Routine Transesophageal Echocardiography Research Articles

Abstract P3012: Routine Monitoring For Intracardiac Thrombosis And Pulmonary Embolism With Intraoperative Transesophageal Echocardiography In Orthotopic Liver Transplantation

Background: Intracardiac thrombosis (ICT) and pulmonary embolism (PE) are significant intraoperative complications during orthotopic liver transplantation (OLT). Despite the high mortality associated with these events, current monitoring practices are inadequate at detecting these complications during OLT. Transesophageal echocardiography (TEE) allows continuous monitoring of myocardial function and detection of ICT/PE. In this study, we aim to report the incidence of ICT/PE during OLT at our center and to advocate for the use of intraoperative TEE as a standard monitoring tool. We also propose a medical management algorithm stratified by the severity of RV dysfunction and pulmonary artery pressure (PAP) in cases of ICT with/without PE. Methods: We conducted a single-center retrospective chart review of OLT patients with intraoperative TEE monitoring from March 13, 2019 - March 13, 2023. Intraoperative data of interest included hemodynamics, RV dysfunction, PAP, presence of ICT and/or PE as identified on TEE and associated medical management. RV dysfunction was graded as mild, moderate, or severe reduction in cardiac contractility. Secondary outcome was mortality during index hospitalization. Results: We identified 99 patients at our center who had intraoperative TEE monitoring during OLT. Prevalence of ICT in this population was 9.09% (n=9), of which 44.4% (n=4) developed hemodynamically significant PE. ICT patients who remained hemodynamically stable were observed without intervention (33%, n=3). Heparin was administered to prevent thrombus enlargement in patients with an increase in PAP but no significant RV dysfunction detected on TEE (22%, n=2). Those showing signs of hemodynamically significant PE with moderate or severe RV failure were given tissue plasminogen activator (tPA) for thrombolysis (44%, n=4). Perioperative mortality among all ICT patients was 44.4% (n=4) due to hemorrhagic shock secondary to coagulopathy and heart failure. Conclusion: The results of this study show the utility of routine TEE use in intraoperative monitoring for identifying ICT and PE in OLT patients, given the high mortality associated with these complications. TEE also allows for a stepwise approach to medical management based on RV function and PAP.

PO-01-107 INTRA-CARDIAC SPINDLE CELL CARCINOMA FOLLOWING CATHETER ABLATION OF ATRIAL FIBRILLATION AND LEFT ATRIAL APPENDAGE CLOSURE

Spindle cell carcinoma (SpCC), a type of squamous cell carcinoma (SCC), is a rare tumor with features similar to sarcoma that often arises from the respiratory system. Myocardial involvement of these tumors has not been described. We present a case of metastatic SpCC diagnosed through routine transesophageal echocardiography (TEE) following left atrial appendage occlusion (LAAO). To describe a rare occurrence of metastatic SpCC diagnosed through routine TEE following LAA occlusion. NA A 61 year old male with a history of coronary artery disease and heart failure presented with persistent symptomatic atrial fibrillation (AF) despite anti-arrhythmic therapy. We performed pulmonary vein isolation (PVI) and during intubation a laryngeal mass was noted. He was diagnosed with T2N0M0 sarcomatoid SCC and had surgery, radiation and chemotherapy (cisplatin). At that time, he was felt to have a favorable 5 year survival prognosis. Six months later he represented with symptomatic AF and underwent repeat PVI. Due to concerns regarding bleeding risk, LAAO was later performed. During follow up TEE at day 45, a new cystic lesion arising from the posterior left atrium and a 2x3cm heterogenous mass associated with the interatrial septum was noted (Figure 1 A-D). CT scan showed new mediastinal masses with extension into the left atrium in the region treated with radiofrequency ablation (Figure 1 E-H). Biopsy revealed SpCC consistent with the initial laryngeal mass. Tumor extending from the perihilar mass and in the fossa ovalis, given the proximity of prior work and prior transseptal puncture, raises the concern for inadvertent iatrogenic spread of tumor and that catheter manipulation facilitated invasion into the LA with the pedunculated mass and seeded the septum. The patient unfortunately continued to decline clinically and shortly thereafter transitioned to comfort care and passed away. We present a case of persistent symptomatic AF in which laryngeal SpCC was diagnosed during initial PVI and rapidly progressive metastatic SpCC diagnosed via TEE in follow up after LAAO. This presentation is concerning for inadvertent iatrogenic spread of tumor from an extracardiac source through PVI. SpCC is more aggressive than typical SCC, however rapid invasion through the chest wall, lung and myocardium within 1.5 months is extremely rare. While primary spindle cell sarcoma of the myocardium has been reported, to our knowledge we report the first case of metastatic SpCC to the heart.

P-wave parameters and their association with thrombi and spontaneous echo contrast in the left atrial appendage.

The aim of this study was to examine the prevalence of abnormal P-wave parameters in patients with thrombus and/or spontaneous echo contrast (SEC) in the left atrial appendage (LAA), and to identify P-wave parameters particularly associated with thrombus and SEC formation. We presume a significant relationship of P-wave parameters with thrombi and SEC. All patients in whom a thrombus or SEC was detected in the LAA on transoesophageal echocardiography were included in this study. Patients at risk (CHA2DS2-VASc Score ≥3) and routine transoesophageal echocardiography to exclude thrombi served as the control group. A detailed ECG analysis was performed. Of a total of 4062 transoesophageal echocardiographies, thrombi and SEC were detected in 302 patients (7.4%). Of these patients, 27 (8.9%) presented with sinus rhythm. The control group included 79 patients. There was no difference in mean CHA2DS2-VASc score in the two groups (p = .182). A high prevalence of abnormal P-wave parameters was detected in patients with thrombus/SEC. Indicators for the presence of thrombi or SEC in the LAA were P-wave duration >118 ms (Odds ratio (OR) 3.418, Confidence interval (CI) 1.522-7.674, p < .001), P-wave dispersion >40 ms (OR 2.521, CI 1.390-4.571, p < .001) and advanced interatrial block (OR 1.431, CI 1.033-1.984, p = .005). Our study revealed that several P-wave parameters are associated with thrombi and SEC in the LAA. The results may help identify patients who are at particularly high risk for thromboembolic events (e.g.,in patients with embolic stroke of undetermined source).

The safety of early discharge following transfemoral transcatheter aortic valve replacement under general anesthesia.

There is growing evidence of the safety of same-day discharge for low-risk conscious sedated TAVR patients. However, the evidence supporting the safety of early discharge following GA-TAVR with routine transesophageal echocardiography (TEE) is limited. To assess the safety of early discharge following transcatheter aortic valve replacement (TAVR) using General Anesthesia (GA-TAVR) and identify predictors for patient selection. We used data from 2,447 TEE-guided GA-TAVR patients performed at Cedars-Sinai between 2016 and 2021. Patients were categorized into three groups based on the discharge time from admission: 24 h, 24-48 h, and >48 h. Predictors for 30-day outcomes (cumulative adverse events and death) were validated on a matched cohort of 24 h vs. >24 h using the bootstrap model. The >48 h group had significantly worse baseline cardiovascular profile, higher surgical risk, low functional status, and higher procedural complications than the 24 h and the 24-48 h groups. The rate of 30-day outcomes was significantly lower in the 24 h than the >48 h but did not differ from the 24-48 h (11.3 vs. 15.5 vs. 11.7%, p = 0.003 and p = 0.71, respectively). Independent poor prognostic factors of 30-day outcomes had a high STS risk of ≥8 (OR 1.90, 95% CI 1.30-2.77, E-value = 3.2, P < 0.001), low left ventricle ejection fraction of <30% (OR 6.0, 95% CI 3.96-9.10, E-value = 11.5, P < 0.001), and life-threatening procedural complications (OR 2.65, 95% CI 1.20-5.89, E-value = 4.7, P = 0.04). Our formulated predictors showed a good discrimination ability for patient selection (AUC: 0.78, 95% CI 0.75-0.81). Discharge within 24 h following GA-TAVR using TEE is safe for selected patients using our proposed validated predictors.

Prevalence of non-infectious masses on intracardiac devices as incidental finding during transoesophageal echocardiography

Abstract Background Incidentally detected masses on the leads of cardiac implantable electronic devices (CIED) present a clinical dilemma and often raise the question whether they should be treated as a device infection. Indeed, they are considered as one of the major Duke criteria for the diagnosis of infectious device endocarditis. However, rather often incidental lead masses are detected in a routine transesophageal echocardiography (TOE) in patients without any signs of infection. Data on the prevalence of such findings are scarce and outdated. Purpose In this study, we aimed to determine the current prevalence and predisposing clinical factors of incidental non-infectious lead masses. Methods In this retrospective single center study, we analyzed all TOE examinations performed between 2020 and 2021 for the indications other than suspected infectious endocarditis. Patients with nonsuspicious leads and the ones with incidental non-infectious lead masses were compared with regard to clinical characteristics, presence of anticoagulation and indication for TOE. Results In total, 1361 TOE examinations were performed within the study period. From those 141 patients with CIED were selected. Thirty-nine patients (27.6%) presented with non-infectious CIED masses. The clinical characteristics of study patients and the TOE indications are listed in Table 1. Patients with incidental CIED mass showed a higher prevalence of dilated cardiomyopathy (38.5%) compared to patients with no CIED mass (16.7%), p=0.004 Table 1. The presence of laboratory sings of infection and cardiovascular risk factors, such as arterial hypertension, diabetes mellitus or chronic kidney disease did not differ significantly between both groups (Table 1). Also, incidental lead masses were less prevalent in patients with oral anticoagulation (Odds ratio 0.33, 95% CI: 0.11–1.00; p=0.048; Figure 1), whereas the distribution of CHA2DS2-VASc Scores did not show any differences. Conclusion The prevalence of incidental non-infectious CIED lead masses in TOE in our study was 27,6%, which is higher, than previously reported 5–10%. We did not observe any association between the incidental CIED lead masses and cardiovascular comorbidities. The absence of the oral anticoagulation seems to be the only clinical risk factor for such findings in our study, suggesting possible thrombogenic genesis. The high prevalence of incidental non-infectious lead masses should be kept in mind in order to avoid the overdiagnosis of CIED infection and unnecessary lead extraction. Funding Acknowledgement Type of funding sources: Public hospital(s).

Intraoperative intracardiac thrombus in liver transplantation: A 9-year retrospective review focusing on treatment and outcomes.

This study characterizes incidence and outcomes surrounding intracardiac thrombosis (ICT) during liver transplantation over 9 years at a single center before and after the routine use of transesophageal echocardiography (TEE). Adult liver transplantation patients from 2011 to 2020 were divided into eras based on routine TEE use. ICTs were identified by querying anesthetic records for search terms. Descriptive statistics included counts and proportions for baseline recipient, donor, intraoperative, and postoperative characteristics. Outcome data were based on date of hospital discharge and date of death. The incidence of ICT increased in the TEE era (2016-2020) compared with the pre-TEE era (2011-2015; 3.7% [25/685] vs. 1.9% [9/491]; p < 0.001). Patients with ICT had significantly higher Model for End-Stage Liver Disease-sodium (MELD-Na) scores, pretransplant hospitalization, malignancy, drug-induced liver injury, hypertension, deep vein thrombosis, reperfusion syndrome, transfused platelets and cryoprecipitate, and use of hemostatic medications. A higher proportion of patients in the ICT group underwent simultaneous liver-kidney transplantation. The patients with ICT were similar, except patients in the pre-TEE era had higher MELD-Na scores and incidences of hepatitis C virus and lower incidences of encephalopathy. In the pre-TEE era, all ICTs presented as intraoperative cardiac arrest, and the 30-day mortality in the setting of ICT was 66.7% (6/9). During the TEE era, 80% of ICTs were diagnosed incidentally or attributed to hemodynamic instability (p=0.002). The 30-day mortality rate was 36% (9/25) in the TEE era (p=0.25). ICT incidence increased in the TEE era, yet the mortality rate was lower, suggesting that routine intraoperative TEE may lead to the early detection of ICT prior to hemodynamic collapse.

The efficacy of three dimensional echocardiography in assessment of aortic atherosclerotic plaques compared to two dimensional echocardiography

Abstract Background Complex aortic atherosclerotic plaques (AAPs) carry a significant risk of embolism. Currently, two-dimensional (2D) transesophageal echocardiography (TEE) is the principal diagnostic tool of AAPs. However, we hypothesized that the data obtained from three-dimensional (3D) imaging may improve AAPs' spatial assessment. Purpose This study was aimed to evaluate the efficacy of 3DTEE in assessment of AAPs. Methods This study includes 96 patients who underwent routine TEE in our center within 2018–2019. The entire aorta including aortic root, ascending aorta, aortic arch, and descending thoracic aorta was investigated using both 2D and 3D TEE. The size and grade of aortic atherosclerotic plaques were compared using both 2D and 3D TEE. In addition, we examined to see if there is any correlation between the grade and size of the plaque, and patient's cardiac risk factors including their history of atherosclerotic diseases. Results Patients with atherosclerotic plaque in the ascending aorta had a larger plaque thickness in both two-dimensional and three-dimensional echocardiography. Obesity was an important risk factor for development of AAPs. Also, patients with a history of cerebrovascular attack (CVA) or transient ischemic attach (TIA) had larger AAPs. While age and gender showed no impact on the thickness of AAPs. According to the results obtained from comparing three-dimensional over two-dimensional echocardiography, one patient (1.04%) showed a decrease in grading scale, while nine patients (9.38%) showed enhancement in their grading (P-value=0.03). For the rest of 86 patients (89.58), atherosclerotic plaque grading was similar using both methods. This means that in almost 9% of cases 3D TEE increases the grading of the attributed atherosclerotic plaque, while it is the same to 2DTEE in most cases. Conclusions The information obtained from three-dimensional echocardiography would be most often very similar to the two-dimensional echocardiography, while in few cases, it would improve the grading scale. Cases with obesity and history of CVA and TIA had larger thickness of AAPs in both 2D and 3DTEE, while age and gender had no impact on plaque thickness. Funding Acknowledgement Type of funding sources: None.

Interdisciplinary approach to surgical treatment for patients with hypertrophic obstructive cardiomyopathy

Hypertrophic cardiomyopathy (HCM) – is the most common genetically determined heart disease, characterized by symmetrical or asymmetrical myocardial thickening (≥15 mm), leading to progressive heart failure and a high risk of sudden cardiac death (SCD). Diagnosis, natural course and treatment of HCM have become sources of uncertainty, misunderstanding and debate due to the increasing complexity of diagnosis in clinical practice, international differences in strategic approaches, advances in the treatment of genetic diseases and cardiac imaging. The aim. To amplify the current concept of HCM pathogenesis and mechanisms of the left ventricular outflow tract (LVOT) obstruction as well as to highlight our own results of HCM surgical correction. Materials and methods. A total of 330 HCM patients underwent surgical correction (septal myectomy) in the National M. Amosov Institute of Cardiovascular Surgery affiliated to National Academy of Medical Sciences of Ukraine. The mean age of the patients was 49.7 ± 15.0 years, median – 53; 168 (50.9 %) were male. Results. Surgical correction of HCM significantly improves the quality of life (80 % of patients were in NYHA II functional class after correction), reduces the symptoms of heart failure (93 % of patients had minimal mitral regurgitation after septal myectomy), decreases LVOT systolic pressure gradient (SPG) (the mean SPG was 18.9 ± 8.5 mmHg versus preoperative 93.6 ± 23.2 mmHg) and lowers the high-risk for SCD in the patients (the mean percentage of high-risk group was 3.78 % after correction). Routine CT planning and intraoperative transesophageal echocardiography helps to avoid severe iatrogenic complications and resect the interventricular septum as accurately as possible, completely eliminating LVOT obstruction. Conclusions. Secondary abnormal chordal attachment cutting, papillary muscle realignment and anterior mitral leaflet plication along with septal myectomy allows to fully correct all phenotype of HCM, is the safe and effective procedure as well as the definitive method of this pathology treatment minimizing the risk of disease recurrence.

Efficacy and safety of direct oral anticoagulants in patients undergoing elective electrical cardioversion: A real-world patient population

BackgroundDirect oral anticoagulants (DOACs) have emerged as the preferred choice of oral anticoagulation in patients with atrial fibrillation. Randomized trials have demonstrated the efficacy and safety of DOAC in patients undergoing electrical cardioversion (ECV); however, there is limited real-world data. ObjectiveTo evaluate the outcome of patients undergoing an elective ECV for atrial tachyarrhythmia in a tertiary referral center who were treated with DOAC or vitamin K antagonist (VKA) without routine trans esophageal echocardiography (TEE). MethodsThis was a retrospective single-center cohort study of consecutive patients undergoing an elective ECV for atrial tachyarrhythmia from January 2013 to February 2020. The primary endpoints were thromboembolism (composite of stroke, transient ischemic attack or systemic embolism) and major bleeding events within 60 days. ResultsA total of 1431 ECV procedures were performed in 920 patients. One-third of the procedures were performed under DOAC (N = 488, 34%) and the remainder of the procedures was performed under VKA (N = 943, 66%). There were no differences between groups with regard to demographic variables (mean age 62.4 ± 11.7, 72% men) and mean CHA2DS2-VASc score (2.3 ± 1.6); however, the VKA group had a higher proportion of patients with co-morbidity. Thromboembolism occurred in 0.41% in the DOAC group versus 0.64% in the VKA group (P = 0.72). Major bleeding events occurred in 0.41% in the DOAC group versus 0.11% in the VKA group (P = 0.27). ConclusionIn a real-world population, the rates of thromboembolism and major bleeding events were low after elective ECV in patients using DOAC or VKA, even without routine TEE.

Routine Transesophageal Echocardiography in Atrial Fibrillation Before Electrical Cardioversion to Detect Left Atrial Thrombosis and Echocontrast.

Transesophageal echocardiography (TEE) before electrical cardioversion (ECV) in atrial fibrillation (AF) is not routinely performed in anticoagulated patients. Starting from TEE findings of anticoagulated and non-anticoagulated patients referred for ECV, we investigated the rate of spontaneous echo-contrast (SEC) and left atrial thrombus (LAT) and identified their independent predictors. A total of 403 patients were included: 262 (65%) had no anticoagulation, 47 (11.7%) were onnovel oral anticoagulant (rivaroxaban), 74 (18.4%) on warfarin INR>2, and 20 (5.0%) on warfarin INR<2.In 41 (10.1%) there was LAT and in 154 (38.2%) SEC. Patients with LAT had a significantly lower left ventricular ejection fraction (LVEF%) (p=0.001). Patients with SEC were significantly older (p=0.04), had lower LVEF% (p<0.0001),higher CHADSVASC score (p<0.0001), and higher rate of coronary artery disease (CAD) (p=0.03). In 56.8% of warfarin patients (INR>2) there was SEC (p=0.002). At multivariate analysis therapeutic anticoagulation with warfarin (p=0.003; OR:2.2; CI: 1.3-3.7),CHADSVASC score (p<0.0001; OR=1.2; CI: 1.1-1.4), and LVEF% (p<0.0001; OR:0.95; CI: 0.93-0.97; inverse relationship) were SEC predictors. A 3.5 CHADSVASC score cut-off was predictor of SEC (AUC: 0.7; p<0.0001). LVEF% was the only predictor of LAT (p=0.02; OR=0.96; CI: 0.93-0.99; inverse relationship). Echocardiography before ECV identifies clear LAT/SEC in more than a third of AF patients, independently by their anticoagulation regimen. LAT/SEC rates increasewith decrement of LVEF%. Increment of CHADSVASC score increases SEC risk. In anticoagulated patients SEC rate remains higher than expected. Therapeutic anticoagulation with Warfarin appears positively and independently correlated to SEC occurrence.

Is transesophageal echocardiography necessary in patients undergoing ablation of atrial fibrillation on an uninterrupted direct oral anticoagulant regimen? Results from a prospective multicenter registry

Thromboembolic stroke is a rare but devastating consequence of atrial fibrillation (AF) ablation. Transesophageal echocardiography (TEE) is recommended to rule out left atrial appendage thrombus; however, its use is variable. The purpose of this study was to assess whether TEE is mandatory in patients undergoing AF ablation on uninterrupted direct oral anticoagulants (DOACs). Data from our prospective multicenter registry of patients with AF undergoing radiofrequency catheter ablation on uninterrupted DOACs were analyzed. All the included patients were on anticoagulation for at least 4 weeks before ablation. All AF ablation procedures were performed under intracardiac echocardiography guidance. Before transseptal puncture, heparin bolus was administered, followed by continuous infusion, with a target activated clotting time of >300 seconds. A total of 6186 patients (3180 on apixaban [51.4%], 2528 on rivaroxaban [40.9%], 404 on dabigatran [6.5%], and 74 on edoxaban [1.2%]) were analyzed. The mean age of the study population was 69.4 ± 10.3 years; 4194 patients (67.8%) were male, and 5120 patients (82.8%) had persistent and long-standing persistent AF. The mean CHA2DS2-VASc score was 2.86±1.58; the mean CHADS2 score was 1.65 ± 1.14. Intracardiac echocardiography ruled out left atrial appendage and left atrial thrombi in all patients and revealed "smoke" in 1672 patients (27.03%). Transient ischemic attack was noted in 1 patient with long-standing persistent AF in the setting of a missed dose of rivaroxaban before ablation. Our study showed that performing AF ablation in patients on uninterrupted DOACs without TEE is safe and feasible in high stroke risk patients. Elimination of routine preablation TEE would have significant economic and clinical implications.

Atherosclerotic plaque detected by transesophageal echocardiography is an independent predictor for all-cause mortality

Atherosclerotic lesions in the great arteries are frequent findings in the elderly. Numerous studies have shown their strong predictive value for cardiovascular disease, embolic events, and mortality. We sought to determine the risk of all-cause mortality depending on the localization of plaques in the thoracic aorta evaluated by transesophageal echocardiography (TEE). A total of 2,054 patients (median age 65 years, interquartile range 52–73; 58% men) who underwent a TEE examination between 01/2007 and 03/2015 were retrospectively analyzed. For each patient, the presence of atherosclerotic lesions in the ascending aorta, the aortic arch, and in the descending aorta, as well as cardiovascular risk factors and survival were documented. Median follow-up period was 48 months (interquartile range 38–58). Multivariate Cox regression analysis indicated plaque in the ascending aorta (HR of 1.36, 95% CI 1.01–1.83, P = 0.046), the aortic arch (HR of 1.78, 95% CI 1.29–2.45, P < 0.001), the descending aorta (HR of 2.01, 95% CI 1.54–2.77, P < 0.001), and plaque in any part of the thoracic aorta (HR of 1.84, 95% CI 1.42–2.4, P < 0.001), as independent predictors for all-cause mortality after adjusting for age, sex, arterial hypertension, hyperlipidemia, smoking, and diabetes. In this study, we could demonstrate that more than mild plaque at any site of the thoracic aorta predicts all-cause mortality. Assessment of atherosclerotic lesions in all segments of the thoracic aorta should be part of every routine TEE examination.

Cost-effectiveness of routine transoesophageal echocardiography during cardiac surgery: a discrete-event simulation study

BackgroundThe aim of this study was to simulate and compare the healthcare and economic outcomes associated with routine use of intraoperative transoesophageal echocardiography (TOE) in patients undergoing cardiac surgery with those associated with a scenario where TOE is not routinely used. MethodsThe impact of TOE on surgical decision-making was estimated through a systematic literature review. Individual short-term morbidity and mortality estimates were generated by application of the Society of Thoracic Surgeons risk calculator. Long-term event rates, unit costs, and utility weights were sourced from published literature and expert opinion. A discrete-event simulation model was then constructed to simulate both the in-hospital and post-discharge outcomes for patients undergoing cardiac surgery. Robustness of the base case results was examined through deterministic and probabilistic sensitivity analyses. An incremental cost–effectiveness ratio of €30 000 per quality-adjusted life-year gained was assumed to represent acceptable cost-effectiveness. ResultsRoutine use of intraoperative TOE was associated with lower costs and higher benefits per patient, which indicates that use of TOE is a dominant strategy. The intervention resulted in the avoidance of 299 cardiac complications, 20 strokes, and 11 all-cause deaths per 10 000 patients. Routine intraoperative TOE was associated with an increased occurrence of bleeding owing to more valvular surgery and subsequent long-term anticoagulation. ConclusionsRoutine intraoperative TOE is a cost-effective procedure for patients undergoing cardiac surgery, leading to lower overall costs. It was associated with a decrease in long-term complications including stroke, cardiac complications, and death, although there was a slight increase in extracranial bleeding events.

P3379Diagnostic value of cardiac computed tomographic angiography in suspected prosthetic valve dysfunction

Abstract Background Echocardiographic assessment of prosthetic mechanical valves is limited by shadows, artefacts and the need for cumbersome Doppler calculations. CT scan has the potential to overcome some of the limitations of echocardiography in assessment of prosthetic valves. Objectives Determine the incremental diagnostic value of cardiac computed tomographic angiography (CTA) over transesophageal echocardiography (TEE) in patients with suspected prosthetic valve dysfunction (PVD) and its impact on treatment decisions. Methods 50 consecutive patients with suspected PVD underwent both 64-slice ECG-gated CT and TEE and the results were compared. Imaging was compared against surgical findings (Reference standard). Echocardiographic evaluation focused on the detection of signs of PVD: vegetations, new or increased paravalvular leakage (PVL), aortic root pseudoaneurysms or abscesses and occluder malfunction. The CT interpreter was blinded to the findings of TEE. Results ECG-gated CT showed findings that were not detected by TEE in fifteen patients (30%). Additional aortic root abscess in four patients (8%), additional aortic root pseudoaneurysm in four patients (8%), and sclero-degenerative change across one of occluder of aortic prosthesis as cause of PVL in another patient (2%) not detected by TEE. CT negated the presence of aortic root abscess in one patient (2%), negated the presence of PVL in another patient (2%) both were detected by TEE. CT diagnosed occluder malfunction in one patient (2%) and underlying cause in two patients (4%) both were not detected by TEE. CT diagnosed presence of aortic arch dissection in one patient (2%) with large aortic root pseudoaneurysm. CT showed minor diagnostic change in six patients (12%). CT showed better delineation of site and periannular extension of aortic root abscess in four patients (8%). CT showed better assessment severity of PVL in one patient (2%) and cause of PVL across mechanical aortic prosthesis in another patient (2%). CT resulted in change of treatment strategy in 14 patients (28%). This included surgical excision of additional aortic root abscess or aortic root pseudoaneurysm in four patients (8%), surgical removal of prosthesis for underlying pathology (vegetation, malfunction due to underlying thrombus or PVL) in four patients (8%), aortic arch replacement with tubular graft and reimplantation of coronaries in one patient (2%) and conservative treatment with antibiotic therapy for small aortic root abscess not detected by TEE in 2 patients (4%), proper anticoagulation therapy and close monitor of INR in one patient (2%). Conclusion ECG-gated CT and TEE are complementary in patients with prosthetic valve dysfunction. Therefore, CT imaging has to be considered after clinical routine workup and TEE in patients with a high suspicion on prosthetic valve dysfunction.

Fibrin Sheath Formation during Mechanical Circulatory Support

Discontinuing mechanical circulatory support is often guided by transesophageal echocardiography (TEE).1,2 TEE was used to guide removal of an bicaval dual-lumen catheter (Avalon Elite, Maquet, Rastatt, Germany) after recovery of lung function in a patient supported with venovenous extracorporeal membrane oxygenation. TEE assessment of the right atrium showed a large fibrin sheath after removal of the catheter (arrow on panel A; LA, left atrium; RA, right atrium). Because of the large size and mobile nature of the retained fibrin sheath, it was percutaneously removed (panel B; LA, left atrium; RA, right atrium; SVC, superior vena cava; AngioVac system, AngioDynamics, USA) to avoid pulmonary embolization.Mechanical circulatory support therapy requires cannulae placement in central vessels for hemodynamic or ventilatory support. The presence of large catheters in central vessels, even for a brief period, can be complicated by fibrin sheath formation as shown in the presented image.1,3 Although unproven, low blood flow rate between a mechanical circulatory support catheter and a central vessel may be the reason for fibrin sheath formation around the catheter. Consequently, a fibrin sheath may form regardless of the degree of anticoagulation during mechanical circulatory support therapy, making routine TEE examination during mechanical circulatory support decannulation potentially important.2 Treatment options for a catheter-related fibrin sheath depend on the size, location, and mobility of the fibrin sheath and include observation, anticoagulation or percutaneous or open surgical removal.3Dr. Essandoh is a consultant for Boston Scientific (Marlborough, Massachusetts).

Infective endocarditis in patients with pyogenic spondylodiscitis: implications for diagnosis and therapy

OBJECTIVEThe incidence of patients with pyogenic spinal infection is increasing. In addition to treatment of the spinal infection, early diagnosis of and therapy for coexisting infections, especially infective endocarditis (IE), is an important issue. The aim of this study was to evaluate the proportion of coexisting IE and the value of routine transesophageal echocardiography (TEE) in the management of these patients.METHODSThe medical history, laboratory data, radiographic findings, treatment modalities, and results of TEE of patients admitted between 2007 and 2017 were analyzed.RESULTSDuring the abovementioned period, 110 of 255 total patients underwent TEE for detection of IE. The detection rate of IE between those patients undergoing and not undergoing TEE was 33% and 3%, respectively (p < 0.0001). Thirty-six percent of patients with IE needed cardiac surgical intervention because of severe valve destruction. Chronic renal failure, heart failure, septic condition at admission, and preexisting heart condition were significantly associated with coexisting IE. The mortality rate in patients with IE was significantly higher than in patients without IE (22% vs 3%, p = 0.002).CONCLUSIONSTEE should be performed routinely in all patients with spondylodiscitis.

Utility of routine transesophageal echocardiography in patients with stroke or transient ischemic attack

In several series of patients with presumed stroke, transesophageal echocardiography (TEE) has seemed advantageous over transthoracic echocardiography (TTE) in that it improves detection of cardiac sources and can lead to changes in the methods of treatment. We hypothesized that the real-world application of TEE in our institution produced results at variance from those previously reported. Our study of 219 patients, referred for TEE for an indication of stroke or transient ischemic attack, found few relevant findings that would have indicated a new diagnosis or required a change in treatment. These results suggest that for most patients in whom TEE is ordered, either a TTE or no cardiac testing would suffice.

Prevalence of left atrial appendage thrombus detected by transoesophageal echocardiography before catheter ablation of atrial fibrillation in patients anticoagulated with non-vitamin K antagonist oral anticoagulants.

There is ongoing controversy about the need for routine transoesophageal echocardiography (TOE) prior to atrial fibrillation (AF) ablation. Recently, the debate was reignited by the publication of a large series of patients showing a prevalence of left atrial appendage thrombus (LAAT) on TOE of 4.4%. We sought to assess the prevalence of LAAT on TOE before AF ablation at our institution. Consecutive patients scheduled for AF ablation at our institution between January 2009 and December 2016 were included. All patients were on oral anticoagulation for at least 4 weeks prior to TOE. Transoesophageal echocardiographies were performed 3-5 days prior to scheduled AF ablation. Data were collected utilizing a prospective database. In all, 668 patients and 943 AF ablation procedures were included. Mean age was 64 ± 11 years, 72% were male, average CHADS2 score was 1.0 ± 1.0, and 72% of the patients had paroxysmal AF. At the time of ablation, 496 (53%) were on non-vitamin K antagonist oral anticoagulants (NOACs) and 447 (47%) were on Warfarin. There were three cases with LAAT (3/943, 0.3%), all of whom had persistent AF and were on Warfarin. Two patients underwent surgical ablation and the third patient did not undergo ablation. In our experience, the prevalence of LAAT in patients on anticoagulation therapy undergoing TOE before catheter ablation of AF is 0.3%, which was much lower than recently reported. None of the patients with paroxysmal AF or on NOACs were found to have LAAT. Rather than routine use of TOE prior to AF ablation, a risk-based approach should be considered.

CLINICAL OUTCOMES AND SAFETY OF TRANSCATHETER AORTIC VALVE REPLACEMENT WITH AND WITHOUT ROUTINE USE OF TRANSESOPHAGEAL ECHOCARDIOGRAPHY

Transesophageal echocardiography (TEE) has been extensively used historically for Transcatheter aortic valve replacement (TAVR) but focus is shifting from routine TEE to ‘as needed’ use. We evaluated patients who had TAVR procedure in our institution from Sep 2012 to Feb 2017. Decision for

Elective Cardioversion in the Era of Novel Oral Anticoagulants – Does a Nurse Administered Verbal Questionnaire for Compliance Negate the Need for Routine Transoesophageal Echocardiography?

Anticoagulation prior to elective external direct current cardioversion (EDCCV) is mandatory. The inability to monitor compliance with novel oral anticoagulants (NOACs) raises a potential safety issue. We aimed to evaluate whether a structured, nurse-led assessment of compliance prior to EDCCV ensures safety without the need for routine transoesophageal echocardiography (TOE). Data was prospectively collected on consecutive patients undergoing EDCCV during 2014-2015. All procedures were supervised by an electrophysiology clinical nurse consultant (EPCNC). Drug compliance was verbally assessed using a standardised questionnaire by the EPCNC. Novel oral anticoagulants compliance was required for a continuous period of 3 weeks prior to EDCCV; otherwise a TOE-guided EDDCV was performed. All patients had follow-up 30 days post-procedure. Three hundred and eleven cardioversions were performed on 256 patients in whom 154 (49.5%) were prescribed a NOAC (rivaroxaban (n=105; 68.2%), dabigatran (n=38; 24.7%), apixaban (n=11; 7.1%)). Median age was 63 years (24-94 yrs), mean CHADS2-Vasc score was 2.0±1.5 and 138 (89.6%) were outpatients. One hundred and twenty-nine (83.8%) EDCCV were for atrial fibrillation and 25 (16.2%) for atrial flutter. Sinus rhythm was achieved in 90.3% of cases. Fourteen patients (9%) assessed as non-compliant underwent TOE. 129 (83.8%) EDCCV were performed without prior TOE. No stroke or systemic embolism was identified in any patient treated with either warfarin or a NOAC. A standardised, verbal questionnaire can be administered to detect NOAC non-compliance in patients undergoing EDCCV. With appropriate compliance assessment a nurse-led EDCCV without routine TOE did not significantly compromise safety in this study group.