Intraoperative Echocardiography Research Articles

Virtual reality-enhanced ultrasound guidance: A novel technique for intracardiac interventions

Cardiopulmonary bypass surgery, although a highly invasive interventional approach leading to numerous complications, is still the most common therapy option for treating many forms of cardiac disease. We are currently engaged in a project designed to replace many bypass surgeries with less traumatic, minimally invasive intracardiac therapies. This project combines real-time intra-operative echocardiography with a virtual reality environment providing the surgeon with a broad range of valuable information. Pre-operative images, electrophysiological data, positions of magnetically tracked surgical instruments, and dynamic surgical target representations are among the data that can be presented to the surgeon to augment intra-operative ultrasound images. This augmented reality system is applicable to procedures such as mitral valve replacement and atrial septal defect repair, as well as ablation therapies for treatment of atrial fibrillation. Our goal is to develop a robust augmented reality system that will improve the efficacy of intracardiac treatments and broaden the range of cardiac surgeries that can be performed in a minimally invasive manner. This paper provides an overview of our interventional system and specific experiments that assess its pre-clinical performance.

Intraoperative Localization of Paravalvular Mitral Prosthetic Regurgitation by 3-Dimensional Color-Flow Transesophageal Echocardiography

PARAVALVULAR REGURGITATION IS a rare but potentially serious complication after valvular surgery. The authors present a patient in whom intraoperative 3-dimensional echocardiography allowed the exact circumferential localization of paravalvular regurgitation after the replacement of a mitral valve prosthesis. The diagnosis was followed by the subsequent surgical correction.

Deterioration of Regional Wall Motion Immediately after Coronary Artery Bypass Graft Surgery Is Associated with Long-term Major Adverse Cardiac Events

Patients undergoing coronary artery bypass graft (CABG) surgery frequently develop wall motion abnormalities diagnosed by intraoperative transesophageal echocardiography. However, the relation between deterioration in wall motion and postoperative morbidity or mortality is unclear. Therefore, the authors hypothesized that deterioration in intraoperative left ventricular regional wall motion immediately after CABG surgery is associated with a higher risk of adverse cardiac events. With institutional review board approval, data were gathered from 1,412 CABG surgery patients. Echocardiographic wall motion score (WMS) was derived using a 16-segment model. Outcomes data were gathered for up to 2 yr after surgery. The primary outcome, major adverse cardiac event, was a composite index of myocardial infarction, need for subsequent coronary revascularization, or all-cause mortality during the follow-up period. Two hundred twenty-one patients (16%) had 254 primary outcome events during follow-up. Postbypass WMS did not change in 812 patients (58%), deteriorated in 219 patients (16%), and improved in 368 patients (26%). Kaplan-Meier analysis showed that patients with deterioration in WMS after CABG experienced significantly lower major adverse cardiac event-free survival than patients with either no change or improvement in WMS (P = 0.004). Cox proportional hazards regression modeling revealed a significant association between deterioration in WMS and the composite adverse outcome (hazard ratio, 1.47 [1.06-2.03]; P = 0.02). The authors confirmed their hypothesis that deterioration in wall motion detected by intraoperative echocardiography after CABG surgery is associated with increased risk of long-term adverse cardiac morbidity. Worsening wall motion after CABG surgery should be considered a prognostic indicator of adverse cardiovascular outcome.

Alcohol septal ablation versus surgical myectomy: a patient with obstructive HCM

A 42-year-old woman with a 20-year history of obstructive hypertrophic cardiomyopathy was referred for alcohol septal ablation following a worsening of symptoms, which had persisted despite medical treatment. Physical examination, electrocardiography, rest-exercise Doppler and two-dimensional echocardiography, coronary angiography, intracoronary myocardial contrast echocardiography, and intraoperative transesophageal and epicardial echocardiography. Symptomatic obstructive hypertrophic cardiomyopathy. The patient was deemed unsuitable for alcohol septal ablation and underwent surgical myectomy guided by intraoperative echocardiography.

Guidelines for Performing a Comprehensive Epicardial Echocardiography Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

TABLE OF CONTENTSIntroduction 921General Guidelines 922Training and Certification 922Indications for TEE 923Management of Patient Sedation 927Sedation and Anesthesia 929Probe Insertion Techniques 930Instrument Controls 930Instrument Manipulation 931Comprehensive Imaging Examination 932ME Views 932TG

Infected right ventricular myxoma and pulmonary valve endocarditis

Case Summary A 44-year-old man with a history of intravenous drug use, hepatitis C, and bipolar disease came to hospital with septic shock and hypoxia requiring low-dose vasopressor support and high-flow oxygen by face mask. Echocardiographic examination revealed a 4.3-cm solid, hyperechoic nodule in the right ventricle. He was treated with intravenous trimethoprim/sulfamethoxazole, vancomycin, and gentamicin for Streptococcus viridans, which had been isolated from the blood and sputum. Computerized tomographic imaging revealed no evidence of any masses in the abdomen or thorax, although there was evidence of pulmonary microemboli and bilateral empyemas. The patient was treated with antibiotics for 6 weeks, with no change noted in the size of the right ventricular mass on serial echocardiography. During this period, the patient’s condition was clinically stable; however, persistent fever and elevated white blood cell count ( 18,000 cells/ L) prompted cardiac surgical consultation. The patient was subsequently taken to the operating room, where the initial intraoperative echocardiography confirmed a solid hyperechoic mass originating in the right ventricle (Figure 1), which was prolapsing across an abnormal pulmonic valve and causing pulmonic insufficiency. An attempt was made to remove the mass through the right atrium. Because of the size of the mass and concern of damaging the tricuspid valve, however, a right ventriculotomy was performed and the mass removed en bloc. The ventriculotomy was closed with running 3-0 Prolene sutures (Ethicon, Inc, Somerville, NJ) and felt. During weaning from cardiopulmonary bypass, transesophageal echocardiography showed severe pulmonary insufficiency secondary to a flail anterior leaflet that had previously been obscured by the ventricular mass. The pulmonary valve was then replaced with a No. 25 Hancock II bioprosthesis (Medtronic, Inc, Minneapolis, Minn). The patient was weaned from cardiopulmonary bypass without difficulty, had an uncomplicated postoperative course, and remains alive and well. The final pathology report confirmed infection of a tricuspid pulmonary valve with gram-positive cocci. The right ventricular mass, which measured 8 5 3 cm, was found to be an infected benign cardiac myxoma with necrosis and numerous gram-positive cocci (Figure 2).

Guidelines for Performing a Comprehensive Epicardial Echocardiography Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Scott T. Reeves, MD, FASE, Kathryn E. Glas, MD, FASE, Holger Eltzschig, MD, Joseph P. Mathew, MD, FASE, David S. Rubenson, MD, FASE, Gregg S. Hartman, MD, and Stanton K. Shernan, MD, FASE, for the Council for Intraoperative Echocardiography of the American Society of Echocardiography, Charleston, South Carolina; Atlanta, Georgia; Tubingen, Germany; Durham, North Carolina; La Jolla, California; and Lebanon, New Hampshire

Acute Pulmonary Thromboembolism During Mitral Valve Repair

Perioperative pulmonary thromboembolism during cardiac surgery is extremely rare. We report a 55-year-old male, who developed acute pulmonary thromboembolism during mitral valve repair. Intra-operative trans oesophageal echocardiography failed to demonstrate thromboembolus in the pulmonary arteries but it showed the secondary signs of acute pulmonary artery obstruction. Thromboembolectomy was done after high index of suspicion on clinical grounds was found and the patient recovered. The diagnostic accuracy and sensitivity of transoesophageal echocardiography in circumstances with altered haemodynamics is questionable and has not been investigated. Therefore, indirect evidence of pulmonary artery obstruction on echocardiography may have a predictive value and failure to demonstrate pulmonary thromboembolism by this tool should not exclude the possibility of it especially when it is highly suspected.

Spontaneous Closure of Small Residual Ventricular Septal Defects After Surgical Repair

Residual shunts may be detected by intraoperative or postoperative echocardiography after surgical closure of a ventricular septal defect (VSD). The hemodynamic relevance and rate of late closure are unknown. Between 1994 and 2005, 198 consecutive patients underwent surgical correction of an isolated VSD (n = 100), tetralogy of Fallot (n = 52) or atrioventricular septal defect (n = 46). Intraoperative transesophageal echocardiography (TEE) was routine, and postoperative transthoracic echocardiography was performed in the intensive care unit, at hospital discharge, and during follow-up. Residual defects were graded as absent, between 1 and 2 mm, or greater than 2 mm. Shunt-related discrepancy was observed between intraoperative TEE and intensive care unit transthoracic echocardiographic findings; significantly so after Fallot repair (p < 0.0001). After discharge, 83% of all residual defects less than 2 mm closed. Of nine residual defects greater than 2 mm, only three closed after a median follow-up of 3.1 years. In patients with residual shunts, they were hemodynamically insignificant, required no medication, and no endocarditis was noted. At last follow-up, there was no significant difference between the percentage of residual shunts among the three groups (p = 0.135). Postsurgical residual VSDs less than 2 mm closed spontaneously in the majority within a year. Defects greater than 2 mm are unlikely to close spontaneously. Residual shunts after atrioventricular septal defect repair almost always close, whereas one third will remain open after Fallot or isolated VSD repair. At midterm follow-up, residual shunts remained hemodynamically and clinically irrelevant. Revision of a residual defect greater than 2 mm on cardiopulmonary bypass at initial repair, guided by TEE, may spare late redo surgery and lifelong antibiotic prophylaxis.

Intraoperative Transesophagial Echocardiography Modifies Strategy in Off-Pump Coronary Artery Bypass Grafting

Off-pump coronary artery bypass graft surgery (OPCAB) can improve operative morbidity and mortality in high risk patients. Intraoperative transesophageal echocardiography (ITEE) is being employed increasingly during cardiac surgery. Routine ITEE was performed in 744 OPCAB patients performed over a five year period. Mean patient age was 69.1 +/- 8.0 years. There were a high percentage of patients over 70 years (39%), diabetics (26%), poor left ventricular function (< or = 35%) (31%), recent myocardial infarction (24%), unstable angina (15%), and preoperative intraaortic balloon pump (5.6%); mean graft number was 3.4. There was a major modification in intraoperative strategy in 117 patients (16%) and minor modification in 77 patients (10%) due to information available through the ITEE (total 26%). Graft revision was performed in 39 patients, graft construction was modified due to severe ascending aortic atherosclerosis in 31, and an intraoperative intraaortic balloon pump was placed due to previously underappreciated left ventricular dysfunction and new intraoperative left ventricular dysfunction in 37 patients. Ten patients were placed on cardiopulmonary bypass due to previously unknown intracardiac pathology (three atrial septal defect repairs and five valvular procedures, two others). Intracoronary shunts were placed due to new wall motion changes during anastomosis in 77 patients. There were two emergent conversions to cardiopulmonary bypass. There were no complications due to ITEE probe placement. Intraoperative transesophageal echocardiography is a valuable adjunct and can result in a major change of surgical strategy in a significant number of patients when used routinely for OPCAB. It may also improve surgical outcome and add to the OPCAB benefits.

Invited commentary

Surgical closure of ventricular septal defects (VSDs), either in isolation or associated with tetralogy of Fallot or complete atrioventricular septal defect, constitutes one of the most common procedures performed by the congenital heart surgeon. With the ubiquitous application of intraoperative and postoperative echocardiography, the surgeon is commonly faced with the dilemma of a child who has undergone VSD closure but has a residual defect seen either in the operating room by transesophageal echocardiography or in the intensive care unit by transthoracic echocardiography.

Incidental Detection of Inferior Vena Caval Dissection by Intraoperative High Frequency Vascular Duplex Ultrasonography

Inferior vena caval (IVC) dissection has been rarely reported. This could be due to less susceptibility of the venous structure to dissect or under recognition of this entity. We first report a case of IVC dissection detected by high frequency surface ultrasonography following tumor thrombectomy of adrenal cortical carcinoma. This report described the value of intraoperative surface echocardiography and reviewed previous literatures with regard to IVC dissection.

Intraoperative Echocardiography for Atrioventricular Canal: Decision-Making for Surgeons

Intraoperative echocardiography has become a standard patient management tool in the assessment of the patient undergoing surgical repair of a congenital cardiac defect. Over the past 15 years transesophageal echocardiography has emerged as an integral part of the intraoperative assessment of the congenital cardiac surgery patient. The important role of intraoperative echocardiography is largely because of its ability to define complex anatomy, identify functional abnormalities, and recognize flow disturbances at the time of surgical repair. Intracardiac defects are particularly suited to the strengths of intraoperative transesophageal echocardiography because of the unobstructed windows that can be obtained. This article focuses on how intraoperative echocardiography can guide surgical decision-making in the patient undergoing repair of an atrioventricular canal defect.

Left Ventricle Apical–Aortic Conduit for Aortic Stenosis

Nativeaorticvalvereplacementistheprocedureofchoice for pure aortic valve stenosis. Occasionally, conventional surgery is deemed unacceptably high risk related to calcificationoftheaorticroot,multiplepreviousmediansternotomies, or patent retrosternal grafts. Implantation of a left ventricle apical‐aortic conduit (AAC) is an alternative approach in patients with these and other conditions that either preclude a median sternotomy or present a high risk for aortic cross-clamping and aortotomy. There are several imaging and postoperative concerns related to this situation. A 64-slice multidetector computed tomography (CT) scan of the chest and abdomen with and without contrast is usually performed to assess the degree of aortic root calcium, calcification of the descending thoracic aorta, and the lay of any retrosternal patent coronary artery bypass grafts. Intraoperative transesophageal echocardiographic assessment of the aortic valve is essential to rule out aortic insufficiency. An apical aortic conduit should be performed in the setting of isolated aortic stenosis. Mild aortic insufficiency can be tolerated but the procedure should be avoided in patients with greater than 1 aortic insufficiency. Intraoperative echocardiography is also valuable to further assess the degree of calcification of the descending aorta to help direct placement of the conduit-to-aorta anastomosis. We prefer to perform the operation with femoro-femoral cardiopulmonary bypass and mild hypothermia (34°C).

Systolic anterior motion after mitral valve repair: Is surgical intervention necessary?

The natural history and management of patients with systolic anterior motion after mitral valve repair are uncertain. We performed a retrospective chart review and survey follow-up of all patients in whom systolic anterior motion developed intraoperatively after mitral valve repair. From January 1993 to December 2002, mitral valve repair was performed in 2076 patients, and in 174 cases (8.4%) systolic anterior motion was identified on intraoperative echocardiography. These patients form the study group. Initially, patients were managed with a combination of beta-blockade, vasoconstriction with phenylephrine, and/or intravascular volume expansion. Four patients had revision of repair because of persistent systolic anterior motion, and 3 additional patients had revision of repair because of mitral regurgitation from other causes. The median follow-up of the remaining 167 patients was 5.4 years (range 0-13.2 years). There were 2 late reoperations, but none were caused by systolic anterior motion or left ventricular outflow tract obstruction. Ninety percent of patients were in New York Heart Association class I, 7% were in class II, and 3% were in class III or IV. Echocardiograms were available for review in 93 patients at a median interval of 5.4 years (range 0.2-12.2 years); 13 patients had systolic anterior motion, and 4 patients had systolic anterior motion with left ventricular outflow tract obstruction. In this experience, most cases of systolic anterior motion resolved with conservative measures including beta-blockade, vasoconstriction, and fluid administration. Persistent systolic anterior motion with left ventricular outflow tract obstruction was documented in 2.3% of patients who had early systolic anterior motion, but late reoperation was not required. Furthermore, the clinical outcomes of patients with systolic anterior motion are comparable to the current norms for mitral valve repair. Ninety percent of patients were in New York Heart Association class I, 7% were in class II, and 3% were in class III or IV.

Acute High-Output Failure from an Aortoventricular Fistula Due to a Ruptured Sinus of Valsalva Aneurysm After Blunt Chest Trauma

Acute High-Output Failure from an Aortoventricular Fistula Due to a Ruptured Sinus of Valsalva Aneurysm After Blunt Chest Trauma

Epicardial Real-Time Three-Dimensional Echocardiography in Cardiac Surgery: A Preliminary Experience

Intraoperative two-dimensional transesophageal echocardiography (2DTEE) is a widely accepted method to guide cardiac valve surgery. The aim of our study was to evaluate the feasibility, effectiveness, and incremental value of intraoperative epicardial real-time three-dimensional echocardiography (RT3DE). Thirty consecutive patients (18 aortic and 12 mitral valve diseases) underwent intraoperative 2DTEE and RT3DE before and after cardiopulmonary bypass. Five observers compared independently 2DTEE to live and full volume images and to the surgical view, to assess the incremental value of RT3DE in depicting the different anatomic structures. Epicardial RT3DE was feasible in all patients. Qualitative evaluation determined RT3DE superiority in depicting aortic cusp morphologic lesions; left ventricular outflow tract spatial relationships with mitral apparatus and aortic root; and both anterior and posterior mitral leaflet scallops, particularly posterior commissure. In our study, epicardial RT3DE has been demonstrated to improve morphologic definition of anatomic valvular lesions and their relationship with cardiac adjacent structures. It may be a valid substitute when the 2DTEE approach is contraindicated, or it could have a complementary role, coupled with 2DTEE, to give additional information for surgical planning.

American Society of Echocardiography/Society of Cardiovascular Anesthesiologists Recommendations and Guidelines for Continuous Quality Improvement in Perioperative Echocardiography

Joseph P. Mathew, MD, FASE, Kathryn Glas, MD, FASE, Christopher A. Troianos, MD, Pamela Sears-Rogan, MD, FASE, Robert Savage, MD, Jack Shanewise, MD, FASE, Joseph Kisslo, MD, FASE, Solomon Aronson, MD, FASE, and Stanton Shernan, MD, FASE, for the Council for Intraoperative Echocardiography of the American Society of Echocardiography, Durham, North Carolina, Atlanta, Georgia, Pittsburgh, Pennsylvania, Washington, DC, Cleveland, Ohio, New York, New York, and Boston, Massachusetts

Robotically Assisted Totally Endoscopic Atrial Septal Defect Repair: Insights From Operative Times, Learning Curves, and Clinical Outcome

Remote access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect and patent foramen ovale. The aim of this study was to address learning curve issues of totally endoscopic atrial septal defect repair on the basis of a single-center experience and to investigate whether long cardiopulmonary bypass and aortic occlusion times influence intraoperative and postoperative outcomes. Seventeen patients (median age, 35 years; range, 16 to 55 years) underwent totally endoscopic atrial septal defect repair using remote access perfusion and robotic technology (da Vinci telemanipulation system). Learning curves were assessed by means of regression analysis with logarithmic curve fit. The effect of operative variables on clinical outcome was analyzed by linear regression using the Spearman's rho coefficient. No operative mortality or serious surgical complications were observed. No residual shunt was detected at intraoperative or postoperative echocardiography. Significant learning curves were noted for total operative time: y(min) = 406 - 49 ln(x) (r2 = 0.725; p = 0.002); cardiopulmonary bypass time: y(min) = 225 - 42 ln(x) (r2 = 0.699; p = 0.003); and aortic occlusion time: y(min) = 117 - 25 ln(x) (r2 = 0.517; p = 0.04), x = number of procedures. Median ventilation time, intensive care unit stay, and hospital length of stay were 7 hours (range, 2 to 19 hours), 26 hours (range, 15 to 120 hours), and 8 days (range, 5 to 14 days), respectively. No correlation was detected between cardiopulmonary bypass time and intubation time (r2 = 0.283; p = 0.326), intensive care unit stay (r2 = -0.138; p = 0.639), or total length of stay (r2 = 0.013; p = 0.962). Totally endoscopic atrial septal defect repair can be performed safely, and learning curves for operative times are steep. Longer cardiopulmonary bypass times had no negative impact on intraoperative and postoperative outcome.

Difficult atrial septal defect closure: Intracardiac echocardiographic visualization of an unexpected caveat

The functional incompetence of the ASD anteroinferior rim due to partial presence of the flap valve is an infrequent caveat for transcatheter closure [1]. An 18-year-old boy with transesophageal echocardiographic diagnosis of 20 mm secundum atrial septal defect (Panel A: AI rim, anteroinferior rim) with Qp/Qs=2.1 and severe dilatation of right cardiac chambers underwent attempt of transcatheter closure. On intraoperative intracardiac echocardiography, the anteroinferior rim was recognized to be composed by flap valve remnant and it appeared clear that the entire anteroinferior rim was extremely floppy with a thickness of 1.1–1.4 mm (Panel B: ASD, atrial septal defect; LA, left atrium; RA, right atrium; AI rim, anteroinferior rim). Real diameter of the defect on aortic valve and four-chamber view measured at the point of minimal bulging and maximal thickness of the rim was 20.1 and 28 mm, respectively. Atrial septal defect closure was attempted (Panel C: ASO, Amplatzer septal Occluder left disk) with the maximal waist diameter (28 mm) of Amplatzer ASD Occluder (AGA Medical Corporation, Golden Valley, MN) which was compatible with the length