). Plasma BNP levels (r=-0.58, p<0.001) were correlated with LAA flow velocity. The area under the curve (AUC) for BNP (AUC 0.803) was larger than that for the CHADS2 score (AUC 0.712), LAVI (AUC 0.664) and LVMI (AUC 0.608) with an optimal BNP cut-off value of 164pg/ml (sensitivity 75.7%, specificity 71.1%). This study showed that a higher plasma BNP was associated with a lower LAA flow velocity in patients with NV-AF and normal LV systolic function. The plasma BNP may complement the role of the CHADS2 score in predicting lower LAA flow velocity.

Detection of angiographically significant coronary obstruction using resting transthoracic coronary Doppler echocardiography.

Transesophageal Doppler echocardiography has shown that significant stenosis can be detected based on the presence of aliasing with color Doppler in the stenotic area. The study aimed to assess the detection of angiographically significant coronary stenosis (ASCS) by analyzing the characteristics and velocities of resting coronary artery flow (RCF) using transthoracic coronary Doppler echocardiography (TCDE). TCDE was performed before diagnostic coronary angiography (CA). The following velocities were measured: peak systolic velocity (PSV), peak diastolic velocity (PDV), mean diastolic velocity (MDV), end-diastolic velocity (EDV), and distal to proximal velocity ratios. Twenty-five patients were included, and CA revealed ASCS in 14 patients. With TCDE, the proximal and distal portions of the left anterior descending artery (LAD) could be measured in 84% of cases. Among 12 patients with ASCS in the distal left main coronary artery (LMCA) or proximal or mid LAD, proximal and distal flow could be measured in ten patients. Proximal diastolic velocities were higher in patients with ASCS in the LAD, and a distal MDV/proximal MDV ratio<0.5 had a 60% sensitivity and a 92% specificity for the detection of ASCS (AUC 0.77, 95% CI 0.56-0.92). For the detection of ASCS limited to the LMCA and/or proximal LAD, the distal MDV/proximal MDV ratio had a sensitivity of 100% and a specificity of 89% (AUC 0.98, 95% CI 0.81-0.99). Resting TCDE can detect ASCS in the LAD, particularly at the proximal level, analyzing the ratio between distal and proximal flow velocities. These results could not be demonstrated in the RCA and CX arteries.

Transesophageal echocardiography for incremental value of Amplatezer cribriform septal occluder for percutaneous transcatheter closure of complex septal defects: Case series

BackgroundThe anatomy of septal defects can be complex and morphologically unpredictable. Balloon sizing of such defects may not be feasible, and an appropriately sized commercial occluder may not be available. Therefore, percutaneous transcatheter closure of such defects can be challenging because of an increased risk of complications. In this study, we have described the efficacy and safety of transcatheter closure of complex septal defects using Amplatzer cribriform occluder devices, assessed by real time three-dimensional (RT 3D) color Doppler transesophageal echocardiography (TEE). Methods and ResultsFour complex septal defects were involved in this investigation: (1) reimplanted multiple atrial septal defects (ASD) with one device embolization; (2) postinfarction ventricular septal defect; (3) long tunnel patent foramen ovale; and (4) postoperative residual ASD. All patients underwent percutaneous transcatheter interventions due to the high risk of surgical complications, and one of the three available cribriform ASD device sizes (18 mm, 25 mm, or 35 mm) was implanted. Perioperative RT 3D TEE combined with fluoroscopy was used for monitoring during the procedure. All defects were successfully occluded by cribriform septal occluder devices using the transcatheter technique. ConclusionOur patients with complex septal defects were successfully treated by transcatheter closure using an Amplazter cribriform septal occluder device with careful planning based on patient presentation and close interdisciplinary collaboration. RT 3D color Doppler TEE provided precise information for the selection of the appropriate occluder device and facilitated the procedure by guiding the catheter through the often challenging patient anatomy.

The value of three-dimensional color Doppler trans-esophageal echocardiography in predicting the number of MitraClip devices needed during the procedure.

PurposeDuring MitraClip procedure, one or more clips might be needed to effectively reduce the mitral regurgitation (MR). Three-dimensional vena-contracta (3D-VC) assessed by color Doppler three-dimensional trans-esophageal echocardiography (3D-TEE) was proven to be well correlated with MR severity. However, its role in predicting the number of MitraClip devices needed during the procedure was not fully determined. Aim of this study is to assess the predictive value of 3D-VC area & length in determining the number of clips needed during the procedure.Methods3D-TEE with color Doppler was performed in 20 patients ( age: 68.9 ± 2.5 years; 65% males; with functional severe/moderately severe MR) who underwent successful MitraClip procedure (reduction of MR to <2+). Manual tracing and measurement of the 3D-VC area (3D-VCA) as well as the 3D-VC length (3D-VCL) was done. These values were compared between patients who received 1 clip (n = 4) and ≥ 2 clips (n = 16).ResultsPatients who received ≥ 2 clips had larger 3D-VC area compared to patients who received 1 clip (0.39 ± 0.23 cm2 vs. 0.13 ± 0.03 cm2, p = 0.04, t = 2.22) . Patients who received ≥ 2 clips had bigger 3D-VC length compared to patients who received 1 clip (1.14 ± 0.33 cm vs. p = 0.005, t = 3.25 ). A cut-off values of 0.20 cm2 & 1 cm for the VCA & VCL respectively, are suggestive that the patient will most likely require more than one MitraClip device to treat his mitral regurgitation.ConclusionsThe 3D-VCA & 3D-VCA using 3D TEE is helpful indetermining the number of MitraClip devices needed during the procedure in functional mitral regurgitation.

Book Review: Atlas of Transoesophageal Color Doppler Echocardiography and Intraoperative Imaging:

Book Review: Atlas of Transoesophageal Color Doppler Echocardiography and Intraoperative Imaging:

Left Ventricular Dilation and Pulmonary Vasodilatation after Surgical Shunt for Treatment of Pre-Sinusoidal Portal Hypertension.

ObjectiveThe aim of this study was to prospectively investigate the long-term cardiovascular and pulmonary hemodynamic effects of surgical shunt for treatment of portal hypertension (PH) due to Schistosomiasis mansoni.LocationThe University of São Paulo Medical School, Brazil; Public Practice.MethodsHemodynamic evaluation was performed with transesophageal Doppler and contrast-enhanced echocardiography (ECHO) on twenty-eight participants with schistosomal portal hypertension. Participants were divided into two groups according to the surgical procedure used to treat their schistosomal portal hypertension within the last two years: group 1—distal splenorenal shunt (DSRS, n = 13) and group 2—esophagogastric devascularization and splenectomy (EGDS, n = 15).ResultsThe cardiac output (5.08 ± 0.91 L/min) and systolic volume (60.1 ± 5.6 ml) were increased (p = 0.001) in the DSRS group. DSRS participants had a significant increase (p < 0.0001) in their left ventricular end-systolic and end-diastolic diameters as well as in their left ventricular end-diastolic and end-systolic volumes (p < 0.001) compared with the preoperative period. No statistically significant difference was found in the patients who underwent EGDS. ECHO revealed intrapulmonary vasodilatation (IPV) in 18 participants (64%), 9 DSRS and 9 EGDS (p > 0.05).ConclusionsThe late increase in the cardiac output, stroke volume and left ventricular diameters demonstrated left ventricular dilatation after a distal splenorenal shunt. ECHO revealed a greater prevalence for IPV in patients with schistosomiasis than has previously been described in patients with PH from liver cirrhosis.

Moderate Aortic Valvular Insufficiency Invalidates Vortex Formation Time as an Index of Left Ventricular Filling Efficiency in Patients With Severe Degenerative Calcific Aortic Stenosis Undergoing Aortic Valve Replacement.

Transmitral blood flow produces a vortex ring (quantified using vortex formation time [VFT]) that enhances the efficiency of left ventricular (LV) filling. VFT is attenuated in LV hypertrophy resulting from aortic valve stenosis (AS) versus normal LV geometry. Many patients with AS also have aortic insufficiency (AI). The authors tested the hypothesis that moderate AI falsely elevates VFT by partially inhibiting mitral leaflet opening in patients with AS. Observational study. Veterans Affairs medical center. Patients with AS in the presence or absence of moderate AI (n = 8 per group) undergoing aortic valve replacement (AVR) were studied after institutional review board approval. None. Under general anesthesia, peak early LV filling (E) and atrial systole (A) blood flow velocities and their corresponding velocity-time integrals were obtained using pulse-wave Doppler transesophageal echocardiography (TEE) to determine E/A and atrial filling fraction (beta). Mitral valve diameter (D) was calculated as the average of major and minor axis lengths obtained in the midesophageal bicommissural (transcommissural anterior-lateral-posterior medial) and LV long-axis (anterior-posterior) TEE imaging planes, respectively. VFT was calculated as 4·(1-beta)·SV/πD(3), where SV = stroke volume measured using thermodilution. Hemodynamics, diastolic function, and VFT were determined during steady-state conditions before cardiopulmonary bypass. The severity of AS (mean and peak pressure gradients, peak transvalvular jet velocity, aortic valve area) and diastolic function (E/A, beta) were similar between groups. Moderate centrally directed AI was present in 8 patients with AS (ratio of regurgitant jet width to LV outflow tract diameter of 36±6%). Pulse pressure and mean pulmonary artery pressure were elevated in patients with versus without AI, but no other differences in hemodynamics were observed. Mitral valve minor and major axis lengths, diameter, and area were reduced in the presence versus the absence of AI. VFT was increased significantly (5.7±1.7 v 3.2±0.6; p = 0.00108) in patients with AS and AI compared with AS alone. Moderate AI falsely elevates VFT in patients with severe AS undergoing AVR by partially inhibiting mitral valve opening. VFT may be an unreliable index of LV filling efficiency with competitive diastolic flow into the LV.

Abstract 16905: Evaluation of Immediate Procedural Outcome After MitraClip Using Automated Quantitaive Real-time Volume Color Flow Doppler Transesophageal Echocardiography

Background: Current echocardiographic evaluation of residual MR after Mitra-Clip is based on a semi-quantitative scale (trace to 4+). We evaluated a previously validated quantitative approach using automated real-time volume color flow Doppler (3D-RTVCFD). Methods: 30 patients (age 82 ± 5) underwent Mitra-Clip implantation guided by 3D-RTVCFD TEE (Siemens SC2000, CA). In 10 patients, data to automatically quantify 3-D regurgitant volume (RV, ml) and fraction (RF, %) and anatomic regurgitant orifice area (AROA) was available (Figure, upper panel). All patients had conventional 2-D Echo data for assessment of MR severity using the standard integrated approach. Results: MR was severe (4+) in 8, and moderately severe (3+) in 2 patients at baseline. MR post Mitra-Clip was mild or trace in 6 (≤1+, Group 1), and moderate in 4 (Group 2) patients. At baseline, the (mean±SD) 3-D RV/RF was 54.5±19.9 ml/60.6±10.2% and the AROA was 0.6±0.2 cm2 for the whole group. Post Mitra-Clip, the 3-D RV/RF was 23.6±10.3 ml/37.0±13.9% (p&lt;0.01/p&lt;0.001 vs. baseline) and the AROA was 0.3±0.1 cm2 (p&lt;0.05). Both Group 1 and Group 2 had similar baseline RF, and both demonstrated a 39% and 38% decrease in RF post Mitra-clip, respectively (Figure, bottom graph). The decrease in AROA in both groups post Mitra-Clip was also significant (~53% in Group 1 and ~59% in Group 2). Thus, despite “moderate” residual MR using the semi-quantitative scale in Group 2, there was significant decreases in both RF and AROA. Conversely, in Group 1 some of the residual MR assessed as “mild” indeed had 3-D RF and AROA in the moderate range, post Mitra-clip. Conclusion: Automated quantitative 3-D real-time volume color flow Doppler TEE offers a quantitative assessment of residual MR post Mitra-clip immediately after the procedure. This may refine decision-making with regard to number of clips. Both accuracy of 3D RTVCFD TEE to quantify MR and it’s predictive value for mid- to long term procedural success need further studies.