Real-time Three-dimensional Transesophageal Echocardiography Research Articles

Delineation of A Paravalvular Leak Origin Between A Rigid Mitral Ring and Supra-Annular Implanted Mechanical Mitral Prosthetic Valve

Paravalvular leakage is not a rare condition among patients with mitral prostheses. Two-dimensional echocardiographic approaches are not sufficient to determine the origin of paravalvular leak that occurs after prosthetic mitral valve replacement. Real-time three-dimensional transesophageal echocardiography provides detailed structural identification of paravalvular leak origin and defect morphology compared to two-dimensional transesophageal echocardiography. Here we present a patient with paravalvular mitral regurgitation from a slit like defect between the mitral anular ring and the prosthetic valve delineated with the utility of 3D fullvolume and 3D color flow imaging modalities.

Why is a new journal dedicated to echocardiography required?

Why is a new journal dedicated to echocardiography required?

Obstructed bi‐leaflet prosthetic mitral valve imaging with real‐time three‐dimensional transesophageal echocardiography

Real-time three-dimensional transesophageal echocardiography (RT3D-TEE) can provide unique visualization and better understanding of the relationship among cardiac structures. Here, we report the case of an 85-year-old woman with an obstructed mitral prosthetic valve diagnosed promptly by RT3D-TEE, which clearly showed a leaflet stuck in the closed position. The opening and closing angles of the valve leaflets measured by RT3D-TEE were compatible with those measured by fluoroscopy. Moreover, RT3D-TEE revealed, in the ring of the prosthetic valve, thrombi that were not visible on fluoroscopy. RT3D-TEE might be a valuable diagnostic technique for prosthetic mitral valve thrombosis.

Right Atrial Lipoma in a Patient With Complete Heart Block

A 70-year-old man with a recent history of high degree AV block presented to the hospital with progressive shortness of breath and dyspnea of exertion. A mobile intracardiac mass was found on transthoracic echocardiogram that was not present in his previous evaluations. Real time three-dimensional (3D) transesophageal echocardiography (TEE) images revealed a spherical mass within the right atrium; no enhancement after microbubble contrast infusion was noted. Modern echocardiography including 3D TEE and echocardiographic contrast perfusion imaging provide numerous advantages for non-invasive evaluation of intracardiac masses. J Med Cases. 2014;5(5):270-272 doi: http://dx.doi.org/10.14740/ jmc1746w

A study of aortic annulus dimension measured by real time three dimensional transesophageal echocardiography in transcatheter aortic valve implantation

Objective To study the feasibility and accuracy of real-time three-dimensional transesophageal echocardiography (RT 3D-TEE) in measuring the aortic annulus dimension(AAD),and compared with CT measurements.Methods The AAD was measured by transthoracic echocardiography (TTE),transesophageal echocardiography(TEE) and RT 3D-TEE in 26 cases who were refered to our center for transcatheter aortic valve implantation(TAVI).Cross-sectional RT 3D-TEE can offer the AAD derived from the aortic annulus area,the maximal AAD,the minimal AAD and the eccentric index(the maximal AAD/the minimal AAD).The echo dimensions were compared with the CT measurements.Results No statistically significant differences were found between RT 3D-TEE and CT,and they have the best correlation(r =0.92,P ＜ 0.05).Meanwhile,There was no statistically significant difference in the eccentric index of the AAD between RT 3D-TEE and CT(1.25± 0.12 vs 1.28± 0.13,P ＞0.05).Conclusions RT-3D TEE imaging not only measure the AAD accurately,but also provide the maximal AAD,minimal AAD and the eccentric index for TAVI. Key words: Echocardiography, transesophageal; Aortic valve stenosis; Heart valve prosthesis implantation

Spontaneous Bileaflet Chordal Rupture Secondary to Myxomatous Degeneration of the Mitral Valve

Mini‐AbstractVarious pathological changes in the mitral valve apparatus have been reported to be associated with ruptured chordae tendineae. Myxomatous degeneration is one of the most common etiologies. The incidence of posterior chordal rupture is higher than that of anterior mitral leaflet. However, spontaneous rupture of both anterior and posterior chordae is very rare. Herein, we present a patient with severe mitral regurgitation due to bileaflet chordal rupture, evaluated by two‐dimensional and real time three‐dimensional transesophageal echocardiography.

Three-Dimensional Analysis of the Left Atrial Appendage for Detecting Paroxysmal Atrial Fibrillation in Acute Ischemic Stroke

Atrial fibrillation impairs left atrial appendage function and the thrombus formation in the left atrial appendage is a major cause of cardioembolic stroke. To evaluate the association between the volume of the left atrial appendage measured by real-time three-dimensional transesophageal echocardiography and presence of paroxysmal atrial fibrillation in patients with cerebral infarction or transient ischemic attack. Real-time three-dimensional transesophageal echocardiography was performed to measure left atrial appendage end-diastolic and end-systolic volumes to calculate left atrial appendage ejection fraction. Patients with normal sinus rhythm at the time of real-time three-dimensional transesophageal echocardiography were divided into groups with and without paroxysmal atrial fibrillation. Volumetric data were corrected with the body surface area. Of 146 patients registered, 102 (29 women, 72·2 ± 10·7 years) were normal sinus rhythm at the examination. In 23 patients with paroxysmal atrial fibrillation, left atrial appendage end-diastolic volume (4·78 ± 3·00 ml/m(2) vs. 3·14 ± 2·04 ml/m(2), P = 0·003) and end-systolic volume (3·10 ± 2·47 ml/m(2) vs. 1·39 ± 1·56 ml/m(2), P < 0·001) were larger and left atrial appendage ejection fraction (37·3 ± 19·1% vs. 57·1 ± 17·5%, P < 0·001) was lower than in the other 79 patients without paroxysmal atrial fibrillation. The optimal cutoff for left atrial appendage peak flow velocity to predict paroxysmal atrial fibrillation was 39·0 cm/s (sensitivity, 54·6%; specificity, 89·7%; c-statistic, 0·762). The cutoffs for left atrial appendage end-diastolic volume, end-systolic volume, and ejection fraction were 4·52 ml/m(2) (sensitivity, 47·8%; specificity, 82·3%; c-statistic, 0·694), 1·26 ml/m(2) (sensitivity, 91·3%; specificity, 60·3%; c-statistic, 0·806), and 47·9% (sensitivity, 78·3%; specificity, 74·7%; c-statistic, 0·774), respectively. In multivariate analysis, all these parameters were independently associated with paroxysmal atrial fibrillation after adjusting for sex, age, diabetes mellitus, and previous stroke. Left atrial appendage volumetric analysis by real-time three-dimensional transesophageal echocardiography is a promising method for detecting paroxysmal atrial fibrillation in acute cerebral infarction or transient ischemic attack.

Usefulness of real-time three-dimensional trans-oesophageal echocardiography for detection of isolated unroofed coronary sinus

We report a case of unroofed coronary sinus not associated with the persistent left superior vena cava. Definite diagnosis of the unroofed coronary sinus was obtained by trans-oesophageal echocardiography, which revealed the unroofed portion with left-to-right shunt. Real-time three-dimensional trans-oesophageal echocardiography could show the whole pictures of the defect, which was useful information for surgical repair.

Cardiac erosion after catheter closure of atrial septal defect: Septal malalignment may be a novel risk factor for erosion

Pericardial tamponade occurred 3 days after the catheter closure of an atrial septal defect (ASD) using Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN, USA). Before the closure, two-dimensional and real-time three-dimensional transesophageal echocardiography demonstrated a deficient aortic rim and atrial septal malalignment. Perforation of the right atrium toward the non-coronary sinus of the aortic root was confirmed at the emergent surgery. Cardiac erosion is one of the most catastrophic complications in ASD patients undergoing catheter closure with Amplatzer Septal Occluder. Hence, several risk factors for this complication are discussed and identified. Oversized device deployment and a deficient aortic rim are accepted factors potentially causing cardiac erosion. Besides, atrial septal malalignment, which is a morphological characteristic of ASD, may be a novel risk factor for cardiac erosion.<Learning objective: Cardiac erosion is a potentially lethal complication when catheter closure of atrial septal defects using Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN, USA) is provided to the patients. However, mechanisms of this complication remain to be completely elucidated. Atrial septal malalignment may be one of the novel risk factors for this catastrophic complication.>

Usefulness of intraoperative real-time three-dimensional transesophageal echocardiography for pre-procedural evaluation of mitral valve cleft: a case report

A precise pre-procedural evaluation of mitral valve (MV) pathology is essential for planning the surgical strategy for severe mitral regurgitation (MR) and preparing for the intraoperative procedure. In the present case, a 38-year-old woman was scheduled to undergo MV replacement due to severe MR. She had a history of undergoing percutaneous balloon valvuloplasty due to rheumatic mitral stenosis during a previous pregnancy. A preoperative transthoracic echocardiography suggested a tear in the mid tip of the anterior mitral leaflet. However, the "en face" view of the MV in the left atrial perspective using intraoperative real time three-dimensional transesophageal echocardiography (RT 3D-TEE) provided a different diagnosis: a torn cleft in the P2-scallop of the posterior mitral leaflet (PML) with rupture of the chordae. Thus, surgical planning was changed intraoperatively to MV repair (MVRep) consisting of patch closure of the PML, commissurotomy, and lifting annuloplasty. The present case shows that intraoperative RT 3D-TEE provides more precise and reliable spatial information of MV for MVRep and facilitates critical surgical decision-making.

A serial fluoroscopy-guided thrombolytic therapy of a mechanical tricuspid prosthetic valve thrombosis with low-dose and ultra-slow infusion of tissue-type plasminogen activator.

Prosthetic valve thrombosis is a life-threatening complication that is seen most commonly in patients with left-sided prosthetic valves. However, mechanical tricuspid valves carry the highest risk of thrombosis of any cardiac valve. Thrombolysis has been performed successfully in right-sided prosthetic valve thrombosis and has been recommended as the first-line treatment in these patients. Although two-dimensional and real-time three-dimensional transesophageal echocardiography are the gold standard imaging modalities for the diagnosis of prosthetic valve thrombosis, right-sided prosthetic valves may not be evaluated precisely. This is a serious problem during the follow-up of patients who receive thrombolytic therapy for tricuspid valve thrombosis. Fluoroscopy is an alternative noninvasive imaging method that provides valuable information about leaflet motion and may be used for such cases with restricted leaflets. Herein, we report a case of tricuspid valve thrombosis who was managed with low-dose (25 mg) and ultra-slow (25 hours) infusion of tissue-type plasminogen activator under the guidance of serial fluoroscopy.

Ventricular septal rupture imaged with real-time three-dimensional transesophageal echocardiography

Ventricular septal rupture is a rare complication of acute myocardial infarction and its diagnosis can be really challenging especially in the case of complex lesions. Echocardiography is the technique of choice for the detection of mechanical complications following myocardial infarction. The introduction of three-dimensional echocardiography offers new imaging possibilities with precise localization and easiest definition of the defect anatomy. This information is of paramount importance in the setting of a percutaneous closure procedure. We describe a case where real-time three-dimensional transesophageal echocardiography correctly defined the complex anatomy of a postmyocardial infarction septal defect with an associated pseudoaneurysm.

Right Atrial Lipoma in a Patient With Complete Heart Block

A 70-year-old man with a recent history of high degree AV block presented to the hospital with progressive shortness of breath and dyspnea of exertion. A mobile intracardiac mass was found on transthoracic echocardiogram that was not present in his previous evaluations. Real time three-dimensional (3D) transesophageal echocardiography (TEE) images revealed a spherical mass within the right atrium; no enhancement after microbubble contrast infusion was noted. Modern echocardiography including 3D TEE and echocardiographic contrast perfusion imaging provide numerous advantages for non-invasive evaluation of intracardiac masses. J Med Cases. 2014;5(5):270-272 doi: http://dx.doi.org/10.14740/ jmc1746w

リアルタイム3 次元経食道心臓超音波検査を用いた急性期虚血性脳血管障害における左心耳の3 次元評価

要旨：【目的】急性期脳梗塞，一過性脳虚血発作における左心耳の3 次元評価項目と心房細動（AF）の関連を明らかにする．【方法】リアルタイム3 次元経食道心臓超音波検査を行った127 例（年齢74±11歳，男性88 例）を持続性AF 33 例，発作性AF 22 例，AF なし72 例の3 群に分け検討した．【結果】持続性AF，発作性AF，AF なし各群で入口部面積（5.73±1.95 cm2，4.45±2.42 cm2，3.23±1.47 cm2，p<0.001），深さ（3.42±0.71 cm，2.95±0.89 cm，2.61±0.70 cm，p<0.001），体積（11.37±6.33 cm3，7.59±5.03 cm3，4.90±2.92 cm3，p<0.001）いずれも有意差を認めた．多変量解析でも入口部面積，体積はAF と有意に関連していた．【結論】急性期虚血性脳血管障害で左心耳の拡大は持続性ないし発作性AF の存在と関連していた．

Real-time three-dimensional transoesophageal echocardiography enables preoperative pulmonary valvulopathy assessment

A 60-year-old male with carcinoid syndrome was referred for the evaluation of carcinoid heart disease. Transthoracic echocardiography (TTE) demonstrated thickened, fixed, and retracted leaflets of the tricuspid valve (TV) with severe tricuspid regurgitation ( Panels A and B ). The pulmonic valve (PV) was not well seen on TTE. Surgical valve replacement to preserve right ventricular function …

Delineation of an Octopus‐Like Thrombus Attached to the Eustachian Valve

Eustachian valve (EV) is a vestige of the valve of the inferior vena cava which directs the umbilical vein blood through open foramen ovale in fetal life. Following birth it gradually regresses, but it may persist in variable size, shape, and thickness as a functionless and benign structure. However, there are reports suggesting that persistent EV may not be completely innocent. It has been accused of being a predisposing cause of patent foramen ovale and paradoxical embolism and also interfering with transseptal interventional procedures. It may serve as a site of infective vegetations and be mistaken as a tumor or thrombus. In the present case, an octopus-like thrombus attached to the EV was delineated with the utility of two-dimensional and real time three-dimensional transesophageal echocardiography. EV was considered to play an essential role in preventing potential pulmonary embolism.

The Use of Real-Time Three-Dimensional Transesophageal Echocardiography for Percutaneous Closure of a Ruptured Sinus of Valsalva Aneurysm

We read with great interest the article by Mukherjee et al entitled “Is real time 3D transesophageal echocardiography a feasible approach to detect coronary ostium during transapical aortic valve implantation?”1 As argued, real-time, 3D echocardiography can provide both diagnostic and procedural advantages in interventional cases taking place in the cardiac catheterization laboratory, and we therefore report a case in which real-time 3D transesophageal echocardiography (3D TEE) helped guide the percutaneous closure of a ruptured sinus of Valsalva aneurysm.

Is Physiologic Annular Dynamics Preserved After Mitral Valve Repair With Rigid or Semirigid Ring?

Various rings are available to achieve more physiologic mitral valve repair from viewpoints of physiologic mitral annular structure or dynamics. We evaluated preoperative and postoperative mitral annular structures and dynamics. Thirty-six patients underwent mitral valve repair for degenerative mitral insufficiency. Carpentier-Edwards Physio II ring (semirigid [Edwards Lifesciences, Irvine, CA]), St. Jude Medical Rigid Saddle Ring (RSR [St. Jude Medical, St. Paul, MN]), and MEMO 3D ring (semirigid [Sorin SpA, Milan, Italy]) were implanted in 13, 12, and 11 patients, respectively. Intraoperative real-time three-dimensional transesophageal echocardiography was performed before and after repair. The postoperative anteroposterior diameter reduction rate from end diastole to end systole was significantly (p<0.0001) larger in MEMO (9.58%±2.91%) than in Physio II (0.98%±1.04%) and RSR (1.94%±1.95%). There were no significant differences in the commissure-to-commissure diameter reduction rates among the groups: 0.81%±1.98% for Physio II, 0.12%±0.53% for RSR, and 0.51%±1.98% for MEMO. The postoperative end-systolic annular height commissure width ratio was significantly (p<0.0001) larger in both Physio II (17.9%±3.0%) and RSR (18.5%±1.6%) than in MEMO (13.6%±3.0%). The postoperative annular height commissure width ratio increase rate from end diastole to end systole was significantly larger in MEMO (5.1%±2.3%) than in Physio II (0.1%±0.6%) and RSR (0.3%±0.5%). Physio II and RSR could restore the physiologic three-dimensional annular shape, but the annular motion was diminished. Conversely, MEMO could preserve both the anteroposterior movement and folding dynamics, but no three-dimensional restoration of the mitral annulus was obtained.

Aortic Root Geometry in Patients with Aortic Stenosis Assessed by Real-Time Three-Dimensional Transesophageal Echocardiography

The authors hypothesized that aortic root geometry is different between bicuspid and tricuspid aortic stenosis (AS) that can be assessed using real-time three-dimensional (3D) transesophageal echocardiography. The aims of this study were (1) to validate the accuracy of 3D transesophageal echocardiographic measurements of the aortic root against multidetector computed tomography as a reference, (2) to determine the difference of aortic root geometry between patients with tricuspid and bicuspid AS, and (3) to assess its impact on pressure recovery. In protocol 1, 3D transesophageal echocardiography and contrast-enhanced multidetector computed tomography were performed in 40 patients. Multiplanar reconstruction was used to measure the aortic annulus, the sinus of Valsalva, and the sinotubular junction area, as well as the distance and volume from the aortic annulus to the sinotubular junction. In protocol 2, the same 3D transesophageal echocardiographic measurements were performed in patients with tricuspid AS (n= 57) and bicuspid AS (n= 26) and in patients without AS (n= 32). The energy loss coefficient was also measured in patients with AS. In protocol 1, excellent correlations of aortic root geometric parameters were noted between the two modalities. In protocol 2, compared with patients without AS, those with tricuspid AS had smaller both sinotubular junction areas and longitudinal distances, resulting in a 23% reduction of aortic root volume. In contrast, patients with bicuspid AS had larger transverse areas and longitudinal distances, resulting in a 30% increase in aortic root volume. The energy loss coefficient revealed more frequent reclassification from severe AS to moderate AS in patients with tricuspid AS (17%) compared with those with bicuspid AS (10%). Three-dimensional transesophageal echocardiography successfully revealed different aortic root morphologies between tricuspid and bicuspid AS, which have different impacts on pressure recovery.

Value of transesophageal echocardiography (TEE) guidance in minimally invasive mitral valve surgery.

The role of intraoperative transesophageal echocardiography (TEE) has increased tremendously since its first use in 1979. Today intraoperative TEE is a class I indication for surgical mitral valve reconstruction for evaluation of mitral valve pathology, graduation of mitral regurgitation and detection of potential risk factors as well as post-repair assessment. Real-time three-dimensional TEE offers anatomical visualization of the mitral valve apparatus, fundamental for virtual surgical planning of proper annuloplasty ring size. As minimally invasive and even off-pump techniques for mitral valve repair become more popular, image guidance by intraoperative TEE will play an essential role.