Intraoperative Transesophageal Echocardiography Research Articles

Usefulness of intraoperative color three-dimensional transesophageal echocardiography for detecting treatable residual mitral regurgitation immediately after mitral valve repair.

Residual mitral regurgitation (MR) immediately after mitral valve (MV) repair is a risk factor for late reintervention. This study aimed to determine the feasibility of color 3-dimensional intraoperative transesophageal echocardiography (3D-IOTEE) for clarifying the mechanism of residual MR and its impact on the conversion rate to MV replacement (MVR). Among 767 patients who underwent MV repair at our institute, 92 consecutive patients in whom an immediate second cardiopulmonary bypass (CPB) was performed due to MV repair for residual MR were evaluated. The patients were divided into the re-repair group [i.e. those in whom repair required additional procedures, n = 77 (83.7 %)] and the MVR group [i.e. patients who underwent MVR alone, n = 15 (16.3 %)]. All patients underwent 3D-IOTEE to evaluate the mechanisms of residual MR. The pathomechanisms were classified into the following five categories: Category 1, inter-scallop malcoaptation; Category 2, suture dehiscence; Category 3, prolapse; Category 4, systolic anterior motion of the MV; and Category 5, tethering. Clinical background and outcomes were compared between the two groups based on the five categories. The rate of MVR conversion by etiology of residual MR after the first MV repair was 68.8 % (n = 11/16) in Category 1; 0 % (n = 0/22) in Category 2; 2.4 % (n = 1/41) in Category 3; 20 % (n = 2/10) in Category 4; and 33.3 % (n = 1/3) in Category 5. Among the 63 patients with Category 2 and 3 etiologies, 62 patients had complete MV re-repair with additional procedures [Category 2, 100 % (n = 22/22); Category 3, 97.6 % (n = 40/41)]. Meanwhile, MVR was performed owing to difficulty in MV repair after the second CPB in 11/16 patients (68.8 %) with Category 1 etiology. In the assessment of MR, 3D-IOTEE is useful for lesion localization and determining the origin and severity of MR, which are key factors in selecting the optimal surgical approach in patients undergoing re-repair.

Central Venous Catheter Migration Into Pleura Diagnosed by Transesophageal Echocardiography.

Central venous catheter (CVC) tip migration is a well reported delayed complication of these vascular access devices with left-sided internal jugular or subclavian vein placement being the primary risk factor for this complication. We report a case of left internal jugular CVC migration and its diagnosis made by the heretofore unreported use of intraoperative transesophageal echocardiography in this context. Moreover, we describe risk factors for CVC migration along with its diagnosis and management.

Right-to-left-shunts in patients scheduled for neurosurgical intervention in semi-sitting position – a literature review based on two case scenarios

BackgroundNeurosurgery performed in the semi-sitting position provides advantages for certain procedures. However, this approach is associated with potential complications, particularly venous air embolism. Due to typically negative venous pressure at the wound site, air can be drawn into the veins. This risk is especially high in patients presenting with an intra- or extracardiac right-to-left-shunt. Transoesophageal echocardiography can be used to detect a patent foramen ovale or other possible pulmonary-systemic shunt before placing the patient in the sitting position.Case presentationIn this report, we present two young patients undergoing scheduled microsurgical vestibular schwannoma removal in a semi-sitting position who were diagnosed with congenital heart defects during routine perioperative assessment to detect possible intracardiac right-to-left shunts, using pre- and intraoperative transesophageal echocardiography (TEE) and additionally conducting an agitated saline bubble study under Valsalva manoeuvre. Patient A was diagnosed with a persistent left superior vena cava and Patient B with an unroofed coronary sinus (UCS). These findings confronted the anesthesiological and surgical teams with difficult individual decisions regarding further perioperative management.ConclusionsPerioperative transesophageal echocardiography is a diagnostic tool to both detect intraoperative position-related air embolisms and to rule out intracardiac right-to-left shunts, e.g. a patent foramen ovale, in order to decide for or against a (semi-)sitting position. Depending on the surgical circumstances a semi-sitting positioning of patients presenting with an intracardiac right-to-left-shunt, e.g. a PFO, can be feasible in individual cases if there is an implemented therapeutic algorithm to immediately terminate significant venous air entry. However, since certain other intra- or extracardiac right-to-left-shunts, such as here presented PLSVC or UCS, are rare, there is no definitive way of estimating the amount of entered air through detected shunts or anomalous vessels. Therefore, it is recommended to avoid a (semi-)sitting position in favour of a lateral or prone position for a patient undergoing intracranial surgery, once the perioperative TEE shows air bubbles in the left atrium or ventricle whose origins cannot be defined solely through TEE for certain in order to ensure patient safety by minimizing the risk of intraoperative paradoxical air embolisms.

Feasibility of Intraoperative 3-Dimensional Speckle-Tracking Echocardiography in Patients Undergoing Surgical Aortic Valve Replacement: A Prospective Observational Pilot Study

To assess the feasibility of intraoperative 3-dimensional speckle-tracking-based myocardial deformation analysis for evaluation of twist, torsion, and strain using speckle tracking, and to investigate the immediate changes in these parameters after aortic valve replacement. Prospective observational study SETTING: Single-center study at a tertiary academic cardiac center PARTICIPANTS: Forty-nine patients undergoing minimally invasive surgical aortic valve replacement INTERVENTIONS: Acquisition of full-volume images of the left ventricle after induction of anesthesia and at the end of surgery using transesophageal echocardiography (TEE), and analysis of the datasets using 3D speckle-tracking-based myocardial deformation analysis (Tomtec Arena). Of the 49 complete volume datasets, 30 (61%) had quality sufficient for speckle tracking. No significant differences were observed between the examinations in terms of ejection fraction (EF) (p = 0.177), global longitudinal strain (GLS) (p = 0.276), circumferential strain (CS) (p = 0.238), twist (p = 0.970), or torsion (p = 0.417). 3D speckle-tracking-based myocardial deformation analysis from intraoperative TEE datasets is feasible in >60% of patients with aortic valve stenosis. There were no statistically significant differences in GLS, CS, twist, or torsion between the intraoperative examinations.

Correlations between intraoperative and postoperative echocardiographic measurements in patients undergoing aortic bioprosthetic valve replacement: a prospective observational study.

Patient-prosthesis mismatch (PPM) should be avoided during surgical aortic valve replacement because PPM would worsen the mortality and morbidity. Diagnosis of PPM could be made using various parameters measured by intraoperative transesophageal echocardiography. However, few studies have examined which parameters correlate most accurately between intraoperative and postoperative values. This single-center prospective observational study analyzed 46 patients who underwent surgical aortic valve replacement (SAVR). Echocardiography was performed at the following 3-time points: preoperatively, intraoperatively, and 1month postoperatively. The correlation between intraoperative and postoperative measurement values, including peak velocity (PV), mean pressure gradient (MPG), effective orifice area (EOA), and effective orifice area index (EOAI), were assessed using Pearson's correlation coefficient. Moreover, to evaluate whether a multivariable linear regression model with intraoperative and postoperative stroke volume added as an explanatory variable improves the correlation, the multiple correlation coefficients were calculated. PV, MPG, EOA, and EOAI measured intraoperatively and 1month postoperatively were significantly correlated. The r values of each measurement were 0.35, 0.344, 0.411 and 0.323, respectively. The multivariable linear regression model showed that the multiple correlation coefficients for MG and EOA were 0.491 and 0.663, respectively. Intraoperative and postoperative PV, MPG, EOA, and EOAI were significantly correlated in patients undergoing SAVR with a bioprosthetic valve. The r value for EOA was 0.441, the largest among the measured values. Adjustment for stroke volume improved the strength of the correlation. Intraoperative evaluation of prosthetic valve function was considered most appropriate using EOA. University Hospital Medical Information Network Clinical Trials Registry, registration number UMIN000046164, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052695 .

Application of a simplified transesophageal echocardiography examination sequence in high-risk cardiac surgery

BackgroundIn cardiac surgical procedures, patients carrying high-risk profiles are prone to encompass complicated cardiopulmonary bypass (CPB) separation. Intraoperative transesophageal echocardiography (TEE), a readily available tool, is utilized to detect cardiac structural and functional pathologies as well as to facilitate clinical management of CPB separation, especially in the episodes of hemodynamic compromise. However, the conventional TEE examination, always performed in a liberal fashion without any restriction of view acquisition, is relatively time-consuming; there appear its flaws in the context of critically severe status. We therefore developed the perioperative rescue transesophageal echocardiography (PReTEE), a simplified three-view TEE protocol consisting of midesophageal four chamber, midesophageal left ventricular long axis, and transgastric short axis.MethodsThis is a single-center and randomized controlled trial which will be implemented in Peking Union Medical College Hospital, Beijing, China. A total of 46 TEE scans are schemed to be performed by 6 operators participating in and randomly assigned to either the PReTEE or the conventional TEE group. This study is purposed to investigate whether the efficiency of discriminating leading causes of difficult CPB wean-off can be significantly improved via an abbreviated sequence of TEE views. The primary outcome of interest is the difference between the groups of PReTEE and the conventional TEE in the successful discrimination of etiologies in specified 120 s. Cox proportional hazards model will be further employed to calculate the outcome difference.DiscussionThe estimated results of this trial are oriented at verifying whether a simplified TEE exam sequence can improve the efficiency of etiologies discrimination during CPB separation in cardiac surgery.Trial registrationClinicalTrials.gov NCT05960552. Registered on 6 July 2023.

Measurements of the Interventricular Septum and Mitral Leaflet Length in Hypertrophic Cardiomyopathy Patients Who Underwent Surgical Myectomy: A Prospective Comparative Multimodality Imaging Study

Transesophageal echocardiography (TEE) plays an important role for real-time procedural guidance during surgical myectomy (SM) for hypertrophic obstructive cardiomyopathy (HOCM). We aimed to compare a) IVS thickness using two (2D) and three-dimensional (3D) intraoperative TEE and pre-operative cardiac magnetic resonance (CMR) and b) mitral valve (MV) leaflet length using 2D, 3D TEE, automatic quantification of mitral valve (AMVQ) and pre-operative CMR. We prospectively studied 50 HOCM patients (age 59 ±12, 44% men) undergoing SM during 2018-2019. Maximal basal, mid, and distal anteroseptum (AS) and inferoseptum (IS) were measured by multiplanar 3D reconstruction on TEE and by short axis imaging on pre-operative CMR, and classified as mild (≤18mm), moderate (18-25mm) or severe (≥ 25 mm) groups, based on AS and IS thickness on CMR. MV leaflet lengths were evaluated by pre-operative CMR and intra-procedural 2D TEE, zoom 3D TEE and AMVQ (EchoPAC, General Electric, Wi). There was a moderate correlation between AS and IS thickness on 3D TEE and CMR (R2=0.46, p<0.01 and R2=0.41, p<0.01 respectively), with 3D TEE showing an average overestimation of 3.8 and 4.7 mm vs. CMR. 3D TEE over-estimated 14 (56%) patients with mild thickness as moderate, and 5 (22%) patients with moderate thickness as severe. Assuming 3D TEE as the gold standard, the closest correlation for anterior mitral leaflet length was with CMR (average overestimation by CMR of 0.5 mm [root mean square deviation or RMSE% 17]), intermediate correlation with 2D TEE (average deviation of 0.6 mm [RMSE%:21]) and no correlation with AMVQ (average deviation of 0.7mm [RMSE% 24]). In conclusion, 3D TEE overestimates IVS thickness vs. CMR in HOCM patients undergoing SM, with greater discrepancy in those with thinner IVS. There are significant differences in MV lengths measured using different imaging techniques.

Outcomes, mortality risk factors, and functional status post-Norwood: A single-center study

BackgroundThe Norwood operation (NO) for infants with univentricular physiology has high interstage mortality. This study evaluated outcomes and risk factors for mortality following NO. MethodsRetrospective single-center study of patients undergoing NO from 2010 to 2020. Analysis used appropriate statistics. ResultsOf 269 patients undergoing NO, 213 (79.2 %) survived to discharge. Non-survivors had longer bypass times, delayed sternal closure, required nitric oxide, higher vasoactive scores, required post-operative catheterization, Extracorporeal Life Support (ECLS), and longer ventilation (p < 0.05). Logistic regression showed moderate-severe atrioventricular valve regurgitation on intraoperative TEE (OR 2.6), requiring nitric oxide (OR 2.63), delayed sternal closure (OR 2.94), post-operative catheterization (OR 10.48), and ECLS (OR 14.54) increased mortality odds (p < 0.05). Multivariable analysis confirmed catheterization (aOR 10.48) and ECLS (aOR 14.54) as significant predictors. Of survivors, 26 (12.3 %) developed new morbidity, 9 (4.2 %) had unfavorable outcomes. Functional status improved from 6.0 to 8.04, mainly in feeding and respiratory domains (p < 0.0001). ConclusionsNorwood survival was 79.2 %. Requiring post-operative catheterization and ECLS significantly increased mortality risk. Multicenter evaluation of these modifiable risk factors is needed to improve outcomes in this high-risk population.

366 A Case Study: Application of Personalised External Aortic Root Support to Overcome a Failing Ross Procedure

Abstract Aortic root aneurysms are traditionally treated by aortic root replacement surgery alone or in combination with aortic valve replacement in a Modified Bentall procedure. We present a novel surgical approach using a Personalised External Aortic Root Support (PEARS) in the management of an aortic root aneurysm in a 24-year-old male, initially presenting in infancy with mixed aortic valve disease who underwent a free root Ross procedure in 2010 aged 11. Follow-up cardiac magnetic resonance imaging and transthoracic echocardiography showed mild aortic and pulmonary valve regurgitation with aortic root dilatation (51mm). In 2022, Computerised tomography (CT) exhibited dilation of the Sinus of Valsalva (43mm) and ascending aorta (56 mm). MDT review deemed redo valve-sparing root replacement appropriate as the ascending aorta was &amp;gt;55mm with an approximate 8mm increase over three years. As the young patient wished to avoid warfarinisation and the autograft valve maintained good function, a reduction PEARS was considered. In September 2023, a reduced aortic PEARS graft (80% reduction) was implemented along with a redo of the right ventricle to pulmonary artery conduit. Whilst applying the PEARS it was noted that there was a retroaortic circumflex artery, care was taken to mobilise this aberrant vessel to avoid compression by the graft. Cardiopulmonary bypass and cross-clamp times were 180 and 116 minutes respectively. Intraoperative transoesophageal echocardiography confirmed good bi-ventricular function with no pulmonary regurgitation additionally on postoperative CT the aortic diameter was 38mm. In conclusion, application of a reduction PEARS is a potential alternative to a valve-sparing aortic root replacement method in young patients.

AngioVac Procedures: Integration of cardiac surgeon and anesthesiologist-led transesophageal echocardiography: A preliminary report

IntroductionThe AngioVac system is a novel, minimally invasive, endovascular technique used to evacuate intravascular or intracardiac vegetation or thrombus. Although most AngioVac procedures are currently performed by interventionalists, this innovative procedure has been gaining attention among the surgical and anesthesia communities. MethodsWe retrospectively reviewed all patients who underwent the AngioVac procedure performed by a cardiac surgeon between August 2019 and December 2022. Fellowship-trained cardiac anesthesiologists operated TEE to navigate the AngioVac cannula during the procedure. The stored TEE images were retrospectively reviewed and independently analyzed by two cardiac anesthesiologists with specific focus on TEE-guided navigation of the AngioVac cannula towards the aspiration target. ResultsEleven patients underwent the AngioVac procedure during the study period. In nine cases, the majority of the vegetation or thrombus was successfully aspirated. In two cases, incomplete aspiration was attributed to the mass burden being too large, firm, and chronic in etiology. Worsening tricuspid regurgitation (TR) was identified in three of the 11 cases. Intraoperative TEE provided the cardiac surgeon with simultaneous display of the AngioVac cannula shaft, its tip, and aspiration target, as well as real-time assessment of TR, facilitating the minute movements essential for successful outcomes. ConclusionsThis study details our experience and the effectiveness of the AngioVac system for treating soft, intracardiac vegetation or thrombus in a minimally invasive manner. Experienced cardiac anesthesiologists have the skillsets and knowledge to provide optimal live TEE imaging necessary for successful maneuvering of the AngioVac cannula.

A Case of Transmural Lipoma of the Right Atrium

Primary cardiac tumors are a relatively rare disease. About 75% of primary cardiac tumors are benign. The most common histological type is myxoma, followed by cardiac fibroma, lipoma, etc. We report a case of a 53-year-old female patient admitted to the hospital due to &amp;quot;repeated palpitations and tightness of breath for 5 years, worsened for 2 days.&amp;quot; Preoperative transthoracic echocardiography revealed a hypoechoic mass approximately 3.1 cm x 3.0 cm in size within the right atrium, suggesting an intracardiac mass: nature? Chest computed tomography (CT) indicated a fat-density nodule within the right atrium, with a larger cross-sectional size of about 3.0 cm x 2.5 cm, suggesting a lipoma. The patient underwent excision of the right atrial mass under cardiopulmonary bypass. Intraoperative transesophageal echocardiography (TEE) revealed a mass within the right atrium, closely connected to the atrial wall, with no signs of tricuspid valve obstruction. Exploration during surgery revealed a yellow, smooth-surfaced mass approximately 3.0 cm x 3.0 cm in size, penetrating the right atrial wall, from which the mass and an additional 2mm margin of the right atrial wall were completely excised. A suitable-sized bovine pericardial patch was used to repair the defect in the right atrial wall. Postoperative TEE showed the disappearance of the right atrial mass. The postoperative pathological result indicated a lipoma. Cardiac lipoma is a rare benign primary cardiac tumor. The common sites of occurrence of this tumor are the right atrium, left ventricle, and pericardium. Based on their location, cardiac lipomas can be divided into three types: subepicardial, intramyocardial, and subendocardial lipomas, with subendocardial lipomas being the most common, accounting for over 50% of primary cardiac lipomas. Clinical symptoms largely depend on the size and growth location of the tumor, and it is generally believed that most cardiac lipomas are asymptomatic. Symptomatic lipomas can be treated with curative surgical excision. Transmural lipomas of the right atrium are relatively rare, and such lipomas may affect adjacent structures both inside and outside the atrial wall. Although the lipoma in this case did not significantly affect valve function or blood flow, the patient experienced repeated symptoms of palpitations and tightness of breath. Despite being a benign tumor, the lipoma in this case exhibited transmural growth within the right atrium, showing a certain degree of invasiveness, making surgical excision an effective treatment method.

Iatrogenic non-coronary leaflet perforation as a complication after robotic mitral valve repair

Iatrogenic aortic regurgitation secondary to leaflet injury is a rare complication of mitral valve surgery. For the first time, we report a patient who had progressive aortic regurgitation due to non-coronary leaflet perforation after robotic mitral valve repair and required aortic valve repair 18 months after this initial surgery. As in our case, aortic regurgitation after mitral valve surgery may remain undiagnosed on intraoperative transesophageal echocardiography or undetected until the patient’s discharge due to gradual enlargement of very small perforations over the postoperative course.

Uncommon presentations of type A quadricuspid aortic valve in the Septuagenarian

BackgroundQuadricuspid aortic valve (QAV) is a rare congenital anomaly characterized by the presence of four cusps instead of the usual three. It is estimated to occur in less than 0.05% of the population, with Type A (four equal-sized leaflets) accounting for roughly 30% of QAV subtypes. Based on limited clinical series, the usual presentation is progressive aortic valve regurgitation (AR) with symptoms occurring in the fourth to sixth decade of life. Severe aortic valve stenosis (AS) and acute AR are very uncommon.Case presentationWe describe two cases of Type A QAV in patients who remained asymptomatic until their seventies with very uncommon presentations: one with severe AS and one with acute, severe AR and flail leaflet. In Case A, a 72-year-old patient with history of moderate AS presents to clinic with progressive exertional dyspnea. During work-up for transcatheter vs. surgical replacement pre-operative computed tomography angiogram (CTA) reveals a quadricuspid aortic valve with severe AS, and the patient undergoes surgical aortic valve replacement. Pre-discharge transthoracic echocardiography (TTE) shows good prosthetic valve function with no gradient or regurgitation. In Case B, a 76-year-old patient is intubated upon arrival to the hospital for acute desaturation, found to have wide open AR on catheterization, and transferred for emergent intervention. Intraoperative TEE reveals QAV with flail leaflet and severe AR. Repair is considered but deferred ultimately due to emergent nature. Post-operative TTE demonstrates good prosthetic valve function with no regurgitation and normal biventricular function.ConclusionsQAV can present as progressive severe AS and acute AR, with symptoms first occurring in the seventh decade of life. The optimal treatment for QAV remains uncertain. Although aortic valve repair or transcatheter option may be feasible in some patients, aortic valve replacement remains a tenable option.

Challenges Regarding the Value of Routine Perioperative Transesophageal Echocardiography in Mitral Valve Surgery.

Transesophageal echocardiography (TEE) is considered an indispensable tool for perioperative evaluation in mitral valve (MV) surgery. TEE is routinely performed by anesthesiologists competent in TEE; however, in certain situations, the expertise of a senior cardiologist specializing in TEE is required, which incurs additional costs. The purpose of this study is to determine the indications for specialized perioperative TEE based on its utility and the correlation between intraoperative TEE diagnoses and surgical findings, compared with routine TEE performed by an anesthesiologist. We conducted a three-year prospective study involving 499 patients with MV disease undergoing cardiac surgery. Patients underwent intraoperative and early postoperative TEE and at least one other perioperative echocardiographic evaluation. A computer application was dedicated to calculating the utility of each type of specialized TEE indication depending on the type of MV disease and surgical intervention. The indications for performing specialized perioperative TEE identified in our study can be categorized into three groups: standard, relative, and uncertain. Standard indications for specialized intraoperative TEE included establishing the mechanism and severity of MR (mitral regurgitation), guiding MV valvuloplasty, diagnosing associated valvular lesions post MVR (mitral valve replacement), routine evaluations in triple-valve replacements, and identifying the causes of acute, intraoperative, life-threatening hemodynamic dysfunction. Early postoperative specialized TEE in the intensive care unit (ICU) is indicated for the suspicion of pericardial or pleural effusions, establishing the etiology of acute hemodynamic dysfunction, and assessing the severity of residual MR post valvuloplasty. Perioperative TEE in MV surgery can generally be performed by a trained anesthesiologist for standard measurements and evaluations. In certain cases, however, a specialized TEE examination by a trained senior cardiologist is necessary, as it is indirectly associated with a decrease in postoperative complications and early postoperative mortality rates, as well as an improvement in immediate and long-term prognoses. Also, for standard indications, the correlation between surgical and TEE diagnoses was superior when specialized TEE was used.

ECG and Atrial Appendage Doppler Discordance Is Common in Patients Undergoing Cardiac Surgery: Prospective Study

BackgroundPatients with atrial fibrillation (AF) remain at increased risk of thromboembolism despite apparent maintenance of sinus rhythm with the cause often attributed to periods of asymptomatic AF. Atrial mechanical discordance, with the body of the left atrium (LA) in sinus rhythm and the left atrial appendage (LAA) in AF may also be a contributor. ObjectivesThe purpose of this study was to assess the frequency of electrocardiogram (ECG) rhythm and LAA and/right atrial appendage (RAA) Doppler ejection phenotype (transesophageal echocardiography [TEE]) discordance in patients undergoing cardiac surgery. MethodsA total of 124 patients undergoing coronary artery bypass graft (CABG), CABG and valve surgery, or isolated valve repair or replacement (valve ± CABG) were prospectively studied. Intraoperative surface ECG rhythm strip and TEE were performed before cardiopulmonary bypass. The ECG and TEE LAA/RAA Doppler spectrum were independently classified as sinus or AF. ResultsOf 107 patients (age 65 ± 12 years; 31% female; 65% CABG, 31% valve ± CABG) without a history of AF, 39 (36%) had ECG and LAA and/or RAA discordance (ECG/LAA Doppler discordance, n = 12 [11%]; ECG/RAA Doppler discordance, n = 35 [33%]). There was no significant difference between concordant and discordant groups with regard to age, gender, history of hypertension, diabetes, heart failure, or stroke (all P > 0.05). ConclusionsA large minority of patients without a history of AF undergoing cardiac surgery have ECG/atrial appendage Doppler discordance, a setting that may promote thromboembolism in non-anticoagulated patients. Clinical parameters do not identify patients at increased risk for discordance.

HOW TO MANAGE MITRAL VALVE POSTERIOR LEAFLET HYPOPLASIA

Abstract Background Mitral valve posterior leaflet hypoplasia is a relatively rare and often congenital anatomical malformation. In this condition, achieving a good and durable mitral valve repair still represents a challenge for surgeons. Methods We present the case of a 43 years old man presenting with exertional dyspnoea due to severe mitral regurgitation. Transthoracic and transesophageal echocardiograms revealed a severe hypoplasia of the posterior mitral leaflet with an significant prolapse of the anterior leaflet (particularly A2–A3), which determined massive regurgitation. The anteroposterior annular diameter was 38 mm with a 4 mm mitro–anular disjunction, left ventricular telediastolic diameter was 59 mm and ejection fraction 68%. No other cardiac malformations were evident; in particular tricuspid valve was normal. Results Surgery was performed through a right mini–thoracotomy with femoral cannulation, using three–dimensional video–assisted technology. The mitral valve was approached from the left atrium, behind the interatrial groove. Surgical inspection revealed a severely hypoplasic posterior leaflet and a wide anterior leaflet prolapsing near the postero–medial commissure (A2–A3) (Figure 1). Based on our previous experience, we decided to repair the valve performing a posterior para–commissural edge–to–edge (A3–P3) followed by an atypical annuloplasty using a bovine pericardium band, shaped on a 40 mm ring sizer, only in the postero–medial portion of the mitral annulus (Figure 2). On the hydrostatic test, the valve showed a satisfactory continence, that was confirmed on the intraoperative TEE. Postoperative course was uneventful and the patient was discharged home on postoperative day 7. Transthoracic echocardiography at discharge showed a good result of the mitral valve repair with no residual regurgitation a medium gradient across the mitral valve of 3 mmHg. Conclusions In our experience, reductive annuloplasty isn’t the optimal treatment for hypoplasic mitral valve posterior leaflet because it lowers the already small posterior leaflet, thus reducing the coaptation surface. To avoid this, we introduced this technique that improved our surgical outcomes.

TEE-Guided Cardiac Surgery in a Child with Mitral Valve Prolapse, Hyperthyroidism and Myasthenia Gravis: A Case Report

Intraoperative transesophageal echocardiography is used to more accurately assess a patient&amp;apos;s cardiac condition and is important for the guidance of cardiac surgery. This case reports a pediatric cardiac surgery performed under TEE guidance in a patient with multiple complications. A 5-year-old child presented with diarrhea as the first symptom. At the age of 2 years, she was admitted to the hospital with ptosis of the right upper eyelid, morning lightness and evening heaviness, hand tremor, and the presence of a murmur in the mid to late stages of cardiac systole on auscultation. She was diagnosed with mitral valve prolapse and myasthenia gravis, which resolved with treatment. Subsequently, she was diagnosed with hyperthyroidism due to obvious protrusion of the eyeballs, and was admitted to the hospital for heart valve surgery after her thyroid function was controlled. Intraoperative TEE suggested mitral valve prolapse combined with embolization of the P2 region. In the complex case of this child, the suture points during mitral valvuloplasty and the scar tissue caused by the mitral valvuloplasty annulus may limit the growth of the annulus as well as the leaflet motion. Therefore, it was recommended that the surgeon perform mitral valve extension to maximize the prognosis. TEE herein guided the cardiac surgical decision making to maximize the prognosis of the child.

Intraoperative Echocardiography: Guide to Decision-Making.

This review aims to provide a concise overview of key recommendations, with a specific focus on common challenges faced by intraoperative echocardiographers when dealing with frequently encountered valvular pathologies and mechanical circulatory support. It offers valuable insights for medical practitioners in this field. The American Society of Echocardiography (ASE) and the American College of Cardiology/American Heart Association (ACC/AHA) have released updated comprehensive guidelines for the use of transesophageal echocardiography (TEE) for the assessment of cardiac structures and implanted devices to help guide intraoperative decision-making. Transesophageal echocardiography (TEE) is a regularly employed intraoperative diagnostic and monitoring tool, offering various modalities for the rapid evaluation of valvular and aortic pathology, hemodynamic disturbances, and cardiac function. It is particularly valuable in assessing and placing mechanical circulatory support (MCS) devices, providing views often challenging to obtain through transthoracic echocardiography. Additionally, intraoperative TEE can be used for decision-making in patients with valvular disease allowing incorporation of patient-specific and situational factors. Echocardiographers can employ this information in real-time to help guide surgical treatment selection such as repair, replacement, or deferral of intervention.

The Use of Pulmonary Artery Catheters and Echocardiography in the Cardiac Surgery Setting: A Nationwide Italian Survey

Wide variations exist in the use of pulmonary artery catheters (PACs) and echocardiography in the field of cardiac surgery. A national survey promoted by the Italian Association of Cardio-Thoracic Anesthesiologists and Intensive Care was conducted. The study occurred in Italian cardiac surgery centers (n = 71). Anesthesiologists-intensivists were enrolled. Anonymous questionnaires were used to investigate the use of PACs and echocardiography in the operating room (OR) and intensive care unit (ICU). A total of 257 respondents (32.2% response rate) from 59 centers (83.1% response rate) participated. Use of PACs seems less common in ORs (median insertion in 20% [5-70] of patients), with slightly higher use in ICUs; in about half of cases, it was the continuous cardiac output monitoring system of choice. Almost two-thirds of respondents recently inserted at least one PAC within a few hours of ICU admission, despite its need being largely preoperatively predictable. Protocols regulating PAC insertion were reported by 25.3% and 28% of respondents (OR and ICU, respectively). Transesophageal echocardiography (TEE) was performed intraoperatively in >75% of patients by 86.4% of respondents; only 23.7% stated that intraoperative TEE relied on anesthesiologists. Tissue Doppler and/or 3D imaging were widely available (87.4% and 82%, respectively), but only 37.8% and 24.3% of respondents self-declared skills in these modalities, respectively; 77.1% of respondents had no echocardiography certification, nor were pursuing certification (various reasons); 40.9% had not attended recent echocardiography courses. Lower PAC use was associated with university hospitals (OR: p = 0.014, ICU: p = 0.032) and with lower interventions/year (OR: p = 0.023). Higher independence in performing TEE was reported in university hospitals (OR: p < 0.001; ICU: p = 0.006), centers with higher interventions/year (OR: p = 0.019), and by respondents with less experience in cardiology (ICU: p = 0.046). Variability in the use of PACs and echocardiography was found. Protocols regulating the use of PACs seem infrequent. University centers use PACs less and have greater skills in TEE. Training and certifications in echocardiography should be encouraged.

Experience of Morphologic Left Ventricle Training in Congenitally Corrected Transposition of the Great Arteries in Children: Evaluation of the Operation Results

The aim. To evaluate the efficacy of morphologic left ventricle (mLV) training through pulmonary artery banding (PAB) in pediatric patients with congenitally corrected transposition of the great arteries.&#x0D; Materials and methods. From 2003 to 2023, 12 patients underwent PAB for mLV training at the Ukrainian Children`s Cardiac Center. The mean age of the patients was 30.3 ± 25.1 months, the mean weight was 11.6 ± 5.2 kg. Hemodynamic parameters were assessed to determine the size of the band applied to the pulmonary artery (PA) trunk during the operation. Intraoperative transesophageal echocardiography was performed in 6 patients. Transthoracic echocardiography (TTE) was performed in the early postoperative period. In the remote period, all the patients underwent TTE and X-ray angiography.&#x0D; Results. During PAB, the mLV pressure averaged 58 ± 12.6% (from 40% to 80%) of the systemic arterial pressure. PAB dilatation was required for one patient in the early postoperative period (postoperative day 2) because of significant hemodynamic changes. In the early postoperative period, the maximum gradient across PA measured by TTE averaged 39.3 ± 10.0 mm Hg (from 25 to 60 mm Hg). There was no hospital mortality.&#x0D; The follow-up period averaged 47.2 ± 26.0 months (8 to 113 months). In the long-term observation period, 2 patients (16.6%) died, one 8 months and the other 5 years after the operation. The double switch operation was performed in 6 patients, on average, 48.2 ± 6.9 months after PAB. According to angiography, the mLV pressure before the double switch operation was 90.2 ± 11.6% of that in the systemic right ventricle. The end-diastolic pressure in the mLV averaged 14 ± 4.1 mm Hg. The peak pressure gradient across the PA measured by echo was 81.3 ± 28.8 mm Hg. The mLV mass index averaged 62.9 ± 8.8 g/m2, the mLV ejection fraction averaged 61.2 ± 2.9%. Overall radiographic and echocardiographic data in these patients indicated that mLV is trained and capable of performing the role of a systemic ventricle after anatomical correction.&#x0D; Conclusions. PA banding as a method of mLV training can be used in patients with congenitally corrected transposition of the great arteries with intact ventricular septum, restrictive ventricular septal defects and severe tricuspid regurgitation.&#x0D; To evaluate the effectiveness of PAB for mLV training, a multimodal diagnostic approach is used, including non-invasive and invasive methods such as TTE, transesophageal echocardiography, and cardiac catheterization. The optimal age for PAB in patients of this group for the purpose of training the LV was on average 2-2.5 years.