Serial Transesophageal Echocardiography Research Articles

In vivo fluid dynamics of the Ventura interatrial shunt device in patients with heart failure.

Interatrial shunts are under evaluation as a treatment for heart failure (HF); however, their in vivo flow performance has not been quantitatively studied. We aimed to investigate the fluid dynamics properties of the 0.51cm orifice diameter Ventura shunt and assess its lumen integrity with serial transesophageal echocardiography (TEE). Computational fluid dynamics (CFD) and bench flow tests were used to establish the flow-pressure relationship of the shunt. Open-label patients from the RELIEVE-HF trial underwent TEE at shunt implant and at 6 and 12month follow-up. Shunt effective diameter (Deff) was derived from the vena contracta, and flow was determined by the continuity equation. CFD and bench studies independently validated that the shunt's discharge coefficient was 0.88 to 0.89. The device was successfully implanted in all 97 enrolled patients; mean age was 70±11years, 97% were NYHA class III, and 51% had LVEF ≤40%. Patency was confirmed in all instances, except for one stenotic shunt at 6months. Deff remained unchanged from baseline at 12months (0.47±0.01cm, P=0.376), as did the trans-shunt mean pressure gradient (5.1±3.9mmHg, P=0.316) and flow (1137±463mL/min, P=0.384). TEE measured flow versus pressure closely correlated (R2≥0.98) with a fluid dynamics model. At 12months, the pulmonary/systemic flow Qp/Qs ratio was 1.22±0.12. When implanted in patients with advanced HF, this small interatrial shunt demonstrated predictable and durable patency and performance.

Diagnostic, prognostic and clinical value of left ventricular radial strain to identify paradoxical septal motion in ventilated patients with the acute respiratory distress syndrome: an observational prospective multicenter study

BackgroundAcute cor pulmonale (ACP) is prognostic in patients with acute respiratory distress syndrome (ARDS). Identification of paradoxical septal motion (PSM) using two-dimensional echocardiography is highly subjective. We sought to describe feature-engineered metrics derived from LV radial strain changes related to PSM in ARDS patients with ACP of various severity and to illustrate potential diagnostic and prognostic yield.MethodsThis prospective bicentric study included patients under protective ventilation for ARDS related to COVID-19 who were assessed using transesophageal echocardiography (TEE). Transgastric short-axis view at mid-papillary level was used to visually grade septal motion, using two-dimensional imaging, solely and combined with LV radial strain: normal (grade 0), transient end-systolic septal flattening (grade 1), prolonged end-systolic septal flattening or reversed septal curvature (grade 2). Inter-observer variability was calculated. Feature engineering was performed to calculate the time-to-peak and area under the strain curve in 6 LV segments. In the subset of patients with serial TEE examinations, a multivariate Cox model analysis accounting for new-onset of PSM as a time-dependent variable was used to identify parameters associated with ICU mortality.ResultsOverall, 310 TEE examinations performed in 182 patients were analyzed (age: 67 [60–72] years; men: 66%; SAPSII: 35 [29–40]). Two-dimensional assessment identified a grade 1 and grade 2 PSM in 100 (32%) and 48 (15%) examinations, respectively. Inter-rater reliability was weak using two-dimensional imaging alone (kappa = 0.49; 95% CI 0.40–0.58; p < 0.001) and increased with associated LV radial strain (kappa = 0.84, 95% CI 0.79–0.90, p < 0.001). The time-to-peak of mid-septal and mid-lateral segments occurred significantly later in systole and increased with the grade of PSM. Similarly, the area under the strain curve of these segments increased significantly with the grade of PSM, compared with mid-anterior or mid-inferior segments. Severe acute cor pulmonale with a grade 2 PSM was significantly associated with mortality. Requalification in an upper PSM grade using LV radial strain allowed to better identify patients at risk of death (HR: 6.27 [95% CI 2.28–17.2] vs. 2.80 [95% CI 1.11–7.09]).ConclusionsIn objectively depicting PSM and quantitatively assessing its severity, TEE LV radial strain appears as a valuable adjunct to conventional two-dimensional imaging.

Abstract 14598: Relationship of Ambulatory Blood Pressure Profiles on Progression of Aortic Atheroma in Patients With Stroke

Introduction: Aortic atherosclerotic burden is known to be associated with an increased risk of ischemic stroke. However, longitudinal data and the risk factors about aortic plaque progression are limited. Hypothesis: We hypothesized that ambulatory blood pressure (BP) variables would play a role in progression of aortic atheroma over 2 years in patients with stroke Methods: 115 patients with who underwent serial transesophageal echocardiography (TEE) over 2 years were enrolled. Aortic atheroma was graded as mild (2-3mm), moderate (3-5 mm), severe (&gt;5mm), or complex (ulceration and/or mobile component) using TEE. Progression of aortic atheroma was defined as an increase of maximal plaque thickness by ≥1 grade. Ambulatory BP monitoring (ABPM) was performed when BP was stabilized. The association between ABPM variables and aortic atheroma progression was assessed. Results: During the median follow-up of 25.0 months, 10 (8.7%) were regressed, 13 (11.3%) were progressed, and 92 (80.0%) remained unchanged. Female had more progression of aortic atheroma (p=0.007). However, baseline LDL cholesterol, change of LDL cholesterol, intensity of statin and baseline plaque thickness were not significantly associated with change of aortic plaque. Regarding ABPM variables, systolic ABPM variables including 24 hour, daytime and nighttime mean systolic BP were associated with progression of aortic atheroma, whereas diastolic BP variables were not associated with change of aortic atherosclerosis. 24 hour, daytime and nighttime mean systolic BP were significantly related to plaque progression even after adjusting for clinical parameters (p=0.007 for 24 hour and daytime SBP, p=0.003 for nighttime SBP). Conclusions: Systolic BP variables were associated with progression of aortic atheroma in patients with stroke, which suggests systolic BP control can be a key to suppress progression of aortic plaques.

Rapidly vanishing left atrial dissection following mitral valve replacement: a case report

BackgroundLeft atrial dissection is an extremely rare complication of mitral valve replacement. Because of its severity, its prompt diagnosis and treatment is mandatory. The most effective treatment (i.e. surgical vs. non-surgical) for left atrial dissection has not been fully established yet.Case presentationHerein, we have reported left atrial dissection after mitral valve replacement in a 68-year-old obese woman. After closing the thorax, transesophageal echocardiography (TEE) revealed an atrial mass of 3 cm × 2 cm, visualized as an oval hypoechoic appearance extending from the posterior annulus of the mitral valve to the posterior wall of the left atrium. Because hemodynamic conditions were stable, surgery was ruled out and conservative treatment with close observation was selected. On postoperative day 2, TEE revealed that the atrial mass had vanished and the broken piece of the endocardium merely remained fluttering in the atrium. On postoperative day 6, the appearance of the left atrium was normalized completely, leaving no traces of left atrial dissection. The patient recovered uneventfully. Serial TEE was a very effective imaging modality during the non-surgical treatment of left atrial dissection.ConclusionsIt is crucial to accurately define diagnosis and optimally consider therapeutic strategies for left atrial dissection based on the hemodynamic conditions of the patient and serial TEE follow-up examinations. In our case study, left atrial dissection was successfully treated with conservative treatment; therefore, we believe that TEE could be a feasible modality for the early diagnosis of this condition.

A Very Long-term Longitudinal Study on the Evolution and Clinical Outcomes of Persistent Iatrogenic Atrial Septal Defect After Cryoballoon Ablation

BackgroundPersistent iatrogenic atrial septal defect (iASD) is a common but poorly characterized complication after cryoballoon (CB) pulmonary vein isolation (PVI) procedures. We therefore investigate its prevalence, evolution, risk factors, and clinical outcomes in a prospective longitudinal study. MethodsA total of 108 patients (41 women, mean age 57 ± 11.3) underwent CB PVI for AF. Serial transesophageal echocardiography (TEE) was performed 9 months and then annually until 6 years after the procedure to study the characteristics of persistent iASD. ResultsPersistent iASD occurred in 33 (30.6%) patients 9 months after CB PVI. Spontaneous closure of iASD was found in 6 (22.2%) and 3 (15.8%) patients 2 and 3 years after the procedures, respectively. No spontaneous closure was observed on 4, 5, and 6-year TEE follow-up. The projected long-term persistence rate of iASD after CB PVI was therefore 20% (30.6% × 0.778 × 0.842). Using multivariate logistic regression, a higher number of cryoapplications (≥ 2 minutes) was the only independent predictor of persistent iASD 9 months after CB PVI (odds ratio [OR] 1.207; 95% confidence interval [CI], 1.033-1.411, P = 0.018). Two (1.9%) patients with significantly larger iASD size than the others (long diameter 12.6 ± 0.8 vs 3.7 ± 1.5 mm, P < 0.001; short diameter 10.9 ± 0.2 vs 3 ± 1.1 mm, P < 0.001) required percutaneous closure because of exertional dyspnea and right ventricular enlargement. Over 129.7 patient-years follow-up, during which iASD persisted, there was no occurrence of neurologic events. ConclusionsApproximately one fifth of patients undergoing CB PVI will have permanently persistent iASD. Patients with defect sizes of greater than 10 mm may need percutaneous closure due to significant left-to-right shunting.

Oral anticoagulation and left atrial thrombi resolution in nonrheumatic atrial fibrillation or flutter: A systematic review and meta-analysis.

Oral anticoagulation (OAC) is prescribed for left atrial thrombi (LAT) in nonrheumatic atrial fibrillation (AF) and/or atrial flutter (AFL). The study objective was to review the existing evidence regarding LAT resolution in nonrheumatic AF and/or AFL with OAC agents. Data sources included PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) between January 1, 1991 and February 10, 2017. English-language studies that assessed LAT resolution with OAC agents in subjects with nonrheumatic AF and/or AFL, by serial transesophageal echocardiography, and with follow-up times ≥ 3weeks and<1 year, were selected. Study quality was assessed using recommendations adapted from the Agency for Healthcare Research and Quality. Pooled LAT resolution rates were evaluated for vitamin K antagonist (VKA) studies and low risk of bias warfarin studies. The pooled LAT resolution rate of 619 subjects from 16 VKA studies was 63.7% (95% confidence interval [CI], 53.3%-72.9%). The pooled LAT resolution rate of 94 subjects from four studies that specified warfarin use, exclusion of prior long-term therapeutic OAC, and target international normalized ratio (INR) ≥ 2.0 and/or average achieved INR ≥ 2.0 was 79.3% (95% CI, 69.8%-86.4%). Two studies in direct-acting oral anticoagulants (DOACs) reported LAT resolution rates of 89.5% (17 of 19) for dabigatran and 41.5% (22 of 53) for rivaroxaban. Warfarin is the most studied initial OAC agent for treating LAT in nonrheumatic AF and/or AFL with a resolution rate of nearly 80%. Further studies in DOACs are warranted.

Rapid progression of Staphylococcus lugdunensis mechanical prosthetic valve endocarditis

Abstract A 66-year-old woman with a remote history of mitral valve replacement (mechanical bileaflet valve) due to rheumatic heart disease presented with symptoms consistent with infectious endocarditis. Subsequent blood cultures grew Staphylococcus lugdunensis. A transesophageal echocardiogram demonstrated large vegetations on the atrial aspect of the mitral valve, with a Doppler derived mean pressure gradient of 13 mmHg (Fig. 1 and Video 1). Appropriate i.v. antibiotics were initiated and a surgical consultation was obtained. A second transesophageal echocardiogram was performed 6 days later after she developed acute respiratory failure secondary to pulmonary edema, requiring mechanical ventilation (Video 2). This examination revealed a significant increase in size of the mitral vegetations, with the largest measuring 2.2 cm in maximum dimension, with new complete obstruction of one mechanical leaflet, and with dense spontaneous echo contrast secondary to prosthetic mitral valve obstruction. She subsequently underwent urgent open heart surgery and redo mitral valve replacement with a bioprosthetic valve. Valve obstruction due to large vegetations occurs rarely with infectious endocarditis and is more common with prosthetic (in comparison with native) valves (1, 2, 3). Serial transesophageal echocardiography imaging was helpful in diagnosing this life-threatening complication

Persistence of iatrogenic atrial septal defect after interventional mitral valve repair with the MitraClip system: a note of caution.

The purpose of this study was to investigate the persistence rates of iatrogenic atrial septal defect (iASD) after interventional edge-to-edge repair with serial transesophageal echocardiography examinations and close clinical follow-up (FU). Transcatheter mitral valve repair (TMVR) with the MitraClip system (Abbott Vascular, Abbott Park, Illinois) is a therapeutic alternative to surgery in selected high-risk patients. Clip placement requires interatrial transseptal puncture and meticulous manipulation of the steerable sheath. The persistence of iASD after MitraClip procedures and its clinical relevance is unknown. A total of 66 patients (76.7% male, mean age 77.1 ± 7.9 years) with symptomatic mitral regurgitation (MR) at prohibitive surgical risk (EuroSCORE II 10.1 ± 6.1%) underwent MitraClip procedures and completed 6 months of FU. Transesophageal echocardiography after FU showed persistent iASD in 50% of cases. Patients with iASD did not significantly differ from patients without ASD concerning baseline characteristics, New York Heart Association functional class, severity of MR, and acute procedural success rates (p > 0.05). When comparing procedural details and hemodynamic measures between groups, MitraClip procedures took longer in patients without iASD (82.4 ± 39.7 min vs. 68.9 ± 45.5 min; p = 0.05), and echocardiography after FU showed less decrease of systolic pulmonary artery pressures in the iASD group (-1.6 ± 14.1 mm Hg vs. 9.3 ± 17.4 mm Hg; p = 0.02). Clinically, patients with iASD presented more often with New York Heart Association functional classes >II after FU (57% vs. 30%; p = 0.04), showed higher levels of N-terminal pro-brain natriuretic peptide (6,667.3 ± 7,363.9 ng/dl vs. 4,835.9 ± 6,681.7 ng/dl; p = 0.05), and had less improvement in 6-min walking distances (20.8 ± 107.4 m vs. 114.6 ± 116.4 m; p = 0.001). Patients with iASD showed higher death rates during 6 months (16.6% vs. 3.3%; p = 0.05). Cox regression analysis found that only persistence of iASD (p = 0.04) was associated with 6-month survival. The persistence rate of 50% iASD after MitraClip procedures is considerably high. Persistent interatrial shunting was associated with worse clinical outcomes and increased mortality. Further studies are warranted to investigate if persistent interatrial shunting is the mediator or marker of advanced disease in these patients.

A Serendipitous Identification of a Lead Extraction Complication

A 57-year-old male with a dual chamber pacemaker and symptomatic, persistent atrial fibrillation (AF) accompanying a febrile illness presented for elective transesophageal echocardiography (TEE)-guided cardioversion. The patient was found to have a large 2.5cm×2.3cm, mobile mass attached to the right atrial lead. Following device and lead extraction, he developed progressive shortness of breath which was attributed to his underlying arrhythmia. One month later, AF ablation was pursued and preablation TEE revealed a dilated main pulmonary artery with a 1.8cm×1.6cm mass in the distal left pulmonary artery, which was corroborated by a 1.4cm×2.5cm filling defect in the descending left pulmonary artery on magnetic resonance angiography (MRA). To our knowledge, this is the first case report to document the distal migration of vegetation material into the pulmonary artery with serial TEE and highlights the risk of pulmonary embolism (PE) in patients with large endocardial lead vegetations undergoing transvenous lead extraction.

Levosimendan versus dobutamine in Tako-tsubo cardiomyopathy

Tako-tsubo cardiomyopathy is a clinical entity characterized by a dysfunction of the left ventricle, usually transient, which manifests itself with symptoms that can mimic an acute coronary syndrome. It is characterized by transient ballooning modification of the left ventricular apex, probably due to neurogenic stimuli resulting in low cardiac output syndrome. The aim of this prospective randomized study was to evaluate, by serial transesophageal echocardiography (TEE), what is the best drug treatment between levosimendan and dobutamine to restore a satisfactory cardiac function in the case of low cardiac output.

Initial Experience with a Disposable Transesophageal Echocardiography Monitoring System during Therapeutic Hypothermia following out of Hospital Cardiac Arrest

Objective: This investigation summarizes the initial clinical experience of trained echocardiographers who utilized a miniaturized disposable monoplane transesophageal echocardiography (TEE) system in patients undergoing therapeutic hypothermia following out of hospital cardiac arrest.Design: A retrospective, single-center, observational study. Setting: A tertiary care university hospital.Patients: We retrospectively reviewed the medical records of 13 consecutive patients undergoing therapeutic hypothermia following out of hospital cardiac arrest in which a disposable monoplane TEE probe was placed to observe myocardial recovery and potentially guide hemodynamic optimization. Measurements and Main Results: A total of 40 imaging sessions were performed. The success rate for obtaining the mid-esophageal four chamber and the transgastric mid-papillary short axis views were 92.5% and 100% respectively. Endocardial border definition was adequate in 90% of imaging sessions to measure left ventricular end diastolic and systolic areas enabling calculation of fractional area of change. Assessment of right ventricular function was possible in 92.5% of imaging sessions.A significant number of imaging sessions (12/40, 30%) provided information that clarified the patient’s biventricular function in the setting of ambiguous invasive pressure monitoring measurements.Conclusions: Acquisition of a mid esophageal four chamber and transgastric mid papillary view was possible with the miniaturized disposable TEE probe in the vast majority of imaging sessions. This information enabled the qualitative assessment of right ventricular function, measurement of left ventricular end systolic, and diastolic area with a high degree of success in patients during therapeutic hypothermia following cardiac arrest. The authors postulate that serial assessment of biventricular function and filling with serial TEE imaging provides information that cannot be reliably inferred from other advanced hemodynamic monitoring devices in routine clinical practice. This work was funded by the Department of Anesthesiology at Vanderbilt University Medical Center.

Abstract 6108: Cardiac 64-slice Multidetector Computerized Tomography in the Management of Prosthetic Heart Valve Obstruction

Differentiation of pannus (P) and thrombus (THR) in prosthetic heart valve obstruction (PHVO) is still a confusive state at the present cardiological practise. Transesophageal echocardiography (TEE) is not fully capable method in this condition. We considered that cardiac 64-slice multidetector computerized tomography (MDCT) may have a value in the management of PHVO. Thirtytwo of 37 pts (22 male, mean age 47±11 years, 17 with atrial fibrillation) with PHVO (35 mitral, 2 tricuspid) were detected with TEE and also with MDCT before and after thrombolytic therapy (TT). Five pts having monoleaflet valves were excluded due to excessive artifacts. Pre-TT MDCT revealed at least 1 culprit mass (CM) which was considered to be the cause of PHVO and the Hounsfield unit (HU) values of CM’s were measured. All pts underwent TT under the guidance of serial TEE. The study consisted of 2 groups up to response of CM’s to TT demonstrated by post-TT MDCT. Group I: Successfully lysed CM’s, Group II: Nonresponder CM’s. TEE disclosed THR in 26 pts, however the cause of PHVO in 6 pts remained undefined. Pre-TT MDCT disclosed 45 distinct CM’s on 32 valves. Post-TT MDCT disclosed the number of CM’s for groups I and II: 26 and 19, respectively. Significant difference between mean HU values of groups was found [87 (range 11–180), 331 (range 168–510), respectively, p&lt;0.001]. A cut-off value of HU&gt;200 predicted nonresponder CM’s (sensitivity 94%, specificity 96%, p&lt;0.001). CM’s of 6 pts with undefined TEE findings were all in group II and pure P was demonstrated surgically. In group I, 17 of 26 (%65) CM’s were completely and the remaining partially lysed which was confirmed by TEE. A cut-off value of HU&lt;100 predicted complete lysis (sensitivity 100%, specificity %95, p&lt;0.001). Subgroup analysis of CM’s with HU=100–200 revealed 10% completely and 80% partially lysis and 10% remained unresponded as confirmed by TEE. MDCT can be a useful technique for evaluation of PHVO caused by THR or P formation. Higher HU values denote P whereas the lower values THR. MDCT can also predict the response to TT. The higher the HU value the less the successful outcome. The CM’s with HU&gt;200 are almost always resistant to TT.

Impending Paradoxical Embolism Presenting as a Pulmonary Embolism, Transient Ischemic Attack, and Myocardial Infarction

A 25-year-old man presented with complaints of nonpleuritic, substernal chest pain, dyspnea, and decreasing exercise tolerance. His vital signs were normal, with the exception of an oxygen saturation level of 93% while breathing room air. During his assessment, he developed transient left facial droop, left arm and leg weakness, and an ataxic gait, which lasted 15 min then resolved spontaneously. Cardiac enzyme levels were elevated, and an ECG revealed T-wave inversion in leads III, aVF, V1, and V2 with evolving ST-segment elevation in leads V3 through V5. The findings of a CT scan and MRI of the head were negative; a Doppler ultrasound of the right lower extremity revealed a thrombus extending from the common femoral vein to the popliteal vein. Cardiac catheterization revealed no evidence of epicardial coronary artery disease. CT pulmonary angiography revealed bilateral pulmonary emboli. Transesophageal echocardiography (TEE) showed a 4-cm, dumbbell-shaped mass lodged in a patent foramen ovale, confirming the diagnosis of an impending paradoxical embolism. The patient was started on therapy with unfractionated heparin, and his thrombus resolved spontaneously by hospital day 5. An impending paradoxical embolism is rare but should be suspected in anyone presenting with evidence of both venous and arterial emboli. The therapeutic options include anticoagulation, thrombolysis, and surgical embolectomy. We would propose that initial treatment with anticoagulation therapy and following with serial TEEs may be appropriate therapy in an otherwise stable patient, with surgical embolectomy or thrombolysis reserved for the treatment of thrombi that do not resolve with anticoagulation therapy or for patients with clinical deterioration.

61-Year-Old Woman With Knee Pain and Confusion

61-Year-Old Woman With Knee Pain and Confusion

Transesophageal Echocardiography and Therapeutic Management of Patients Sustaining Blunt Aortic Injuries

No objective criteria have been described to help selecting patients with major blunt aortic injury (BAI) for postponed surgical repair. The efficacy of conservative management of minor BAI needs further evaluation. We studied 31 patients (Injury Severity Score, 48 +/- 15) who sustained a BAI diagnosed using transesophageal echocardiography (TEE). In patients with major BAI, the timing of surgery was made on the basis of clinical findings (grade 2) or TEE results (grade 3). We retrospectively separated patients into group I (rapid surgery, < or = 12 hours; n = 13) and group II (late or no surgery; n = 11). All major BAIs were confirmed by alternative imaging modalities or surgery. Patients with minor BAI (grade 1; n = 7) prospectively underwent conservative management with serial TEE follow-up. All patients with grade 3 BAI (n = 4) were promptly operated on. No group II patient died as a result of aortic rupture, and all of them exhibited a small false aneurysm formation (ratio between the maximal diameter of the injured aortic isthmus and the diameter of the normal descending aorta < 1.4) and hemomediastinum (< 7.2 mm). TEE follow-up of group II patients (mean, 5 months) showed stable BAI, whereas follow-up of patients with minor BAI (mean, 15 months) disclosed total healing (n = 3) or stable lesions (n = 4). Conservative management of minor BAI with serial follow-up appears to be appropriate. In patients with a grade 2 BAI and small false aneurysm formation and hemomediastinum, postponed surgical repair appears to be safe. However, these TEE criteria remain to be tested prospectively.

Incidence of Cerebral Embolism after Cardioversion of Atrial Fibrillation: A Prospective Study with Transesophageal Echocardiography and Cerebral Magnetic Resonance Imaging

After cardioversion of atrial fibrillation the risk for cerebral embolism is increased. There is little knowledge about the incidence of cerebral embolism for patients with transesophageal echocardiography (TEE)-guided cardioversion under oral anticoagulation. Consecutive patients with atrial fibrillation and TEE-guided cardioversion were included in the study. We performed serial TEE studies, Holter electrocardiography, cranial magnetic resonance imaging, and clinical examinations during a period of 4 weeks before and after cardioversion. Oral anticoagulation was continued or initiated in all patients. During the observation period 6 of 127 (4.7%) patients had new embolic lesions after cardioversion documented on cerebral magnetic resonance imaging. Patients with an event were significantly older (P = .04) and had a larger left atrium (P = .04) than patients without event. Patients with atrial fibrillation and oral anticoagulation have a low rate of clinical apparent cerebral embolism after TEE and anticoagulation-guided cardioversion. The rate of silent cerebral embolism is almost 5%. Age and left atrial size are predictors for an event.

Trombose de prótese biológica mitral: importância do ecocardiograma transesofágico no diagnóstico e acompanhamento pós-tratamento

To report the clinical and echocardiographic findings of bioprosthetic mitral valve thrombosis and the value of transesophageal echocardiography (TEE) in its diagnosis and monitoring of thrombolysis. One hundred and eleven patients with mitral bioprostheses underwent TEE, and 4 out of 7 suspected of having a thrombus on these prostheses were included in the study (mean age = 60.2+/-10.2 years; 2 men). The diagnosis was confirmed with serial TEE and clinical evolution. The morphologic features of the prosthetic leaflets, as well as the presence and characteristics of attached echogenic masses were investigated. The mean gradient through the prosthesis and the valvular area were obtained. The diagnosis of bioprosthetic mitral valve thrombosis was established 48.7+/-55.2 months after surgery. Two patients had ischemic stroke in the early postoperative period. The mean overall gradient was high (11.4+/-3 mmHg) and the valvular area reduced (1.24+/-0.3 cm2). On TEE, echogenic masses on the left ventricular face of the mitral bioprosthesis suggestive of thrombus were evidenced in all patients. On serial TEE (136+/-233 days), in 2 patients the thrombus had disappeared and in 2 others it was smaller after treatment, the mean gradient dropped to 6.2+/-3 mmHg (P = 0.004; 95% CI), and the valvular area increased to 2.07+/-0.4 (P = NS). TEE proved to be useful for detecting bioprosthetic mitral valve thrombosis and was effective in monitoring the treatment in all patients.

Aortic Intimal Injuries from Blunt Trauma: Resolution Profile in Nonoperative Management

To provide preliminary data on the resolution profile of aortic intimal injuries treated nonoperatively and on the safety of nonoperative management of these injuries. Five blunt trauma patients diagnosed by transesophageal echocardiography (TEE) with traumatic intimal injury of the aorta were assigned to nonoperative management. This included beta-blockade to maintain systolic blood pressure between 80 and 90 mm Hg and heart rate between 60 and 80 beats/min, serial TEE studies, and invasive monitoring in the intensive care unit. The evolution of injury, the effectiveness of nonoperative treatment, and the potential need for an operative intervention were monitored. The patients had a mean Injury Severity Score of 32 and sustained multiple associated thoracic and extrathoracic injuries. Aortic injuries were located at the level of the ligamentum arteriosum and in the descending aorta adjacent to the diaphragm in three and two patients, respectively. The mean size of injury was 12.5 mm (range, 5-20 mm) and a thrombus attached to the endothelium was present in three of the five patients. Complete resolution of injury occurred within 9.4 +/- 6.6 days (range, 3-19 days). All patients remained hemodynamically stable and adequately perfused. All demonstrated progressive resolution of their aortic intimal injuries. No complications related to the aortic injuries were identified during a mean follow-up of 16.8 months. This small series suggests that aortic intimal injuries smaller than 20 mm in hemodynamically stable patients treated with beta-blockade resolve within several days. This approach appears safe when monitored by serial TEE studies performed by experienced experts, and continuous invasive hemodynamic monitoring.

Transaortic repair of blunt traumatic cardiac wall and papillary muscle rupture

Transaortic repair of blunt traumatic cardiac wall and papillary muscle rupture

Case 5—2000 Confusion of aortic valve and parts of an aortic root prosthesis during intraoperative transesophageal echocardiography

An 81-year-old woman with aortic valve stenosis (3+), aortic valve insufficiency (1+), and coronary artery disease was scheduled for elective aortic valve replacement and coronary bypass surgery. The patient suffered from syncopal episodes and dyspnea at rest. Comorbidities were slight renal insufficiency, diabetes mellitus type IIb, and hyperlipoproteinemia. The patient received oral digitoxin, furosemide, simvastatin, glibenclamide, bisoprolol, and ramipril. Preoperative transesophageal echocardiography (TEE) and transthoracic echocardiography had shown a severely calcified aortic valve (area, 0.7 cm 2 Schuenemann S Andreas S Kreuzer H Werner GS Complete morphologic and functional resolution of endocarditis of a Toronto stentless porcine bioprosthesis: A study by serial transesophageal echocardiography. J Am Soc Echocardiogr. 1998; 11: 77-79 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ), left ventricular hypertrophy (wall thickness, 16 mm), and a transvalvular maximum systolic gradient of 88 mmHg (mean, 54 mmHg). Ejection fraction was 50%. Cardiac catheterization had revealed a 70% stenosis of the left anterior descending coronary artery (LAD).