Intraoperative Echocardiography Research Articles

Evaluation of Transmitral Pressure Gradients in the Intraoperative Echocardiographic Diagnosis of Mitral Stenosis after Mitral Valve Repair

ObjectiveAcute mitral stenosis (MS) following mitral valve (MV) repair is a rare but severe complication. We hypothesize that intraoperative echocardiography can be utilized to diagnose iatrogenic MS immediately after MV repair.MethodsThe medical records of 552 consecutive patients undergoing MV repair at a single institution were reviewed. Post-cardiopulmonary bypass peak and mean transmitral pressure gradients (TMPG), and pressure half time (PHT) were obtained from intraoperative transesophageal echocardiographic (TEE) examinations in each patient.ResultsNine patients (9/552 = 1.6%) received a reoperation for primary MS, prior to hospital discharge. Interestingly, all of these patients already showed intraoperative post-CPB mean and peak TMPGs that were significantly higher compared to values for those who did not: 10.7±4.8 mmHg vs 2.9±1.6 mmHg; p<0.0001 and 22.9±7.9 mmHg vs 7.6±3.7 mmHg; p<0.0001, respectively. However, PHT varied considerably (87±37 ms; range: 20–439 ms) within the entire population, and only weakly predicted the requirement for reoperation (113±56 vs. 87±37 ms, p = 0.034). Receiver operating characteristic curves showed strong discriminating ability for mean gradients (AUC = 0.993) and peak gradients (area under the curve, AUC = 0.996), but poor performance for PHT (AUC = 0.640). A value of ≥7 mmHg for mean, and ≥17 mmHg for peak TMPG, best separated patients who required reoperation for MS from those who did not.ConclusionsIntraoperative TEE diagnosis of a peak TMPG ≥17 mmHg or mean TMPG ≥7 mmHg immediately following CPB are suggestive of clinically relevant MS after MV repair.

Coronary Artery Spasm After Cryo Maze III Procedure

The Cox Maze III procedure has been simplified with the availability of tissue ablation devices; however, complications related to their use are recognized. We report a case of 45-year-old woman who underwent mitral valve repair and concomitant Cryo-Maze procedure. She had reversible right coronary artery spasm develop after the procedure demonstrated by ST-segment elevation changes and coronary angiography, which was reversed with intracoronary nitroglycerin. The region of spasm suggested it as a consequence of proximity of the right coronary artery to the right atrial ablation lines.

A survey for the evaluation of the training period of cardiology specialists in Turkey

To evaluate postgraduate training period, social life and problems of cardiology residents in Turkey by using a questionnaire form and to compare with the core curriculum of European Society of Cardiology for general cardiology. Overall, 529 residents of cardiology ages in range of 24-35 years (mean age: 26.5±2.0 years, 81.4% male) participated as volunteers in this cross-sectional survey study. An 86-item questionnaire form was used to evaluate the education process, capacity of knowledge and skill and social effectiveness level of participants. The questionnaire were composed both closed- and open-ended questions. The questionnaire form was filled in with the face-to-face communication method. The data of survey were compared with the core curriculum of European Society of Cardiology for general cardiology training period. Chi-square or Fischer exact test was used for statistical analysis. The participants were working in various university hospitals (70.3%) and training-research (state) hospitals in 31 different provinces in Turkey (40.8% in Marmara region). They visited 40±10 outpatients and 10±5 hospitalized pts daily in the clinics. The 3-5 residents worked at the clinic on night shifts and mostly (89%) 8 or more night shifts per month were held in their first training years. During first three-years of training 76% of residents have performed echocardiography, 40.8%-transesophageal echocardiography and 10% - intraoperative echocardiography. The 84.3% of them evaluated exercise tests, 76.4%-Holter electrocardiography and 53.3%-tilt-table tests. The rate of residents working in coronary angiography laboratories was 54.3%. The 53.7% of residents performed coronary angiography and 64%-only in the 4th year of their training. The number of coronary angiography performance was under expected when compared with European Society of Cardiology curriculum. The 18.5% of residents were participated as assistant researcher in an international multi-center study and only 10% had an article published in national journals (4.3% published in Science Citation Index). The 30.6% considered the cardiology training period in their centers to be insufficient, whereas 37.4% found it partially sufficient and 31.9% sufficient. Only 32.9% of participants could dedicate time for social activities. According to the referred core curriculum of ESC for general cardiology the training of cardiology residents in non-invasive applications is adequate however coronary angiography applications are slightly insufficient in Turkey. In addition, the number of publications per capita is quiet low.

Intraoperative contrast echocardiography to verify the surgical occlusion of a single extrahepatic portosystemic shunt in a dog

This report details a bubble echocardiographic study carried out during the surgical treatment of a congenital single extrahepatic portosystemic shunt (PSS) in a Labrador Retriever. After celiotomy, agitated saline was injected through a jejunal vein and microbubbles appeared rapidly in the right cardiac chambers. The test confirmed the presence of a PSS, helping the surgeon to identify the vessel concerned and to rule out a second shunt. Successively, portography confirmed what the exploratory celiotomy had revealed before with the aid of the bubble study: a single shunt was located between the portal vein and the right renal vein. It was completely ligated, as all the criteria for this solution were met. Intraoperative contrast echocardiography (ICE) was easy to perform, helpful and undemanding. It is proposed here as an intraoperative ancillary test to diagnose all PSS and to confirm successful treatment when complete shunt closure is possible.

Impact of Intraoperative Epicardial Real-Time Three-Dimensional Echocardiography as a Surgical Guide on Systemic Atrioventricular Valve Plasty of Congenital Heart Disease

The aim of the study is to assess the feasibility and accuracy of intraoperative epicardial RT3DE (IERT3DE) for obtaining anatomical information of systemic atrioventricular valve as a surgical guide in congenital heart disease.

Intraoperative echocardiography and surgical treatment of traumatic pericarditis in a pregnant cow

Traumatic pericarditis is one of the most significant bovine cardiac diseases. The authors describe the use of intraoperative echocardiography and successful surgical treatment of a case of traumatic pericarditis. A seven-year-old Hungarian Simmental dairy cow in late pregnancy showed severe oedema of the throat region and brisket, as well as jugular distension. Cardiac auscultation demonstrated tachycardia with a normal cardiac rhythm. The heart sounds were muffled, but no cardiac murmur or splashing sounds were heard. A large amount of echogenic fluid with some strands of fibrin was seen in the pericardial and right pleural cavities by ultrasonography. Ultrasound-guided pericardiocentesis demonstrated the presence of a thick, fetid and purulent exudate. Pericardiotomy was performed in standing position with sedation and local anaesthesia. After costal resection, intraoperative echocardiography was performed. It showed an echogenic tract between the caudal pericardium and diaphragm, but no foreign body was seen. Two weeks after the surgery, the cow delivered a healthy bull-calf. Intraoperative echocardiography - not reported earlier - can be applied to evaluate the entire bovine pericardial sac and heart. The report also demonstrates that surgical treatment of traumatic pericarditis can be successful in carefully selected cases.

Patient with Posterior Mediastinal Mass Requiring Urgent Cardiopulmonary Bypass

T HE literature on anesthetic concerns and perioperative care of patients with mediastinal masses has focused almost exclusively on anterior mediastinal masses. Posterior mediastinal masses traditionally have been suggested to carry a low risk of anesthetic implications. We present the case of a patient with a posterior mediastinal mass who experienced hemodynamic and respiratory decompensation upon induction of general anesthesia and required urgent transition to cardiopulmonary bypass (CPB). Our case illustrates the importance of real-time imaging provided by transesophageal echocardiography (TEE) in explaining the etiology of intractable hemodynamic instability and a new finding of significant pericardial and left pleural effusion not seen on preoperative imaging. TEE made clear the urgent need to initiate CPB because it revealed a near total compression of the left atrium, which was obstructing delivery of volume to the left ventricle. In addition, this case demonstrates the inadequacy of “stand-by” CPB and the need for every institution to establish an interdisciplinary team to develop, before surgery, a formal plan for the perioperative care of patients with mediastinal masses.

Aberrant Azygos Vein Complicating Postatrial Septal Defect Repair Intraoperative Echocardiography Examination

Aberrant Azygos Vein Complicating Postatrial Septal Defect Repair Intraoperative Echocardiography Examination

Cerebral Oximetry for the Prediction of Neurological Dysfunction in Cardiosurgical Patients

Objective: to study the efficiency of intraoperative transeosophageal echocardiography in the detection of indications for and contraindications to early activation in the operating room after myocardial revascularization under extracorporeal circulation. Subject and methods. One hundred and eighty-six patients aged 55.0±0.6 years were examined. A Sonos Agilent 5500 apparatus and a multipurpose Omni-2 transducer were used for ultrasound study. Left ventricular ejection fraction was determined in the four-chamber (Simpson) and transgastric views (visualization of the left ventricle in cross-section at the level of the papillary muscles). To identify impaired myocardial contractility hindering immediate activation, the authors analyzed the data of examining 142 patients who might undergo tracheal extubation in the operating room. A decreased left ventricular ejection fraction of less than 50% in the transgastric view was considered to be a contraindication to activation. The sensitivity of echocardiography in the differential diagnosis of acute myocardial infarction _ was studied in 44 patients with echocardiographic signs of acute myocardial ischemic lesion. Results. A left ventricular ejection fraction of less than 50% (41.5±2.2%) in the transgastric view was a refusal criterion for immediate patient activation. This group of patients, as compared with those having a left ventricular ejection fraction of 60.1±1.7%, had a longer duration of inotropic therapy (45.2±2.1 and 13±1.1 hrs; p<0.05) and a more prolonged length of postoperative intensive care unit stay (36.2±1.7 and 18.8±0.75 hrs; p<0.05). The correlation coefficient between the left ventricular ejection fraction at the end of surgery and the duration of inotropic therapy was 0.51 (p<0.0001) and that with an intensive care unit stay was 0.48 (p=0.00018). Among the patients with electrocardiographic signs of acute myocardial ischemic lesion, ultrasound study did not confirm the diagnosis in 65.9% of cases, which allowed early activation to be performed without complications. Acute akinesis of the left ventricular walls in 93.8% was a sign of acute myocardial infarction verified later on by X-ray contrast and laboratory studies. Conclusion. Transeosophageal echocardiographic monitoring is a highly effective diagnostic technique that can detect patients with left ventricular systolic dysfunction and verify acute ischemia and infarction of the myocardium, which substantially increases the safety of patient activation in the operating room after myocardial revascularization. Key words: ultrasound monitoring, transeosophageal echocardiography, early tracheal extubation, early activation of cardiosurgical patients, myocardial revascularization, aortocoronary bypass surgery.

Intraoperative echocardiography assessment of left and right ventricular function

Over the past 25 years, echocardiography technology has improved tremendously and intraoperative transoesophageal echocardiography (TOE) has become the gold standard cardiac monitor and diagnostic tool. Although there is limited scientific evidence to substantiate this belief, there is a perception that intraoperative TOE provides valuable information that significantly influences clinical management and improves patient outcome. 1,2 Several investigators have documented its benefits in the critically ill patient and during complex cardiovascular surgery. 3,4,5 Two recent retrospective analyses related to alterations during routine cardiac surgery from intraoperative TOE have also suggested its cost effectiveness. 6,7

An improved algorithm for intraoperative registration of computed tomographic left atrial images

Although anatomically accurate and highly detailed, preoperative computed tomographic (CT) images of the left atrium (LA) are of limited utility for guiding catheter navigation, in part because of changes in LA shape which occur between preoperative and intraoperative settings. Such changes may produce errors in spatial juxtaposition, or 'registration', of the CT image to the intraoperative environment. The goal of this study was to assess a new algorithm for CT image registration. In each of 10 patients, CT images were registered using LA endocardial points derived from intraoperative intracardiac echocardiography (CartoSound, Biosense). Two registration algorithms were compared: (i) CartoMerge (Biosense), a 'rigid' algorithm in which the CT image was not malleable; (ii) ImageMorph, a non-rigid algorithm in which CT image was malleable and was altered so as to more precisely fit the intraoperative point locations. There were no significant differences in LA volume or pulmonary vein antral dimensions on CT images after registration using CartoMerge vs. ImageMorph. Shape changes induced by ImageMorph were not concentrated in any one LA region. Registration quality was significantly better using ImageMorph, as was mock circumferential ablation accuracy. The potential for improved CT image-guided ablation accuracy using ImageMorph calls for further study to discern whether this algorithm yields tangible procedural and clinical benefits relative to currently available algorithms.

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Current concepts in mitral valve prolapse—Diagnosis and management

Although mitral valve prolapse as a disease entity has been recognized for over 50 years, its precise definition has been elusive. Initial reports based the diagnosis on auscultatory findings (late systolic click - murmur), with left ventricular angiography as a confirmative test. Echocardiography, first the M-mode, and subsequently the two-dimensional, became the dominant diagnostic modality. However, the early reports did not distinguish between billowing valve and flail valve. The advent of surgical repair techniques provided a different perspective; the surgical definition of mitral valve prolapse is often different from that of cardiologists. Intraoperative echocardiography gained wide acceptance necessitating a common language to describe precise terminology of the leaflet anatomy and definition of valve prolapse. The present report proposes a terminology and definitions of valve prolapse with relevance to surgical mitral valve repair. The addition of real-time 3D transesophageal echocardiography now provides highly accurate localization of lesions and the multi segment assessment of valve pathology. The etiologic considerations and surgical repair techniques with the role of echo - surgery team in improved patient outcome are described.

Role of pericardium in the maintenance of left ventricular twist

BackgroundThe role of pericardium in left ventricular (LV) twist has not been directly investigated. We sought to determine the role of pericardium in maintenance of LV twist function in an...

Transesophageal Echocardiography of a Dislodged Left Atrial Appendage Thrombus and Its Subsequent Surgical Removal During Coronary Artery Bypass Graft Surgery

Left atrial appendage (LAA) thrombus is a common finding in patients with atrial fibrillation and a major source of emboli that cause strokes. The incidental finding of an LAA thrombus during cardiac surgery is an infrequent finding during routine intraoperative echocardiography, and optimal management is not well defined. A case of a large, incidentally discovered LAA thrombus that became mobile on initiation of cardiopulmonary bypass in a patient undergoing coronary artery bypass graft surgery is presented. Intraoperative transesophageal echocardiography diagnosed the thrombus, discovered its dislodgement from the LAA, and very interestingly demonstrated its surgical removal. This case demonstrates the ability of intraoperative transesophageal echocardiography to alter surgical management and provides support for its routine use in cases in which LAA thrombi are likely.

Initial, intra-operative, and post-operative evaluation of children with pulmonary atresia with intact ventricular septum with emphasis on the coronary connections to the right ventricle

Pulmonary atresia and intact ventricular septum (PAIVS), more than most congenital cardiac defects, requires detailed assessment for initial decision making and to guide intraoperative procedures. Among the important questions to answer are the degree of tricuspid valve (TV) and right ventricular (RV) hypoplasia and whether or not significant connections exist between the coronary arteries and the right ventricle (RV-CACs). When the TV and RV hypoplasia are severe and/or significant RV-CACs exist, these lesions are thought to preclude a two-ventricle repair (2VR) at most institutions. Our approach, however, is that these lesions can be defined and successfully treated making an adequate 2VR probable. We have developed and successfully employed a combined echocardiographic and angiographic approach for neonates at the severe end of the PAIVS spectrum and particularly those with RV-CACs that has guided and allowed 2VRs in these infants. Our approach includes preoperative, intraoperative and postoperative echocardiography including transthoracic, transesophageal (TEE) and cardiac surface imaging. The echocardiographic studies are used to define the TV and RV abnormalities and determine if RV-CACs are present. Significant RV-CACs are indicated by bidirectional flow in the RV-CAC with associated coronary flow reversal and dilated major coronary arteries with abrupt caliber changes at the site of the connection. When significant RV-CACs are present, cardiac catheterization with complementary right ventricular and aortic root angiography from similar projections aids localization of the connections as well as the associated coronary stenoses and interruptions which seem to result from hypertensive, hypoxic perfusion. The combined use of these techniques allows preoperative localization of significant RV-CACs while the use of intraoperative transesophageal and epicardial surface echocardiography aids in their ligation. Postoperatively, identification of any regional wall motion abnormality by TEE, should prompt a search for previously undetected or residual coronary artery connections. This detailed diagnostic approach to the evaluation and treatment of PAIVS will even allow infants at the severe end of the spectrum to be on a 2VR track.

The utility of intraoperative real-time three-dimensional transesophageal echocardiography in cardiac valvular diseases

Objective To evaluate the usefulness of real-time three-dimensional transesophageal echocardiography(RT-3D-TEE)in cardiac valvular diseases.Methods Preoperative and postoperative RT-3D-TEE studies were performed in 32 patients who had undertaken cardiac valve repair or valvular replacement using Philips iE33 with X7-2 probe,and quantitative analysed the mitral structure in cases of mitral valve prolapse by using online QLAB7.0 quantitative analysis software.Results RT-3D-TEE can demonstrate the anatomicsl structure clearly,evaluate the function of cardiac valves precisely,and reveal details of type,position and extent of lesions vividly in surgical view.RT-3D-TEE helped correct misdiagnose in 2 cases,revised surgical plans in 3 cases,and guided implementation of remedial surgery in 1 case.Conclusions RT-3D-TEE can present images lively,and it can provide adequate information for preoperative diagnosis,aid the formulation of surgical plan and evaluate surgical effect. Key words: Echocardiography,real-time three-dimensional; Echocardiography,transeophageal; Heart valve diseases

Invited Commentary

Intraoperative echocardiography delivers abundant real-time data, but with it, the burden of reacting or not to findings that are institution-dependent, operator-dependent, probe-dependent, and subjective. Reporting a large series of intraoperative transesophageal echocardiography (IOTEE) studies and subsequent surveillance transthoracic echocardiography (TTE), Hanna and colleagues [1] reinforce our understanding of the incidence and fate of residual ventricular septal defects (VSDs) after operative repair.

Recommendations for the practice of echocardiography in infective endocarditis

Echocardiography plays a key role in the assessment of infective endocarditis (IE). It is useful for the diagnosis of endocarditis, the assessment of the severity of the disease, the prediction of short- and long-term prognosis, the prediction of embolic events, and the follow-up of patients under specific antibiotic therapy. Echocardiography is also useful for the diagnosis and management of the complications of IE, helping the physician in decision-making, particularly when a surgical therapy is considered. Finally, intraoperative echocardiography must be performed in IE to help the surgeon in the assessment and management of patients with IE during surgery. The current 'recommendations for the practice of echocardiography in infective endocarditis' aims to provide both an updated summary concerning the value and limitations of echocardiography in IE, and clear and simple recommendations for the optimal use of both transthoracic and transoesophageal echocardiography in IE.

Review of surgical ventricular restoration: A procedure to treat cardiac failure

Severe heart failure refractory to medical treatment necessitates the use of other modalities of treatment. Surgical ventricular restoration (SVR) surgery can provide relief until donour hearts are available or when transplantation is contraindicated. In this review we look at the physiological basis for improvement in cardiac function and cardiac and haemodynamic changes that occur after SVR. We also compile the reported factors affecting surgical outcome, criteria for patient selection and predictors of postoperative mortality. NYHA class, presence of diastolic failure, severe impairment of contractile function and presence of mitral regurgitation were the most important determinants. Various different procedures for achieving SVR are briefly discussed. Importance of mitral valve repair/replacement, coronary artery bypass grafting and intraoperative echocardiography in improving postoperative result is highlighted. Role of perioperative medication (anti-arrhythmics, ACE inhibitors and β-blockers) is briefly studied at the end of the review.