Intraoperative Transesophageal Echocardiography Research Articles

Anesthetic management of chronic thromboembolic pulmonary hypertension for surgical pulmonary thromboendarterectomy: A narrative review

Abstract Chronic thromboembolic pulmonary hypertension (CTEPH) is caused due to the total or partial occlusion of the pulmonary vasculature due to organized thrombus, leading to severe pulmonary hypertension and eventually right heart failure, which makes anesthetic management very challenging. Pulmonary endarterectomy (PTE) is the treatment of choice for patients with operable CTEPH. The objective of the present review is to examine the preoperative evaluation, anesthesia technique, and postoperative management in the intensive care unit (ICU) of patients with CTEPH after PTE. We identified published journal articles in the last 25 years from PubMed and Google Scholar databases with the keywords “chronic thromboembolic pulmonary hypertension,”“ anesthetic management of pulmonary thrombo-endarterectomy,” and “perioperative management of CTEPH.” One hundred fifty-three articles were reviewed, out of which 30 articles were retrieved finally. Based on the articles reviewed, we inferred that a balanced anesthesia technique should be carefully chosen to avoid hemodynamic collapse. Transesophageal echocardiography (TEE) is used to assess biventricular function, peak pulmonary artery pressure, the severity of tricuspid regurgitation, location and extent of thrombus, and guide pulmonary artery catheter insertion. Deep hypothermic circulatory arrest (DHCA) is utilized to perform a complete endarterectomy into segmental and subsegmental arterial branches. This narrative review article highlights the role of anesthesiologists in preoperative evaluation, intraoperative TEE guidance, anesthetic management, and postoperative management of complications such as reperfusion pulmonary edema, residual pulmonary hypertension, intrapulmonary hemorrhage, and the consequences of DHCA in patients with CTEPH undergoing surgical PTE.Future research is required to study the effects of DHCA and free radical injuryon postoperative complications and its prevention.

Intraoperative Transesophageal Echocardiography in Acute Type A Aortic Dissection: Contemporary Approach.

Intraoperative Transesophageal Echocardiography in Acute Type A Aortic Dissection: Contemporary Approach.

Intraoperative Transesophageal Echocardiography Quantification of Mitral Regurgitation by Regurgitation Volume and Fraction Using 2D and 3D Techniques.

Intraoperative quantification of mitral regurgitation (MR) is sometimes necessary to quantify the severity of incidentally detected MR during cardiac surgeries. We aimed to compare and correlate the regurgitant volume (Rvol) and regurgitant fraction (RF) using 2D proximal isovelocity surface area (PISA) and 3D vena contracta area (VCA) with the 3D volumetric method and the integrated multiparametric approach. A prospective observational study was conducted on 37 patients undergoing mitral valve surgery for MR. Intraoperative quantification of the severity of MR was done using 2D PISA and 3D VCA methods and was compared with the 3D volumetric method. All three methods were compared with the integrated multiparametric method to obtain cutoff values for identifying severe MR. The correlation coefficients for Rvol with VCA and PISA with the 3D volumetric method were 0.688 and 0.58, respectively. VCA and PISA overestimated the Rvol (VCA = 77.93 ± 27.82 ml, PISA = 76.13 ± 19.25 ml) compared to the 3D volumetric method (66.12 ± 20.30 ml); the RF by the three methods was comparable. Using the receiver operating characteristic-area under curve (AUC) comparing Rvol by these methods with the integrated multiparametric method, the 3D volumetric method performed the best. The Rvol VCA and PISA overestimated MR severity compared to the 3D volumetric method with moderate to good correlation. Rvol 3D was superior with a higher AUC when compared with the integrated multiparametric approach. The RF by the three methods was comparable, albeit with a higher threshold in quantifying severity compared to the conventional criteria.

Perioperative Considerations, Anesthetic Management and Transesophageal Echocardiographic Evaluation of Patients Undergoing the Ross Procedure

The Ross procedure introduced a new technique for aortic valve replacement by utilizing a pulmonary autograft to replace the diseased aortic valve. This approach provides a living, dynamic valve substitute capable of growth and adaptation to systemic pressures while addressing the limitations of mechanical valves, which require lifelong anticoagulation, and bioprosthetic valves, which lack durability and growth potential. The Ross procedure offers superior hemodynamic performance and freedom from anticoagulation. While initially popular, utilization declined due to its technical complexity and concerns regarding the potential for the failure of two valves, requiring additional operations. Advances in surgical techniques, such as reinforced autografts, improved myocardial protection, and better homograft preservation, coupled with evidence of favorable long-term outcomes, have renewed interest in the procedure. Preoperative imaging with echocardiography, cardiac magnetic resonance imaging, and computed tomography angiography ensures optimal patient selection and preparation. Intraoperatively, precise autograft harvesting, accurate implantation, and meticulous right ventricular outflow tract reconstruction are critical for success. Blood conservation techniques, such as acute normovolemic hemodilution and retrograde autologous priming, are employed to minimize transfusion-related complications. The anesthesiologist plays a critical role, including meticulous monitoring of myocardial function and hemodynamics, with intraoperative transesophageal echocardiography being essential for assessing valve integrity and ventricular function. Recent studies suggest that the Ross procedure can restore life expectancy in appropriately selected patients, reinforcing its value as a surgical option for managing aortic valve disease.

Echocardiographic characteristics of paravalvular leak following surgical aortic valve replacement: a retrospective cohort study.

Paravalvular leak (PVL) is a recognized complication following surgical aortic valve replacement (SAVR), with a reported incidence ranging from 1% to 10%. Although some patients with mild PVL remain asymptomatic, others may develop clinically significant complications such as heart failure or hemolysis, underscoring the importance of early detection and timely intervention. While previous research has largely emphasized the risk factors and prognostic implications of PVL, limited literature focuses on the detailed echocardiographic characteristics of both the native aortic valve prior to SAVR and the PVL itself following surgery. Therefore, the objective of this study was to investigate the echocardiographic features of PVL after SAVR-specifically its origin, severity, and correlation with the calcified location of the preprocedural aortic valve. This retrospective cohort study, conducted at a single academic institution, investigated all SAVR procedures performed from June 2010 to October 2022. PVL was identified using intraoperative transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) within 1 year postoperatively. The echocardiographic characteristics of PVL after SAVR, including its origin and severity, as well as its correlation to the calcified location of the preprocedural aortic valve, were investigated along with the incidence. Of the total 948 SAVR cases, PVL was identified in 77 (8.1%) intra- and/or postoperatively. Ten of the 77 cases were excluded from the analysis due to missing stored echocardiographic images, resulting in 67 PVL cases being investigated. The origin of PVL was identified in 62 cases on a short-axis (SAX) view of the aortic valve, with the most common site being the mid-portion of right coronary cusp (RCC) of the native aortic valve position in 22 cases (35.5%), followed by the non-coronary cusp (NCC) and the left coronary cusp (LCC), each in 12 cases (19.4%). Calcification of the preprocedural native aortic valve, ranging from mild to severe, was observed in 38 cases (56.7%). Among these 38 cases with a calcified native valve, the location of PVL was identified in 36 cases, showing a significant correlation between the location of calcification and the position of PVL (r=0.74, P<0.001). Of the 67 PVL cases detected intraoperatively and/or postoperatively, severity was mild in 58 cases (86.6%) and moderate in 9 cases (13.4%), with no severe cases. PVL following SAVR was observed in 8.1% of cases either intraoperatively or within the first year postoperatively. The majority of PVL cases were mild in severity. The most common site of PVL was the mid-portion of the RCC at the native aortic valve position. A significant correlation was found between the location of calcification in the preoperative native valve and the site of PVL.

A retrospective cohort study on the intraoperative monitoring of right ventricular function in tumors involving the inferior Vena Cava

BackgroundThis study aimed to evaluate right ventricular function during surgery for tumor thrombus in the inferior vena cava (IVC) and/or right atrium (RA) using intraoperative transesophageal echocardiography (TEE). It also sought to provide evidence supporting the monitoring and hemodynamic management of the right heart by examining the relationship between the use of vasoactive drugs and changes in right ventricular function in patients with RA invasion versus those with thrombus limited to the IVC after tumor resection.MethodsA retrospective analysis was conducted on patients who underwent IVC tumor resection at Peking University People’s Hospital between June 201 3and October 2021. The collected data included patient demographics, right ventricular function parameters (measured by intraoperative TEE), perioperative use of vasoactive drugs, and postoperative hemodynamics. Patients were categorized into two groups: RA (tumor invading the right atrium) and IVC (tumor confined to the IVC).ResultsThe study included 15 patients, 11 of whom (73.3%) had RA invasion. Both fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE) showed significant improvement postoperatively. The postoperative right ventricular end-diastolic volume (RVEDV) was larger in the RA group, who also experienced longer hospital stays.ConclusionsPostoperative right ventricular systolic function improved in patients with IVC thrombus. However, RA invasion was associated with longer recovery times, underscoring the need for targeted management to prevent right ventricular failure, particularly following relief of IVC obstruction.

One-stage Surgery for Intracardiac Leiomyomatosis.

Intracardiac leiomyomatosis is a rare, histologically benign, but biologically aggressive tumor developed from uterus. This study aimed to summarize our experience with one-stage surgery for intracardiac leiomyomatosis. We retrospectively reviewed seven patients who underwent surgical treatment for intracardiac leiomyomatosis between May 2016 and November 2021. All seven patients were female, aged 35 to 57 years. All lesions in the veins and cardiac chambers were removed entirely. Four of the seven patients received tumor thrombectomy through an abdominal approach. The other three patients received median sternotomy and cardiopulmonary bypass. No perioperative deaths or serious complications occurred during the observation period. The mean operation time in the abdominal approach group was shorter than that in the cardiopulmonary bypass group (308.9 ± 93.2 minutes vs. 486.3 ± 108.6 minutes; P=0.031). Blood loss during surgery in the abdominal approach group was less than that in the cardiopulmonary bypass group (1625 ± 216 mL vs. 2500 ± 1080 mL; P=0.148). All seven patients were free from tumor recurrence or death during the follow-up. For patients with intracardiac intravenous leiomyomatosis single-stage operation through an abdominal approach under the surveillance of intraoperative transesophageal echocardiography without the need for cardiopulmonary bypass for specified patients is feasible. Patients in the abdominal approach group can benefit from a shorter operation time and less blood loss. In our small series of varied presentations and tumor extent, we have been able to avoid two-stage surgery, because even short-term interval between the two operations may result in recurrence.

Intraoperative fluorescence angiography after arterial switch operation.

A full-term neonate with d-transposition of the great arteries and an intact ventricular septum was referred to our institution. We successfully performed an arterial switch operation with the LeCompte maneuver. Intraoperative transesophageal echocardiography revealed moderate mitral regurgitation (MR) immediately after weaning from cardiopulmonary bypass. Indocyanine green, diluted 20 times with saline and blood, was injected through the arterial line to perform contrast imaging and check for problems with the reconstructed coronary arteries. Clear coronary visualization was achieved. MR improved over time and had almost disappeared by the time the patient returned to the intensive care unit.

Multiple Levels of Obstruction at Atrial Level After Senning Procedure Conversion to Arterial Switch Operation: Role of Intraoperative Transesophageal Echocardiography.

Multiple Levels of Obstruction at Atrial Level After Senning Procedure Conversion to Arterial Switch Operation: Role of Intraoperative Transesophageal Echocardiography.

Thoracic Aorta Measurements Using Intraoperative Transesophageal Echocardiography: Validation via Cardiac Magnetic Resonance.

Thoracic Aorta Measurements Using Intraoperative Transesophageal Echocardiography: Validation via Cardiac Magnetic Resonance.

Transesophageal Echocardiography-Related Complications During Mitral Valve Repair in Dogs.

Transesophageal echocardiography (TEE) is an indispensable modality in cardiac surgery; however, the complications associated with its use in veterinary clinical settings remain unclear. To investigate the complications associated with TEE probe manipulation during mitral valve repair in dogs and identify the risk factors for new mucosal injuries. This prospective study evaluated 60 client-owned dogs that underwent TEE to support mitral valve repair. Esophageal endoscopy was performed twice-once after anesthesia induction and once before extubation-to assess esophageal mucosal injuries during the procedure. The type of injury was classified as 'complex' (intramural hematoma and mucosal laceration), 'minor' (petechiae and ecchymosis), or 'minute' (visible only on narrowband imaging) lesions. During the surgery, TEE was performed three times. Hemodynamics were evaluated before the initial TEE insertion and immediately after it was removed. Of the 60 dogs, newly detected mucosal lesions were observed in 20 dogs and classified as 'minor' in four and 'minute' in 16 dogs. These 'minute' lesions were not visible with conventional endoscopy, and no 'complex' lesions were identified. No significant factors were associated with the presence of mucosal lesions. After TEE insertion, systolic blood pressure decreased from 95 ± 13 mmHg to 92 ± 11 mmHg (p = 0.008), and heart rate decreased from 128 ± 25 bpm to 123 ± 24 bpm (p < 0.001). Intraoperative TEE results in a low incidence of esophageal mucosal injuries. Hemodynamic changes could occur during TEE manipulation, underscoring the need for close monitoring.

Tricuspid valve annulus remodeling and regurgitation analysis with 3-D transesophageal echocardiography after percutaneous transcatheter edge-to-edge repair

Abstract Introduction Tricuspid transcatheter edge-to-edge repair (Tr-TEER) is becoming an effective treatment for severe tricuspid regurgitation (TrR) in symptomatic patients who are high-risk candidates for surgery. Purpose Aims of the study were to assess immediate changes in tricuspid valve (TV) anatomy following Tr-TEER and to investigate the relationship between baseline geometry and residual intraoperative TrR. Methods Thirty-one consecutive patients (average age 77.3 years) with symptomatic severe TrR (≥ grade 4) underwent Tr-TEER. Intraoperative transesophageal echocardiographic 2D and 3D images were obtained before and immediately after the procedure. 3D datasets were analyzed offline using specialized software for 3D TV morphology analysis. Results All patients successfully underwent Tr-TEER: 24 patients (77%) achieved an optimal result with residual regurgitation ≤ 2, while 7 patients (23%) had a residual grade 3 or 4. The 3D datasets were suitable for analysis in 29 patients. Anatomic parameters of the TV, obtained via intraoperative transesophageal echocardiography before and after Tr-TEER, are presented in Table 1. The 2D and 3D annulus area, perimeter, diameter in the 2- and 4-chamber view, and minor and major diameter of the tricuspid annulus significantly decreased post-procedure. A significant reduction in TrR was noted regardless of annulus changes. Conclusions Tr-TEER is linked to a significant decrease in TrR and notable changes in TV geometry, particularly a substantial reduction in annulus area and perimeter. This may contribute to the effectiveness of Tr-TEER in promptly reducing TrR.

Immediately improved diastolic function as determined by pulmonic vein Doppler-intraoperative TEE in TAVR patients and the impact of valvulo-arterial impedance

Abstract Background A recent study demonstrates that most TAVR patients experience immediate improvement in diastolic function as determined by pulmonic vein Doppler (PvD) measurements. Valvulo-arterial impedance (Zva) is a marker of global LV load and represents both valvular and arterial load. Zva &amp;gt; 3.5 has been shown as a predictor of poor adverse outcomes. We hypothesize that Zva might have an effect on the change in pulmonic vein Doppler after TAVR. Purpose This study aims to demonstrate the impact of valvulo-arterial impedance and the immediate improvement of diastolic function in TAVR patients as assessed by pulmonic vein Doppler-intraoperative TEE. Materials and Methods Patients who underwent TAVR from January 2020 to September 2023 and were performed pulmonic vein Doppler by intraoperative TEE (right upper pulmonic vein from 90-110° mid-esophageal view) during TAVR and measured S-, D-, and A- wave velocity. We obtained the blood pressure and transthoracic echocardiographic parameters to calculate the Zva [(systolic blood pressure + mean pressure gradient across the aortic valve)/stroke volume index by LVOT doppler]. To compare the PvD change between Zva &amp;lt; 3.5 and Zva ≥ 3.5, use chi-square for categorical data and a paired t-test for continuous data. Results 79 patients (mean age was 80.6 ± 5.6 years, 43 female) were enrolled in this study. S-wave was the only parameter with significantly increased velocity from baseline (33.2 ± 13.8 cm/s vs. 49.1 ± 18.6 cm/s, p &amp;lt; 0.001), whereas D-wave and A-wave did not significantly change from baseline (33.1 ± 14.5 cm/s vs. 33.3 ± 12.0 cm/s, p = 0.88; and 12.7 ± 7.8 cm/s vs. 13.3 ± 7.3 cm/s, p = 0.52, respectively). Of the 37 patients who had an S/D ratio &amp;lt; 1 at baseline, 26 of them converted to an S/D ratio &amp;gt; 1 immediately post-TAVR (Figure 1). In the group of Zva &amp;lt; 3.5, the number of patients who had PvD changed significantly compared with the group of Zva ≥ 3.5 (Figure 2). Conclusion The majority of patients in this study demonstrated that diastolic function improved immediately following TAVR using a pulmonic vein Doppler. S/D &amp;gt; 1 has improved significantly in the group with normal valvulo-arterial impedance (Zva &amp;lt; 3.5). Figure 1 Figure 2

Dynamics of the mitral valve annulus in hypertrophic obstructive cardiomyopathy patients undergoing septal myectomy: insights from 3D transesophageal echocardiography

Abstract Background Mitral annulus (MA) dynamics in HOCM patients and the impact of surgical myectomy on them is not fully understood. This study aimed to evaluate the MA dynamics and their changes after septal myectomy in HOCM patients. Methods This prospective, single-center study included 26 HOCM patients undergoing septal myectomy. Intraoperative Three-dimensional Trans-Esophageal Echocardiography (3DTEE) for the mitral valve (MV) was performed pre- and post-surgery followed by offline analysis of the acquired volumes to assess MA dimensions and dynamics before and immediately after myectomy using a dedicated post-processing software (4D MV analysis, QLAB version 15, Philips Healthcare). Results Pre-operatively, throughout four phases of the cardiac cycle (late diastole, early systole, mid-systole, and late systole), there were no significant dynamic changes in MA dimensions, Specifically, the anteroposterior (AP) diameter (3.753 ± 0.48, 3.756 ± 0.48, 3.866 ± 0.49, and 3.997 ± 0.49 cm, respectively; P=0.286), inter-trigonal diameter (2.88 ± 0.59, 2.89 ± 0.58, 2.89 ± 0.58, and 2.93 ± 0.60 cm, respectively; P=0.982), inter-commissural diameter (3.52 ± 0.38, 3.519 ± 0.36, 3.509 ± 0.35, and 3.526 ± 0.37 cm, respectively; P=0.999), 3D saddle-shaped annulus area (11.336 ± 2.26, 11.346 ± 2.27, 11.599 ± 2.3, and 12.031 ± 2.41 cm², respectively; P=0.714), annulus height (1.135 ± 0.24, 1.154 ± 0.25, 1.164 ± 0.24, and 1.148 ± 0.24 cm, respectively; P=0.981), aorto-mitral angle (105.64 ± 11.7, 104.62 ± 11, 103.8 ± 9.4, and 104.9 ± 10.40, respectively; P=0.949), and saddling (0.322 ± 0.06, 0.328 ± 0.06, 0.33 ± 0.06, and 0.326 ± 0.07, respectively; P=0.231). Post-operative comparisons revealed a notable _yet not statistically significant_ increase in the intercommissural and intertrigonal diameters in the mid systolic phase after myectomy that may be related to the relief of the obstruction. However, no statistically significant changes in MA dynamics throughout the four phases of the cardiac cycle regarding the AP diameter (P=0.939, 0.914, 0.965, and 0.505, respectively), inter-trigonal diameter (P=0.709, 0.701, 0.797, and 0.710, respectively), inter-commissural diameter (P=0.597, 0.990, 0.396, and 0.328, respectively), 3D saddle-shaped annulus area (P=0.854, 0.828, 0.880, and 0.619, respectively), annulus height (P=0.344, 0.318, 0.27, and 0.342, respectively), aorto-mitral angle (P=0.756, 0.702, 0.320, and 0.255, respectively), and saddling (P=0.1, 0.2, 0.062, and 0.067, respectively). Conclusion In HOCM patients, MA exhibits reduced dynamic motion, with a notable loss of normal systolic AP contraction and saddling. Immediate postoperative assessments did not demonstrate significant improvements in MA dynamics. Therefore, further longitudinal studies are necessary to assess long-term changes in MA dynamics due to LV remodeling following septal myectomy procedures.

Complications in transesophageal echocardiography: a prospective observational study.

Abstract Background Transesophageal echocardiography (TEE) is a routine examination that serves to answer various clinical questions. Due to the nature of the procedure, mechanical complications of the probe as well as complications due to administered sedation are rare but possible. Previous investigations have particularly focused on complications in long-lasting intraoperative TEE and TEE in critically ill patients in the intensive care setting. Little data exists on complications of TEE in non-critically ill patients. Methods From January until Juli 2024, consecutive patients with indication for TEE were included at our tertiary university center for this prospective observational study. Critically ill patients were not included. The patients were divided into a high-risk cohort (received oral anticoagulation on the day of the procedure, known esophageal varices) and a low-riskcohort (all other patients). A questionnaire investigating complications was performed via telephone interview 1-4 weeks after the examination. Results A total of 101 patients (54% male) with a mean age of 66 years (range 26-86) were included in this preliminary analysis. Most common indication for TEE was to exclude intracardiac thrombi before ablation therapy (32%) or cardioversion (18%), evaluation of valvular heart disease (32%), search for source of embolism (9%), and suspicion for endocarditis (6%).Mean time of examination was 5 minutes and 49 seconds. Sixty-four patients (63%) were in the low-risk cohort, thirty-two patients (32%) were in the high-risk cohort. No major complications occurred. A total of 25% of patients reported slight discomfort of the throat lasting for 1-2 days. A total of 11% reported bloody tinged sputum and/or coughing for 1-2 days. Two patients consulted their general practitioner due to these symptoms. Conclusion No serious complication occurred in this prospective investigation. However, discomfort of the throat for a few days after examination was frequent and even resulted in further medical consultations at the general practitioner. This needs to be addressed in the pre-examination consultation.

Berry syndrome, a rare congenital cardiac structural abnormality with 1-stage surgical repair: A case report

Rationale: Berry syndrome is a complex congenital heart anomaly characterized by a combination of aortopulmonary window, interrupted aortic arch or hypoplastic aortic arch or coarctation of the aorta, anomalous origin of the right pulmonary artery, patent ductus arteriosus, and intact ventricular septum. It is an extremely rare condition, with approximately 100 reported cases to date. Patient concerns: In this article, we report a case of a 6-year-old girl with Berry syndrome who presented with significant ischemic and hypoxic symptoms. Diagnoses: Based on the patient’s medical history and examinations, a definitive diagnosis of Berry syndrome was established. Interventions: She underwent a 1-stage surgical treatment and had a successful discharge. The surgical process was aimed to preserve the growth potential of the aorta and pulmonary arteries while achieving unobstructed left ventricular outflow and continuity of the aortic arch, ensuring no shunting between the main pulmonary arteries. Outcomes: Intraoperative transesophageal echocardiography confirmed continuous flow through the aortic arch and no shunting between the MPA and the aorta.

Managing Recurrent Carbon Dioxide Embolism During Laparoscopic Hepatectomy With Transesophageal Echocardiography Guidance: A Case Report.

Carbon dioxide gas emboli is a potentially fatal complication that occurs more frequently during laparoscopic hepatectomy compared to other laparoscopic surgeries. The patient featured in this report had massive gas embolism confirmed by intraoperative transesophageal echocardiography (TEE) that were associated with episodes of severe hypoxemia, hemodynamic instability, and right ventricular failure requiring conversion to open hepatectomy. Abrupt abdominal decompression resulted in massive hemorrhage from a previously undetected defect in the middle hepatic vein. The report demonstrates the successful management of gas embolism during laparoscopic hepatectomy even with a significant delay in vascular repair and highlights the critical role of TEE.

Potential of right ventricular function assessment with echocardiography in transcatheter aortic valve replacement:

BackgroundRight ventricular (RV) function assessment by echocardiography can be challenging due to its complex morphology. Also, increasing use of sedation rather than general anesthesia for transfemoral approach transcatheter aortic valve replacement (TAVR) reduces the need for intraoperative transesophageal echocardiography (TEE). Recent clinical studies have demonstrated the importance of 3-dimensional (3D) echocardiography and a longitudinal strain for RV function assessment. In this study, we compared RV function echocardiographic assessment methodologies in TAVR and investigated its clinical utility.MethodsThis was a prospective, observational study of TAVR at a large academic hospital. Inclusion criteria were adult patients undergoing TAVR requiring intraoperative TEE between April 2023 and October 2023. Exclusion criteria include an absolute contraindication to TEE, a pacemaker, or suboptimal intraoperative echocardiography images. The primary goal is to assess the correlation of 3D RV ejection fraction (EF) with RV fraction area change (FAC), and tricuspid annular plane systolic excursion (TAPSE). The secondary goal is to assess the correlation of RV free wall longitudinal strain (FWLS) with any newly diagnosed postoperative ventricular arrhythmia, including complete atrioventricular block (CAVB) and left bundle branch block (LBBB).ResultsAmong 33 patients who underwent TAVR, 4 patients were excluded due to poor image quality, and 7 patients were excluded due to existing pacemaker. Thus, data for 22 patients were analyzed in this study. There was a good correlation between 3D RVEF and RV FAC (correlation coefficient 0.789. p = 0.0000482), but poor correlation between 3D RVEF and TAPSE (correlation coefficient 0.182. p = 0.444). Eight patients developed a new left or right BBB and CAVB postoperatively, and 3 patients required permanent pacemaker. Regression analysis of pre and post valve deployment showed RV free wall RVFWLS was each correlated with postoperative new BBB or CAVB (pre valve deployment: hazard ratio 1.272, 95% CI 1.075 to 1.505, p = 0.004981; post valve deployment: hazard ratio 1.134, 95% CI 1.001 to 1.286, p = 0.04846). No mortality was reported during the follow-up period, and no significant tricuspid regurgitation (more than moderate) was reported.Conclusion3D RVEF and RV FAC showed a good correlation. Intraoperative RVFWLS has the potential to predict postoperative new occurrence of BBB or CAVB.

Long-term experience of the modified David V re-implantation technique for valve-sparing aortic root replacement.

The modified David V technique is one of the valve-sparing aortic root replacement (V-SARR) techniques, which is an alternative to traditional composite valve graft root replacement techniques. We aimed to analyse our long-term experience with the modified David V re-implantation technique for the treatment of aortic root aneurysm and significant aortic valve insufficiency. From March 2009 to November 2021 the modified David V re-implantation technique, one of the V-SARR techniques, was performed on 48 patients in our centre. The results were analysed retrospectively. Two different-sized grafts were used in all patients. The grafts used in the proximal position were larger than the distal grafts. We performed both intra-operative and post-procedural transoesophageal echocardiography on each patient. All patients were followed by means of transthoracic echocardiography. The mean follow-up period was 5.7 ± 3.1 years. The mean age of this cohort was 56.3 ± 14.3 years (24-79) and the majority were men (75%). The mean aortic root diameter was 5.1 ± 0.6 cm. The mean diameter for the assending aorta was 5.4 ± 2.1 cm. The in-hospital mortality rate was 4.2% (n = 2). One patient needed aortic valve replacement in the early postoperative period. Two (4.2%) patients died in the early postoperative period and four (8.3%) died in the late postoperative period. Overall survival was 91 ± 4 and 86 ± 5% at one and five years, respectively. Aortic valve insufficiency was at moderate levels postoperatively. Freedom from moderate to severe residual aortic insufficiency was 89.6% at 10 years. None of the patients needed late re-operation of the aortic valve postoperatively. Freedom from valve re-operation was 100% at the end of the follow up. Our study shows that the David V technique is associated with excellent long-term durability, a remarkably low rate of valve-related complications, and it protects the re-implanted native aortic valve from a second operation. Additionally this technique could be safely implemented in patients with a bicuspid aortic valve and acute type A aortic dissection without leaflet deformity.

Multimodal transesophageal echocardiography in the surgical resection of patients with hepatocellular carcinoma and inferior vena cava tumor thrombus.

The incidence and mortality rate of hepatocellular carcinoma (HCC) are increasing globally. HCC with inferior vena cava tumor thrombus (HCCIVCTT) represents an advanced stage of the disease. Research suggests that for patients with advanced HCCIVCTT, liver resection combined with thrombectomy is a safe and feasible option that can provide moderate survival benefit. The aim of this study was to evaluate the application value of multimodal transesophageal echocardiography (TEE) in the perioperative period for patients with HCCIVCTT. TEE was used for routine intraoperative examination in 17 patients to determine the location and classification of tumor thrombi, guide the proper placement of the inferior vena cava occlusion band during surgery, and evaluate whether the tumor thrombus was completely removed postoperatively. Among the 17 patients with HCCIVCTT, tumor thrombi invaded the hepatic veins and extended into the inferior vena cava, with 3 cases of extension into the right atrium. The tumor thrombi varied in shape, size, and echogenicity, with high-velocity turbulent flow signals observed within the occluded vessels. There were 10 cases of type I, 4 cases of type II, and 3 cases of type III. Under the guidance of intraoperative TEE, preocclusion bands were successfully placed above the tumor thrombi in type I and II patients, with real-time dynamic monitoring showing no rupture or dislodgement of the thrombi, and postoperatively, the thrombi appeared to be completely removed. TEE plays an important role in the perioperative management of HCCIVCTT. It can aid in deterring the type of tumor thrombus, selecting the suitable surgical method, and postoperatively assessing the completeness of tumor thrombus removal.