Postoperative Transesophageal Echocardiography Research Articles

Experimental study of the bilateral asymmetric single-rivet occluder device for transcatheter patent foramen ovale closure with reserved interatrial septal puncture area.

To evaluate a noval bilateral asymmetric single-rivet occluder with reserved interatrial septal puncture area for treating patent foramen ovale (PFO). The study established a pig model of patent foramen ovale (PFO) by puncturing the oval fossa and then performing high-pressure balloon dilation. A specially designed bilateral asymmetric occluder for the reserved interatrial septal puncture area was then. used to close the PFO through catheter-based intervention. The pigs were kept for 3 months before undergoing a second catheter-based intervention, involving interatrial septal puncture using a newly developed occluder in the reserved interatrial septal puncture area. During 6 months, the experimental pigs underwent assessment using digital subtraction angiography (DSA), echocardiography, and histological evaluation. A patent foramen ovale (PFO) model was successfully established in 6 pigs using the puncture atrial septum high-pressure balloon dilation method. The diameter of the unclosed PFO was measured (3.56 ± 0.25 mm). Using the newly developed occluder device, all 6 pigs with unclosed PFO underwent successful catheter-based closure surgeries, with intraoperative and postoperative transesophageal echocardiography showing excellent device positioning and complete closure without residual shunting. After 3 months of implantation, the catheter-based interatrial septal puncture was performed through the reserved interatrial septal puncture area, and all procedures were successful. Immediately following euthanasia, a histological examination revealed intact and undamaged occluder devices with visible puncture holes in the reserved interatrial septal puncture area. No fracture of the nitinol wire was observed, and the surface of the occluder device showed coverage of endothelial and connective tissues. Utilizing a bilateral asymmetric single-rivet occluder device implanted through the reserved interatrial septal puncture area has proven effective in closing PFO. After implantation, the occluder device allows subsequent interatrial septal puncture procedures through the reserved area. The novel occluder device demonstrated excellent closure performance, biocompatibility, and puncturability in the experiment. This indicates the feasibility of conducting further catheter-based interventions on the interatrial septum.

Advancing paediatric cardiac imaging: a comprehensive analysis of the feasibility and accuracy of a novel 3D paediatric transoesophageal probe.

Pediatric transoesophageal echocardiography (TOE) probes have remained two-dimensional (2D) limiting their use compared to adults. While critical in pediatrics for interventions and post-surgery assessments, technological advancements introduced a three-dimensional (3D) pediatric TOE probe. This study assessed the new 3D pediatric TOE probe (GE 9VT-D) for feasibility, handling, and imaging quality. At Children's Hospital of Toulouse, 2-month prospective study enrolled children undergoing TOE with the new probe. All imaging modalities were rated by 2 operators using a 5-point Likert-type scale from 1 (very poor) to 5 (very good) quality. Forty-five children, median age 3.7 (range: 2 months-14.7 years) median weight 7.8 kg (range: 4.3-48 kg) underwent 60 TOEs: 25% pre-surgery, 45% post-surgery, 28% during percutaneous procedures, and 2% in intensive care. Probe handling was "very easy" in all cases without adverse events. The median score of 2D, 2D colour, pulsed Doppler and 3D were noted 5 out of 5 and continuous Doppler and 3D colour 4 out of 5. The 3D image quality remained consistent irrespective of the patient weighing above or below 7.8 kg (p = 0.72). Postoperative TOEs identified two cases needing further interventions, emphasizing its value in evaluating surgical outcomes and also for guiding percutaneous interventions. Our comprehensive evaluation demonstrates that the new 3D pediatric TOE probe is feasible and provides high-quality imaging in pediatric patients. The successful integration of this novel probe into clinical practice has the potential to enhance diagnostic accuracy and procedural planning, ultimately optimizing patient outcomes in pediatric cardiac care.

Bone cement migrated to the right heart resulting in perforation of the ventricular wall with cardiac tamponade.

An 85-year-old man came to our emergency department because of acute shock due to cardiac tamponade. Four days ago, he underwent percutaneous vertebroplasty of the T12-L4 spine because of a compression fracture of the vertebral body, and post-operative X-ray suggested a leakage of bone cement from the L1 vertebra (Panel A). Computed tomography revealed a linear-shaped hyperattenuated lesion extending from the right heart into the pericardial cavity accompanied by massive pericardial effusion (Panel B). The patient underwent emergency surgery after pericardial puncture. Intra-operative transoesophageal echocardiography revealed a strong echo in the right ventricle (Panel C; Supplementary data online, Movie S1). The pericardial cavity was opened and plenty of clots were found, the foreign body was found on the surface of the right ventricle with sharp exposed end and was pulled out, and the right ventricular wall was repaired (Panel D; Supplementary data online, Movie S2). The foreign body was hard, formed a needle-shaped, measured ∼6×0.3 cm, and was diagnosed as bone cement (Panel E). Post-operative transoesophageal echocardiography revealed no obvious residuum in the heart or vena cava. The patient was in good condition initially after the surgery, but later died of respiratory failure caused by a severe pulmonary infection.

Left atrioventricular valve repair after primary atrioventricular canal surgery: Predictors of durability

ObjectiveAcute outcomes after atrioventricular canal defects (AVCD) surgery in the current era are excellent; yet despite surgical advances, ∼15% of patients require future left atrioventricular valve (LAVV) repair. Among patients with AVC who undergo LAVV repair after primary AVC surgery, we sought to characterize the durability of these repairs. Specifically, we aimed to determine predictors for reintervention following an LAVV repair in patients with repaired AVCD, with a focus on postoperative transesophageal echocardiography (TEE). MethodsWe reviewed all patients undergoing LAVV repair (after a primary AVCD surgery) at Boston Children's Hospital between 2010 and 2020. Competing risk analysis was performed to evaluate cumulative incidence of LAVV reinterventions. Predictors of LAVV reintervention were evaluated using multivariable Cox regression. ResultsA total of 137 LAVV repairs following primary AVCD surgery were performed in 113 patients. Median age and weight at LAVV repair were 25 months (interquartile range, 12-76 months) and 11.1 kg (interquartile range, 7.8-19.4 kg). Original anatomy was complete AVCD in 87 (63%), transitional AVCD in 27 (20%), and partial AVCD in 23 (17%) cases. Over a median follow-up of 12 months (interquartile range, 1.3 months-4 years), 47 (34%) of the LAVV repairs required LAVV reintervention. Reinterventions included a total of 27 LAVV re-repairs and 20 LAVV replacements. In multivariable analysis, age at LAVV repair younger than 72 months, partial AVCD anatomy, left ventricle dysfunction, mean LAVV stenosis gradient ≥5 mm Hg, and multiple jets of regurgitation on postoperative LAVV repair TEE were associated with LAVV reintervention. Grade of LAVV regurgitation on postoperative TEE was not an independent risk factor, but reintervention rates were high when residual LAVV stenosis gradient was ≥5 mm Hg and residual mild LAVV regurgitation was present on postoperative TEE (47%) and even higher when residual LAVV stenosis gradient was ≥5 mm Hg and LAVV regurgitation was greater than mild (73%). ConclusionsReintervention rates remain high for LAVV repairs that occur after primary AVCD surgery, particularly for patients with LAVV stenosis gradient ≥5 mm Hg and mild or greater LAVV regurgitation on postoperative TEE.

PO-02-134 REAL WORLD CLINICAL MANAGEMENT AFTER SURGICAL LEFT ATRIAL APPENDAGE EXCISION

Surgical left atrial appendage (LAA) closure is an increasingly utilized approach to mitigate the risk of cardioembolic stroke in patients with atrial fibrillation (AF). Optimal stroke prevention management after surgical LAA management with respect to imaging and continuation of oral anticoagulation (OAC) is not well understood. To elucidate real world clinical management of patients undergoing surgical LAA management. Over a 7-year period at a single center, 458 participants carried a diagnosis of AF and underwent surgical exclusion of their LAA during concomitant cardiac surgery. Clinical follow-up, including transesophageal echocardiography (TEE) data and OAC use were catalogued via chart review. Success of LAA ligation was defined as maximal stump depth < 1.0 cm (with no distal leak) in all dimensions imaged. Of the 458 participants, 115 (25%) had a post-operative TEE (with average post-operative time of 36 weeks). Of these 115 patients, 95 were discharged from cardiac surgery on OAC and 83/115 (72%) had successful LAA closure by TEE criteria; 19/115 had inadequate closure and 13/115 did not have sufficient image quality to assess LAA closure. Among the 83 patients with TEE-verified successful LAA closure, 7 had stroke during follow-up; of these strokes 3/7 occurred within 4 weeks of cardiac surgery. Only 1/7 patients was not on OAC at the time of their stroke. (Table 1) Among the 83 patients with successful LAA closure, 70 had been discharged on OAC following cardiac surgery. Of these 47/70 subsequently had their OAC discontinued; 43/47 of those discontinuations occurred after the TEE. Most patients undergoing surgical LAA management do not receive follow-up TEE imaging. When TEE is performed, surgical excision of the LAA is shown to have a moderate success rate. Clinical management after surgical LAA management, with regard to LAA imaging and OAC continuation, is highly heterogeneous.

Percutaneous left atrial appendage closure using the LAmbre device in patients with atrial fibrillation and left atrial appendage thrombus.

Left atrial appendage closure (LAAC) is considered a valid alternative for the prevention of thromboembolic stroke in patients with persistent left atrial appendage thrombus (LAAT) despite adequate anticoagulation. However, the data on LAAC using the LAmbre device for patients with LAAT is limited. This study was performed to explore efficacy and safety as well as to share the experience of the modified LAAC procedure with the LAmbre device. A total of 7 patients with persistent LAAT despite adequate anticoagulation underwent modified LAAC with the LAmbre device between November 2019 and April 2022. Transesophageal echocardiography was performed 3 months postoperatively to detect device-related thrombosis and peridevice leak. The patients' clinical events were evaluated during the perioperative and follow-up periods. The median age, CHA2DS2-VASc score, and HAS-BLED score of all patients were 71 [53-73], 3 [2-4], and 2 [2-3], respectively. In the procedure, a cerebral protection system was used in two patients. LAAC with the LAmbre device was successfully performed in all patients without perioperative events. During the median follow-up of 383 [325-865] days, postoperative transesophageal echocardiography was performed in six (85.7%) patients. Device-related thrombosis was detected in one (16.7%) patient, and no significant peridevice leak was observed. No thromboembolic event or bleeding event occurred in any patients. LAAC with the LAmbre device is effective and safe when performed by experienced operators in highly selected patients with LAAT after adequate anticoagulation.

Abstract 10734: Percutaneous Closure of Aorto-Right Atrial Fistula: An Interesting Case of Marfan’s Syndrome and Fistula Formation

Case Presentation: A 43-year-old male with a history of Marfan’s syndrome, coronary artery disease and mitral valve endocarditis status-post mitral valve annuloplasty was admitted with NYHA class IV symptoms and cardiogenic shock. Two distinct color-flow jets on transesophageal echocardiography (TEE) supported evidence for fistulae formation at the aortic sinus and the right atrium (RA). After stabilization, closure options were discussed with the patient and a multi-disciplinary team including a cardiothoracic surgeon, structural heart disease specialist and heart failure specialist. Shared decision for percutaneous closure of the fistula was made. Figure 1A, demonstrates a peri-operative TEE with two distinct fistulae with color-flow jets emanating from the sinus of Valsalva into the RA. Each fistula orifice measured approximately 3mm in diameter with 5mm of separation. Under fluoroscopy, trans-aortic wire and sheath were used to cross a single fistula into the RA. An 18mm occluder device (Figure 1B and 1C), was deployed via transaortic into the RA. Intracardiac echocardiography revealed good device position and trivial jet. Post-operative TEE verified successful occlusion of both fistula. The patient tolerated the procedure and was discharged. He was seen in clinic two weeks post-discharge and reported resolution of his dyspnea. Conclusion: Aorto-atrial fistulas (AAF) are rare, complex and life-threatening; however, potentially treatable conditions. While most cases are acquired, congenital causes exist. This is an interesting case that illustrates a unique presentation of a rare condition and showcases potential for endovascular treatment. There are no randomized clinical trials and more scientific evidence is required to establish recommendations for a diagnostic and treatment algorithm. Until then clinical judgment with consideration for percutaneous closure seems a viable option.

Composite reconstruction of right ventricle and tricuspid valve for cardiac angiosarcoma

Composite reconstruction of right ventricle and tricuspid valve for cardiac angiosarcoma

Clinical application of percutaneous left atrial appendage occlusion guided only by transesophageal echocardiography without fluoroscopy and angiography in the patients with nonvalvular atrial fibrillation.

The objective of this study was to understand the clinical efficacy and application of the percutaneous left atrial appendage occlusion (PLAAO) guided only by the transesophageal echocardiography (TEE) in patients with nonvalvular atrial fibrillation (NVAF), without using the fluoroscopy and angiography. During the time period of this study from June 2020 to June 2021, 32 patients underwent PLAAO and all underwent a TEE guided approach. The anatomical features of the left atrial appendage (LAA) were evaluated and observed by TEE before and during the procedure. LAA occluder device was selected for the appropriate size. Intraoperative TEE guided and monitored the process of PLAAO in real-time, and also evaluated the stability and tightness of the occluder device, following monitored postoperative complications. The PLAAO procedure was successful in all the patients. No serious complications like dislocation of the occluder and embolism were seen. Postoperative TEE demonstrated that the PLAAO occluder devices were in a good position without residual shunting. PLAAO only guided by TEE may become a safe and reliable surgical procedure, which can protect surgeons and patients from radiation, and can gradually become a novel surgical method of PLAAO with the practical application value.

The prognostic value of transesophageal echocardiography after transvenous lead extraction: landscape after battle.

In patients undergoing transvenous lead extraction (TLE) transesophageal echocardiography (TEE) provide valuable information after procedure. We analyzed data from 936 TEE performed in patients undergoing TLE between 2015 and 2019 (mean follow-up 566.23±224.47 days) and assessed the role of echocardiographic phenomena after procedure. Increment in tricuspid regurgitation (TR) was observed in 9% of patients after TLE. Factors increasing the risk of TR were: binding sites between lead and right ventricle (RV) (OR: 5.429), tricuspid valve (TV) (OR: 3.42), superior vena cava (SVC) (OR: 3.30) and lead-to-lead adhesions (OR: 2.88). Predisposing factors of residual structures after TLE were: asymptomatic masses on the leads (AMEL) (OR: 1.68), binding sites between SVC and cardiac structures (OR: 1.72), and multiple leads (OR: 1.30). Probability of vegetation remnants increased in the presence of abandoned leads (OR: 7.91). The risk factors of tamponade were: dwell time of the oldest lead (OR: 1.17), lead-to-lead adhesion (OR: 22.47), binding sites between lead and TV (OR: 6.08), RA (OR: 11.50), SVC (OR: 4.47), higher LVEF (OR: 2.35; P=0.006), female gender (OR: 5.43), multiple leads (OR: 2.11), looped leads (OR: 4.90) and AMEL (OR: 6.42). The risk of lead fracture was increased by: lead-to-lead adhesion (OR: 5.69), fibrosis binding the lead to RV (OR: 5.16), RA (OR: 2.39) and dwell time of the oldest lead (OR: 1.068). The mortality rate was 11.97% during follow-up. The risk of death was increased by: severe TR and vegetation remnants. The most important phenomena evaluated after TLE are: tricuspid valve function, residual fibrosis and vegetation remnants, progression of pericardial effusion and retained lead fragments. Postoperative TEE provides information about the results of TLE and helps establish further management.

Transesophageal Evaluation of Reconstructive Surgery for Aortic Valve Stenosis

BACKGROUND: With transesophageal echocardiography (TEE), were evaluated morphological characteristics and early hemodynamic parameters of stentless three leaflets pericardial patch in patients with aortic stenosis (AS) undergoing aortic valve (AV) surgery.&#x0D; AIM: The aim of the study was to point the importance of two-dimensional and three-dimensional TEE imaging intra and early postoperatively.&#x0D; METHODS: At Zan Mitrev Clinic, 2002–2020, were included 377 patients following the actual guidelines of European Society of Cardiology for valvular disease, whereas patients with dilatation of aortic annulus, rheumatoid arthritis, and chronic program on hemodialysis were excluded from the study. Instead of using a standard prosthesis, we made a reconstructive surgery implanting three new created leaflets using bovine/equine pericardium by replacing destroyed valve cusps. Leaflets were implanted separately, using continuous sutures with two supported stitches and that is how real stentless AV without any stent or sowing ring was created. Intraoperative and post-operative TEE was performed.&#x0D; RESULTS: 377 pts with aortic valvular disease (211–56% male, and 166–44% female; 82–21, 75% with AS, 32–8, 49% with aortic insufficiency, and 263–69, 76% with combined stenosis and insufficiency) were included in the study. Post-operative TEE showed aortic morphology close to normal AV, average pressure gradient was 8 mmHg. 121 pts got a combination with aortocoronary bypass (2.3 grafts per pts). 4 patients were re-operated. Mortality rate was 12.46% (44 pts). Follow-up period was 18 years.&#x0D; CONCLUSIONS: Real stentless aortic bioprosthesis is with a close morphology and hemodynamic parameters as a normal valve. TEE such as tool for assessment of AV morphology, anatomy of aortic root, pre-, and intra-operative plays a pivotal role in guiding case selection, surgical planning, and in evaluating procedural success.

\u201cOne-stop shop\u201d: safety and efficacy of combining atrial septal defect occlusion and left atrial appendage closure for patients with atrial septal defect and atrial fibrillation

BackgroundOne-stop occlusion, which is defined as the combination of atrial septal defect [ASD] or patent foramen ovale [PFO] occlusion and left atrial appendage [LAA] closure, in patients with ASD/PFO and atrial fibrillation (AF) has not yet been investigated systematically. This study aimed to evaluate the safety and efficacy of one-stop occlusion in the treatment of adult patients with ASD/PFO and AF.MethodsInpatients with AF and ASD/PFO were recruited between August 2014 and April 2019. Preoperatively, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were conducted to identify the ASD/PFO size and margin, presence of thrombus in the LAA, and LAA orifice width and depth at 0°, 45°, 90°, and 135°. After confirmation of the indications of LAA closure (LAAC) and ASD/PFO occlusion, the procedures were performed simultaneously under general anesthesia. Oral anticoagulants were administered for 45–60 days, followed with regular evaluation of TTE and TEE.ResultsForty-nine patients (age, 65.6 ± 9.6 years) were recruited in this study, including 24 patients with ASD and 25 patients with PFO. They were treated with LAAC and ASD/PFO occlusion successfully. The mean ASD size and mean diameter of the ASD occluders were 14.2 ± 7.7 and 25.4 ± 8.5 mm, respectively. The mean PFO size was 3.5 ± 0.4 mm. The mean maximal LAA orifice width and depth were 20.5 ± 3.4 and 28.3 ± 3.6 mm, respectively. All patients were implanted with a Watchman device (diameter, 27.1 ± 2.9 mm). Postoperatively, all patients took anticoagulants orally for 45–60 days, and their mean postoperative follow-up duration was 29.0 ± 12.1 months. Postoperative TEE showed that all had normal positioning of the LAA and ASD/PFO occluders. At 45–60 days after operation, TEE showed that the LAA and ASD/PFO occluder were in the normal position; however, two patients who took warfarin and novel oral anticoagulants, respectively, have developed occluder thrombosis. After adjusted anticoagulant therapy, TEE showed that the thrombus disappeared at 6 months after operation.ConclusionOne-stop occlusion is safe and effective for the treatment of adult patients with ASD/PFO and AF. It is also feasible to administer warfarin or novel oral anticoagulants after operation.

Minimally invasive surgical repair for unroofed coronary sinus syndrome directed by three-dimensional transesophageal echocardiography

BackgroundThe recent remarkable development of cardiac imaging technology for unroofed coronary sinus syndrome has led to accurate preoperative diagnosis. We report a case of unroofed coronary sinus syndrome repaired via a minimally invasive approach, under the excellent command of three-dimensional transesophageal echocardiography.Case presentationA 77-year-old woman with hypertension was admitted for aggravation of bilateral leg edema and diagnosed with type III unroofed coronary sinus syndrome with Qp/Qs ratio of 1.6:1. The unroofed portion was detected at the atrial side between P2 and P3 of posterior mitral leaflet by preoperative three-dimensional transesophageal echocardiography. Right minithoracotomy was performed at the fourth intercostal space and cardiopulmonary bypass routinely established. Right atriotomy and left atriotomy incisions were made under antegrade cardioplegic arrest. The unroofed portion was revealed at the same location by preoperative transesophageal echocardiography and was clearly recognized only by endoscopy, not by direct vision. It was repaired by direct running suture under endoscopic visualization. We observed no blood cardioplegia leakage or mitral insufficiency, which was also confirmed by postoperative transesophageal echocardiography. The patient’s postoperative course was uneventful and she was discharged home 14 days after surgery without any residual shunt.ConclusionsSuccessful repair of unroofed coronary sinus syndrome was safely and effectively achieved by a minimally invasive approach supported by preoperative three-dimensional transesophageal echocardiography.

A new method of left atrial appendage occlusion for the prevention of thromboembolic complications in patients with atrial fibrillation during coronary artery bypass grafting

Aim. To optimize the surgical technique for left atrial appendage (LAA) occlusion in patients with atrial fibrillation (AF) during coronary artery bypass grafting.Material and methods. The study included 60 patients with atrial fibrillation (AF). The patients were randomly divided into 2 groups. In the first group of patients, LAA was closed using the developed two-suture technique. In patients of the second group, a purse string suture was applied to the LAA. All patients underwent transesophageal echocardiography (TEE) before surgery to rule out the presence of intracardiac blood clots. To assess the effectiveness of the method in the postoperative period, TEE was performed.Results. According to postoperative TEE, one case of LAA recanalization in each group was revealed (p&gt;0,05). In the second group, the residual LAA cavity after applying a purse string suture was revealed. During the follow-up period, there were no neurological complications and deaths.Conclusion. According to the study results, it was found that the proposed two-suture technique for LAA occlusion is not less effective than the purse-string suture. The developed technique of two-suture epicardial occlusion of LAA showed actual technical advantages, allowing to optimize this surgery in different categories of patients.

Reimplantation for annular stabilization in bicuspid aortic valve repair.

To review the outcomes of bicuspid aortic valve repair with the reimplantation technique. From 2006 to 2018, 46 patients with bicuspid aortic valve underwent the reimplantation procedure for aortic valve repair. Those patients were included in this study. The mean age was 45 ± 15years and 44 were male. Preoperative echocardiography showed a mean ventriculoaortic junction diameter of 28 ± 3mm. The mean diameter at the sinus of Valsalva was 41 ± 9mm. The minimum cusp height was 19 ± 3mm. Regarding cusp repair technique, central plication was used in 45 patients, free margin reinforcement in 10 patients, and patch repair in 4 patients. Follow-up was performed by annual echocardiography. There were no hospital deaths. All patients were found with either no/trivial or mild AR on postoperative transesophageal echocardiography. The postoperative ventriculoaortic junction diameter was 23 ± 2mm and 83 ± 17% preoperatively. Freedom from moderate AR was 85 ± 6% at 5years, and freedom from reoperation was 93 ± 4% at 5years. Reimplantation for bicuspid aortic valve repair showed acceptable mid-term outcomes.

Optimizing P2 Neochordal Length and Stability in Mitral Valve Repair With Use of a Polypropylene Loop.

Determining the optimal length of artificial chordae tendineae and then effectively securing them is a major challenge in mitral valve repair. Our technique for measuring and stabilizing neochordae involves tying a polypropylene suture loop onto the annuloplasty ring. We used this method in 4 patients who had moderate-to-severe mitral regurgitation from degenerative posterior leaflet (P2) prolapse and flail chordae. Results of intraoperative saline tests and postoperative transesophageal echocardiography revealed only mild insufficiency. One month postoperatively, echocardiograms showed trivial regurgitation in all 4 patients. We think that this simple, precise method for adjusting and stabilizing artificial chordae will be advantageous in mitral valve repair.

Aortic Valve Repair: Baku Experience

Objective: Aortic valve repair could represent an alternative to valve replacement resulting in optimal hemodynamic conditions and avoiding anticoagulation. We analysed our results of aortic valve repair due to leaflets and root pathology. Methods: Between 2004-2019, we operated 74 patients with aortic valve and aortic root disease. Mean age was 49.2±14.7 years. 10 (13.5%) of them were females and 64 (86.5%) males. 18 (24.3%) patients were admitted with isolated aortic valve pathology. 15 (20.3%) patients had urgent operation for type A acute dissection, 14 (18.9%) aortic root aneurysm and 21 pts (28.4%) aortic root and ascending aortic aneurysm. All patients had peri-operative transesophageal echocardiography (TEE). We performed 18 (24.3%) isolated aortic valve repair operations, 38 (51.4%) reimplantation procedures, 16 (21.6%) remodeling procedures and 2 (2.7%) aortic valve repair and extraaortic ring implantation. The spectrum of valve repair techniques included free margin plication, subcomissural annuloplasty, resuspension, autologuos pericardial patch, leaflet replacement, neocomissura, decalsification, and comissurotomy. Results: Post-operative TEE showed trivial or grade I regurgitation for all patients. There were 2 (2.7%) in-hospital deaths (both had David procedure in acute Type A aortic dissection). Mean hospital stay was 8±4 days. Mean follow-up period was 49±11 months. In this period, we lost 1 patient (1.3%). Late echocardiography in the remaining 71 patients revealed mild aortic insufficiency in 66 patients (92.9%), moderate in 4 (5.6%), and moderate-severe in 1 patient (1.4%). Echocardiography confirmed the durability of the valve repair. Conclusions: Aortic valve repair operations, either as an isolated valve repair or in combination with surgery of the root, is an effective procedure with excellent mid-term and long-term outcomes without significant valve-related complications. KEYWORD: e-PD-49 The authors do not declare any conflict of interest.

Interventricular septal hematoma complicating placement of a ventricular assist device in an infant and support with bi-atrial cannulation.

Interventricular septal hematoma complicating placement of a ventricular assist device in an infant and support with bi-atrial cannulation.

Discussion

Discussion

P1455 Succesfully surgical management of "transit thrombus"

Abstract A 74-year-old woman was admitted in the emergency department in November 2018 for dyspnea, sudden chest pain and hemodynamic instability. Se had a previous history of pelvic fracture in September 2018, complicated with subdural hematoma secondary to therapeutic anticoagulation that wassurgically managed in October 2018. A through pulmonary arteries CT revealed massive pulmonary thromboembolism with right ventricle overload and pulmonary infarction. Because of history of cerebral hemorrhage, fibrinolytic treatment was ruled out and surgical approach of pulmonary embolism was decided. An intraoperative transesophageal echocardiogram demonstrates a thrombus in the right atrium (Figure 1A, yellow arrow), with invasion through the interatrial septum through a patent foramen ovale (Figure 1B, yellow arrow) with extension to mitral valve plane in the left ventricle (Figure 1C, yellow arrow). "Transit thrombus" was removed, patent foramen ovale was closed and bilateral pulmonary embolectomy was performed. In postoperative transesophageal echocardiography, no residual thrombus in cardiac chambers was seen and the closure of the foramen ovale was checked (Figure 1D). During the postoperative period, the patient presented cardiac tamponade, treated with pericardial drainage. Once this complication was overcome, the evolution was satisfactory and the patient could be discharged. This case demonstrates that performing a transesophageal echocardiogram before a surgical embolectomy in the setting of pulmonary embolism is essential. It allows detect the presence of cardiac thrombi, assess the interatrial septum integrity (where the CT has limitations), and allows to guide the surgical treatment. Abstract P1455 Figure.