Early Transesophageal Echocardiography Research Articles

SUB ACUTE HAEMOPHILUS PARAINFLUENZAE ENDOCARDITIS: A CASE REPORT AND REVIEW OF LITERATURE

Haemophilus species are an infrequent cause of subacute bacterial endocarditis. They are fastidious Gram-negative bacteria belonging to the oropharyngeal microflora, and are slow-growing their growth is enhanced by the presence of carbon dioxide. Herein, we describe the case of a 19-year-old male with no relevant medical history who was admitted for fever and general symptoms and was found to have sub acute native mitral endocarditis secondary to H. parainfluenzae. He underwent successful mitral valve repair with good long term outcomes. This case also highlights the ability of a rare bacterium, Haemophilus parainfluenzae, to cause a sub acute septic process and multiple complications including septic emboli. Early identification of this bacterium from blood cultures and early transoesophageal echocardiography is essential for obtaining the diagnosis and allowing early start of adequate treatment.

Impact of early transesophageal echocardiography on therapeutic management of patients with acute embolic strokes of undetermined source (ESUS)

Up to one-fourth of ischemic strokes remain cryptogenic after standard evaluation. The ESUS concept for embolic strokes of undetermined source was defined in 2014, the patients being supposed to benefit from anticoagulation, but the studies are negative as of this date. Transthoracic and transesophageal (TEE) echocardiography are the main diagnostic tools for cardiac and aortic sources of embolism, the second being superior. However, its therapeutic impact is not fully determined, since it is not recommended in ESUS. We aimed to assess prospectively, in consecutive ESUS patients admitted to our stoke unit, the rate of treatment change induced by transesophageal echocardiography (TEE), and to identify predictive factors for such modifications. Acute ESUS patients were prospectively included to undergo TEE within seven days. Demographic, laboratory, MRI and echocardiographic data were recorded. The primary endpoint was the rate of TEE induced therapeutic modification. Between October 2016 and May 2018, 154 ESUS patients entered the analyses. TEE changed the treatment in 22 patients (14.3%): anticoagulation in 7, cardiac surgery in 2, dual antiplatelet therapy for complex aortic arch atheroma in 10, antibiotics in 2 and atrial septal defect closure in 1. Patients with TEE induced treatment modification were significantly older (68.9 vs. 59.0 years, P < 0.001), and had more vascular risk factors: diabetes mellitus (36.4% vs. 15.9%, P = 0.036), hypertension (68.2% vs. 43.9%, P = 0.035), hypercholesterolemia (72.7% vs. 28.8%, P < 0.001) and more CRP (63.6% vs. 33.3%, P = 0.007), hs Troponin I (50.0% vs. 22.7%, P = 0.007) and NT-pro-BNP (31.8% vs. 9.8%, P = 0.011) elevation. There was a trend to more multiple infarcts on DWI MRI in treatment change group (50.0% vs. 31.8%, P = 0.097). TEE lead to a treatment modification in 14% of cases. Selected ESUS patients may benefit from TEE.

Follow-up imaging after left atrial appendage closure

Because device-related thrombus (DRT) portends a poor prognosis after left atrial appendage closure with the Watchman device, surveillance transesophageal echocardiography (TEE) is recommended at 45 days and 1 year. However, oral anticoagulants are just discontinued at 45 days, rendering this early TEE unlikely to detect DRT. Indeed, DRT is most likely to occur after instituting aspirin monotherapy. The purpose of this study was to evaluate the alternative strategy of first TEE imaging (or computed tomography) at 4 months post-Watchman implantation. After Food and Drug Administration approval, consecutive patients undergoing Watchman implantation at 2 centers received TEE or CT at 4 months and 1 year, along with a truncated drug regimen: 6 weeks of an oral anticoagulant (or clopidogrel in a subset) plus aspirin, then 6 weeks of dual antiplatelet therapy, and finally aspirin monotherapy. Of the 530-patient cohort (mean age 78.7±7.9 years; 65.5% (n = 347) male; CHA2DS2-VASc score 4.5±1.4), 465 patients (87.7%) received 4-month imaging: 83.0% (440 of 530) TEE and 4.7% (25 of 530) computed tomography. Over a median follow-up of 12 months, 16 ischemic strokes (ISs), 8 transient ischemic attacks, and 1 systemic embolization occurred. Importantly, no IS occurred between 45 days and 4 months; the sole transient ischemic attack in this period (at ∼2 months) occurred 1 week after transcatheter aortic valve replacement. DRT was detected in 2.4% (11 of 465) at 4 months and 0.9% (2 of 214) at 1 year. No IS, but 1 leg embolization, was observed after DRT detection. Delaying the first imaging post-Watchman implantation to 4 months was associated with no IS between 45 days and 4 months, the "vulnerable" period of this follow-up strategy.

Acute arterial embolism of lower extremity after mitral valve replacement in a chronic lymphocytic leukaemia patient: a case report

Introduction Acute arterial embolism is a potential severe complication after cardiac surgery: it can be a clinical manifestation of early prosthetic valve (PV) thrombosis, whose incidence is higher in case of mechanical mitral valve or in presence of subtherapeutic anticoagulation, hemodynamic (atrial fibrillation) or haemostatic (obesity, anaemia, renal failure) predisposing factors (1). EACTA guidelines recommend to start anticoagulation during the first 24 hours after surgery, balancing the haemorragic risk(2). Although, in presence of specific comorbidities and risk factors, life-threatening thrombotic events can complicate postoperative period even following the international recommendations. Methods We report a 73-year-old man, suffering from chronic lymphocytic leukaemia (without treatment) and paroxysmal AF who received mitral mechanical valve replacement with a On-X 27/29 mm valve placed on anti-anatomic position because of a severe mitral insufficiency (with chordal systolic anterior movement) and single coronary artery by-pass graft. Unfractionated heparin (UFH) and acetylsalicylic acid were started 18 hours after surgery, in order to maintain an aPTT ratio of 1.5 to 2.5. On postoperative day (POD) 4 patient presented sudden pain and signs of acute hypoperfusion in left leg (distal femoral artery territory), requiring urgent surgery. Transthoracic echocardiography was performed but limited by artefacts and suboptimal acoustic windows. Considering the high risk surgery and the usefulness of early transoesophageal echocardiography (TOE), the patient received a general anaesthesia with tracheal intubation. Results Successful open embolectomy on the common femoral artery was performed; UFH perfusion was maintained during the whole duration of the procedure without haemorrhagic complication. Intraoperative TEO detected spontaneous echo contrast in left atrial appendage and reduced motion with impaired coaptation of the right leaflet (red arrows in figure); neither valvular-atrial-ventricular thrombus nor increased transvalvular gradient nor regurgitation were found. Postoperative TEO (POD 3) showed a PV with normal leaflets movement, without significative stenosis/regurgitation. Warfarin was started on POD 4 and heparin bridging was discontinued when INR target range was reached. Discussion In patient with multiple thrombotic risk factor (id malignancy, AF) adequate anticoagulation level can be difficult to reach: in these cases, serious thrombotic complications must be highly suspected even when guidelines have been followed. Prompt diagnosis and aggressive treatment are crucial to guarantee a good prognosis. Early TOE and a “tailored” anticoagulation therapy play a fundamental role in the management of such complications.

PT098 Early Transesophageal echocardiography and empirical antibiotic therapy may prevent higher mortality and morbidity in medically treated patients of infective endocarditis

<dm:abstracts xmlns:dm="http://www.elsevier.com/xml/dm/dtd"><ce:abstract xmlns:ce="http://www.elsevier.com/xml/common/dtd" xml:lang="en" id="abs0010" view="all" class="author"><ce:section-title id="sectitle0010">Abstract</ce:section-title><ce:abstract-sec id="abssec0010" view="all"><ce:simple-para id="abspara0010" view="all">Streptococcus bovis bacteremia is well known to be associated with colorectal tumor. But most physicians are unaware of the association between Streptococcus sanguis bacteremia and colorectal malignancy. In this case report, we highlight this association and discuss a case of Streptococcus sanguis bacteremia complicating endocarditis associated with a late stage invasive colonic adenocarcinoma</ce:simple-para></ce:abstract-sec></ce:abstract></dm:abstracts>

Initial resuscitation guided by the Surviving Sepsis Campaign recommendations and early echocardiographic assessment of hemodynamics in intensive care unit septic patients

To compare therapeutic interventions during initial resuscitation derived from echocardiographic assessment of hemodynamics and from the Surviving Sepsis Campaign guidelines in intensive care unit septic patients. Prospective, descriptive study in two intensive care units of teaching hospitals. The number of ventilated patients with septic shock who were studied was 46. Transesophageal echocardiography was first performed (T1<3 hrs after intensive care unit admission) to adapt therapy according to the following predefined hemodynamic profiles: fluid loading (index of collapsibility of the superior vena cava≥36%), inotropic support (left ventricular fractional area change<45% without relevant index of collapsibility of the superior vena cava), or increased vasopressor support (right ventricular systolic dysfunction, unremarkable transesophageal echocardiography study consistent with sustained vasoplegia). Agreement for treatment decision between transesophageal echocardiography and Surviving Sepsis Campaign guidelines was evaluated. A second transesophageal echocardiography assessment (T2) was performed to validate therapeutic interventions. Although transesophageal echocardiography and Surviving Sepsis Campaign approaches were concordant to manage fluid loading in 32 of 46 patients (70%), echocardiography led to the absence of blood volume expansion in the remaining 14 patients who all had a central venous pressure<12 mm Hg. Accordingly, the agreement was weak between transesophageal echocardiography and Surviving Sepsis Campaign for the decision of fluid loading (κ: 0.37 [0.16;0.59]). With a cut-off value<8 mm Hg for central venous pressure, κ was 0.33 [-0.03;0.69]. Inotropes were prescribed based on transesophageal echocardiography assessment in 14 patients but would have been decided in only four patients according to Surviving Sepsis Campaign guidelines. As a result, the agreement between the two approaches for the decision of inotropic support was weak (κ: 0.23 [-0.04;0.50]). No right ventricular dysfunction was observed. No patient had anemia and only three patients with transesophageal echocardiography documented left ventricular systolic dysfunction had a central venous oxygen saturation<70%. A weak agreement was found in the prescription of fluid loading and inotropic support derived from early transesophageal echocardiography assessment of hemodynamics and Surviving Sepsis Campaign guidelines in patients presenting with septic shock.

Early echocardiographic detection of a massive intracardiac thrombus in a patient scheduled for orthotopic liver transplantation

Transesophageal echocardiography (TEE) in cases of orthotopic liver transplantation is gaining acceptance for intraoperative hemodynamic monitoring. The timepoint of TEE probe insertion varies and is based on the fear of bleeding complications in the setting of portal hypertension with esophageal varices. In this case, early insertion of the TEE probe and examination resulted in the early detection of a large intracardiac thrombus, and thus the cancellation of the planned procedure. This case highlights the potential value of early TEE examination in orthotopic liver transplantation.

Choice of echocardiography method for postoperative evaluation of mitral valve replacement with a mechanical prosthesis

The French Cardiology Society (SFC) systematically recommends (Class I) transesophageal echocardiography (TEE) after any mitral valve replacement with a mechanical prosthesis (MMVR). Taking into account the increasing workload of echocardiography laboratories, our attitude was to propose that only post-operative transthoracic echocardiography (TTE) is performed. The purpose of this study was to evaluate the possible risks of this simplified procedure. We performed a precise analysis of one full year of practice of MMVR with exhaustive follow-up for the first 2 years concentrating on thromboembolic complications. From January to December 2003, 84 MMVRs (46 after rheumatic fever, 22 degenerative disease, 11 infective endocarditis (IE) and 5 ischemia) were conducted in 45 women and 39 men of average age 61 years. Early mortality (<30 days) concerned 5 patients (5.9%). A control TTE to determine normal prosthetic function was performed 7+/-2 days after surgery and this revealed 2 cases of nonobstructive thrombosis which were treated medically, 3 cases of paraprosthetic regurgitation, and 1 vegetation due to underlying IE. Actuarial survival was 90.5% at 1 year and 83.3% at 2 years. After a mean follow-up of 179.3 patient-years, 5 patients were reoperated (5.9%): 1 for IE, 1 for paravalvular regurgitation, 1 for mitral valve insufficiency with haemolysis, and 2 for obstructive prosthetic valve thromboses. In addition there were 2 cases of prosthetic valve thrombosis, 8 ischemic strokes (2 ministrokes, 6 sequelar strokes), and 1 peripheral embolism. The global thromboembolic complication rate was therefore 6.1 per 100 patient-years (n=11). There were 4 hemorrhagic events, i.e. a rate of 2.2 events per 100 patient-years. 63% of the 1193 INR conducted were within the target range (3-4.5), 26% were below 3 and 11% were greater than 4.5. 35% of patients with thromboembolic complications had an INR<3. Morbidity and mortality during the first 2 years after MMVR were relatively high but equivalent to the values of comparable series in the literature. These complications would not have been reduced by a more precise screening based on early TEE. Despite the increasingly litigious nature of the doctor-patient relationship, it would probably be excessive to oppose that this guideline was not followed in a dispute; in particular as it is difficult to apply this measure as echocardiography departments are overworked.

Atrial fibrillation: is there a role for low-molecular-weight heparin?

Atrial fibrillation (AF) is the most common form of tachyarrhythmia and carries a significant risk of serious thromboembolic complications. Anticoagulation is used for long-term thromboprophylaxis and for short-term management in a number of clinical situations, among which is the medical or electrical cardioversion of AF to sinus rhythm. Current guidelines recommend prompt cardioversion with heparin cover for AF of <48 h duration, and several weeks of warfarin therapy prior to cardioversion when the duration of disease is longer. Recent animal and human studies, however, have shown that swifter cardioversion is likely to be more successful in achieving sinus rhythm and in reducing the risk of recurrence of AF. Other observations have demonstrated that thrombi can develop within a few hours of the development of AF. These considerations suggest that cardioversion should be carried out as early as possible in all cases, and that the most sensitive means of detecting atrial thrombi, currently transesophageal echocardiography (TEE), should be used to screen all patients prior to cardioversion. Within this context, there is growing interest in the use of low-molecular-weight heparin (LMWH) as an anticoagulant therapy in AF. Compared with unfractionated heparin, LMWH therapy does not involve prolonged intravenous administration, hospitalization, or laboratory monitoring; LMWH therefore has the potential to greatly simplify anticoagulation therapy for AF, especially pericardioversion. Recent studies have demonstrated that LMWH can be used safely and effectively in place of unfractionated heparin for acute treatment at the onset of AF and during early cardioversion. For example, in patients with AF, a strategy of immediate administration of dalteparin (100 IU/kg s.c. twice daily) continued for 11 days, combined with early TEE and immediate cardioversion in patients with no thrombus, resulted in sinus rhythm in 74% of patients after a median of 7 days. Low-molecular-weight heparin therapy may also find a role perioperatively and in selected patients, notably those with warfarin intolerance, as a replacement for warfarin following cardioversion. Controlled clinical studies are still required, however, to establish a firm, evidence-based foundation for the use of LMWHs in AF.

Transesophageal Echocardiography (TEE) in the Evaluation of Infective Endocarditis

Echocardiography is an essential tool for the modern diagnosis and management of infective endocarditis and its complications. The negative predictive value of surface imaging is inadequate to rule out endocarditis in most instances; diagnostic sensitivity is improved by way of the transesophageal approach. The clinical scenario and pretest probability of disease should guide the use of transesophageal versus transthoracic imaging. Those at high risk for endocarditis or its complications in particular should undergo early TEE. Serial studies may be required to guide management. In the setting of an initially negative echocardiographic study, a repeat examination is indicated if the clinical suspicion of endocarditis persists or if the clinical picture changes. Combined transthoracic echocardiography and TEE may supply complementary information useful in management and follow-up. As most published research predates recent advances in imaging, the impact of changing technology, such as harmonic and three-dimensional imaging, in the management of endocarditis is yet to be determined.

Early transoesophageal echocardiography in cryptogenic and lacunar stroke and transient ischaemic attack

OBJECTIVESTo test the hypothesis that transoesophageal echocardiography (TOE) carried out within three days of a first stroke or transient ischaemic attack of cryptogenic or lacunar type may disclose more thrombi...

901-119 Non-occlusive Prosthetic Thrombosis on Transoesophageal Echocardiography After Mitral Surgery: Evolution with Medical Treatment

Transoesophageal echocardiography (TEE) after mitral valve replacement (MVR) with a mechanical prosthesis may reveal non-occlusive thrombi in the prosthesis in asymptomatic patients (pts). The clinical implications of these thrombi remain however debated. Between 1988 and 1993, 183 consecutive pts underwent MVR with a bileaflet prosthesis (Saint-Jude 134, Sorin 22, Carbomedics 20, Duromedics 7). Their mean age was 56 ± 13 yrs. Early TEE was performed 15 ± 6 days after surgery and revealed thrombi in the prosthesis in 22 pts (12%). No pt had symptoms. Two pts were re-operated on because of large, mobile thrombi. In the 20 other cases, Doppler did not show any obstruction in the prosthesis (mean gradient 5 ± 2 mmHg [3–9]), and the motion of both leaflets was normal on TEE and fluoroscopy. A total of 27 thrombi was visualized in these 20 pts. Maximal size of the thrombi was &lt;5 mm in 9 cases, 5 to 10 mm in 12 cases, and &gt;10 mm in 6 cases; 70% of these thrombi were mobile. These 20 pts were treated by carefully controlled anticoagulation with heparin (serum levels 0.2 to 0.4 U/mL) andlor vitamin K antagonists (INR 3 to 4.5). No pt received thrombolytic therapy. Repeat TEE in these 20 pts showed that thrombi disappeared after one month in 15 cases (75%), and in all the cases after a mean period of 58 ± 99 days [7–210]. Only one pt experienced a transient ischaemic attack without sequelae. (1) Non-occlusive thrombi in the prosthesis are frequently observed on early TEE after MVR. (2) They seldom cause embolic events. (3) They disappear with anticoagulant therapy, in the majority of cases within one month.

Are wall thickening measurements reproducible?

An early transesophageal echocardiography (TEE) study reported that there was high inter- and intraobserver variability in measurements of wall thickening (WT). This study reevaluated TEE for the measurement of WT in the transverse plane and, for the first time, evaluated it in the longitudinal plane. Ten patients were studied with a biplane TEE probe inserted and positioned to obtain a transverse short-axis (SA) view of the left ventricle at the midpapillary muscle level. A longitudinal transgastric long-axis (LA) view of the left ventricle was then obtained. This measurement sequence was performed four times in each patient. Off-line analysis was performed independently by two observers. In each tomographic cut of the ventricle, four locations for measurement were defined. WT was measured in three consecutive beats, and the results averaged (WT1). The observers repeated the measurements (WT2) 2 wk later, and the intra- and interobserver differences (mm) were calculated. Average differences for the intraobserver comparisons of wall thickening were small (0.08-0.24 mm), but the high standard deviations (1.17-2.44 mm) suggest significant variability between individual measurements. Thus it appears that measurements of wall thickening with small mean intraobserver bias may be possible, but to offset the potential for variability, multiple measurements are necessary. Also, careful standardization of location and edge definition is important to limit interobserver variability.