Multiplane Transesophageal Echocardiography Research Articles

Tricuspid leaflet identification on 2D multiplane transoesophageal echocardiography: lessons from 3D

Abstract Funding Acknowledgements Type of funding sources: None. Background —Tricuspid valve (TV) leaflet identification by two-dimensional (2D) transoesophageal echocardiography (TOE) is complex due to the high variability of the combinations of leaflets visualized in each view. While three-dimensional (3D) imaging can easily overcome this problem by acquiring the whole valve anatomy, the overall image quality is often suboptimal and the technique somewhat unsuitable for real-time monitoring during interventional procedures like TriClip implantation. Using information derived from both 2D and multiplanar reconstruction (MPR) of 3D datasets, we aimed at describing anatomical landmarks able to identify TV leaflets easily and effectively during multiplane 2D TOE. Methods —TOE data from 83 patients was retrospectively collected. Multiplane 2D images of the TV and matching 3D datasets recorded from the same probe position were compared to precisely identify the leaflets visualized on each 2D image. To increase the number of multiplane (orthogonal) 2D images available for analysis, a novel approach was used: the 3D data of each patient was appropriately sliced to simulate and accurately match what would be seen by "sweeping" the cursor across the TV during real-time multiplane imaging (Fig. 1). After data analysis, a comprehensive "two-step" reference table was generated. To evaluate the clinical utility of the findings, eleven (11) echocardiographers were shown a random set of 5 images, and asked to label the leaflets visualized, prior and after a brief explanation on how to use the proposed reference table. Results —After removal of redundant information, a total of 231 sets of leaflets combinations was obtained. The number of leaflets visualized (one or two) and the presence (or absence) of the interventricular septum allowed consistent identification of the TV leaflets depicted in the 2D home view, as confirmed by correlation with the matching 3D MPR dataset. A similar analysis was carried out on the orthogonal 2D images resulting from three different multiplane cursor positions (distal, mid, and proximal to the aortic valve/interventricular septum). By combining information from the two views, leaflet identification was accurate, intuitive and easy, as summarized in the reference table (Fig. 2). The accuracy in exact leaflet recognition was rather modest (mean score of 1 out of 5) among echocardiographers with different experience in TV TOE, but significantly increased (mean score of 3.2 out of 5) with the adoption of the proposed approach, accounting for a 44% improvement in accuracy (p <0.001). Conclusion — Simple anatomical landmarks allow precise TV leaflet identification during multiplane 2D TOE. A simplified two-step approach significantly improves accuracy in leaflet recognition among both beginners and advanced echocardiographers.

Disturbances of the ascending aorta biomechanics in moderate dilatation and aneurysm

Aim. To compare disturbances of the ascending aorta (AA) biomechanics in pa­­tients with moderate dilatation and aneurysm using segmental aortic strain ultrasound.Material and methods. Fifteen patients with moderate AA dilatation (40-49 mm), 17 patients with AA aneurysm (≥50 mm) and 11 healthy volunteers (AA<40 mm) were examined using 2D multiplane transesophageal echocardiography (TEE). The entire thoracic aorta (TA) was assessed. Using 2D speckle-tracking TEE, global peak systolic circumferential strain (GCS, %), global peak systolic circumferential strain normalized to pulse pressure (GCS/PP) and aortic stiffness (β2) index at 4 TA levels (sinuses of Valsalva, sinotubular junction, mid-ascending aorta, descending aorta) were calculated.Results. In healthy volunteers with TA diameter of 26,6 mm (25,2; 28,4) unidi­rec­tional uniform GCS of 9,7% (8,4; 11,7), GCS/PP of 18,4 (14,9; 2,.6) and uniform aortic stiffness (β2) 5,9 (4,8; 6,7) in all TA segments were revealed. There was a pro­portionally significant decrease in deformation parameters up to negative values and an increase of the ascending aortic wall stiffness from the aortic annulus to the descending aorta with a maximum in the highest dilatation zone in patients with moderate dilatation and aneurysm. Moreover, in these patients aortic wall strain and stiffness did not differ in all TA segments (p>0,05). The AA diameter in maximum dilatation zone in patients with aneurysm was significantly higher than in patients with moderate dilatation — 52 mm (51; 55) versus 47 mm (45; 48), p<0,001, respectively. An inverse correlation between the AA diameter in maximum dilatation zone and aortic strain (GCS: r=-0,61; p<0.001 and GCS/PP: r=-0,62; p<0,001) and a direct correlation with the aortic stiffness (β2) index (r=0,56; p<0,05) were revealed.Conclusion. Assessment of the aortic biomechanics along with the AA diameter has an independent diagnostic value when choosing an individual surgical strategy in patients with moderate dilatation and AA aneurysm.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Left atrial appendage orifice dimensions in Japanese atrial fibrillation population measured by multiplane transesophageal echocardiography.

Successful implantation of the WATCHMAN device requires an accurate understanding of left atrial appendage (LAA) anatomy and orifice dimensions. Racial differences are observed in LAA size when comparing Asians with non-Asians. A total of 170 patients (123 male, 67.4 ± 9.2years) with paroxysmal or persistent atrial fibrillation (AF) underwent transesophageal echocardiography before catheter ablation or cardioversion (September 2018 to September 2019). As per the recommendations of the WATCHMAN device, the maximal LAA ostial diameters were measured at multiplane angles of 0°, 45°, 90°, and 135°. The majority of patients (121/170, 71%) had an LAA orifice size within 17-25mm. Fifteen (8.8%) patients had undersized (< 17mm) and eight (0.5%) had oversized (> 31mm) LAA. One patient in this population had no LAA. LAA size was significantly larger in patients with persistent AF than in those with paroxysmal AF (23.3 ± 4.2mm vs. 20.0 ± 3.0mm, p < 0.001) and in male patients than in female patients (22.4 ± 4.2 vs. 20.9 ± 3.7mm, p = 0.03). LAA orifice dimension was significantly correlated with CHADS2 score, the left atrial volume (LAV), E/e', and the left ventricular ejection fraction. Persistent AF, body mass index, and LAV were independently associated with LAA orifice dimension in multivariate analysis. This study demonstrated the distribution of LAA orifice dimension in the Japanese AF patients. This finding should be used as a reference to understand the racial characteristics of LAA size for the WATCHMAN procedure.

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 &amp;gt;3–5 mm (no mobile/ulcerated components), 4 - atheromas &amp;gt; 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 &amp;lt; 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 &amp;lt; 0,001 and 3D r = 0,30, p &amp;lt; 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 &gt;3-5 mm (no mobile/ulcerated components), 4 - atheromas &gt; 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&lt;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&lt;0,001 and 3D rs =0,30, p&lt;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.

Intraoperative Transthoracic Echocardiography for a Neonate Using an Adult Multiplane Transesophageal Echocardiography Probe

Miura, Daisuke MD*; Yamada, Yasutaka MD*; Nakao, Misaki MD*; Sakaguchi, Yoshiro MD†; Mizuno, Keiichiro MD‡ Author Information

Removal of liver tumors extending in the right atrium without extracorporeal assistance

Abdominal tumors associated with thrombus formation in the IVC are related to a poor prognosis, especially if the thrombus extends to the right atrium (RA). Complete surgical resection of the tumor and thrombus is considered the only chance of potential cure; however it is challenging for the surgeon. Usually, sternotomy or thoracotomy with extracorporeal cardiopulmonary bypass (CPB) has been necessary to perform the intrathoracic IVC isolation and finally remove the thrombus thus preventing any emboli from forming. But this procedure is both complex and associated with a high post operative risk inherent mainly to the CPB and circulatory arrest. Surgical resection of the tumor with thrombus formation in the inferior vena cava extending to the right atrium (2–2'5 cm) can be performed without the use of cardiopulmonay bypass. However, this technique is unknown to most of general surgeons We described the surgical technique, avoiding a thoracic access and CPB, therefore decreasing post-operative morbidity and mortality: Surgical steps (Figs. 1, 2): 1) Abdominal approach. 2) Liver vascular control. 3) Intra-pericardial IVC isolation through transdiaphragmatic approach under a multiplane transesophageal echocardiography (TEE), 4) Tumor resection combined with IVC resection (If it is necessary) an 5) Removal intracaval and intra-atrium tumor trmbi.

Right and left atrial appendage function in patients with atrial septal aneurysm without patent foramen ovale.

Atrial septal aneurysm (ASA) is a risk factor for arterial embolism. Despite prior reports concerning paradoxical embolism through a patent foramen ovale, atrial dysfunction and atrial arrhythmias might represent an additional mechanism for arterial embolism.The aim of this study was to evaluate right and left atrial appendage contractilty in patients with ASA. A total of 30 patients with ASA (10 males/20 females, mean age 50.2 +/- 15.3 years) and 30 controls (12 males/ 18 females, mean age 47.7 +/- 10 years) were included. Conventional transthoracic and multiplane transoesophageal echocardiography were performed in patient and control groups. Flow and myocardial velocity were measured in both atrial appendages. Baseline characteristics of both groups were comparable. Flow velocity and myocardial contraction velocity in both atrial appendages were significantly lower in ASA patients. Compared to the control group, patients with ASA had a larger length, base and area of both appendages. In ASA patients right and left atrial appendage function are impaired. Biatrial dysfunction may cause arrhythmia and thromboembolism.

Abstract 425: Is Adventitial Thickening a Pathogenic Factor in Aortic Atherosclerosis?: A Controlled Transesophageal Echocardiographic Study

Background: Aortic (Ao) atherosclerosis is common in systemic lupus erythematosus (SLE), is best assessed by transesophageal echocardiography (TEE), and is characterized by increased intima-media thickness (IMT) and plaques. Although TEE may also allow characterization of Ao adventitial thickness (AT), there is limited data on the pathogenic role of adventitial thickening in Ao atherosclerosis. Methods: 68 SLE patients (62 women, age 36 ± 12 years) and 25 age-and-gender matched healthy controls (22 women, age 34 ± 11 years) underwent multiplane TEE. At a depth of 3-4 cm using narrow sector scan, 2-dimensional guided M-mode images were obtained to assess the presence of plaques, IMT outside of plaques, AT outside of plaques, and AT in plaques at three different levels of the thoracic Ao (proximal, mid, distal). At each aortic level, 3 IMT and 3 AT measurements were taken during end diastole using electronic calipers. These measurements were then averaged. Unaware of subjects’ clinical data, one observer assessed for IMT and plaques while a second observer assessed AT. For purpose of analysis, intima-media thickening was defined as &gt;1 mm which is &gt;2SD above the corresponding overall mean IMT in controls (0.66 ± 0.17 mm), and adventitial thickening as &gt;1.07 mm which is &gt;2SD above the corresponding overall mean AT in controls (0.81 ± 0.13 mm). Plaques were defined as focal-protruding IMT &gt;50% of the surrounding vessel wall at any aortic level. Results: As shown in Table 1A, intima-media thickening and plaques were greater in patients than in controls. Similarly, adventitial thickening was more common in patients than in controls. In addition, AT was greater in patients with intima media thickening, plaques, and intima-media thickening or plaques ( Table 1B) . Furthermore, AT was greater in plaques than AT outside of plaques ( Table 1C ). Conclusion: Adventitial thickening is a pathogenic factor of Ao atherosclerosis in SLE.

Hemodynamic assessment of ventilated ICU patients with cardiorespiratory failure using a miniaturized multiplane transesophageal echocardiography probe.

To assess the feasibility, image quality, diagnostic accuracy, therapeutic impact and tolerance of diagnostic and hemodynamic assessment using a novel miniaturized multiplane transesophageal echocardiography (TEE) probe in ventilated ICU patients with cardiopulmonary compromise. Prospective, descriptive, single-center study. Fifty-seven ventilated patients with acute circulatory or respiratory failure were assessed, using a miniaturized multiplane TEE probe and a standard TEE probe used as reference, randomly by two independent experienced operators. Measurements of hemodynamic parameters were independently performed off-line by a third expert. Diagnostic groups of acute circulatory failure (n = 5) and of acute respiratory failure (n = 3) were distinguished. Hemodynamic monitoring was performed in 9 patients using the miniaturized TEE probe. TEE tolerance and therapeutic impact were reported. The miniaturized TEE probe was easier to insert than the standard TEE probe. Despite lower imaging quality of the miniaturized TEE probe, the two probes had excellent diagnostic agreement in patients with acute circulatory failure (Kappa: 0.95; 95% CI: 0.85-1) and with acute respiratory failure (Kappa: 1; 95% CI: 1.0-1.0). Accordingly, therapeutic strategies derived from both TEE examinations were concordant (Kappa: 0.82; 95% CI: 0.66-0.97). The concordance between quantitative hemodynamic parameters obtained with both TEE probes was also excellent. No relevant complication secondary to TEE probes insertion occurred. Hemodynamic assessment of ventilated ICU patients with cardiopulmonary compromise using a miniaturized multiplane TEE probe appears feasible, well-tolerated, and relevant in terms of diagnostic information and potential therapeutic impact. Further larger-scale studies are needed to confirm these preliminary results.

The role of Flexi Slice imaging by real time 3D transesophageal echocardiography in measurement of left atrial appendage in patients with atrial fibrillation

Objective To measure left atrial appendage (LAA) in patients with atrial fibrillation using Flexi Slice imaging by real time 3D transesophageal echocardiography(TEE), and compare with common multiplane TEE. Methods Forty-six patients with atrial fibrillation were performed 2D and real time 3D TEE. Zero degree, 45°, 90° and 135° plane were acquired by 2D TEE and Flexi Slice remolding. Maximum and minimum values of ostium of left atrial appendage were acquired in the short axis view of LAA by Flexi Slice remolding. Results Compared with 2D TEE, values acquire by Flexi Slice in measurement of LAA ostium showed no significant difference(P>0.05). The depth measurement by Flexi Slicein 45° and 90° plane showed significant difference with 2D TEE(P-values were successively 0.045, 0.002), and in 0 and 135° plane showed no difference. All values measured by 2D TEE and Flexi Slices showed significant correlation. Bland-Altman plot showed that 94.29% of plots were among limits of agreement, which was (–2.5 mm, 2.9 mm). The maximum values of LAA ostium values ranged from 30° to 160°, among which 87%(40/46 cases) distributed between 90° and 150°, and minimum values ranged from 0° to 160°, among which 85%(39/46 cases) distributed between 0° and 60°. Conclusions Measurement of LAA can be well achieved by Flexi Slice imaging, which showed significant advantage compared with 2D TEE. Key words: Echocardiography, real-time three-dimensional; Echocardiography, transesophageal; Atrial fibrillation; Atrial appendage

Abstract 632: Premature Aortic and Carotid Stiffness in Systemic Lupus Erythematosus: Which One is First or Worse?

Background: Increased aortic and carotid stiffness are common in patients with systemic lupus erythematosus (SLE) and are associated with increased morbidity and mortality. Although the aorta and carotid arteries have different anatomy, hemodynamics, and cardiovascular disease implications, it is unknown whether stiffness affects these arterial beds in a parallel or divergent fashion. Methods: 43 SLE patients (41 women, age 36 ± 11 years) and 17 age-and-sex matched healthy volunteers (14 women, age 34 ± 12 years) underwent clinical and laboratory evaluations and multiplane transesophageal echocardiography and carotid ultrasonography for assessment of aortic and carotid stiffness, respectively. Stiffness at the proximal, mid, and distal thoracic aorta and stiffness of the right common carotid artery were assessed using a standard Pressure-Strain Elastic Modulus, defined as = k (sBP – dBP)/[(sD - dD)/dD)] where k = conversion factor from mmHg to Nm -2 (Pascal units), sBP = systolic blood pressure, dBP = diastolic blood pressure, sD = systolic diameter, and dD = diastolic diameter. Results: Aortic stiffness was significantly higher in SLE patients than in controls after adjusting for age and atherogenic risk factors (7.96 ± 4.16 versus 5.77 ± 2.32 units, p = 0.01). However, carotid stiffness was similar in patients and controls (6.39 ± 2.70 versus 5.55 ± 2.68 units, p = 0.29). In SLE patients, aortic stiffness was significantly higher than carotid stiffness (7.96 ± 4.17 versus 6.39 ± 2.70 units, p = 0.02). In relation to age at diagnosis of SLE, aortic stiffness occurred earlier and was greater than carotid stiffness (RM ANCOVA, p = 0.03). Conclusion: Aortic stiffness is higher and precedes carotid stiffness in young adult SLE patients. These findings of an accelerated and divergent pathogenesis of aortic as compared to carotid stiffness may be explained by SLE-related chronic or recurrent autoimmune-mediated inflammation and thrombogenesis superimposed on the severe anatomic curvature, higher pulse pressure, and higher reciprocating shear stresses of the aorta as compared to the nearly straight and less oscillating shear forces of the carotid arteries.

Real time three-dimensional transesophageal echocardiographic evaluation of aortic valve perforation.

This study evaluated the feasibility of real time three-dimensional transesophageal echocardiography (RT3DTEE) in the diagnosis and localization of aortic valve perforation. Aortic valve perforation was diagnosed in 12 patients by multiplane two-dimensional transesophageal echocardiography (2DTEE). We studied the feasibility of RT3DTEE using en face view in detection and precise localization of the aortic valve perforation. The artifactual dropout on RT3D images of aortic valve can mimic perforation and lead to a false positive diagnosis. We defined a true perforation as the hole with thicker margin and its visibility in both systole and diastole. We combined the RT3D images from 10 subjects with relatively normal aortic valve without perforation (test group) with the 12 with perforation for a blind review by an experienced echocardiographer. There were 14 perforations in 12 patients. The perforation was located in the left coronary cusp in 1, the noncoronary cusp in 7, and the right coronary cusp in 6 patients. In the subgroup of 9 patients with 11 perforations, all were confirmed at surgery. In test group the artifact mimicking perforation was frequently encountered (7/10 or 70%). However, they did not meet the criteria for true perforation except in 1 (1 false positive). All true perforations were correctly recognized. En face imaging with RT3DTEE can be used to confirm aortic valve perforation and its spatial location. However, RT3D should be used as an extension to comprehensive 2DTEE and color flow imaging.

GW25-e2227 Correlation Analysis of Transesophageal Echocardiographic Parameters and Atrial Fibrillation Thromboembolism Risk Scoring

By analyzing the correlation of multiplane transesophageal echocardiography (TEE) parameters and atrial fibrillation (AF) thromboembolism risk assessment scoring system (CHADS2 and CHA2DS2-VASc), discuss the potential value of TEE parameters in predicting the risk of thromboembolism in atrial

Frequency and Significance of Right Atrial Appendage Thrombi in Patients with Persistent Atrial Fibrillation or Atrial Flutter

Atrial fibrillation (AF) and atrial flutter (AFL) are strong atrial thrombosis (THR) risk factors. In recent-onset tachyarrhythmias, the incidence of left atrial appendage (LAA) THR, detected by transesophageal echocardiography (TEE), has been widely studied, ranging from 6% to 18% (AF) and 4% to 11% (AFL). On the contrary, few studies have assessed right atrial appendage (RAA) THR, and there is no information on the relation between the RAA flow characteristics and the presence of RAA THR. The aims of this study were to evaluate the incidence of RAA THR in a population of patients undergoing TEE-guided cardioversion for recent-onset atrial tachyarrhythmias and to analyze RAA Doppler flow and its relation to thrombus formation. From 1998 to 2012, patients admitted to the emergency department for persistent, non-self-terminating atrial tachyarrhythmia lasting >2days who gave informed consent for TEE-guided cardioversion were prospectively enrolled in the study. Among 1,042 patients, complete anatomic and functional studies of the LAA and RAA were feasible in 983 (AF, n= 810 [23%]; AFL, n= 173 [5%]). The presence of RAA and LAA THR, appendage emptying velocities, and the presence of severe spontaneous echocardiographic contrast were studied. The overall incidence of atrial THR was 9.7% (96 of 983). The incidence of THR was 9.3% (91 of 983) in the LAA and 0.73% (seven of 983) in the RAA (P<.01). In the AF and AFL groups, the incidence of LAA THR was 10.3% (83 of 805), compared with 0.75% (six of 805) for RAA THR (P<.01). Among patients with AFL, the incidence of LAA THR was 6% (10 of 178), compared with 0.6% (one of 178) for RAA THR (P<.01). The mean LAA peak emptying velocity was 24cm/sec (range, 10-32 cm/sec) in patients with LAA THR, compared with 38cm/sec (range, 20-59 cm/sec) in those without THR; the mean RAA peak emptying velocity was 17±7cm/sec in patients with RAA THR, compared with 34±13 cm/sec in those without THR (P<.001). RAA thrombi are significantly less frequent than LAA thrombi but may reach large dimensions. Multiplane TEE allows RAA morphologic and functional assessment. Before TEE-guided cardioversion, both the LAA and the RAA must be routinely studied.

Comparison of Transesophageal Echocardiography Versus Computed Tomography for Detection of Left Atrial Appendage Filling Defect (Thrombus)

Patients with atrial fibrillation, who are referred for radiofrequency pulmonary vein antral isolation, frequently undergo transesophageal echocardiography (TEE) to detect and/or exclude left atrial or left atrial appendage (LAA) thrombus and cardiac computed tomographic angiography (CCTA) to define and/or evaluate left atrial and pulmonary venous anatomy. Previous studies have reported CCTA to have high sensitivity and negative predictive value (NPV) for detecting thrombus in the LAA. Previous studies determining an optimal LAA/ascending aorta (AA) Hounsfield unit (HU) density ratio for detection of LAA thrombus have been small, with limited numbers of thrombi. We thus sought to determine both the optimal cutoff for LAA HU density and LAA/AA HU density ratio in detecting LAA thrombus compared with TEE in a multicenter population. We included 84 patients who had undergone CCTA and TEE. LAA was evaluated by 64-row CCTA qualitatively (visual filling defect) and quantitatively (measurement of LAA HU density and LAA/AA HU density ratio), using a 1-cm area of interest in the same axial plane. Results were compared with TEE visualization of thrombus or spontaneous echo contrast. Qualitative identification of thrombus in LAA by CCTA compared with TEE detection of thrombus had a sensitivity of 100%, a specificity of 77.9%, a positive predictive value (PPV) of 51.6%, an NPV of 100%, and a total accuracy of 82.1%. The optimal LAA HU density cutoff for thrombus detection was 119 with a sensitivity of 88%, a specificity of 86%, PPV 56%, and an area under the curve of 0.923 (p = 0.0004). The optimal LAA/aorta HU ratio was 0.242 with a sensitivity of 87%, a specificity of 88%, a PPV of 64%, and an area under the curve of 0.921 (p = 0.0011). There is no significant difference (p = 0.72) between both areas under the curve, and both measurements improved the specificity and PPV compared with qualitative measures. Multidetector computed tomography is an imaging technique that can exclude LAA thrombus with very high NPV. Quantitative measurement of LAA HU density (cutoff 119) or LAA/aorta HU density ratio (cutoff 0.242) improves accuracy of positively detecting LAA thrombus. This technique is especially useful when delayed scanning is not performed and LAA is found incidentally after the patient scanning is complete.

Positioning of the ablation catheter in total endoscopic ablation

Minimally invasive ablation of atrial fibrillation is an option in patients not suitable for or refractory to catheter ablation. Total endoscopic ablation can be performed via a monolateral approach, whereby a left atrial box lesion is created. If the ablation is introduced from the right side, the positioning of the ablation catheter on the partly hidden left pulmonary veins is of vital importance. Using thoracoscopy in combination with multiplane transoesophageal echocardiography, the anatomical position of the ablation catheter can be established. Our experience in over 60 procedures has confirmed this to be a safe technique of total endoscopic ablation.

Differences of morphological and functional characteristics of patent foramen ovale between patients with and without cryptogenic brain ischemia

Purpose: To assess in a prospective study whether morphological and functional parameters of Patent Foramen Ovale (PFO) differ between patients with and without cryptogenic ischemic stroke or Transient Ischemic Attack (TIA). Methods: A total of 331 consecutive patients with cryptogenic brain ischemia underwent contrast multiplane transesophageal echocardiography (265 patients with ischemic stroke and 66 patients with TIA). The control group consisted of 312 consecutive patients without the history of stroke or TIA. We analysed 103 patients (64 male; mean age 52,9±12,3 years) with cryptogenic cerebrovascular event and PFO (Group I; 31,1% of all patiens with brain ischemia) and compared them to 56 control patients (19 male; mean age 50,0±12,7 years) with PFO (Group II; 18,0% of the control group). Following parameters were investigated: diameter of the PFO, length of the PFO, presence of the atrial septal aneurysm, presence of the Eustachian valve, shunt severity (graded with a 1-3 scale). Diameter and length of the channel were correlated with the shunt severity. Results: Patients with cryptogenic brain ischemia had significantly larger PFO diameter and higher prevalence of large PFO (≥ 4 mm) compared to the control group (2,5±1,6 mm vs 2,1±1,1 mm, p < 0,05; 17,5% vs 5,3%, p < 0,05). There was no significant difference between Group I and Group II in prevalence of the atrial septal aneurysm (14,6% vs 21,4%) and Eustachian valve (4,9% vs 7,1%), in the tunnel length (13,7±5,4 mm vs 12,8±5,8 mm) and in the degree of the shunt (1,8±0,7 vs 1,8±0,8). Both groups did not differ in the proportion of the shunt identified only after the Valsalva manoeuvre (41,7% vs 51,8%). There was a significant correlation between the PFO diameter and the degree of the shunt in patients with brain ischemia (r = 0,54, p < 0,0001). A weak but significant correlation was found between the tunnel length and the degree of the shunt in these patients (r = 0,21, p < 0,05). Morphological and functional parameters of PFO were not different between patients with ischemic stroke and TIA. Conclusions: The results may support the hypothesis that the decisive characteristic of the PFO distinguishing the patients with cryptogenic brain ischemia and asymptomatic patients is the diameter. Symptomatic patient have significantly larger PFO diameter and higher proportion of large PFO. The PFO diameter positively correlates with the degree of the shunt. Symptomatic and asymptomatic patients did not differ in the tunnel length, in the degree of the shunt and in the prevalence of atrial septal aneurysm or Eustachian valve.