Midesophageal View Research Articles

Efficacy and safety of pulmonary artery catheterization with combined transesophageal echocardiography and pressure waveform: A prospective observational study

ObjectiveThis study investigated whether pulmonary artery catheter placement method with combined transesophageal echocardiography and pressure waveform measurement improve the placement success rate within 5 min and reduce the incidence of arrhythmia during pulmonary artery catheter placement compared to conventional pulmonary artery catheter placement with pressure waveform measurement only. MethodsThis single center prospective observational study included 129 patients scheduled for cardiac surgery. Patients were divided into two groups. In the conventional group, the pulmonary artery catheter was placed by monitoring the pressure waveform and the length of placement; in the combination group, not only were the pressure waveform and the length monitored but also the following transesophageal echocardiography images: “mid esophageal bicaval view,” " mid esophageal modified bicaval view,” a mirror image of “mid esophageal 4 chamber view,” “mid esophageal right ventricular inflow-outflow view,” and “mid esophageal ascending aortic short axis view." ResultsA 1:1 propensity score matching was used to adjust for confounding factors. The success rates of pulmonary artery catheter placement within 5 min in the conventional and combination groups were 85.5 % vs. 97.8 % (p = 0.032) before matching, and 73.7 % vs. 100 % (p = 0.001) after matching. The incidences of arrhythmias in the conventional and combination groups were 28.9 % vs. 17.4 % (p = 0.20) before matching, and 28.9 % vs. 18.4 % (p = 0.42) after matching. ConclusionPulmonary artery catheter placement with transesophageal echocardiography had a significantly higher rate of successful placement within 5 min, but no significant differences were observed in the incidences of arrhythmias.

A proposed rescue transesophageal echocardiographic protocol for anesthetized dogs.

To describe the acquisition and pitfalls of a 3-view transesophageal echocardiography (TEE) protocol in anesthetized, dorsally recumbent dogs. 8 beagles, 1 to 2 years old, 7.4 to 11.2 kg. Dogs were anesthetized, mechanically ventilated, and placed in dorsal recumbency. A TEE probe was advanced, and 3 views were performed: midesophageal 4-chamber and long axis (ME 4C and ME LAX) and caudal esophageal short axis (CE SAX) at the level of the papillary muscles. Probe insertion depth, flexion, omniplane angle, and image acquisition time were recorded. Two observers assessed 24 video clips each and identified anatomical structures. The ME 4C and ME LAX were obtained at 35 (30 to 40) cm insertion depth, omniplane at 0° and 103° (90 to 116), respectively. Views were obtained in ≤30 seconds once the TEE was in the cervical esophagus. Left-sided structures were identified in all cases, whereas right-sided structures were not always simultaneously obtained in the ME 4C, requiring further probe manipulation. All structures were identified on ME LAX. CE SAX was obtained at 40 (35 to 45) cm, omniplane at 0°, and in 15 (10 to 90) seconds. A true SAX view (circular left ventricle at the level of papillary muscles) could not be obtained in all dogs. A 3-view TEE protocol using core views as those described in humans may be applicable to dogs under general anesthesia and in dorsal recumbency. The CE SAX view at the level of the papillary muscles appears more difficult to obtain with consistency than midesophageal views.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

MODIFIED DEEP TRANSGASTRIC TRANSESOPHAGEAL ECHOCARDIOGRAPHY IMAGING OF SUPERIOR VENA CAVA

<h3>Background</h3> Superior vena cava is usually interrogated intraoperatively by a standard bi-caval view as suggested by American Society of Echocardiography. A modified deep transgastric transesophageal echocardiography view is suggested that will superior interrogation of the superior vena cava intraoperatively. <h3>Objective</h3> Evaluation of a modified deep transgastric imaging of superior vena cava in patients undergoing cardiac surgery. <h3>Methods and material</h3> A modified deep transgastric imaging of superior vena cava was performed in children undergoing cardiac surgery. The deep transgastric interrogation with color Doppler blood flow map showed the venous return pattern. A pulse wave Doppler signal analysis was also feasible. The position of the tip of a central venous catheter tip that was inserted through the internal jugular vein could be seen. An agitated saline contrast injected into the left upper limb could exclude the presence of a left superior vena cava. In patients undergoing a undergoing a bi-directional Glenn shunt, considerable length of superior vena cava was visualized. In a child with a partial anomalous pulmonary venous drainage and a superior sinus venosus ASD, a point of the pulmonary vein joining the superior vena cava could be identified as it was possible to interrogate a considerable length of superior vena cava compared to the standard mid esophageal bi-caval view. The deep transgastric TEE interrogation of superior vena cava revealed a residual gradient in the superior vena cava following a sinus venosus atrial septal defect repair that was corrected at the same sitting. A color Doppler blood flow map across the superior vena cava following removal of a directly inserted venous cannula showed turbulence and a continuous-wave Doppler signal analysis revealed a residual gradient that was immediately corrected by the surgeon in another patient. <h3>Conclusion</h3> In conclusion, the deep transgastric TEE view of the superior vena cava is clinically useful. The doppler alignment is parallel to SVC flow (less than 20 degree) which is superior to bi caval view, where the doppler alignment is almost perpendicular to the flow. The probable difficulties that may be encountered that would interfere with proper visualization are: (i) poor contact of the probe with cephalad aspect of the stomach, (ii) air in the stomach, (iii) use of inadequate contact jelly, and (iv) lack of experience. There is a deep learning curve that can be a practical impediment but once honed, it could be a really useful adjunct to our routine trans-esophageal views.

Transesophageal echocardiographic imaging of the coronary sinus: a retrospective analysis of mid-esophageal views and a novel transgastric view

BackgroundTransesophageal echocardiographic imaging plays an important role in assessing coronary sinus anatomy prior to placement of a retrograde cardioplegia cannula. The coronary sinus can be imaged in the long axis by advancing the TEE probe from the mid-esophageal 4-chamber view or using a modified mid-esophageal bicaval view, while a short axis view can be obtained in the mid-esophageal 2-chamber view. While use of a transgastric view is only briefly mentioned in the literature as an alternative to mid-esophageal views, the authors commonly include it in our comprehensive transesophageal echocardiographic exam of the coronary sinus. This study examines the various imaging strategies. We hypothesize that the transgastric view offers comparable coronary sinus imaging to the mid-esophageal views.MethodsAfter approval by our institutional review board, the intraoperative transesophageal echocardiographic exams for 50 consecutive elective cardiac surgical patients with a comprehensive echocardiographic assessment of the coronary sinus were retrospectively reviewed and analyzed to evaluate imaging of the coronary sinus in the various views. For each view, we noted and recorded if the coronary sinus and coronary sinus cannula were visualized. Statistical analysis required pairwise comparisons between each of the 4 views. P values were calculated using McNemar’s Exact test.ResultsBoth the coronary sinus and coronary sinus cannula were visualized a majority of the time for each view. There was no statistically significant difference between each view in its ability to visualize the coronary sinus, nor was there a statistically significant difference between each view in its ability to visualize the coronary sinus cannula.ConclusionsUse of a transgastric window provides the echocardiographer with an effective alternate modality for imaging the coronary sinus when mid-esophageal views are limited.

Immediately improved LA function demonstrated with pulmonic vein Doppler-intraoperative TEE in TAVR patients

Abstract Background Recent studies exhibited the immediately improved left atrium (LA) function by Doppler mitral inflow and mitral annular velocity by tissue Doppler and left atrial appendage flow velocity. This study aims to investigate the improvement of LA function by pulmonic vein Doppler parameters performing by an intraoperative transesophageal echocardiogram (TEE) during transcatheter aortic valve replacement (TAVR). Material and methods Patients who underwent TAVR from January 2020 to September 2021 and pulmonic vein Doppler were acquired by TEE (right upper pulmonic vein from 90–110° mid-esophageal view) during TAVR with the explicit image. We obtained S-, D-, A-wave velocity; LV end-diastolic pressure (LVEDP) and mean pressure gradient across aortic valve (mean-AVPG) from invasive catheter both pre-TAVR and immediate post-TAVR. All parameters between pre-TAVR and post-TAVR were compared with paired t-test. Results 38 patients (mean age 79.7±5.6 years, 17 female) were enrolled in this study. S-wave was only significant parameter with increased velocity from baseline (30.3±24.6 cm/s vs 50.2±23.2 cm/s, p&amp;lt;0.001), whereas D-wave and A-wave were not significantly changed from baseline (35.1±15.2 cm/s vs 33.7±11.0 cm/s, p=0.6; and 14.3±8.6 cm/s vs 13.0±8.9 cm/s, p=0.4, respectively). LVEDP was not significantly changed from baseline (19.6±9.5 mmHg vs 18.7±8.1 mmHg, p=0.49) but mean-AVPG was significantly decreased after TAVR (53.8±11.8 mmHg vs 6.1±5.6 mmHg, p&amp;lt;0.001). We also noted 25 patients who had S/D ratio &amp;lt;1 at baseline, 19 of 25 patients were changed to S/D ratio &amp;gt;1 immediately post TAVR. Conclusion This study demonstrated the improved LA function with pulmonic vein Doppler after TAVR. S-wave is the only parameter to be improvement immediately post TAVR and change to S/D ratio &amp;gt;1 in majority of patients. Funding Acknowledgement Type of funding sources: None.

Evaluation of the Simpson's Method to Determine Left Ventricular Ejection Fraction Using the Transgastric Two-Chamber View.

Left ventricular chamber size and functional assessment by transesophageal echocardiography can be difficult if visualization is poor in the mid-esophageal views. However, the accuracy of using the Simpson's method in the transgastric 2-chamber (TG2C) as an alternative approach has not been assessed. The Simpson's method was performed by 2 independent reviewers using midesophageal 2-chamber (ME2C) and TG2C views. Echocardiographic images were retrieved retrospectively for 49 adult cardiac surgical patients. Two-way random effects intraclass correlation coefficients demonstrated no significant interobserver variability. Linear mixed effects models showed no significant differences in ME2C and TG2C measurements with regard to EDV (P=.4407), ESV (P=.5113), or EF (P=.0610).Compared to the ME2C view, the TG2C view had better image quality of the LV walls (image quality score median [interquartile range]: 2.00 [.00] vs 1.00 [1.00]; P<.0001), but worse image quality of the mitral annulus (1.00 [1.00] vs 2.00 [.00]; P<.0001) and LV apex (.00 [1.00] vs 2.00 [1.00]; P<.0001). This study suggests the Simpson's method can be applied to the TG2C view as an alternative to the standard midesophageal method to estimate chamber volumes and EF.

Incidence and risk factors for mechanical injuries caused by the transesophageal ultrasound probe manipulation in the setting of transfemoral transcatheter tricuspid repair

Abstract Funding Acknowledgements Type of funding sources: None. Background Leading right heart failure due to tricuspid regurgitation results in retrograde hepatic venous congestion with subsequent gastropathy and hyperemia of the gastric mucosa. Due to increased portal pressure as well as possible cirrhosis cardiaque, the risk for esophageal varices is greatly increased. In addition, associated with atrial dilatation, these patients usually suffer from atrial fibrillation and receive an oral anticoagulation/ direct anticoagulation (OAC/DOAC) as insult prophylaxis. Heparinization with a target ACT &amp;gt; 250 seconds is necessary during transfemoral transcatheter tricuspid repair (TTTR). Alternation between transgastric and midesophageal view with the transesophageal ultrasound probe is usually performed to better guide TTTR. Sufficient wall contact is crucial for good imaging. All of these conditions increase the risk for periprocedural gastric and/or esophageal injury. Purpose The aim of this study was to assess the incidence and risk factors for mechanical irritation and bleeding caused by the TEE probe manipulation in the setting of TTTR. Methods In this prospective cohort study patients received gastroscopy preinterventional and on the first day after TTTR. Statistical analysis was performed with IBM SPSS.28, t-Test was used to compare patients with and without postinterventional lesions. Results From December 2020 to July 2021, 18 patients with indication for TTTR were included in this study. The mean age of the patients was 77.8 (± 7.5) years. Thirteen patients (72.2%) had antral gastritis and 4 patients (22.2%) had corpus gastritis preinterventionally. Esophageal varices were not detectable in any patient. Postinterventionally, 10 patients (55.6%) showed lesions (hematoma or coagulated pressure points) (Fig. 1), and 2 patients (11%) required interventional treatment with hemoclips. The main lesion sites were midesophageal at 20-25 cm, 1 lesion at the Z-line. A mean of 5.7 (± 2.5) position changes took place; the mean procedural duration was 88 (± 27.8) min. The number of clips placed (p = 0.64), the procedural duration (p = 0.99) and the number of position changes (p = 0.48) did not differ between the group of patients with and without injuries after TTTR (Tab 1). Conclusion More than 50% of patients with TTTR showed postprocedural injuries (lesions) of the esophagus. Contrary to our assumption, mainly lesions midesophageal could be detected. Due to the procedure as well as the severe underlying disease, gastrointestinal bleeding is a potential complication in the context of a TTTR. Consideration should be given to implementing regular control gastroscopy after TTTR to reduce the procedure-related complication rate. Due to the high incidence of procedure-related lesions, further research in larger patient collectives is necessary. Abstract Figure. Abstract Figure.

Abstract 12870: Transesophageal Echocardiography to Guide Correct Implantation Site of the Leadless Pacemaker

Introduction: MICRA™ (Medtronic USA) leadless pacemakers are used to avoid complications common to conventional pacemakers, but there is still a 4% risk of complications (e.g., cardiac perforation, tamponade, and embolization). Septal device implantation may decrease risk, but helpful cardiac landmarks (e.g., tricuspid valve, pulmonary valve (PV)) are not seen under fluoroscopy. There is little guidance regarding alternative intra-procedural (IP) imaging. We studied the spatial relationship of the MICRA™ to cardiac landmarks via transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE). Methods: Our prospective observational study included 23 patients undergoing MICRA™ implantation with TEE ( Table 1) . Interventricular septal placement was confirmed by fluoroscopy, electrocardiography (ECG) and TEE. Distances between the device and cardiac landmarks were measured by TTE and TEE and analyzed with ECG parameters during pacing ( Fig 1A, Fig 1B ). Results: Septal positioning of the device was achieved in all patients. TEE transgastric (0-20/90-110°) and lower mid-esophageal (40-60/130-150° with biplane) views best visualized device position. The aortic valve (AV) in the TTE apical 5 chamber view was used as a surrogate for RV apex to PV distance. With appropriate septal deployment, QRS morphology showed earlier R wave transition and 44% increased QRS width ( Table 1 ). Conclusions: TEE can guide appropriate leadless pacemaker septal implantation, and correlates with QRS pacing morphology. Further studies are required to establish reference ranges of distances from the device to cardiac landmarks to prove optimal device deployment.

Multiple Color Doppler Flow Jets Into The Atria in a Child With Heterotaxy Syndrome

A nine-month-old girl (weight: 7.92 kg; height: 70 cm) was taken to the operating room for the creation of a bilateral bidirectional Glenn shunt and atrial septectomy. Patent ductus arteriosus stenting had been done when the child was four days old. Transthoracic echocardiography showed heterotaxy (left atrial isomerism) with situs inversus, discordant atrioventricular and concordant ventriculoarterial connections (ventricular ‘noninversion’), a large ventricular septal defect, membranous pulmonary atresia with a hypoplastic main pulmonary artery, confluent branch pulmonary arteries, aorta anterior and to the right of the pulmonary artery, and bilateral superior vena cava with no bridging vein. The left superior vena cava was draining into the left-sided atrium (morphologic right atrium), while the right superior vena cava was draining into the same atrium via a massively dilated coronary sinus. The inferior vena cava was interrupted, with hemzygous continuation to the left superior vena cava. A computerized tomography scan revealed a right-sided stomach with a midline liver, and demonstrated the complex vascular communications (Fig 1, A and B). Transesophageal echocardiography confirmed the preoperative diagnosis (Fig. 2, Fig. 3; Videos 1 and 2). Color- flow Doppler mapping in the mid-esophageal view demonstrated multiple jets into both the atria and the right-sided ventricle (Fig 4, A and B; Videos 3 and 4). Pulse-wave Doppler of a dominant jet revealed a biphasic flow (Fig 5; Video 5). The intramyocardial origin of the jets was traced toward the aorta (Fig 6; Video 6). Fig. 2The midesophageal, four-chamber transesophageal echocardiography view with color- flow Doppler map showing demonstrating the anatomic abnormality in the child. View Large Image Figure Viewer Download Hi-res image Fig. 3The midesophageal, four-chamber transesophageal echocardiography view with color- flow Doppler map demonstrating the left superior vena cava. Left SVC, left superior vena cava. View Large Image Figure Viewer Download Hi-res image Fig. 4(A) The midesophageal transesophageal echocardiography views with color-flow Doppler map demonstrating jets (white arrows) into the left atrium. (B) The right atrium and the right ventricle. View Large Image Figure Viewer Download Hi-res image Fig. 5The midesophageal pulse-wave Doppler signal interrogation of the jet by transesophageal echocardiography. View Large Image Figure Viewer Download Hi-res image Fig. 6The midesophageal transesophageal echocardiography view displaying the color-flow Doppler mapping delineating the origin of the jet (white arrows). View Large Image Figure Viewer Download Hi-res image

TEE image quality improvement with our devised probe cover.

Our hypothesis was that our devised transesophageal echocardiography probe cover with the capacity for pinpoint suction would improve image quality. Prospective cohort study. Single tertiary medical center. Patients undergoing surgery requiring intraoperative transesophageal echocardiography. Suctioning with inserted orogastric tube. Changes in image quality with suctioning were assessed by 2 methods. In method #1, investigators categorized the quality of all acquired images on a numeric scale based on each investigator's impression (1: very poor, 2: poor, 3: acceptable, 4: good, and 5: very good). In method #2, the reproducibility of the left ventricular fraction area change (LV FAC) was assessed, assuming that improved transgastric midpapillary short-axis view image quality would yield better LV FAC reproducibility. With method #1, for midesophageal views, 26.5%, 70.5%, and 3.0% of images showed improved, the same, and worsened image quality, respectively. For transgastric views, 55.3%, 43.3%, and 1.4% showed improved, the same, and worsened image quality, respectively. For deep transgastric views, 60.0%, 38.0%, and 2.0% showed improved, the same, and worsened image quality, respectively. With method #2, the presuction group had an ICC of 0.942 (95% CI: 0.91, 0.965). The postsuction group had an ICC of 0.988 (95% CI: 0.981, 0.993). Our investigation validates the potential image quality improvement withour devised TEE probe cover. However, its clinical validity needs to be confirmed by further studies.

TEE Midesophageal bicaval view. Wire in the correct position passing through the right atrium and entering in the superior vena cava

TEE Midesophageal bicaval view. Wire in the correct position passing through the right atrium and entering in the superior vena cava

TEE Midesophageal bicaval view dual color of a two stage venous cannula in a correct position during systemic perfusion.

TEE Midesophageal bicaval view dual color of a two stage venous cannula in a correct position during systemic perfusion.

The Application of Transesophageal Echocardiography in Mitral Valve Repair With Tendon Reconstruction.

Objective: To investigate whether tendon reconstruction during mitral valve repair can be effectively guided by transesophageal echocardiography (TEE), using the mid-esophageal bi-commissure view, bicaval view and the aortic valve–mitral valve transition short-axis view.Methods: A total of 40 patients that underwent mitral valve repair with artificial tendineae were recruited. Before the operation, conventional transthoracic echocardiography was used to determine whether mitral valve repair would be possible. Following intraoperative anesthesia, two-dimensional and three-dimensional TEE reconstructions were used to assess the state of the valve and tendon and to make a repair plan.Results: TEE accurately diagnosed single functional tendon rupture and predicted single artificial tendon implantation in 88% of cases (23/26). TEE accurately diagnosed single functional tendon rupture and predicted the implantation of two artificial tendons in 100% of cases (4/4). TEE accurately diagnosed two or more functional tendon ruptures and predicted the implantation of two artificial tendons in 100% of cases (5/5). The length of the tendon cord predicted by TEE (2.45 ± 0.15 mm) was not significantly different (P > 0.05) from the length of the cord that was actually implanted (2.31 ± 0.11 mm). TEE also accurately predicted the size of the annuloplasty ring in 86% of cases (33/38), with differences of 2 mm or less compared to the size of the ring that was actually implanted.Conclusion: Both the mid-esophageal bi-commissure view, bicaval view and the short-axis view of the aortic valve–mitral valve transition can reduce the difficulty of tendon reconstruction by helping to determine what length of tendon and what size of artificial annulus are required.

Association betweenLeft Atrial Appendage function assessed by speckle-tracking echocardiography and the presence ofLeft Atrial Appendage stasis in patients with atrial fibrillation

Abstract Objectives The aim of this study was to determine the association of LAA left atrial appendage funtion as assessed by speckle-tracking imaging with LAA stasis and thrombus in patients with nonvalvular atrial fibrillation (AF). Methods A total of 154 consecutive patients with AF referred for transesophageal echocardiography (TEE) were prospectively enrolled. Of these, 29 (18.8%) patients had LAA dense spontaneous echo contrast (SEC) and/or thrombus. Besides standard echocardiography we assessed global, basal, middle and apical LAA longitudinal strain (LS) in mid-esophageal TEE views obtained at 0°, 45°, 90° and 135° by using speckle-tracking echocardiography (STE). Results Patients were comparable with regard to the clinical data. A subgroup with LAA stasis or thrombus had enlarged LAA size, impaired LAA emptying fraction (LAAEF) and reduced LAA emptying velocity than control group.LAA global and segmental LS were significantly decreased in patients with dense SEC or thrombus. Receiver operating characteristic curve analysis revealed that the LAAEF of 61.5%, the LAA GLS of 8.02%, LAA segmental LS of (basal) 8.07%, (middle) 9.08%, (apical) 8.43% (P&amp;lt;0.0001) were the optimal cutoff values for distinguishing both subgroups. All the LAA strain parameters as well as LAAEF were independently associated with the presence of LAA stasis or thrombus in multivariate analyses, with additional significance over the CHA2DS2-VASc score. Conclusion Speckle-tracking echocardiography may be used to describe LAA function during AF, allowing identification of patients with higher risk of LAA stasis or thrombus and providing incremental value over the CH2ADS2-VASc Score. Figure 1 Funding Acknowledgement Type of funding source: None

Transesophageal echocardiography (TEE) in cardiac arrest: results of a hands-on training for a simplified TEE protocol

BackgroundIntegration of transesophageal echocardiography (TEE) with Focused Cardiac Ultrasound (FoCUS) can impact decision-making, assist in the diagnosis of reversible etiologies and help guiding resuscitation of patients with cardiac arrest.ObjectiveTo evaluate the ability of emergency physicians (EPs) to obtain and maintain skills in performing resusTEE after a course with clinical training in the cardiac surgery theatre.MethodsTen EPs without previous TEE experience underwent a resusTEE course, based on a 2-h workshop and an 8-h hands-on training. The training was performed in a cardiac surgery theatre tutored by cardiovascular anesthesiologists. The six taught views were mid-esophageal four-chamber (ME4CH), mid-esophageal long axis (MELAX), mid-esophageal two-chamber (ME2CH), mid-esophageal bicaval view (MEbicaval), transgastric short axis (TGSAX) and aorta view (AOview). The EPs were evaluated by a cardiovascular anesthesiologist at the end of the course as well as after 12 weeks according to a standardized evaluation method. Once the course was completed, resusTEE exams, performed by EPs in Emergency Department (ED), were monitored for a 12-week period.ResultsThe average assessment of the ten EPs by the tutors was higher than 4 points out of 5, both at the end of the course and after 12 weeks. Probe insertion, acquisition and interpretation of the different views scored on average more than 4 points out of 5 except for TGSAX that showed worsening after 12 weeks. Trainees performed twelve resusTEE exams in ED in patients with out-of-hospital cardiac arrest (OHCA) over 12 weeks after the course. EPs used only four out of six taught views in clinical practice, in the following order of frequency: ME4CH, AOview, MEbicaval and MELAX.ConclusionsEPs, after a course with clinical training in the cardiac surgery theatre, can successfully acquire and maintain the skills needed to perform resusTEE. However, among the six views learned in the course, EPs used only four of them (ME4CH, MEbicaval, MELAX and AOview).

Transesophageal echocardiography (TEE) disclosed Takotsubo syndrome in the midesophageal two-chamber view and inotropic agents initiated because of left ventricular dysfunction

Transesophageal echocardiography (TEE) disclosed Takotsubo syndrome in the midesophageal two-chamber view and inotropic agents initiated because of left ventricular dysfunction

Transesophageal echocardiography (TEE) revealed a left atrial appendage thrombus in the midesophageal two-chamber view, which led to anticoagulation therapy

Transesophageal echocardiography (TEE) revealed a left atrial appendage thrombus in the midesophageal two-chamber view, which led to anticoagulation therapy

P218 Accuracy and reproducibility of aortic root assessment by eSie Valves in patients candidate to transcatheter aortic valve implantation: a comparative study with computed tomography

Abstract Background Accurate imaging assessment of the aortic root (AR) is critical for prosthesis sizing in transcatheter aortic valve implantation. Multislice computed tomography (MSCT) is the gold standard for this purpose. 3D transesophageal (3D-TOE) reconstruction tools have recently been introduced, which automatically configures a geometric model of AR from 3D-TOE dataset and perform quantitative analyses of the AR. Purpose The aim of the study was to compare semi-automated measurements of AR obtained by eSie Valves (EV) (Siemens Medical Solution, California, USA) tool with MSCT. Methods We prospectively enrolled 26 consecutive patients (mean age 79.5 ± 7.5 years; 38% men) with severe symptomatic aortic stenosis (mean gradient 48.8± 13.6 mmHg) who underwent both 3D-TOE and MSCT as part of TAVI evaluation protocol. Volumetric datasets of the AR, acquired with 3D-TOE in mid-esophageal view, were analyzed with EV tool. EV tool automatically detected AR landmarks and, after user validation, created 3D model of AR providing values of area, perimeter, diameters of aortic annulus (AA) and coronary ostia heights (Fig 1). Results EV tool analysis on 3D-TOE volumetric data sets was feasible in all patients. Strong correlation between EV tool and MSCT assessment for AA major diameter (r = 0.79), AA minor diameter (r = 0.81), AA perimeter (r = 0.89) and AA area (r = 0.89) (all p&amp;lt; 0.0001) was found. On average EV tool underestimated MSCT measurements of AA major diameter (1.2 mm, 4.5%), AA minor diameter (2.6 mm, 11.3%), AA perimeter (4 mm, 5.2%) and AA area (65.3 mmq, 13.6%). Moderate correlation between the two methods, already in this initial sample, for right coronary artery ostium height (r = 0.53, p = 0.007) was discovered. Finally, weak correlation for left coronary artery ostium height (r = 0.33, p = 0.1) was revealed. EV tool measurements from two different volumetric datasets of the same patient showed an excellent reproducibility intraclass correlation coefficient (ICC) for AA area 0.94 and ICC for right coronary height 0.98. Conclusion With these initial results EV tool could be used in clinical practice for quick and reliable assessment of AA area, perimeter and diameters. A larger group of patients will be needed to assess the consistency of coronary ostia height evaluation by EV tool. Abstract P218 Figure. eSie Valve landmarks and 3D model of AR

PFO "angioplasty": The preparation of a very stiff and long tunnel for device closure.

Patent foramen ovale (PFO) closure is a widely performed procedure. Understanding the anatomy is mandatory in order to perform the procedure successfully. The degree of overlap between the septum primum and secundum is called the tunnel. In particular, long and stiff tunnels may prevent the correct positioning of devices that have a fixed distance between the right and left atrial discs. We evaluated retrospectively 361 patients with PFO closure between January 2012 and June 2014 in our institution and were treated due to previous history of ischemic stroke. By TEE, the overlap between septum primum and secundum is usually better seen on the bicaval view that is obtained at 75-90° midesophageal views. Tunnel length and PFO opening were measured. Twelve subjects (median age 35 years; range 30-58 years; three females) showed a long (median 22 mm; range 15-32 mm) and rigid tunnel (median opening 2 mm; range 1-4 mm). Angioplasty of the tunnel was performed by using peripheral angioplasty balloons with a length ranging from 4 to 8 cm and a diameter between 8 and 12 mm. After angioplasty, the tunnel appeared shorter (12 mm; range 8-16 mm) and less rigid (median opening 8 mm; range 7-12 mm). The following devices were implanted: 25 mm Amplatzer PFO occluder in three patients; 25 mm Gore septal occluder in nine subjects. Median fluoroscopy time was 8 min (range 6-10 min). No complications occurred. At a median follow-up of 12 months (range 2-18 months), no problems occurred and all subjects but one (trivial residual shunting) showed a complete closure. Angioplasty of a PFO rigid and stiff tunnel is a feasible and safe option. © 2016 Wiley Periodicals, Inc.