Multiplane Probe Research Articles

Anesthetic management of a patient with situs inversus totalis undergoing coronary artery bypass grafting surgery: a case report

BackgroundAnesthetic management of coronary artery bypass grafting surgery (CABG) in a dextrocardia patient with situs inversus totalis is rarely encountered and seldom reported in the literature.Case presentationA 76-year-old Japanese female patient had been diagnosed with situs inversus totalis and coronary artery disease of 3 vessels, and she subsequently underwent elective CABG. A preoperative examination showed almost normal results. ECG showed right deviation with the normal lead position. In the operating room, ECG leads were applied in reverse. Pulmonary artery catheterization was performed via the left internal jugular vein. A transesophageal echocardiography (TEE) probe was introduced without difficulty. A different angle was needed to acquire the desired views because of her atypical anatomy.ConclusionCareful perioperative evaluation, intraoperative management, and inspection of multiplane angle and probe adjustments in TEE are needed for anatomically abnormal patients.

Measurement of coronary sinus blood flow using transesophageal echocardiography to estimate the adequacy of revascularization in patients undergoing off-pump coronary artery bypass grafting

Introduction Revascularization of coronary artery increases the blood flow in the coronary sinus (CS) too. The study aimed to measure the CS blood flow using transesophageal echocardiography (TEE) to estimate the adequacy of revascularization in patients undergoing off-pump coronary artery bypass grafting. Patients and methods After ethical committee approval, 100 patients scheduled for elective coronary artery bypass grafting were included in this study. After induction of balanced anesthesia according to institutional protocol, a 5-Hz multiplane phased-array TEE probe was inserted into patients’ esophagus, and the following parameters were calculated at pre-revascularization and post-revascularization periods: velocity time integral of CS, coronary sinus diameter, coronary sinus cross-section area, and coronary sinus blood flow (CSBF) per beat and per minute. Results Our study showed a statistically significant increase in velocity time integral in the post-revascularization period as compared with the pre-revascularization period (P Conclusion TEE is a superior modality to evaluate CSBF before and after coronary artery bypass revascularization to determine the adequacy of surgical revascularization in real time during off-pump coronary artery bypass revascularization.

P771 3D versus 2D transesophageal echocardiography in the detection of thoracic aorta atherosclerosis stage and prediction of coronary atherosclerosis

Abstract Background 2D transesophageal echocardiography (TEE) was approved as a suitable method for the assessment of thoracic aorta (TA) atherosclerosis. Purpose A comparison between 2D and 3D multiplane TEE for qualitative and quantitative assessment of aortic atheromas and for coronary atherosclerosis prediction. Methods 180 consecutive CAD patients (104 men, 76 women, mean age 62 ± 7 years) were examined. 2D and 3D TEE was performed using Philips IE33 xMatrix system and a X7-2t multiplane probe. 2D study of TA was performed using Live xPlane mode. 3D study of TA was performed using Live 3D and Full Volume modes. Qualitative and quantitative assessment of every atheroma was performed using 2D and 3D modes. The degree of severity and distribution of the TA atheromatosis was evaluated according to the classification of ASE and EACVI (2015): grade 0 – intimal-medial thickness ≤1 mm, 1 – intimal thickness ≤2 mm, 2 – focal or diffuse intimal thickening of 2-3 mm (small atheromas), 3 – atheromas >3–5 mm (no mobile/ulcerated components), 4 - atheromas > 5 mm (no mobile/ulcerated components), 5 - grade 2, 3, or 4 atheromas plus mobile or ulcerated components. After TEE all patients underwent digital coronary angiography and SYNTAX Score was calculated. Findings were presented as M ± SD or n (%). Results 620 atheromas were analysed: 109 in the ascending part, 8 in the arch and 503 in the descending part. On average 3,43 ± 2,15 atheromas per patient were revealed. Atheromas height in 3D was significantly higher (p < 0,001), than in 2D, being 0,38 ± 0,09 mm and 0,26 ± 0,07 mm, respectively. Atheromas height increase in 3D was 0,12 ± 0,06 mm. In 3D 88% of atheromas have shown irregular contours while in 2D only 35% of atheromas had rough countors. The mobile component in 6 out of 9 atheromas was revealed only in 3D. In 2D 1-5 stages of TA atheromatosis were revealed in 22 (12%), 103 (57%), 43 (24%), 7 (4%) and 4 (2%) cases, respectively. In 3D 1-5 stages of TA atheromatosis were revealed in 16 (9%), 25 (14%), 90 (50%), 38 (21%) and 10 (5%) cases, respectively. With 3D TEE 72% of patients were found to have higher gradation of TA atheromatosis stage. The direct Spearman’s correlation between a stage of TA atheromatosis and SYNTAX Score which has been established for 2D r = 0,32 p < 0,001 and 3D r = 0,30, p < 0,01, respectively. Conclusions A comparison between 2D and 3D TEE has shown, that 3D is more precise method of qualitative and quantitative assessment of aortic atheromas and diagnosis of TA atheromatosis stage. 3D ultrasound stage of TA atheromatosis is a surrogate marker of severity and prevalence of coronary atherosclerosis.

Possibilities and limitations of three-dimensional transesophageal echocardiography in the diagnosis of thoracic aorta atherosclerosis

To compare the possibilities and limitations of the two-dimensional (2D) and three-dimensional (3D) multiplane transesophageal echocardiography (TEE) for the diagnosis of the thoracic aorta (TA) atherosclerosis stage, qualitative and quantitative assessment of aortic atheromas and coronary atherosclerosis prediction.Materials and methods. 2D and 3D multiplane TEE of the TA was performed in 180 consecutive CAD patients (104 men, 76 women, mean age 62,4±7,5 years) using Philips IE33 xMatrix system and a X7-2t multiplane probe. Ascending aorta, accessible parts of the arch and descending TA were visualized in 2D mode with standard protocol using Live xPlane mode. 3D study of TA was performed using Live 3D and Full Volume modes. 2D and 3D studies were recorded as video clips series on a system hard drive with subsequent off line processing on a QLab 10.8 (Philips) workstation. Qualitative and quantitative assessment of every atheroma was performed using 2D and 3D modes. The degree of severity and distribution of the TA atheromatosis was evaluated according to the classification of ASE and EACVI (2015): grade 0 - intimal-medial thickness ≤1 mm, 1 - intimal thickness ≤2 mm, 2 - focal or diffuse intimal thickening of 2-3 mm (small atheromas), 3 - atheromas >3-5 mm (no mobile/ulcerated components), 4 - atheromas > 5 mm (no mobile/ulcerated components), 5 - grade 2, 3, or 4 atheromas plus mobile or ulcerated components. After TEE all patients underwent digital coronary angiography. SYNTAX Score was calculated in 122 (67,7%) patients with no coronary stents and bypass grafts.Results. 620 atheromas were analysed: 109 (17,6%) in the ascending part, 8 (1,3%) in the arch and 503 (81,1%) in the descending part. On average 3,4±2,1 atheromas per patient were revealed. Atheromas height in 3D was significantly higher (p<0,001), than in 2D, being 0,38±0,09 cm and 0,26±0,07 cm, respectively. Averaged atheromas height increase in 3D was 0,12±0,06 cm. In 3D 87,7% of atheromas have shown irregular contours while in 2D only 35,4% of atheromas had rough countors. The mobile component in 6 (66,6%) out of 9 atheromas was revealed only in 3D. In 2D 1-5 stages of TA atheromatosis were revealed in 22 (12,2%), 103 (57,2%), 43 (23,9%), 7 (3,9%) and 4 (2,2%) cases, respectively. In 3D 1-5 stages of TA atheromatosis were revealed in 16 (8,9%), 25 (13,9%), 90 (50%), 38 (21,1%) and 10 (5,5%) cases, respectively. With 3D TEE 130 (72,2%) patients were found to have higher gradation of TA atheromatosis stage. TA atheromatosis was not detected in 1 (0,6%) patient. The direct Spearman's correlation between a stage of TA atheromatosis and SYNTAX Score which has been established for 2D rs =0,32 p<0,001 and 3D rs =0,30, p<0,01, respectively.Conclusion. A comparison between 2D and 3D TEE has shown, that 3D is more precise method of qualitative and quantitative assessment of aortic atheromas and diagnosis of TA atheromatosis stage which allows, ultimately, to change the stage of TA atheromatosis towards a higher gradation. 3D ultrasound stage of TA atheromatosis is a surrogate marker of the severity and prevalence of coronary atherosclerosis.

Feasibility of Using Multiplane Stress Imaging to Add Measurement of LV Ejection Fraction Response to Exercise to Regional Wall Motion Scoring During Stress Echo

Multiplane 4D imaging probes not only increase accuracy of stress echo by reducing image acquisition time whilst maintaining orthogonal triplane views, but also have the potential to add a biplane ejection fraction (LVEF) measurement to the standard regional wall motion scoring. Methods: We prospectively studied 67 consecutive patients undergoing a treadmill stress echocardiogram using a Bruce protocol. Multiplane images of the left ventricle were obtained at rest and post exercise using a GE Vivid 9 scanner and a 4D multiplane probe. All studies were performed by a single senior sonographer. The time taken to obtain the images post exercise was recorded and the LVEF measured off line using EchoPac™ BT12 software and Simpson's biplane method. Results: We included 67 patients (52 male, 15 female) over 12 months, ranging in age from 28 to 85 years, (63 ± 11 years, mean ± SD). The patients’ sizes varied with BSA ranging from 1.53–2.38 m2 (mean 1.92m2). Images suitable for standard regional wall motion scoring were obtained in 95%, within 35 ± 9 seconds, and the LVEF was measurable in 100% of these patients. Conclusion: Left ventricular ejection fraction response to exercise could be measured using multiplane 4D imaging in all patients with suitable stress echo images. Whilst the clinical utility of this will depend on the context in which it is used the results do suggest that it is feasible to incorporate this into standard stress echo protocols and may add important information to regional wall motion scoring.

Quadricuspid Aortic Valve: Echocardiographic Assessment and Anatomic Correlation

Quadricuspid aortic valves are very rare, with a reported incidence of 0.008% in autopsy series and 0.010.04% in echocardiography series. (1, 2) Depending on the size of each aortic cusp, seven anatomic types or variants are described: type A, four equal cusps; type B, three equal cusps and one smaller cusp; type C, two equal larger cusps and two equal smaller cusps; type D, one large, two intermediate and one small cusp; type E, three equal cusps and one larger cusp; type F, two equal larger cusps and two unequal smaller cusps; and type G, four unequal cusps. (3) Aortic regurgitation is the most prevalent finding, with an incidence of about 75% of cases, while aortic stenosis is extremely rare (0.7%). (4) These images correspond to a 63-year-old hypertensive male patient, smoker, with hypertension and dyslipidemia, who was admitted due to non-ST segment elevation acute coronary syndrome. Coronary angiography revealed severe disease in three coronary vessels. Preoperative transthoracic color Doppler ultrasonography showed left ventricular dilatation with severe deterioration of systolic function (EF 30% biplane Simpson method) due to mid anteroseptal, mid anterior apical, mid lateral apical, and strictly apical akinesia, with hypokinesia in the rest of the segments. The aortic root was not dilated, and the aortic valve appeared to be quadricuspid with mild fibrosis of valve cusps. Color Doppler visualized a central regurgitant jet of moderate intensity, with a pressure half time of 466 msec and vena contracta of 0.4 cm. A preoperative transesophageal echocardiography was performed using GE Vivid 7 equipment with multiplane probe for better assessment of the aortic valve and cusps, and to confirm the mechanism of regurgitation. Mid-esophageal four-chamber view at 0° with anteflexion of the probe tip and 44-45° rotation provided a mid-esophageal short axis view of the aortic valve in the center of the image, with its four equal cusps, which would correspond to the type A variant (Image A, arrow), and color Doppler revealed central regurgitant jet originating in the valve coaptation point (Image B, arrow). From this view it is possible to observe in detail the valvular structure, analyze the cusps, insertion, type of lesion and coaptation point. Increasing REFERENCES

The Miniaturized Multiplane Micro-Transesophageal Echocardiographic Probe: A Comparative Evaluation of Its Accuracy and Image Quality

The initial experience with the miniaturized multiplane micro-transesophageal echocardiographic probe (MTEE) reported high-quality diagnostic imaging in small infants. The aim of this study was to compare the diagnostic accuracy and image quality of the intraoperative MTEE with the pediatric multiplane transesophageal echocardiographic probe (PTEE). Infants weighing <5 kg who underwent intraoperative transesophageal echocardiography were identified. Studies using the MTEE were matched 1:1 with those using the PTEE by cardiac diagnosis. The postoperative transesophageal echocardiograms, obtained using either probe, were reviewed for the presence of 11 cardiac abnormalities. Postoperative transesophageal echocardiograms were compared with predischarge transthoracic echocardiograms to assess accuracy. Using receiver operating characteristic curves, the areas under the curve for the MTEE and PTEE were compared. Two pediatric cardiologists scored six image quality metrics on equal numbers of studies obtained with the MTEE and the PTEE. Composite scores from both reviewers were used to compare image quality. The study included 110 transesophageal echocardiograms per probe type. The mean weight for the MTEE was lower than for the PTEE (3.15±0.58 vs 3.70±0.52kg, P<.001). There was no significant difference in the diagnostic accuracy of the MTEE and PTEE using receiver operating characteristic curves. The numbers of residual anatomic lesions missed by the MTEE and PTEE were similar (19 vs 22, respectively). The composite image quality score was worse for the MTEE compared with the PTEE (81% vs 92%, respectively, P<.0001). Although the image quality of the MTEE is inferior compared with the PTEE, its diagnostic accuracy in infants weighing <5kg is comparable.

小児用マルチプレーンプローベを用いた周術期経食道心エコー:乳幼児における先天性心疾患手術にもたらす影響

背景:周術期経食道心エコー(TEE)は体格の問題から乳幼児での使用や効果に制限があった. 目的:小児用マルチプレーンプローベ(PMP)を用いた周術期TEEの有用性について調査検討すること. 対象と方法:2007年以降に周術期TEEを試みた412例を使用プローベによりA群(PMP), B群(小児用バイプレーン), C群(成人用MP), D群(挿入不能)の4群に分類した. 年齢分布, 基礎心疾患, 手技追加の有無, 術後経過, 挿入不能理由とその影響について調査した. 結果:A群は0～4歳が86％(乳児33％), B群は5～9歳が57％, C群は15歳以上が70％, D群は乳児が83％であった. 手術手技追加はA群16例, C群6例で, B群に該当例はなかった. 単純心奇形はA群で35％, B群で94％, C群で48％であった. A群の手術手技追加は右室流出路再建7件, 房室弁再形成6件, 残存短絡閉鎖3件, 上大静脈狭窄解除1件であった. D群は心臓外疾患, 低体重が多く, 1例で術後15日で再手術を必要とした. 結語:複雑心奇形が多い乳幼児期の開心術においてPMPを用いたTEEの効用は大きく, 予後改善につながると考えられる.

Paradoxical Thromboembolism: A Trip Better Left Untraveled

Introduction Pulmonary embolism is a common sequela of deep vein thrombosis (DVT). Less well documented is the occurrence of DVT and its relationship to stroke via an intracardiac shunt such as a patent foramen ovale (PFO). We report a case of DVT and stroke in conjunction to the presence of intracardiac thrombus and a moderate-sized PFO. Methods This is a case study report of a 61-year-old woman with a previous medical history of hyperlipidemia only who traveled to Mexico from the Unites States. The trip included three long bus trips of 12, 13, and 14 hours in duration. This patient presented to a hospital in Mexico with severe headache and right-sided weakness. The patient was diagnosed and treated for left hemispheric stroke and eventually transported to our hospital in Houston, Texas, for further stroke evaluation and management. With the use of a Philips IE33 8 MHz linear array probe and multi-plane TEE probe as well as a Siemens Sequoia 4V phased array probe, we were able to safely and accurately diagnose and manage the patient's condition until intervention could be safely performed. Results Multiple diagnostic imaging tests were performed, including a bilateral lower-extremity duplex venous ultrasound, duplex carotid ultrasound, transthoracic and transesophageal echocardiograms, as well as computed tomography scans of the chest and brain. With the patient's current condition and symptoms as well as the collected findings, our test results indicated that a paradoxical thromboembolic event had most likely occurred. There was right lower-extremity DVT, bilateral pulmonary embolisms, and large and highly mobile thrombus within the right-side chambers of the heart that occasionally protruded through a moderate size patent foramen ovale of 0.9 cm. The left distal common carotid artery and internal carotid artery were found to be occluded, and initial computed tomography scan of the brain showed a large left middle cerebral artery distribution infarct. Conclusion Venous thromboembolic disease can cause stroke in the presence of an intracardiac shunt such as a PFO. The use of vascular and cardiac ultrasound examinations is critical in determining the etiology of cerebrovascular events. We document a rare case of combined DVT, pulmonary embolism, intracardiac thrombus, PFO, and extracranial carotid arterial occlusion. Although the prevalence of DVT and intracardiac shunts alone is high, it is unclear from the literature which patients would benefit from PFO closure.

Transoesophageal echocardiography using the miniaturised multiplane probe during paediatric cardiac intervention in children below 5.5 kg – an initial experience

IntroductionUntil recently intra-operative transesophageal echocardiography (TOE) has not been feasible in neonates and small infants. TOE is routinely used intra-operatively at our institution in children >5.0 kg, below this weight...

Novel Use of Transesophageal Echocardiographic Probe for Intraoperative Epicardial Imaging

We studied 3 patients in whom standard transesophageal echocardiography was either not feasible nor offered suboptimal images. A standard multi-plane transesophageal echocardiography probe was covered in a sterile sheath containing ultrasonic gel, and the tip of the probe was placed on the beating heart by the surgeon. Echocardiographic imaging planes were selected by combining multi-plane imaging with "flexion" and "extension" of the probe by the echocardiographer, with minimal surgical manipulation. Good-quality "epicardial-transesophageal echocardiography" images were obtained in all cases, allowing effective decision-making by the surgeon. The small size of the probe and availability of multi-plane imaging allowed comprehensive and detailed imaging of the heart with minimal manipulation of the probe. There were no side effects attributable to the epicardial-transesophageal echocardiography. The new technique of epicardial echocardiography with a multi-plane transesophageal echocardiography probe overcomes the limitations of conventional transesophageal echocardiography and of epicardial echocardiography in selected patients and allows excellent visualization of cardiac structure and function with minimal interference with the surgical field, and with no extra expenditure.

Invited Commentary

It is with great interest and congratulations to the authors [1Zyblewski S.C. Shirali G.S. Forbus G.A. et al.Initial experience with a miniaturized multiplane transesophageal probe in small infants undergoing cardiac operations.Ann Thorac Surg. 2010; 89: 1990-1994Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar] that we engage this initial data regarding the newest tool to arrive on the scene of pediatric transesophageal imaging—now entering a third decade in which the development of small pediatric probes has allowed routine use in infants—with the potential for safe multiplane imaging evident now, even within the realm of low birth-weight infants.An appropriate priority for defining safety in the intraoperative setting is evident in this study's design. The hemodynamic data offered, although not all-encompassing, provide an initial assurance that within the scope of this experience, the multiplane microprobe is as well tolerated as its larger predecessors. We note that some relatively minor hemodynamic sequelae of probe insertion (eg, transient loss of upper extremity pulse) may not be detected in the scope of the methods outlined; however, the data obtained do give a broad assessment of probe safety and tolerance in the infant population that is reassuring.Confirmation of the fidelity of the imaging resolution provided by the multiplane microprobe, although not directly compared in this series with probes already in use, can also be reasonably inferred from the delineation of the expected detection of surgically relevant anatomic and physiologic data present in this surgical series. That inference seems particularly legitimate given the level of longstanding surgical imaging experience represented by these investigators and despite the limited numbers of an initial described experience.We look forward to further study and future data forthcoming in the group of infants weighing less than 2.0 kg (n = 2) because they represent particular challenges in regard to reliable probe placement and tolerance—with perhaps the most to gain from reliable intraoperative data in this era of increasing definitive repair of complex defects in very small infants. It is with great interest and congratulations to the authors [1Zyblewski S.C. Shirali G.S. Forbus G.A. et al.Initial experience with a miniaturized multiplane transesophageal probe in small infants undergoing cardiac operations.Ann Thorac Surg. 2010; 89: 1990-1994Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar] that we engage this initial data regarding the newest tool to arrive on the scene of pediatric transesophageal imaging—now entering a third decade in which the development of small pediatric probes has allowed routine use in infants—with the potential for safe multiplane imaging evident now, even within the realm of low birth-weight infants. An appropriate priority for defining safety in the intraoperative setting is evident in this study's design. The hemodynamic data offered, although not all-encompassing, provide an initial assurance that within the scope of this experience, the multiplane microprobe is as well tolerated as its larger predecessors. We note that some relatively minor hemodynamic sequelae of probe insertion (eg, transient loss of upper extremity pulse) may not be detected in the scope of the methods outlined; however, the data obtained do give a broad assessment of probe safety and tolerance in the infant population that is reassuring. Confirmation of the fidelity of the imaging resolution provided by the multiplane microprobe, although not directly compared in this series with probes already in use, can also be reasonably inferred from the delineation of the expected detection of surgically relevant anatomic and physiologic data present in this surgical series. That inference seems particularly legitimate given the level of longstanding surgical imaging experience represented by these investigators and despite the limited numbers of an initial described experience. We look forward to further study and future data forthcoming in the group of infants weighing less than 2.0 kg (n = 2) because they represent particular challenges in regard to reliable probe placement and tolerance—with perhaps the most to gain from reliable intraoperative data in this era of increasing definitive repair of complex defects in very small infants. Initial Experience With a Miniaturized Multiplane Transesophageal Probe in Small Infants Undergoing Cardiac OperationsThe Annals of Thoracic SurgeryVol. 89Issue 6PreviewThere has been reluctance to use intraoperative transesophageal echocardiography (TEE) in small infants. We assessed the utility and safety of a new miniaturized multiplane micro-TEE probe in small infants undergoing cardiac operations. Full-Text PDF

Initial Experience With a Miniaturized Multiplane Transesophageal Probe in Small Infants Undergoing Cardiac Operations

There has been reluctance to use intraoperative transesophageal echocardiography (TEE) in small infants. We assessed the utility and safety of a new miniaturized multiplane micro-TEE probe in small infants undergoing cardiac operations. Hemodynamic and ventilation variables were prospectively recorded before and after micro-TEE insertion and removal in infants weighing 5 kg or less undergoing cardiac operations. The study included 42 patients with a mean weight of 3.6 +/- 0.9 kg (range, 1.7 to 5 kg). All probe insertions were successful. There were no complications or clinically significant changes in hemodynamic or ventilation variables. Information provided by TEE resulted in surgical revision in 6 of the 42 patients. The micro-TEE provides high quality, useful diagnostic images without hemodynamic or ventilation compromise in small infants undergoing cardiac operations. This advance is important with the growing trend towards complete repair of complex structural heart disease in small infants.

Three-Dimensional Transesophageal Echocardiography Is a Major Advance for Intraoperative Clinical Management of Patients Undergoing Cardiac Surgery

Echocardiography is a key assessment tool for the evaluation of cardiac structure and function. The ability to image cardiac structures using 3-dimensional (3D) echocardiography is evolving. In this article, we present some of the key features of the emerging 3D technology and review its applications with an emphasis on real-time 3D transesophageal echocardiography.

Feasibility of transesophageal echocardiography in birds without cardiac disease

To establish a technique of transesophageal echocardiography (TEE) in birds without cardiac disease and describe the imaging planes obtained. Validation study. 18 birds including 3 pigeons (Columbia livia), 3 barred owls (Strix varia), 2 red-tailed hawks (Buteo jamaicensis), 1 goose (Anser anser), 1 mallard duck (Anas platyrhynchos), 1 Muscovy duck (Cairina moschata), 2 brown pelicans (Pelecanus occidentalis), 2 Hispaniolan Amazon parrots (Amazona ventralis), 2 red-fronted macaws (Ara rubrogenys), and 1 military macaw (Ara militaris). For each bird, anesthesia was induced and maintained by use of isoflurane. A pediatric, multiplane transesophageal ultrasound probe was passed into the esophagus and adjusted to the level of the heart for echocardiography. Probe positions were recorded via fluoroscopy, and associated imaging planes were described. TEE was performed successfully in all birds except the pelicans, 1 Hispaniolan Amazon parrot, and the red-fronted macaws. Five imaging planes of the heart were consistently viewed from 3 positions of the probe (identified as caudal, middle, and cranial positions relative to the cardiac silhouette). M-mode echocardiography of the left ventricle and the aortic root was performed. Color flow and spectral Doppler ultrasonographic images of in- and outflow regions were obtained. One Hispaniolan Amazon parrot died as a result of esophageal perforation. TEE examination of birds was feasible and provided a larger number of imaging planes with better resolution and details than those typically achieved via a transcoelomic approach. However, TEE should be performed with caution in psittacines.

Venous Air Embolism during Total Laparoscopic Hysterectomy

Total laparoscopic hysterectomy (TLH) has become a widely accepted alternative to total abdominal hysterectomy (TAH). The aim of this study was to compare the incidence and grade of venous air embolism (VAE) in TLH to those in TAH using transesophageal echocardiography. Eighty-two American Society of Anesthesiologists physical status I patients scheduled for either TLH or TAH were enrolled. After induction of general anesthesia, a multiplane transesophageal echocardiography probe was inserted. The midesophageal four-chamber or bicaval view was continuously monitored. An independent transesophageal echocardiography-certified anesthesiologist graded VAE. All patients undergoing TLH showed VAE, and 37.5% of patients had VAE grade higher than III. Fifteen percent of patients undergoing TAH showed VAE, and all of them were grade I. No patient in this study showed hemodynamic instability or electrocardiogram changes at the time of VAE occurrence. Most instances of VAE during TLH occurred during transection of the round ligament and dissection of the broad ligament. The incidence of VAE in patients undergoing TLH was 100%. VAE grade in TLH was higher compared to that in TAH, especially during transection of the round ligament and dissection of the broad ligament. Although the hemodynamic instability associated with VAE during TLH was not observed in this study, anesthesiologists must be vigilant for detection of VAE during TLH.

Lambl’s Excrescence on Aortic Valve Detected by Transesophageal Echocardiography

A 69-yr-old woman was scheduled for mitral valve replacement and coronary artery bypass graft surgery. Her medical history included mitral stenosis and a single coronary artery disease. She was given anticoagulation therapy for paroxysmal atrial fibrillation. Preoperative transthoracic echocardiography demonstrated mitral stenosis and trivial aortic regurgitation but no abnormal intracardiac structures. After induction of general anesthesia, we placed a transesophageal multiplane probe (Philips Electronics, Eindhoven, Netherlands). Two dimensional transesophageal echocardiography (TEE) confirmed doming and calcification of the mitral valve. Color flow Doppler imaging in the midesophageal long- and short- axis views demonstrated a trivial eccentric jet of aortic regurgitation from the commissure between the right and left coronary cusp. The midesophageal long-axis view showed the presence of a filamentous structure on the aortic valve (AV), which was not noticed by the preoperative transthoracic echocardiography. The structure was very thin, approximately 10-mm long, and was flapping in the aortic root (Figs. 1A and B), (Video clip 1; please see video clip available at www.anesthesia-analgesia.org).Figure 1.: A, Midesophageal long axis view. A flapping structure (arrow) on the aortic valve, which was flapping in the aortic root. B, Aortic valve short axis view. A stalk attached on left coronary cusp (arrow). Ao = aorta, LA = left atrium, LV = left ventricle.We first performed mitral valve replacement with a mechanical valve from the right atrium via the atrial septum. Second, we performed coronary artery bypass to the left anterior descending branch with the left internal thoracic artery. Third, we opened the ascending aorta to observe the flapping structure. The structure was attached to the free edge of the left coronary cusp. We decided to resect it to avoid systemic embolization and to confirm the diagnosis. The structure was a 12-mm fibrous tissue (Fig. 2). We presumed it was a flapping piece torn from the commissure between the right and left coronary cusp along the edge of the left coronary cusp. Because pathological examination revealed that the structure consisted of connective tissue covered by a single layer of endothelial cells, we diagnosed Lambl’s excrescence. After uneventful weaning from cardiopulmonary bypass, subsequent TEE confirmed that the filamentous structure on the AV was no longer present and the degree of aortic regurgitation remained trivial.Figure 2.: A picture of the resected flapping structure. Pathological examination revealed that the structure consisted of connective tissue covered by a single layer of endothelial cells.The differential diagnoses of the flapping structure in the AV included imaging artifact, vegetation, thrombus, redundant leaflet, flap due to aortic dissection, papillary fibroelastoma, and Lambl’s excrescence. The TEE imaging from multiple planes excluded a possibility of imaging artifact. We easily excluded the diagnosis of vegetation, because inflammatory findings and a history of infections endocarditis were absent. We also excluded thrombus because the structure was very thin and filamentous. We dismissed the possibility of a redundant leaflet or a flap due to aortic dissection, because three cusps of the AV were depicted clearly by TEE. The distinction between papillary fibroelastoma and Lambl’s excrescence was particularly difficult. Papillary fibroelastoma typically appears on echocardiography as a small pedunculated, homogenous, well-demonstrated mobile mass attached by a small stalk. Although these findings may be applied to Lambl’s excrescence, the stalk of papillary fibroelastoma has a broader base than Lambl’s excrescence. Papillary fibroelastoma has a jelly-like appearance, whereas Lambl’s excrescence consists of fibrous tissue. Lambl’s excrescences are valve strands and have a small mobile density of connective tissue. They are thin (<1 mm), long (>10 mm) filiform projections from heart valves and show undulating independent motion.1 They are more commonly seen on the mitral valve than on the AV, typically near the closure line of the mitral valve. Although it was first reported that they were composed of fibrin, morphologic analysis revealed collagen.1,2 Valve strands were reported in 39% of elderly patients who had TEE for suspected cardiogenic embolic stroke, giving an odds ratio (95% confidence interval) of ischemic stroke in patients with mitral valve strands of 2.2 (1.4–3.6; P < 0.005).3 In other studies, however, no relation between brain infarction or clinical embolic events and valve strands was demonstrated.4 Cohen et al. have shown that strands on native mitral valves do not increase the risk of recurrent brain infarction.5 More recent reports suggest that no specific treatment is needed in patients with stroke who had native valve strands as a single abnormality.6,7 However, we decided to resect the flapping structure to confirm a precise diagnosis. Further study is necessary to determine how to treat Lambl’s excrescence.

3D Echocardiography: A Review of the Current Status and Future Directions

Ultrasound technology has improved markedly in the past 10 to 15 years, prompting echocardiographers to extend its use in studying cardiac structure and function. New ultrasound equipment and techniques offer superior image quality, greater accuracy, and expanding capabilities. As a result, more and improved imaging modalities are available for evaluating cardiac anatomy, ventricular function, blood flow velocity, and valvular diseases. Threedimensional (3D) echocardiography offers the ability to improve and expand the diagnostic capabilities of cardiac ultrasound. However, as with any emerging technology, the enthusiasm to embrace a new technique must be tempered by a critical appraisal of the evidence supporting its use. It is essential to assess the limitations as well as the unique capabilities it provides. Cardiac imaging should be safe, accurate, versatile, comprehensive, and cost-effective, while providing important clinical information. Criteria for appropriate utilization should be based on current evidence and updated as new information becomes available. To justify the use of a new 3D modality, its unique contribution to clinical practice must be critically analyzed. In this article we review the status of 3D echocardiography, examine the evidence for its use in various clinical situations, and propose guidelines for appropriate application of this technique based on available evidence.

633 Improvement of the comprehensive analysis of mitral regurgitant jet with live three-dimensional color-flow doppler

s S97 Eur J Echocardiography Abstracts Supplement, December 2006 Technologies, with multiplane TEE probe. Fifteen patients had successful mitral valve repair and 35 patients required valve replacement. The echocardiographic data were compared with intraoperative findings. Results: An interpretable 3D image was obtained in 47 from 50 patients. There was an excellent correspondence between the echocardiographic characterization of the mitral valve morphology and surgical inspection. 3D TEE reconstruction correctly identified the lesions, as confirmed intraoperatively. The MR etiology was: mitral valve prolapse in 13 p, endocarditis lesions in 22 p, rheumatic disease in 6 p, and degenerative disease in 2 p. The patients with mechanical prosthesis underwent surgical correction for periprosthetic MR. Based on intraoperative findings, sensitivity for the diagnosis of MR mechanism using 3D TEE was 92% and specificity was 98%. Conclusions: In patients with significant MR, 3D echo offers a correct view of the entire valve, allowing a complete assessment of the mitral apparatus. This technique can be useful, an advantage to the surgeon in the surgical planning of mitral valve repair.

Transesophageal 3-dimensional versus cross-sectional echocardiographic assessment of the volume of the right ventricle in children with atrial septal defects

The study was designed to investigate the value of assessing right ventricular volume by transoesophageal 3-dimensional echocardiographic techniques compared with the standard transoesophageal cross-sectional approach. Echocardiography was performed using a multiplane probe. The 3-dimensional data sets were reconstructed after electrocardiographic and respiratory gated scanning, calculating the 3-dimensional volumes by the method of multiple slices. Cross-sectional determination of volume was performed using a modified area-length method, and the biplane multiple slice method following Simpson's rule. We studied 15 patients, with ages ranging from 6 to 19 years, and body surface areas from 1.1 to 1.67 square metres. It proved possible top determine volumes with both methods in all patients. As determined by 3-dimensional echo, volumes were greater, being 113.0 plus or minus 61.2 millilitres at end-systole, and 61.7 plus or minus 36 millilitres at end-diastole, than those calculated from cross-sectional images using Simpson's rule, which gave values of 92.5 plus or minus 52 millilitres, and 41.3 plus or minus 22 millilitres. Compared to the values obtained using the area-length method, at 116.9 plus or minus 61 millilitres, and 60.3 plus or minus 30 millilitres, there were only small differences at end-systole, with a bias of 1.4, and limits of agreement of 20.9 millilitres, as well as at end-diastole, when bias was minus 3.8, and limits of agreement 22.3 millilitres. Correlation was also good, with coefficients of 0.93, and 0.91, respectively. The mean difference between the volumes by 3-dimensional acquisition and the multiple slice method was larger, with higher limits of agreement, at end-diastole showing bias of 20.5, and limits of agreement of 30.1 millilitres, and for end-systole bias of 20.4, and limits of agreement of 32.2 millilitres. Our data confirm that cross-sectional echocardiographic assessment of right ventricular volumes in children with atrial septal defects is quick, and reasonably reliable in clinical practice when employing the area-length method.