Real-time 3D Transesophageal Echocardiography Research Articles

Mitral valve early systolic billowing induces following annular expansion and leaflet augmentation in Barlow's disease: sequential analysis using 3D echocardiography.

Although systolic expansion of the annulus has been recognized in Barlow's disease, the mechanisms of the unique pathological movement of the annulus and its relation to the leaflet augmentation have not yet been clarified. We aimed to investigate the detailed mechanisms of the characteristic mitral apparatus dynamics in Barlow's disease by frame-by-frame sequential geometric analysis using real-time 3D transoesophageal echocardiography. Fifty-three patients with Barlow's disease and severe mitral regurgitation without torn chordae, as well as 10 controls, were included. We evaluated geometric changes in the mitral complex using 3D transoesophageal echocardiography at five points during systole. To identify early systolic billowing of leaflets, the annulo-leaflet angle was measured. We also performed a more detailed analysis in four consecutive frames just before and after leaflet free-edge prolapse above the annulus plane. The median annulo-leaflet angle of both leaflets in early systole was >0° (above annulus plane) in patients with Barlow's disease, and billowing of the leaflet body was observed from early systole. The prolapse volume of both leaflets increased markedly from early to mid-systole [1.60 (0.85-2.80) to 4.00 (2.10-6.45) mL; analysis of variance (ANOVA), P < 0.001; post hoc, P < 0.05]. With frame-by-frame analysis, dynamic augmentation of the annulus and leaflets developed between frames just before and just after leaflet free-edge prolapse (ANOVA, P < 0.01; post hoc, P < 0.05). In Barlow's disease, early systolic billowing of the mitral leaflet induces systolic annulus expansion followed by leaflet augmentation and leaflet free-edge prolapse.

Real-time 3D Transesophageal Echocardiography for the Placement of Ventriculoatrial Shunt: A Case Series and Technical Note.

Ventriculoatrial (VA) shunts are used to manage hydrocephalus and idiopathic intracranial hypertension when peritoneal drainage of cerebrospinal fluid is not feasible. The technique of distal catheter placement during VA shunt insertion is controversial, especially between fluoroscopy-guided and transesophageal echocardiography (TEE)-guided techniques. We retrospectively reviewed our utilization of 2-dimensional (2D) ultrasound-guided internal jugular vein catheterization combined with 3-dimensional (3D) TEE-guided distal VA shunt placement and compared it to the conventional fluoroscopy-guided technique. Ten patients underwent 18 VA shunt insertion procedures between November 2012 and October 2022. The patients had a mean (SD) age of 50 (19) years, body mass index of 35 (14)m/kg², and minimal comorbidities. All had previously undergone failed ventriculoperitoneal shunt procedures. The use of 2D ultrasound to guide internal jugular vein catheterization and 3D TEE to guide distal catheter placement resulted in 22-minute shorter surgical times compared with the fluoroscopy-guided technique (91 minutes vs. 113 minutes, respectively). No complications were noted with either technique. The combined use of 2D ultrasound and 3D TEE allowed for faster procedure times and more precise distal catheter confirmation, contributing to a more streamlined surgical procedure. This small case series underscores the feasibility, efficiency, and safety of anesthesiologist-delivered combined 2D ultrasound and 3D TEE during VA shunt insertion. The use of 3D TEE allows repeated confirmation of distal catheter position and has potential to improve patient safety during rare but complex VA shunt insertion procedures.

Three-dimensional Echocardiography during Percutaneous Mitral Balloon Valvuloplasty

Percutaneous mitral balloon valvuloplasty (PMBV) has been frequently used as an alternative to open or closed surgical mitral commissurotomy for the treatment of selected patients with symptomatic rheumatic mitral stenosis. PMBV has been proven a safe and effective method, often performed under fluoroscopic guidance. With the advent of three-dimensional echocardiography (3DE), interventional cardiologists have been able to successfully perform complex procedures such as paravalvular leak closure, transcatheter edge-to-edge repair of the mitral valve (MV) using MitraClip, etc. With the expertise derived from these procedures, 3DE has received considerable interests in many other procedures, including PMBV. Pre-, intra-, and postprocedural assessments of the mitral valve (MV) area; commissural splitting; the presence, degree, and location of mitral regurgitation; and other procedure-related complications can be more accurately and readily made using 3DE. In addition, real-time 3D transesophageal echocardiography has been proven to be more accurate than two-dimensional (2D) techniques in identifying specific MV abnormalities associated with complex diseases. Moreover, real-time 3DE offers the advantage of shorter fluoroscopy and radiation times throughout PMBV. This article reviews the use of 3DE during PMBV in light of the most recent literature and based on expertise and discusses the pros and cons of 3DE, with emphasis on its superiority to conventional 2D echocardiography.

Three-Dimensional Transesophageal Echocardiography in Percutaneous Catheter-Based Cardiac Interventions.

Cardiac structural and valve interventions have remained surgical procedures for several decades. The ability to directly visualize the region of interest during surgery made imaging of these structures pre- and postsurgery a secondary tool to compliment surgical visualization. The last two decades, however, have seen rapid advances in catheter-based percutaneous structural heart interventions (SHIs). Due to the "blind" nature of these interventions, imaging plays a crucial role in the success of these procedures. Fluoroscopy is used universally in all percutaneous cardiac SHIs and helps primarily in the visualization of catheters and devices. However, success of these procedures requires visualization of intracardiac soft tissue structures. Due to its portable nature and rapid ability to show cardiac structures online, transesophageal echocardiography (TEE) has become an integral tool for guidance for all percutaneous SHI. Transcatheter aortic valve replacement-one of the earliest catheter-based procedures-while initially dependent on TEE, has largely been replaced by preprocedural cardiac CT for accurate assessment of valve sizing. Developments in echocardiography now allow live three-dimensional (3D) visualization of cardiac structures mimicking surgical anatomy during TEE. Besides showing actual 3D intracardiac structures, 3D-TEE allows visualization of the interaction of intracardiac catheters and devices with soft tissue cardiac structures, thereby becoming a "second pair of eyes" for the operator. Real-time 3D-TEE now plays an important role complementing multiplane two dimensional and biplane TEE during such interventions. In this review, we discuss the incremental role of 3D-TEE during various SHIs performed today.

Mapping of the myxomatous mitral valve: The three-dimensional extension of mitral annular disjunction in surgically repaired mitral prolapse.

This study aimed to describe the heterogeneous extension of mitral annular disjunction (MAD) and assess the hypotesis that different phenotypes of disjunction are not associated with increased surgical challenges. Mitral regurgitation (MR) is the most common end-stage scenario of degenerative mitral valve disease (DMVD). Few data exist on the three-dimensional extension and geometry of MAD, as well as for its role in valvular dynamic and coaptation. A total of 85 consecutive subjects, who underwent elective mitral valve repair (MVR) for MMVD at our Institution between November 2019 and October 2021, were studied retrospectively. The extension and geometry of MAD was assessed using the digitally stored volumetric datasets of real-time 3D transesophageal echocardiography (TEE). Annular phenotypes and surgical repair techniques were analyzed. Mitral annular disjunction was diagnosed in 50 out of 85 patients (59%) with Barlow disease (BD). A detailed analysis of MAD extension was conducted on 33 patients. Two pattern of disjunction were identified: a bimodal shape was highlighted in 21 patients, while a more uniform distribution of the disjuncted annulus was observed in 12 patients. The bimodal pattern was characterized by lower disjunction distance (DD) at the 140°-220° arch (3.6 ± 2.2 mm), while a more regular DD was measured in the remaining patients. All patients successfully underwent MVR. Triangular leaflet resection was performed in 58% of the cases, neochordae implantation in 9%, and notably a 27% received an isolated annuloplasty. Rather than a binary feature, MAD should be taken into account in its complex and heterogeneous morphology, where two major phenotypes can be identified. Despite its anatomical complexity, MAD was not associated with an increased surgical challenge; conversely a peculiar subgroup of patient was successfully treated with an isolated annuloplasty.

Real-time 3D echocardiographic transilluminated imaging combined with artificially intelligent left atrial appendage measurement for atrial fibrillation interventional procedures.

Aims: This study investigated the feasibility and accuracy of real-time three-dimensional (3D) echocardiographic transilluminated imaging (TrueVue Glass) in left atrial appendage (LAA) anatomical morphology and artificial intelligence (AI)-assisted 3D automated LAA measurement (3D Auto LAA) software in the preoperative evaluation of LAA occlusion (LAAO) in patients with atrial fibrillation (AF). Method and results: Thirty-seven patients with AF were selected. Two-dimensional (2D) and real-time 3D transesophageal echocardiography (RT3D-TEE) were performed preoperatively, using conventional 3D, the new 3D TrueVue Glass mode, and cardiac computed tomography angiography (CCTA) to assess and type the morphology of LAA. Physiological parameters were measured using traditional 2D and 3D manual (3D Manual LAA), 3D Auto LAA, and CCTA. TrueVue Glass for LAA outer contour display was compared with CCTA. Comparisons were based on correlation and consistency in measuring the maximum diameter (LZ max), minimum diameter (LZ min), area (LZ area), and circumference (LZ cir) of LAA landing zone (LZ). Times and variabilities were compared. The concordance rate for external shape of LAA was 97.14% between TrueVue Glass and CCTA. 3D Auto LAA and 3D Manual LAA have a stronger correlation and higher consistency in all parameters. 3D Auto LAA showed higher intra- and interobserver reproducibility and allowed quicker analysis (p < 0.05). LAAO was performed in 35 patients (94.59%), and none of which had serious adverse events. Conclusion: TrueVue Glass is the first non-invasive and radiation-free visualization of the overall external contour of LAA and its adjacent structures. 3D Auto LAA simplifies the measurement, making the preoperative assessment more efficient and convenient while ensuring the accuracy and reproducibility. A combination of the two is feasible for accurate and rapid assessment of LAA anatomy and physiology in AF patients and has practical application in LAAO.

Transesophageal Echocardiography (TEE)-Guided Paravalvular Leak (PVL) Closure: Expanding Horizons Beyond Operating Room

AbstractParavalvular leak (PVL) is a common, yet challenging entity occurring due to dehiscence of the annular tissue around the prosthetic valve, resulting in regurgitation of blood retrogradely. Although any prosthetic valve can be subjected to the risk of developing PVL, it is most commonly reported with the mitral valve followed by the aortic valve. The incidence of mitral PVL is around 7 to 17%, whereas with the aortic valve it is 5 to 10%. Symptomology can vary from asymptomatic patients with mild PVL to disabling symptoms pertaining to heart failure and hemolysis. TEE plays a pivotal role in the overall assessment along with procedural guidance for their closure. Multiple two-dimensional (2D) imaging views are required to scan the entire sewing ring diameter of a prosthetic valve. Three-dimensional (3D) TEE can give crucial information such as the number, size, shape, and circumference of the defects. 3D mitral en face view can give anatomical localization of the defect. During the procedure, TEE can assist in the confirmation of the position of the guidewire through the defect and not through the prosthetic valve. It also helps to conform to the adequate positioning of the vascular plug device and unrestrictive movement of the native prosthetic heart valve. TEE when combined with fluoroscopy can help in real-time guidance of passage of the guidewire and transcatheter device in relation to the prosthetic valve. Recently, Ahmed et al have named this technology as “Fusion Technique,” where they have combined real-time 2D and 3D TEE with fluoroscopy to facilitate the closure of PVL. Now that the time of minimally invasive surgery has taken over conventional surgery and fast tracking and enhanced recovery after surgery (ERAS) is the need of the moment, percutaneous PVL closure is preferred over surgical PVL closure. A study done by Gakrinho et al showed that percutaneous PVL closure has a reasonable success rate along with a low complication rate and the results are comparable to surgical treatment in high-risk patients. We hereby share our experience of the successful closure of PVL via the transcatheter technique using various 2D and 3D techniques.

C40 THREE–DIMENSIONAL FINGER TEST: A NEW ECHOCARDIOGRAPHIC METHOD TO LOCATE THE BEST ACCESS SITE DURING NEOCHORD PROCEDURE

Abstract Background The NeoChord procedure is a trans–ventricular, beating–heart chordal implantation for severe degenerative mitral valve regurgitation due to prolapse or flail leaflet and it is performed using a dedicated device (DS 1000 system, NeoChord, Inc. St. Louis Park, MN). The use of the transesophageal echocardiography (TEE) is crucial to guide the procedure. Bi–dimensional (2D) imaging completed with simultaneous biplane view during surgeon finger pushing on the LV wall (finger test) is currently used to choose the LV access, which is usually on the mid–distal infero–lateral wall (ILW), between the papillary muscles (PMs) at the inferior level of their insertion on LV wall. This simulation helps the operators to evaluate the safe distance to PMs to minimize the risk of damaging the sub–valvular apparatus during the insertion of the device. We aimed to compare a new 3D method with the conventional one in terms of safety and better localization of the desired entry site. Methods During the procedure finger test has been performed with conventional 2D imaging and simultaneous biplane method. It has been completed using the real time 3D TEE placing the sample box in the bi–commissural view of the LV including the PMs and the apex. The resulting 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator finger pushing on the desired segment of the LV wall. We asked the first operator, the second operator and the cardiac surgery fellow, separately, to evaluate location of their finger pushing, in terms of desired position and safety of access, both with 2D method and the 3D method to estimate the inter–operator concordance. Results From March 2019 to September 2021 42 consecutive cases have been performed using finger test completed with 3D method without complications related to the trans–ventricular access. Regarding the choice of the right and safe entry site, the percentage of agreement between operators was higher using LV real time 3D rendering compared to the conventional finger test [82 + 21% Vs 59% + 29%, IC 95%, p: 0,04]. Conclusion Three–dimensional finger test is easy to perform and decreases inter–operator variability of image interpretation facilitating the surgeons to choose the best entry site in term of anatomical localization and safety.

Role of three-dimensional imaging techniques in the management of transcatheter closure of complex atrial septal defects

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitario Reina Sofia. Instituto de investigación biomédica Maimonides Introduction Percutaneous closure is nowadays considered the treatment of choice of ostium secundum atrial septal defects (ASD) but complex defects may be a challenging. In the last years, the imaging techniques used for ASD assessment have improved considerably, allowing therapeutic approaches in patients with complex morphological features particularly in those with absence of rims. However, there are no studies about the impact of 3D imaging techniques on transcatheter closure of ASD as compared with 2D imaging along time . Purpose To compare the impact of real time 3D Transesophageal echocardiography (3D-RT TEE) and cardiac computed tomography (CCT) on the profile as well as on the success rate of transcatheter closure of complex ASD as compared to 2D imaging. Methods We selected 106 adults patients suffering from ASD of complex anatomy (large≥30 mm, multiple, multifenestrated, aneurysmal, or deficiency of posterior or inferior rims) from 1998 to 2020. Along this time, we compared closure success rate, morphological characteristics, and procedure complications after ASD transcatheter closure. We defined closure success rate as a complete closure without complications. In our study, ASD assessment and further intervention was performed by two-dimensional transesophageal echocardiography (2D-TEE) from 1998 to 2007 (n = 66), whereas 3D-RT TEE and CCT was performed from 2008 to 2020 (n= 40). Results The type of ASD complexity was different between the two diagnostic approaches. Thus, those patients management by 2D-TEE showed more number in large ASD (40,9%), multiple-ASD (34,8%), fenestrated (10,6%), aneurysmal (7,6%) and with lower ring deficiency (6,1%) as compared to those with 3D-RT TEE and CCT (10%, 25%, 15%, 15%, and 35%, respectively, p &amp;lt; 0,05). Although no significant differences were observed, patients from the 2D group needed a second surgical closure more frequently than those treated with 3D-RT TEE and CCT (12,1% vs 5%, p = 0.31). In our study, there were few complications (10 (9,4%), with no significant differences according to the imaging technic used (2D-TEE group: 3 device embolisms, 2 cardiac tamponade, 2 complications of the femoral access; 3D-RT TEE and CCT group: 2 device embolisms and 1 complication of the femoral access. All of them were resolved intraprocedure. Importantly, closure success was higher in those patients manage by 3D-RT TEE and CCT in comparison to 2D-TEE (88% vs. 67%, respectively, p &amp;lt;0.05). Conclusion Transcatheter closure of complex ASD is a secure procedure. However, the use of 3D TEE and cardiac CT improves the success rate of this approach as compared to 2D-TEE and changes the profile of complex ASD treated by transcatheter closure in favor of those with absence of some rims

Real-time 3D transoesophageal echocardiography visualization of congenital double orifice mitral valve.

Real-time 3D transoesophageal echocardiography visualization of congenital double orifice mitral valve.

Role of 3D Transesophageal Echocardiography for Transcatheter Mitral Valve Repair-A Mini Review.

Edge-to-edge transcatheter mitral valve repair (TMVr) using MitraClip has been evolving rapidly in patients with severe mitral regurgitation (MR) at high surgical risk or having contraindications for surgery. Three-dimensional (3D) echocardiography plays an important role in the management of severe MR. In particular, 3D transesophageal echocardiography (TEE) imaging allows the evaluation of MV geometry and quantification of MR severity with dedicated software. Real-time 3D TEE is also commonly used to guide TMVr and facilitate the procedure. Further development of 3D echocardiography may help achieve safer and more beneficial results. The following article summarizes the current knowledge and the future perspectives of 3D TEE in TMVr.

Real-time 3D transesophageal echocardiography for the assessment of secundum atrial septal defects in children

Real-time 3D transesophageal echocardiography for the assessment of secundum atrial septal defects in children

Assessment of atrial septal defect using 2D or real-time 3D transesophageal echocardiography and outcomes following transcatheter closure.

BackgroundThe assessment of interatrial septum (IAS) requires a standardized, systematic approach, including two-dimensional transthoracic echocardiography (2D TTE), 2D transesophageal echocardiography (2D TEE), and three-dimensional (3D) TEE. Although 2D TEE has been widely used for the preoperative assessment of atrial septal defect (ASD), its ability to provide reliable information is often limited due to the structural characteristics of IAS. The introduction of 3D TEE provides a unique “en face” view of IAS, which allows the visualization and accurate measurements of diameters, area, and rims of ASD. Hence, appropriate ASD imaging information is particularly important in successful transcatheter closure.MethodsIn this retrospective study, 2D TTE/TEE, and 3D TEE were performed before ASD closure, with 2D minimal and maximal diameters, areas, and residual rims being recorded. Adequate 3D TEE imaging data sets were collected and then analyzed. ASD related parameters were compared using different echocardiography. Patients who underwent ASD closure completed a clinical follow-up.ResultsThe mean defect maximal diameter and aperture area by 3D TEE was significantly larger than that of the corresponding 2D TEE (P<0.05). There was no statistical difference in the minimal and maximal diameter or area by TEE for circular-shaped ASDs. For oval ASDs, mean minimal diameter on 2D TEE was larger than that on 3D TEE. The mean maximal diameter measured using 2D TEE was smaller than the 3D TEE measurement (16.0±7.1 vs. 19.8±8.6; P<0.05). For complex-shaped defects, there were statistical differences in minimal and maximal diameter between TEEs. Furthermore, 2D and 3D TEE had a longer superior vena cava (SVC) residual rim than did 2D TTE (P<0.05). The 3D TEE residual rims of the inferior vena cava (IVC) was significantly larger than the corresponding 2D TEE. There was a very strong correlation between the residual rim measurements using 3D and 2D TEE. However, the limits of agreement between 2D and real-time 3D TEE measurements were more apparent in the IVC rim group than in the other groups.ConclusionsOur study confirms the value of 3D TEE in assessing ASD shape and size reported by previous studies, and is also the first to accurately and systematically characterize ASD residual rim in complex ASDs.

Three-dimensional transesophageal echocardiography in diagnosis of intermediate atrioventricular septal defect in the adult: case report and literature review

BackgroundIntermediate type atrioventricular septal defect is less frequent than complete or partial atrioventricular septal defect, and is rarely encountered in the elderly and the utility of three dimensional transesophageal echocardiography in the diagnosis has not been reported to date.Case presentationIn this case report, we described a rare case of an intermediate atrioventricular septal defect in an adult patient and we showed the valuable utility of real time 3D transesophageal echocardiography in the diagnosis and future surgical planning. The patient was referred to a tertiary center for an elective surgical repair. Finally, we provided a detailed review of the literature concerning the intermediate type of atrioventricular septal defect.ConclusionAlthough 2D transthoracic and transesophageal echocardiography enables diagnosis of the intermediate type atrioventricular septal defect, precise assessment of anatomy of atrioventricular septal defects and common atrioventricular valve was enabled only by real time 3D echocardiography.

Comparison of Four Different Techniques for Estimation of Left Ventricular Volumes Using Intraoperative Real Time Three Dimensional Transesophageal Echocardiography--A Prospective Observational Study

The primary objective of the present study was to compare cardiac output derived with four methods of QLab (Philips, Amsterdam, Netherlands) software using real-time three-dimensional (3D) transesophageal echocardiography, with cardiac output obtained with the 3D left ventricular outflow tract (LVOT) cardiac output method. The secondary objective was to assess left ventricular (LV) volumes, LV ejection fraction, and cardiac output derived with four different methods of real time 3D transesophageal echocardiography processed in QLab software and to determine whether these parameters differed among these four methods. A prospective observational study. A tertiary referral center and a university level teaching hospital. The study comprised 50 patients scheduled for elective coronary artery bypass surgery without any concomitant valvular lesions. Three-dimensional full-volume datasets were obtained in optimum conditions. The 3D datasets were analyzed using four different methods in QLab, version 9. In method A, LV volumes were derived without endocardial border adjustment. In method B, LV volumes were obtained after endocardial border adjustment in the long-axis view alone. In method C, the iSlice tool (Philips) was used to adjust the endocardial borders in 16 short-axis slices. In method D, endocardial borders were adjusted after dataset processing to obtain LV volumes. The cardiac output derived with the 3D echocardiography LVOT method was 3.93 ± 1.44 L/min, with method A was 3.26 ± 1.42 L/min, with method B was 3.51 ± 1.2 L/min, with method C was 4.01 ± 1.40 L/min, and with method D was 4.18 ± 1.58 L/min. There was a significant positive correlation between the cardiac output derived using the 3D LVOT method and method C (r = 0.71). Readjusting the endocardial border contours resulted in higher LV volumes than the volumes estimated using semiautomated border algorithms. The iSlice method produced the highest and the most accurate LV volumes, although it required the longest time to analyze and derive results. The ejection fraction obtained with all four methods of QLab demonstrated no statistical differences and had a strong correlation with the two-dimensional echocardiography-derived left ventricular ejection fraction.

Real-time three-dimensional transesophageal echocardiographic guidance versus fluoroscopic guidance for transvenous temporary cardiac pacemaker implantation during transcatheter aortic valve implantation surgeries.

BackgroundFluoroscopic guidance is the traditional method for the implantation of transvenous temporary cardiac pacemakers (TVTPs). This study aimed to compare the time, effectiveness, and safety of real-time three-dimensional transesophageal echocardiography (3D TEE) with those of fluoroscopy in guiding TVTP implantation.MethodsThe records of patients who underwent transcatheter aortic valve implantation (TAVI) guided by real-time 3D TEE or fluoroscopy between July 1, 2016, and June 30, 2020, were retrospectively analyzed. TVTPs were implanted by anesthesiologists via the right internal jugular vein (IJV) in the real-time 3D TEE-guided group (3D TEE group), and by interventional cardiologists via the femoral vein in the fluoroscopy-guided group (fluoro group).ResultsA total of 143 patients (3D TEE-group n=79, and fluoro group n=64) were included. No statistical differences were observed in the baseline characteristics of the two groups. TVTPs were successfully implanted in all of the patients. The needle-to-pace time was significantly shorter in 3D TEE group than in fluoro group (5.2±2.9 vs. 8.5±4.6 min, P<0.001). Further, the incidence of access complications was significantly lower in 3D TEE group than in fluoro group (3.8% vs. 12.5%, P<0.05). One patient in fluoro group who suffered cardiac perforation underwent drainage via pericardiocentesis. No patients in either group died because of TVTP placement. The total complication rates were significantly lower in 3D TEE group than in fluoro group (19.0% vs. 39.1%, P<0.05). No statistically significant differences existed between groups in terms of pacing threshold, the incidence of permanent pacemaker insertion after surgery, the length of postoperative intensive care unit (ICU) stay, or the duration of postoperative hospitalization.ConclusionsReal-time 3D TEE-guided can be used to effectively, quickly, and safely guide TVTP implantation. The procedure can be performed by properly trained anesthesiologists. Therefore, real-time 3D TEE is a suitable option for guiding perioperative TVTP implantation in patients undergoing cardiac surgery.

"Pulmonary Valvular Endocarditis in the Patient with Pulmonary Stenosis A Case Report with Real-Time 3DTEE& MDCT-640"

Pulmonary valvular stenosis is usually an isolated congenital anomaly and occurs in 7% to 12% of patients with congenital...

Understanding Non-P2 Mitral Regurgitation Using Real-Time Three-Dimensional Transesophageal Echocardiography: Characterization and Factors Leading to Underestimation

P2 prolapse is a common cause of degenerative mitral regurgitation (MR); echocardiographic characteristics of non-P2 prolapse are less known. Because of the eccentric nature of degenerative MR jets, the evaluation of MR severity is challenging. The aim of this study was to test the hypotheses that (1) the percentage of severe MR determined by transthoracic echocardiography (TTE) would be lower compared with that determined by transesophageal echocardiography (TEE) in patients with non-P2 prolapse and also in a subgroup with "horizontal MR" (a horizontal jet seen on TTE that hugs the leaflets without reaching the atrial wall, particularly found in non-P2 prolapse) and (2) the directions of MR jets between TTE and real-time (RT) three-dimensional (3D) TEE would be discordant. One hundred eighteen patients with moderate to severe and severe degenerative MR defined by TEE were studied. The percentage of severe MR between TTE and TEE was compared in P2 and non-P2 prolapse groups and in horizontal and nonhorizontal MR groups. Additionally, differences in the directions of the MR jets between TTE and RT 3D TEE were assessed. Eighty-six percent of patients had severe MR according to TEE. TTE underestimated severe MR in the non-P2 group (severe MR on TTE, 57%; severe MR on TEE, 85%; P<.001) but not in the P2 group (severe MR on TTE, 79%; severe MR on TEE, 91%; P=.157). Most "horizontal" MR jets were found in the non-P2 group (85%), and this subgroup showed even more underestimation of severe MR on TTE (TTE, 22%; TEE, 89%; P<.001). There was discordance in MR jet direction between two-dimensional TTE and RT 3D TEE in 41% of patients. Non-P2 and "horizontal" MR are significantly underestimated on TTE compared with TEE. There is substantial discordance in the direction of the MR jet between RT 3D TEE and TTE. Therefore, TEE should be considered when these subgroups of MR are observed on TTE.

Pulmonary valvular endocarditis in the patient with pulmonary stenosis: A case report with Real-time 3DTEE&amp; MDCT-640

Pulmonary valvular endocarditis in the patient with pulmonary stenosis: A case report with Real-time 3DTEE&amp; MDCT-640

Transesophageal guidance for trans-catheter trans-septal mitral valve in valve implantation

Introduction In patients with high surgical risks, transcatheter mitral valve-in-valve replacement (VIV-TMVR) offers a less invasive alternative to open surgical approach for failing mitral bioprosthetic valves (1). Valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) in failing aortic valve bioprosthesis is already an established technique worldwide (2). Transesophageal echocardiography (TEE) plays a vital role in the intraoperative management of these cases. Here we describe the approach to TEE evaluation and guidance of VIV-TMVR. Methods TEE is used for full assessment of the heart pre-procedurally as well as throughout the procedure to guide the placement of the new mitral valve and at the end to assess the integrity of the placement and to detect any complications.Both 2D B and color doppler modes as well as real-time, zoom and full volume 3D TEE modalities can be used to serve different purposes. Results Successful placement of an Edward Sapien S3 Valve (29 mm) under TEE guidance Discussion Pre-procedurally, severity and etiology of the bioprosthetic mitral valve disease should be confirmed using TEE (Fig 1A) as well as identification of factors that would contraindicate a VIV-TMVR such as infective endocarditis, severe paravalvular leak, bioprosthetic valve dehiscence or significant prosthesis-patient mismatch. It is also imperative to complete a baseline assessment of the right and left ventricular size and function, left atrial size and look for any pericardial effusion. During the procedure, TEE may rarely be used for guidewire placement into the IVC by the interventional cardiologists. Next, a combination of bicaval (90-110°) and aortic short axis (30-45°) views are used to guide the cardiologist to puncture the interatrial septum. The ideal site for puncture in these cases is determined in mid systole to be posterior and superior on the septum about 3-4 cm above the mitral annular plane. (Fig 1B) The puncture and passing of guidewire into the left atrium is followed by the passing of the valve deployment system, all of which are easily visible on TEE toggling between 2D and live 3D modes. (Fig 1C,D&E) Post-deployment TEE assessment include confirmation of the stability of the new valve as well as ensuring leaflets are moving freely with no or minimal mitral regurgitation, no paravalvular leaks and no flow restriction across the valve. (Fig 1F) The size, severity and directionality of the interatrial shunt created by the iatrogenic atrial septal puncture site should be assessed using color and spectral doppler, (Figure 1G) which may require placement of an Amplatzer ASD percutaneous closure device (Figure 1H).