Repeat Transesophageal Echocardiography Research Articles

Left atrial appendage thrombus in patients with atrial fibrillation who underwent oral anticoagulation.

Electric cardioversion of atrial fibrillation (AF) is associated with an increased risk of embolism, with embolic material existing in the heart cavities. The initiation of oral anticoagulation therapy reduces the risk of thromboembolic events. The aims of this study were to evaluate the prevalence of left atrial appendage (LAA) thrombi in non-valvular AF, to compare vitamin K antagonists (VKAs) and non-vitamin K oral anticoagulants (NOACs) with respect to thrombus prevalence, and to evaluate the rate of LAA thrombus persistence on repeat transesophageal echocardiography (TEE) after treatment change. We enrolled 160 consecutive AF patients who presented with an AF duration > 48 h and had undergone TEE before cardioversion. Left atrial appendage thrombus was observed in 12 (7.5%) patients, and spontaneous echo contrast 4 was observed in 19 (11.8%) patients; the incidence was similar between the NOAC and VKA groups (8.9% vs. 3.6% and 12.4% vs. 18.5 %, respectively). Among patients on NOAC, thrombus prevalence was detected in 8.4% of users of rivaroxaban, 8% of users of dabigatran, and 12.5% of users of apixaban. The LAA thrombus developed in 7.5% of patients despite anticoagulation therapy, demonstrating similar prevalence rates among patients either on NOAC or VKA. Lower mean LAA flow velocity and a history of vascular disease were independent predictors of embolic material in the LAA. It seems that in the case of embolic materials in LAA under NOAC treatment, switching to VKA provides additional clinical benefit to the patients.

Transthoracic echocardiographic Doppler metrics in evaluating bioprosthetic tricuspid valve dysfunction.

There is currently limited information on the utility of transthoracic echocardiography (TTE)-derived Doppler parameters for assessing bioprosthetic tricuspid valve (BTV) dysfunction. Our study aimed to establish the precision and appropriate reference ranges for routinely collected transthoracic Doppler parameters in the assessment of BTV dysfunction. We retrospectively evaluated 100 BTV patients who underwent TTE. Based on redo surgical confirmation or more than 2 repeat TTE or transesophageal echocardiography (TEE) examinations, patients were allocated to normal (n=61), regurgitant (n=24), or stenotic (n=15) BTV group. Univariate and multivariate binary logistic regression were performed to identify TTE Doppler parameters that detected BTV dysfunction. The VTI ratio (VTITV/VTILVOT) was the most accurate Doppler parameter for detecting BTV dysfunction, with a ratio of>2.8 showing 84.6% sensitivity and 90.2% specificity. VTI ratio>3.2, mean gradient (MGTV)>6.2mmHg and pressure half-time>218ms detected significant BTV stenosis, with sensitivities of 100%, 93.3% and 93.3% and specificities of 82.4%, 75.3% and 87.1%, respectively. After multivariate analysis, the VTI ratio>2.8 (OR=9.00, 95% CI=2.13-41.61, p=.003) and MGTV>5.1mmHg (OR=6.50, 95% CI=1.69-27.78, p=.008) were the independent associations of BTV dysfunction. With these cutoff values, 75.0%-92.2% of normal and 62.5%-96.0% of dysfunctional BTV were identified. Doppler parameters from TTE can accurately identify BTV dysfunction, particularly with VTI ratio>2.8 and MGTV>5.1mmHg, to assess the need for additional testing with TEE.

Left atrial appendage thrombus with severe mitral stenosis: Responders and non-responders to anticoagulation

Introduction and objectiveMitral stenosis (MS) is one of the most frequently observed valvular heart lesions in developing countries and is due to different etiologies. The effects of anticoagulation in different types of left atrial appendage (LAA) are unknown. The current study aimed to determine the resolution of LAA thrombus on transesophageal echocardiography (TEE) after three months of optimal anticoagulation in patients with different types of LAA at baseline cardiac computed tomography of patients with severe MS. MethodsThis prospective cohort study observed the frequency of LAA thrombus resolution after three months of anticoagulation therapy in patients with severe MS. The response rate in different morphologies of LAA and locations was also assessed. Thrombus resolution after three months of warfarin therapy was assessed on repeat TEE. ResultsA total of 88 patients were included, mean age 37.95±11.87 years. Repeat TEE showed thrombus resolution in only 27.3% of patients. The rate of thrombus resolution was 8/12 (66.7%), 4/28 (14.3%), 8/36 (22.2%), and 4/12 (33.3%) for patients with cactus, cauliflower, chicken wing, and windsock LAA type, respectively. The resolution rate was 0/12 (0%), 4/44 (9.1%), and 20/32 (62.5%) for patients with thrombus in the base, body, and tip of the LAA, respectively. ConclusionThe cactus type of LAA morphology and thrombus at the LAA tip responded well to three months of anticoagulation, however, patients with thrombus in the LAA base and body and cauliflower and chicken wing morphology were non-responders and could benefit from early referral for surgical management.

Abstract 17496: Exploring the Benefits: Role of Repeat Transesophageal Echocardiography (TEE) in Patients Anticoagulated for Four Weeks

Background: A left atrial appendage (LAA) thrombus is a well-known complication of atrial fibrillation (AF). Vitamin K antagonists (VKAs) have been well studied been considered the gold standard for thromboembolic prophylaxis. We present a case of LAA thrombus despite compliance with VKAs. Clinical presentation: A 70-year-old female with atrial fibrillation and diabetes presented with left-sided weakness and left facial droop, CT head showed right middle cerebral artery infarct. Vitals were unremarkable. Electrocardiogram showed AF with a rapid ventricular response. She was on warfarin with the most recent international normalized ratio level of 2.3. Transthoracic echocardiography revealed an ejection fraction of 55%, severe left ventricular hypertrophy, and severely dilated left atrium (LA) with LA diameter of 5.3 cm (>= 4.7 cm in women indicates severe dilatation). Transesophageal echocardiography (TEE) with bubble study demonstrated a large thrombus in the LAA with evidence of patent foramen ovale. The pulse wave Doppler (PWD) of the LAA on TEE also showed an LAA velocity of <20 cm/sec, which indicated that there was the highest probability that the thrombus was forming within LAA. Hypercoagulability work-up for thrombosis while on Coumadin such as anti-B2 glycoprotein, anticardiolipin, and factor V Leiden mutation were negative. The patient was started on enoxaparin with appropriate follow-up upon discharge. Discussion: The prevalence of LAA thrombus in patients with AF receiving a minimum of 3 weeks of anticoagulation, was approximately 3%. The presence of a LAA thrombus is a known contraindication to cardioversion and catheter ablation in patients with AF as it can result in cardioembolic stroke. However, current guidelines for cardioversion do not recommend pre-procedural TEE in patients undergoing cardioversion for AF if they have been on therapeutic oral anticoagulation for at least 3 weeks while TEE use remains variable before catheter ablation.

Mechanical extraction of a pulmonary valve vegetation in a patient with endocarditis.

A 44-year-old male known with small ventricular septal defect, but no previous history of intravenous drug abuse presented to an outside hospital with fever, chills, and back pain. A chest computed tomography showed multifocal nodular and consolidative pulmonary opacities with borderline enlarged mediastinal lymph nodes (Panel, A). Blood cultures grew Staphylococcus lugdunensis; given suspicion of infective endocarditis causing septic pulmonary emboli, he was transferred to our hospital. Transoesophageal echocardiography (TEE) on admission showed highly mobile masses attached to the native tricuspid (B) and to the sub-pulmonary area of the right ventricular outflow tract along with posterior leaflet perforation of the tricuspid valve with mild-to-moderate regurgitation (C). The sub-pulmonary lesion was in the path of the high-velocity left-to-right jet through the ventricular septal defect (D; Supplementary data online, Video S1), explaining the unusual location. Patient had persistent bacteremia despite appropriate antibiotic therapy and eventually developed haemoptysis and acute respiratory failure requiring intubation. At repeat TEE showed interval increase in the size of the sub-pulmonic vegetations. In the absence of haemodynamically significant lesions, the multidisciplinary team recommended percutaneous transcatheter mechanical vegectomy rather than surgical intervention.

Normalizing arterial blood pressure in patients with aortic stenosis does not prevent grading discrepancies between pre-cardiopulmonary bypass transesophageal echocardiography and transthoracic echocardiography.

Aortic stenosis (AS) grading discrepancies exist between pre-cardiopulmonary (pre-CPB) transesophageal echocardiography (TEE) and preoperative transthoracic echocardiography (TTE). Prior studies have not systematically controlled blood pressure. We hypothesized that normalizing arterial blood pressure during pre-CPB TEE for patients undergoing valve replacement for AS would result in equivalent grading measurements when compared to TTE. Single University Hospital. Prospective, Interventional. Thirty-five adult patients underwent procedures for valvular AS between February 2017 and December 2020 at Medical University of South Carolina. Study participants had a TTE within 90 days of their procedure that documented blood pressure, peak velocity (Vp), mean gradient (PGm), aortic valve area (AVA), and dimensionless index (DI). During pre-CPB TEE, if a patient's mean arterial pressure (MAP) fell more than 20% below their baseline blood pressure obtained during TTE, measurements were recorded as "out of range." Phenylephrine was administered to restore MAP to the baseline range and repeat TEE measurements were recorded as "in-range." Differences between imaging modalities and grading parameters were examined using a series of linear mixed models. P values were Bonferroni-adjusted to account for multiple comparisons. Significant discrepancies between TEE and TTE were observed for Vp, PGm, and DI despite blood pressure normalization across all subjects and for out-of-range measures and corrected measures. There were no statistically significant differences between TEE and TTE for AVA. Blood pressure normalization during pre-CPB TEE is not sufficient to avoid AS grading discrepancies with preoperative TTE.

Abstract 13881: Utility of Cardiac CT for Evaluation of Infectious Endocarditis

Background: Infectious endocarditis (IE) usually presents with variable imaging findings and is associated with high morbidity and mortality. Transesophageal echocardiography (TEE) is the gold standard method for diagnosing IE. However, the presence of prosthetic or calcified valves poses a diagnostic challenge for detection of IE and associated structural abnormalities. In recent years, there is growing literature supporting cardiac CT scan as an adjunct to TEE in such cases. Studies have also shown that cardiac CT has significantly high sensitivity for detecting peri-annular complications. Case A 79 year old male who underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis one year ago presented with a one week history of worsening confusion and fatigue. His prior medical history includes non-ischemic cardiomyopathy with low ejection fraction (30-35%), deep vein thrombosis (DVT) and pulmonary embolism (PE). Labs were notable for leucocytosis 27,300/uL and thrombocytopenia with platelet count 20,000/uL. Patient was bacteremic with blood cultures growing oxacillin-resistant Staphylococcus epidermidis. TEE revealed a small vegetation concerning for infection versus thrombus. A CT abdomen revealed a 3.8 cm splenic infarct. Tagged WBC scan was thereafter considered to help delineate, but came back negative. Decision Making In setting of thrombocytopenia, repeat TEE was deemed unsafe. Alternatively, the patient underwent cardiac CTA which revealed hypoattenuating leaflet thickening (HALT) involving >75% of aortic valve leaflets (Figure 1) with no perivalvular leak or abscess thereby confirming IE. Conclusion Cardiac CT offers distinct advantages and has emerged as a great adjunct to echocardiography for the workup of IE, especially in patients who have contraindications to TEE or with prosthetic valves where echocardiography is sub-optimal. The report further elucidates the role of cardiac CT as an imaging adjunct for IE.

Abstract 272: Infective Endocarditis Of Unicuspid-unicommisural Aortic Valve

Approximately, 75% of patients with infective endocarditis have underlying structural heart disease at the time of diagnosis. Aortic valve disease is associated with up to a quarter of patients, with aortic regurgitation being the most common abnormality. A unicuspid aortic valve (UAV) is an extremely rare congenital anomaly with a prevalence of 0.02%. We present a unique case of UAV with a devastating association. Case Summary: A 32-year-old male intravenous drug abuser presented with weakness after 18-hours of symptom onset. He was afebrile but tachycardic, with left-sided hemiparesis and sensory loss. Brain CT-scan revealed a hypodensity within the right cerebral hemisphere, a CTA of head-neck revealed an acute right MCA infarct with malignant cerebral edema. Due to deteriorating clinical condition, he was intubated for airway protection and underwent emergent hemi-craniectomy. Blood cultures grew enterococcus faecalis. Transthoracic echocardiogram showed abnormal aortic valve with severe regurgitation. Transesophageal echocardiography (TEE) demonstrated unicuspid unicommissural aortic valve with a small mobile echodensity attached to the left ventricular outflow tract aspect. Decision Making: He received a 6-weeks course of ceftriaxone and vancomycin with negative repeat blood cultures. Given poor clinical state, he was deemed poor candidate for valve replacement and was discharged to long-term rehabilitation facility. Four-months later, he was re-admitted with fevers. Repeat TEE demonstrated multiple aortic valve vegetations. He subsequently underwent successful minimally invasive aortic valve replacement. Conclusion: Unicuspid unicommisural aortic valve is an extremely rare condition that can be complicated by aortic stenosis more often than regurgitation. Infective endocarditis has been reported in 11% among UAV patients and can lead to valvular destruction with severe regurgitation which can be catastrophic in some patients

Paravalvular Leak After Mitral Valve Replacement or Another Source for a Regurgitant Jet?

A 73-YEAR-OLD man (height: 169 cm, weight: 55kg), with a history of mitral valve repair, tricuspid annuloplasty, and Maze procedure, presented to the authors' emergency department with an 8-day history of profound fatigue. Multiple blood cultures grew Streptococcus dysgalactiae. Transesophageal echocardiography (TEE) showed vegetations on the anterior mitral valve leaflet and mild-to-moderate mitral regurgitation. He was started on intravenous antibiotics (ampicillin and clindamycin) for a diagnosis of infectious endocarditis, but he did not improve. Magnetic resonance imaging indicated acute cerebral infarction during the patient's hospital course. Repeat TEE showed worsening mitral regurgitation and enlarging mitral valve vegetations. As a result, the patient was taken to the operating room for redo mitral valve replacement, maze procedure, and left atrial appendage (LAA) ligation. Intraoperative TEE confirmed the presence of vegetations on both the anterior leaflet and annuloplasty ring. The native mitral valve was excised and replaced with a 31-mm bioprosthesis. LAA ligation also was performed. After weaning from cardiopulmonary bypass, a modified midesophageal long-axis view with color Doppler imaging demonstrated abnormal blood flow near the bioprosthetic valve (Fig 1; Video 1). What is the diagnosis?

MANAGING HEART FAILURE WITH REDUCED EJECTION FRACTION: WHAT TO KNOW?

The estimated population of congestive heart failure (CHF) patients in Pakistan is 28 millions.1 Besides epidemics of type 2 diabetes mellitus and coronary heart disease, South Asian countries are also be at an increased risk of heart failure at earlier ages than other racial/ethnic groups.2 Heart failure sub classified into three categories:
 
 With preserved ejection fraction (LVEF>50%),
 Mid-range ejection fraction (LVEF41-49%),
 Reduced ejection fraction (LVEF<40%).3
 
 According to studies in United States of American (USA) and United Kingdom (UK)4,5 heart failure with reduced ejection fraction (HFrEF) prevalence has increased due to ageing population, improved survival from myocardial infarction and high prevalence of co-morbid conditions like diabetes and obesity. With increasing number of young patients (<40 years) with acute myocardial infarction (AMI) 12%6 in our population, prevalence of heart failure with predisposing factors need to be explored.
 Other than diagnosing and work up of these patients, the most challenging part is the pharmacological treatment by therapeutic agents proven to reduce morbidity and mortality in HRrEF. Registries have shown under-usage of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), angiotensin receptor-neprilysin inhibitor (ARNI), Beta-blockers and mineralocorticoid receptor antagonists (MRA) in such patients.7 Reason of not acheving the outcomes were due to not attaining the target levels of drugs dosages.8
 With recommendations from new guidelines new novel drug therapies i.e. sodium-glucose cotransporter-2 (SGLT2) inhibitors, most debatable questions from the physicians are keeping in view the hemodynamic status and kidney function. Questions coming to the Physicians minds include;9
 
 Should all guideline directed medical therapies be started together or stage wise?
 Which drugs should be titrated first?
 How quick can one up-titrate B-blockers and ARNI?
 At what level of kidney impairment should one stop ACE/ARB/ARNI/SGLT2 inhibitors?
 When should one refer these patients for cardiac resynchronization therapy device (CRTD) or Heart Transplantation?
 When should one repeat transesophageal echocardiography (TEE)?
 
 Physicians need to have clear answers and stance on the above queries.
 HFrEF is a major public health concern in our population especially with early onset of ischemic heart disease (IHD). Awareness, education and up to date knowledge regarding early diagnosis, work up and adjustments of drugs in such patients with proper follow up is important to reduce the ever rising morbidity and mortality in our population.
 
 References
 
 Sheikh SA. Heart failure in Pakistan: A demographic survey. J Card Fail. 2006;12(8):S157.
 Martinez-Amezcua P, Haque W, Khera R, Kanaya AM, Sattar N, Lam CS, et al. The upcoming epidemic of heart failure in South Asia. Circ Heart Fail. 2020;13(10):e007218.
 Yancy CW, Jessup M, Bozkurt B, Butler J, Casey Jr DE, Colvin MM, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776-803.
 Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation. 2020;141(9):e139-596.
 Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Ccirculation. 2015;131(4):e29-322.
 Batra MK, Rizvi NH, Sial JA, Saghir T, Karim M. Angiographic Characteristics and in Hospital Outcome of Young Patients, Age Up to 40 Versus More Than 40 Years Undergoing Primary Percutaneous Coronary Intervention. J Pak Med Assoc. 2019;69(9):1308-12.
 Greene SJ, Butler J, Albert NM, DeVore AD, Sharma PP, Duffy CI, et al. Medical therapy for heart failure with reduced ejection fraction: the CHAMP-HF registry. J Am Coll Cardiol. 2018;72(4):351-66.
 Konstam MA, Neaton JD, Dickstein K, Drexler H, Komajda M, Martinez FA, et al. Effects of high-dose versus low-dose losartan on clinical outcomes in patients with heart failure (HEAAL study): a randomised, double-blind trial. Lancet. 2009;374(9704):1840-8.
 Murphy SP, Ibrahim NE, Januzzi JL. Heart failure with reduced ejection fraction: a review. JAMA. 2020;324(5):488-504.

The association of anticoagulation therapy characteristics with left atrial thrombus lysis in patients with nonvalvular persistent atrial fibrillation

Purpose. The aim of this study was to reveal the effect of the duration and characteristics of anticoagulant therapy on the clot dissolution in the left atrial appendage (LAA) in patients with persistent atrial fibrillation (AF).Material and methods. The repeat transesophageal echocardiography was performed in 68 patients with persistent AF, because the thrombus was detected in the LAA during the first examination. Of these, 37 (54.4%) patients started or continued to receive warfarin and 31 (45.6%) patients continued to receive the direct oral anticoagulants. Transesophageal echocardiography was repeated after 3-5 weeks. One follow-up examination was for 53 patients, two follow-up examination was for 11 patients and three follow-up examination was for 4 patients. Cox regression analysis was performed to identify factors affecting the likelihood of clot dissolution and Kaplan-Meier survival analyses with log-rank tests were used to compare the clot dissolution time.Results. The chance of the LAA thrombus lysis is 50% after 35.0 ± 3.7 days of receiving anticoagulants. This time is reduced to 30.0 ± 1.4 days for small thrombus (no more than 18 mm), and it increases to 45.0 ± 7.4 days (p = 0.038) for large thrombus. The dissolution time of small thrombus depends on the characteristics of the treatment: the median of the dissolution curve is 24.0 ± 3.7 days when the patients received the direct oral anticoagulants, and the median of the dissolution curve is 40.0 ± 7.2 days (p = 0.009), if the patients received warfarin. The dependence of the dissolution time of large thrombus on the characteristics of treatment did not found.Conclusion. The LAA thrombus dissolution time in patients with atrial fibrillation depends on their size, and the dissolution time of small thrombi depends on the characteristics of anticoagulant therapy.

A Mass in the Left Ventricular Outflow Tract After Mitral Valve Replacement

A 34-year-old woman presented with a four-year history of shortness of breath and dyspnea on exertion that had worsened over the preceding six months. The patient had a stroke two years before her current presentation but had no residual neurologic deficits. Transthoracic 2 two-dimensional echocardiography revealed severe mitral stenosis (peak/mean gradients = 21/14 mmHg), with a mitral valve area of 0.7 cm2 by the pressure-half time method, and calcific thickened mitral valve leaflets with commissural fusion and subvalvular thickening. Pulmonary hypertension was present (right ventricular systolic pressure of 45 mmHg). Left ventricular (LV) ejection fraction was normal (62%). The left atrium (LA) was dilated (60 mm) but LA thrombus was absent. Normal sinus rhythm was present. During surgery, the native mitral valve was replaced with a 25-mm bileaflet mechanical prosthesis. Preservation of both the mitral leaflets and the subvalvular apparatus was carried out. Repeat transesophageal echocardiography (TEE) showed the mechanical prosthesis to be functioning well. In the midesophageal aortic valve (AV) long-and short-axis views, a new mass measuring 8 × 7 mm was seen moving into the aortic root in systole and the left ventricular outflow (LVOT) tract in diastole (Fig. 1, A-C and Video loop 1). Color-flow Doppler did not reveal any systolic flow turbulence (Fig 1, D and Video loop 1). What is the diagnosis?

Novel Method of Administering Pharyngeal Anesthesia before Transesophageal Echocardiography

The most unpleasant reaction upon insertion of a transesophageal echocardiography (TEE) probe is a gag reflex, which is a normal defense mechanism that prevents foreign bodies from entering the trachea, pharynx, and larynx. The gag reflex causes excessive salivation, which may increase the risk of aspiration. When extreme, a hyperreflexive gag may result in lacrimation, sweating, fainting, or overt panic attacks, which further impair the ease of TEE probe insertion, may force a deeper level of conscious sedation with increased associated risk, and could impact future decisions by patients needing repeat TEE.

How Negative Is Culture-Negative Endocarditis in the Presence of a Pacemaker?

Abstract A case report of a 70-year-old man with pacemaker placed for atrial fibrillation in 1999 (generator change in 2016). His illness began 4 months earlier with “hots-and-colds” sensation for which he was admitted to an outside hospital and treated for community-acquired pneumonia for 7 days. Fevers persisted after discharge, and he received a 7-day doxycycline course 1 week later. Persistent fevers led to a second admission at the outside hospital. Infectious workup was negative but transesophageal echocardiography showed mass on pacemaker lead so he was transferred to our hospital. No mass on repeat transesophageal echocardiography (TEE) was seen, so he was discharged as culture-negative endocarditis on a 6-week course of vancomycin and ceftriaxone. New fevers after antibiotics led to another admission. He was found to have a high-grade methicillin-susceptible Staphylococcus aureus bacteremia at this time but still negative TEE. Pacemaker was empirically extracted and was found to be encased in thrombus. Intraoperative TEE with bubble study showed patent foramen ovale with left atrial clot. Lead/thrombus cultures were positive for methicillin-susceptible Staphylococcus aureus and were treated with oxacillin.

Superior Vena Cava Endocarditis in a Patient with Anterior Chest Wall Tunneled Catheter for Hemodialysis

Healthcare related bacterial endocarditis represents a significant portion of endocarditis seen today. Suspicion for these infections should be particularly high in patients with chronic indwelling central venous catheters, and most notably, in patients with hemodialysis catheters. These infections may have a predilection for the superior vena cava due to proximity of the catheters to the great veins of the neck. Transthoracic echocardiography and/or trans-esophageal echocardiography should be done promptly in patients in which there a high suspicion for such infections, in order to identify these lesions, and guide appropriate management with either antibiotics or surgical intervention. We present a 59-year-old female with multiple comorbidities including diabetes mellitus and end-stage renal disease requiring dialysis via an anterior chest wall catheter, who presented with fever, chills, and abdominal pain. She was found to have pus in and around her catheter. Further evaluation with trans-esophageal echocardiography revealed the presence of a superior vena cava vegetation extending into the right atrium. She received a 6 week course of appropriate antibiotics with repeat trans-esophageal echocardiography showing a significant reduction in the size of the vegetation. Patient remained afebrile, and without leukocytosis and negative blood cultures for the remainder of her hospital stay.

Repeat transesophageal echocardiography in infective endocarditis: An analysis of contemporary utilization.

Current guidelines from the American Heart Association (AHA) recommend repeating transesophageal echocardiography (TEE) in three to five days if there is high suspicion of IE despite an initial TEE that was negative. This recommendation, however, is based on limited published data. This investigation attempts to identify specific factors that prompted repeat TEE and evaluate the yield of IE-related findings demonstrated by repeat TEE as compared to initial or prior TEE. A retrospective cohort who had at least one repeat TEE during an index hospitalization or initial course of antimicrobial therapy for IE between January 2014 and September 2018. We assessed the impact of repeat TEE on IE diagnosis and patient management and included a comparative analysis of patients with initial TEE only. Overall, 59 (44.7%) of 132IE patients underwent repeat TEE. In a comparative analysis that involved patients who had undergone an initial TEE only versus those who had repeat TEE, male gender (P=.029) and presence of a prosthetic valve or annuloplasty ring (P=.017) were significantly associated with repeat TEE. Importantly, 8 (17.4%) of repeat TEE were critical for IE diagnosis, 8 (17.4%) impacted antimicrobial management, and 11 (23.9%) supported cardiovascular surgical intervention. From a population-based cohort of incident IE cases, repeat TEE was more frequently (44.7%) done in patients with suspect or proven IE and associated complications than anticipated. Repeat TEE remains pivotal in a contemporary practice that involves critical aspects of IE diagnosis and management.

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.

Anticoagulants in left atrial thrombus resolution

Aim: Warfarin has been used for protection from peripheral embolism in patients with atrial fibrillation (AF) and it has been shown that the direct oral anticoagulants are effective in protection against stroke as much as warfarin and cause lower bleeding complications. Our aim is to compare the efficacies of different anticoagulants in resolution of left atrial appendage thrombi.Materials and Methods: 264 patients were included in study. 39 patients had left atrial appendage thrombus; 17 patients underwent a repeat transesophageal echocardiography (TEE) after switching/administering an anticoagulant treatment regimen.Results: Thrombus was detected in 3 patients using apixaban, who were switched to dabigatran. Those patients were found to have thrombus resolution by the repeat TEE procedures. Of 5 patients using warfarin, 3 were switched to dabigatran, in one of whom thrombus resolution was not achieved. One patient continued warfarin with a target INR of 2.5-3.5 and a repeat TEE showed complete thrombus resolution. The remainder patient using warfarin was swithed to rivaroxaban, with complete thrombus resolution having been achieved. Two patients using edoxaban had their thrombi resolved by dabigatran. Seven patients were not receiving any anticoagulant regimen. Among these, warfarin was administered to 4 patients and apixaban to 2; repeat TEEs showed no thrombus. The remainder patient was administered low molecular weight heparin, and repeat TEE showed persistence of LAA thrombus.Conclusion: Irrespective of patients being anticoagulated, TEE should be planned before interventional procedures and cardioversion. If thrombus develops in a patient receiving anticoagulant treatment, switching to a different anticoagulant would be a logical option.

93 A hemodynamic challenge in assessment of echocardiographic mitral regurgitation severity

Abstract Mitral regurgitation severity is, in accordance to current recommendations, typically evaluated by echocardiography. Several hemodynamic factors may influence this evaluation, especially systemic arterial blood pressure at the time of echocardiographic evaluation. A 71-year-old woman was admitted in our Cardiology ward with acute decompensated heart failure. She had been previously admitted about 3 months earlier by acute decompensated heart failure, and at that time, admission transthoracic echocardiography (TTE) demonstrated mitral regurgitation, which was evaluated as severe. Systolic systemic arterial blood pressure at the time of that TTE was registered as 135mmHg. For further evaluation of mitral regurgitation mechanism, the patient underwent transoesophageal echocardiography (TEE), and in that exam mitral regurgitation was assessed as only moderate. For that exam, patient was sedated with 5mg of intravenous Midazolam, a drug with known secondary hypotensive effect. Although systemic arterial blood pressure was not described in the TEE report, retrospective analysis of nursery blood pressure records showed that patient was hypotensive during exam with systolic arterial blood pressure of 80-90mmHg. Patients was discharged, and in actual admission, concern was raised that mitral regurgitation could have been underestimated in previous TEE due to reduced afterload caused by the hypotensive effect of sedation. It was then decided to repeat TEE, and, in order to counterpose the hypotensive effect of Midazolam, TEE was performed under intravenous continuous infusion of Phenylephrine, a selective α-1 receptor antagonist with a significant vasopressor effect and minimal effect on cardiac contractility. Systolic systemic arterial blood pressure during this exam was recorded as 135-140mmHg. In this exam mitral regurgitation was confirmed as severe and patient was patient was oriented for mitral valve surgery. DIscussion This case illustrates the importance of assessment of hemodynamic status of the patient during echocardiographic evaluation of mitral regurgitation severity, and presents a pharmacological strategy to compensate hypotensive effects of sedative agents used during TEE.

Double-Chamber Left Atrium After Mitral Valve Surgery

A 44-YEAR-OLD woman (height 158 cm, weight 62 kg) presented with shortness of breath on mild exertion of several months duration. An electrocardiogram indicated the presence of atrial fibrillation with a ventricular rate of 80 to 100/min. Transthoracic echocardiography revealed severe mitral stenosis with an enlarged left atrium. The patient was scheduled for mitral valve replacement surgery. After induction of anesthesia, transesophageal echocardiography (TEE) confirmed the previous findings and demonstrated layered thrombus in the left atrium along the atrial septum. The mitral valve was approached transseptally, and the layered thrombus along the left atrial wall was excised. The mitral valve was replaced with a bioprosthetic mitral valve (Epic, 27 mm; Abbott, Chicago, IL). After the patient was separated from cardiopulmonary bypass, repeat TEE demonstrated an apparent “double chamber” in the left atrium (Fig 1, Fig 2; Videos 1 and 2). What is the diagnosis? Fig 2Transesophageal echocardiography midesophageal long-axis view showing a septumlike shadow inside left atrium. View Large Image Figure Viewer Download Hi-res image