TEE Images Research Articles

Three-dimensional transoesophageal echocardiography for the assessment of clip attachment to the leaflets in percutaneous edge-to-edge repair of the mitral valve

Single leaflet clip attachment (SLA) is a prevalent complication in percutaneous edge-to-edge repair of the mitral valve, leading to the recurrence of significant mitral regurgitation. The objective of this retrospective analysis was to evaluate a novel 3-D transoesophageal echocardiographic method for the assessment of clip attachment to the mitral leaflets. We analysed a total of 87 patients treated for symptomatic mitral regurgitation. In 47 patients, clip attachment to the leaflets was assessed by conventional 2-D transoesophageal echocardiography supported by biplane TEE images (biplane TEE group). In 40 patients, clip attachment to the leaflets was assessed by the intraprocedural 3-D volume method in addition to the conventional method (volumetric TEE group). The primary endpoint was defined as clip complications consisting of SLA and clip displacement at any time after clip implantation. Clip complications occurred in nine patients (19.1%) in the biplane TEE group and in two patients (5%) in the volumetric TEE group (p=0.06). Regarding the grade of mitral regurgitation, in the follow-up period we observed a more pronounced deterioration in the biplane TEE group than in the volumetric TEE group. These findings suggest that the additional use of 3-D volumetric transoesophageal echocardiography for the assessment of clip attachment to the mitral leaflets may contribute to a reduced rate of subsequent clip complications.

Abstract 18759: Benefit of TEE in Patients Over 50 with Unexplained Stroke and Normal TTE Study

Objective: Aside from oral anticoagulation in patients with intracardiac thrombus, current guidelines and scientific evidence do not support specific therapeutic interventions for most other TEE findings. We sought to examine the effect of performing TEE on therapeutic management in patients over age 50 with unexplained stroke. Specific TEE findings sought to explain the cause of stroke generally include cardiac thrombi (particularly LA and LAA) or spontaneous contrast, inter atrial septal anomalies (particularly PFO), and atheromatous disease of the aorta. We hypothesized that there would be minimal incremental value in performing TEE added to a normal TTE study. Methods: We retrospectively analyzed consecutive patients over 50 yrs who underwent TEE for unexplained stroke. Patients in sinus rhythm were included if TTE results were normal. Normal TTE was defined as normal LVEF, no intracardiac masses or shunts, absence of severe valvular heart disease. Results: TEE images and clinical data of 263 patients were analyzed. Baseline characteristics included mean age of 66.7 yrs, (range 50-91 yrs), 42.5% were female. TEE findings demonstrated complex plaque of the ascending aorta or arch in 44/263 (16.7%). PFO was found in 18/263(%), 25/263(%) had atrial spetal aneurysm (ASA), and 11/263(%) had both ASA and PFO. Spontaneous contrast was seen in 13/263 (4.9%). 1 patient had LA thrombus. Overall 38% had a TEE finding which could explain the etiology of stroke but 1/263 (0.4%) had a finding which changed therapy based on current guidelines or substantial scientific evidence. 6 months follow up was available on 85 patients, and 13(15%) of these patients developed new PAF. Conclusions: Our study demonstrates no incremental value of TEE to a normal TTE study in patients over 50 with unexplained stroke in sinus rhythm. As reported in prior studies, it is not uncommon for TEE to disclose findings such as aortic atheroma or interatrial septal anomalies, however these findings generally do not alter therapeutic management and therefore routine performance of TEE in these patients may not be justified. It needs to be determined whether subsequent PAF episodes were etiology or result of stroke.

An Adult Patient with Fontan Physiology: A TEE Perspective

Fontan and Baudet described in 1971 the separation of the pulmonary and systemic circulations resulting in univentricular physiology. The evolution of the Fontan procedure, most notably the substitution of right atrial-to-pulmonary artery anastomosis with cavopulmonary connections, resulted in significantly improved late outcomes. Many patients survive well into adulthood and are able to lead productive lives. While ideally under medical care at specialized centers for adult congenital cardiac pathology, these patients may present to the outside hospitals for emergency surgery, electrophysiologic interventions, and pregnancy. This presentation presents a “train of thought,” linking the TEE images to the perioperative physiologic considerations faced by an anesthesiologist caring for a patient with Fontan circulation in the perioperative settings. Relevant effects of mechanical ventilation on pulmonary vascular resistance, pulmonary blood flow and cardiac preload, presence of coagulopathy and thromboembolic potential, danger of abrupt changes of systemic vascular resistance and systemic venous return are discussed.

Abstract 17767: Geometric Differences in the Mitral Apparatus Between Ischemic Cardiomyopathy and Lone Atrial Fibrillation with Significant Mitral Regurgitation: A Real-Time Three-Dimensional Echocardiography Study

Introduction: Real-time three-dimensional transesophageal echocardiography (3D TEE) is a new technique that allows superior visualization of the mitral annulus and leaflet to two-dimensional TEE. We sought to elucidate the geometric differences in the mitral apparatus between lone atrial fibrillation (AF) and ischemic cardiomyopathy (ICM) with significant MR by 3D TEE. Methods: This study consisted of 20 patients (pts) with ischemic MR and 20 pts with functional MR due to lone AF. The severity of MR was evaluated on a basis of vena contract width (VCW). 3D TEE images were evaluated with dedicated mitral valve quantification software (Figure). Mitral annular anteroposterior (AP) and commissure-commissure (CC) diameters, AP-CC diameter ratio, area, and height which corresponds to annular saddle-shape depth (Figure) were analyzed at mid-systole. Tenting height, and tenting volume were also determined. Additionally, coaptation length (overlap length of the anterior and posterior leaflet) was measured in three locations; medial (CLm), central (CLc) and lateral (CLl). Results: No difference in VCW was found between lone AF pts and ischemic MR pts. Lone AF pts had greater AP (38 ± 5.0 vs. 30 ± 4.6 mm) and CC diameters (39 ± 4.9 vs. 33 ± 4.2 mm), AP-CC diameter ratio (0.99 ± 0.08 vs. 0.90 ± 0.06), and mitral annular area (12 ± 2.7 vs. 8.7 ± 2.2 cm 2 ) and smaller annular height (2.1 ± 0.8 vs. 4.3 ± 1.7 mm) than ischemic MR pts (all p<0.001). Although tenting volume was similar (2.8 ± 2.0 vs. 3.2 ± 1.6 ml, p=ns), tenting height was smaller in lone AF pts than ischemic MR pts (6.9 ± 3.2 vs. 9.0 ± 2.4 mm, p<0.05). CLc was smaller in lone AF pts than ischemic MR pts (3.1 ± 0.5, 3.5 ± 0.9 mm, p<0.05), whereas there were no differences in CLm and CLl between the two groups. Conclusion: 3D TEE clarified geometric differences in the mitral apparatus between ischemic MR and functional MR in lone AF pts.

A complicated transseptal puncture during Mitraclip procedure: saved by 3D-TEE

We report a case where real-time three-dimensional transoesophageal echocardiography (3D-TEE) was able to detect a complicated transseptal puncture during a Mitraclip procedure which was not seen on the two-dimensional TEE (2D-TEE) images. This case demonstrates the incremental value of 3D-TEE during transseptal puncture.

A three-dimensional insight into the complexity of flow convergence in mitral regurgitation: adjunctive benefit of anatomic regurgitant orifice area

Mitral effective regurgitant orifice area (EROA) using the flow convergence (FC) method is used to quantify the severity of mitral regurgitation (MR). However, it is challenging and prone to interobserver variability in complex valvular pathology. We hypothesized that real-time three-dimensional (3D) transesophageal echocardiography (RT3D TEE) derived anatomic regurgitant orifice area (AROA) can be a reasonable adjunct, irrespective of valvular geometry. Our goals were to 1) to determine the regurgitant orifice morphology and distance suitable for FC measurement using 3D computational flow dynamics and finite element analysis (FEA), and (2) to measure AROA from RT3D TEE and compare it with 2D FC derived EROA measurements. We studied 61 patients. EROA was calculated from 2D TEE images using the 2D-FC technique, and AROA was obtained from zoomed RT3DE TEE acquisitions using prototype software. 3D computational fluid dynamics by FEA were applied to 3D TEE images to determine the effects of mitral valve (MV) orifice geometry on FC pattern. 3D FEA analysis revealed that a central regurgitant orifice is suitable for FC measurements at an optimal distance from the orifice but complex MV orifice resulting in eccentric jets yielded nonaxisymmetric isovelocity contours close to the orifice where the assumptions underlying FC are problematic. EROA and AROA measurements correlated well (r = 0.81) with a nonsignificant bias. However, in patients with eccentric MR, the bias was larger than in central MR. Intermeasurement variability was higher for the 2D FC technique than for RT3DE-based measurements. With its superior reproducibility, 3D analysis of the AROA is a useful alternative to quantify MR when 2D FC measurements are challenging.

Real-Time 3-Dimensional Transesophageal Echocardiography of the Atrioventricular Septal Defect

Being able to view the morphological details of the heart malformation in any patient with the diagnosis of atrioventricular septal defect (AVSD) is invaluable in surgical planning, especially in the current era of modified 1-patch versus 2-patch techniques. Real-time 3-dimensional transesophageal echocardiography (RT 3D TEE) is a recently developed technique that allows real-time high-quality images akin to viewing the heart specimen. We present the principal pathomorphological features of AVSD as visualized by RT 3D TEE. The hallmark of AVSD is a common atrioventricular junction guarded by a common atrioventricular valve.1 In the normal heart, when seen from atrial perspective, the aortic valve is wedged between the mitral and tricuspid valve. In AVSD, because of the common AV junction, the aortic valve is in an “unwedged” position (Figure 1). The valve consists of 5 leaflets: the superior and inferior bridging leaflets, each of which overrides the ventricular septum, a left mural leaflet, a right anterior, and a right inferior leaflet (Figure 2). Whether the bridging leaflets are joined together distinguishes the complete form from the partial form. In partial AVSD (also termed “ostium primum ASD”), a tongue of leaflet tissue connects the bridging leaflets and the undersides of these leaflets …

Left juxtaposed atrial appendages in a patient with dextrocardia and tricuspid atresia: TEE images

Left juxtaposed atrial appendages in a patient with dextrocardia and tricuspid atresia: TEE images

Giant unruptured non-coronary sinus of Valsalva aneurysm presenting as tricuspid stenosis

Fig. 1. (A) CT scan image. CT scan shows giant non-coronary sinus of Valsalva aneurysm with neighbouring structures. Arrows indicate closed aortic valves. Ao: aorta, NC-SVA: non-coronary sinus of Valsalva aneurysm, LV: left ventricle, PA: pulmonary artery. (B) TEE image. Trans-oesophageal echocardiography shows aortic cusps level image of sinus of Valsalva aneurysm. *Arrows show aortic cusps, **Arrows show tricuspid leaflet, RV: right ventricle, SVA: sinus of Valsalva aneurysm.

TEE images of adult anomalous left coronary artery from pulmonary artery

TEE images of adult anomalous left coronary artery from pulmonary artery

The routine use of live three-dimensional transesophageal echocardiography in mitral valve surgery: clinical experience

Perioperative monitoring of mitral valve (MV) anatomy, function, and pathology is essential for surgical management of different MV disease. To overcome the several potential pitfalls of two-dimensional transesophageal echocardiography (2D TEE) and offline 3D TEE. Live 3D TEE was used to assess 73 patients (44 men and 29 women) with Carpentier type II MV regurgitation undergoing MV surgery perioperatively. The isolated segment most frequently involved was A2/P2, but A1or P1 rarely was involved in an isolated lesion or combined lesions. The agreement between 3D TEE finding and surgery was 88% (64/73). In nine patients, the live 3D TEE images revealed more segments or scallops with prolapse than the surgeon noted intraoperatively. Live 3D TEE allows more sensitivity and was feasible identification of prolapse or flail of individual segments of MV leaflets during surgery. We conclude that live 3D TEE should be regarded as an important adjunct to the standard 2D TEE examination in making decisions about MV surgery.

An Elongated Oval-Shaped Echolucent Structure Centered in the Transverse Aortic Arch: Evidence of a Vascular Disaster or a Lucky Break?

A PLEASANT, VERY COOPERATIVE, 58-year-old, 160-cm, 79-kg woman presented to the authors' institution for evaluation of acute, severe chest pain radiating to her back. She was otherwise asymptomatic. The patient had a past medical history of well-controlled essential hypertension and tobacco abuse but had been previously healthy and denied a history of cardiovascular disease. The patient was initially treated with intravenous morphine and esmolol while further work-up was conducted. The physical examination was completely unremarkable; heart sounds were normal without murmur, the lungs were clear to auscultation, the peripheral pulses were strong and equal in all 4 extremities, and no focal neurologic deficits were observed. A chest radiograph was obtained and transesophageal echocardiography was performed as part of the evaluation (Fig 1, Fig 2, respectively). What is the diagnosis? Why was the patient neurologically intact? Fig 2A 2-dimensional TEE image of the transverse aortic arch showing the presence of an elongated oval-shaped echolucent structure. View Large Image Figure Viewer Download Hi-res image

Live three-dimensional transesophageal echocardiographic imaging of novel multielectrode ablation catheters

Use of novel, anatomically-designed multielectrode catheters for ablation of paroxysmal atrial fibrillation(AF) has been reported1 and may potentially reduce operative times, limiting exposure to radiation. The concurrence of advances in catheter technology with the introduction of live 3-Dimensional transesophageal echocardiography (3D TEE) has potential to improve the efficiency and safety of ablation procedures. A case of AF ablation using anatomically-designed multielectrode catheters guided by live 3D TEE imaging is presented. A 42-year-old man presented with a history of persistent AF having failed antiarrhythmic drug therapy and DC cardioversion. He subsequently underwent pulmonary vein isolation and LA ablation under general anesthesia using novel multielectrode ablation catheters with unique 3-dimensional configurations. During the procedure, live 3D TEE images were acquired with a 3-D Matrix TEE transducer (iE33 system, X7-2T transducer; Philips Medical Systems, Andover, MA, USA). Transseptal puncture was performed with live 3D TEE imaging and fluoroscopy. Under live 3D TEE guidance, three multielectrode ablation catheters (Ablation Frontiers, Inc., Carlsbad, CA, USA) were used for ablation and mapping of the pulmonary veins, LA roof, mitral isthmus, and LA septum. Figure 1 shows a live 3-D TEE still image of the pulmonary vein ablation catheter (PVAC) in the left atrium near the right upper pulmonary vein (RUPV); the PVAC catheter is also shown ex vivo and with fluoroscopic imaging in relation to the His-bundle(HIS) and coronary sinus(CS) catheters and TEE probe. The complex configurations of the PVAC, the multi-array ablation catheter (MAAC), and the multi-array septal catheter (MASC) can be readily appreciated with live 3D TEE (see Video Attachment) and confidence during catheter placement and ablation was subjectively greatly improved. Figure 1 Localization of intracardiac catheters using standard 2-D echocardiography is complicated by cardiac and respiratory motion, catheter orientation, and proper identification of the catheter tip. 2-dimensional imaging is further limited in clearly defining the complex configuration and larger profile of these new multielectrode ablation catheters. In the use of multipolar ablation catheters, contact between the active electrode of the ablation catheter and the targeted cardiac tissue is an essential part of reducing risk of major complications and achieving successful ablation.1 While high resolution 3D anatomical mapping of LA anatomy can be obtained by pre-interventional MRI or CT scanning, TEE offers the only practical means of live 3D imaging of cardiac tissue during the intervention. Live 3D TEE has been used with conventional ablation catheters for real-time imaging of contact without the need for excessive manipulation during LA catheter ablation for AF;2, 3 this case demonstrates that the ability to image tissue contact with live 3D TEE is preserved with novel catheters with complex geometry. The ability of live 3D TEE to image and guide the use of these novel catheters is evident, as is the potential for enhanced patient safety and reduced operative duration. As use of complex catheters increases, an expanding role for perioperative echocardiographers in guiding ablation procedures is anticipated.

Feasibility of real-time three-dimensional transoesophageal echocardiography for guidance of percutaneous atrial septal defect closure

Intracardiac echocardiography (ICE) and two-dimensional transoesophageal echocardiography (2D TEE) are used in most centres for guiding transcatheter atrial septal defect (ASD) closure. ASDs have complex shapes that are not well characterized with 2D imaging. Real-time 3D TEE (RT3D TEE) provides en-face visualization of the ASD, allowing precise assessment of ASD dimensions. Accordingly, our aims were (i) to determine the feasibility of RT3D TEE to guide ASD closure and (ii) to compare ASD and balloon dimensions (BDs) using RT3D TEE vs. ICE and 2D TEE. Thirteen patients with ostium secundum ASD underwent transcatheter ASD closure. 2D TEE, RT3D TEE, and ICE images were acquired sequentially. RT3D TEE was feasible in all patients. Comparing RT3D TEE and 2D imaging, the mean difference in long-axis dimension was +0.5 mm (P= NS for both), and -1.4 mm in short-axis (2D TEE, P < 0.05; ICE, P = 0.06). BD was greater with 3D TEE vs. ICE (+0.9 mm). RT3D TEE can be used to guide transcatheter ASD closure with the advantages of lower cost than ICE, and ability to visualize en-face views of the ASD. ASD and BD as measured by RT3D TEE differ when compared with 2D imaging.

Coronary persistent abscess

Coronary stent infection is an uncommon condition with sinister prognosis. We came across a case of coronary stent infection with abscess formation . Staph aureus was identified as the culpable organism in microbiological specimens. The patient was appropriately treated with antibiotics and underwent coronary bypass grafting with debridement of abscess cavity. Figure 1 Figure . Panel A and B shows TEE images of coronary stent surrounded by abscess cavity.

Spontaneous echocardiographic contrast (SpE) associated with mechanical valve (MHV) closure: Evaluation by TEE and an in-vitrocomparison between two different mechanical bileaflet and a bioprosthetic valves

SpE is a poorly understood phenomenon with recent reports of a variety of bright echoes seen in patients with MHV. The present study was undertaken to review the TEE images of patients with prosthetic mitral valves and to compare and validate the clinical observations with in-vitro investigations. Our goals were to gain a better understanding of whether microbubbles are associated with a specific type of mitral valve prosthesis and to correlate this association with left ventricular function (LVF) and with the dynamics of the transvalvular flow.

Renal cell carcinoma in the inferior vena cava demonstrated by transesophageal echocardiography

thrombus. Resection of renal cell carcinoma from the IVC can now be assisted by intraoperative use of the TEE. Treiger et al6 reported accurate placement of caval clamps guided by the TEE with successful tumor removal in a series of 5 patients. In their study, there was a consistent correlation between the gross specimen and the TEE image. The presence of strands projecting from the tumor thrombus in the present case has not been previously reported. Because the strands appeared to be intact until the application of caval clamps, disintegration may have occurred during the resection of the tumor from the IVC. Small fragments remaining in the IVC may then have embolized when the caval clamps were removed to restore blood flow. The patient’s subsequent clinical course of lung metastases after tumor resection indicates that pulmonary seeding with tumor probably occurred in the perioperative period. The fragile appearance of these projections on TEE makes embolization prior to surgery likely. The occurrence of this tumor morphology may therefore be a sign of poor prognosis. The use of the TEE during resection of renal cell carcinoma may become standard practice in identification of the tumor extension. As increasing numbers of IVC thrombi are imaged, a correlation between their appearance on TEE and the gross morphology should provide insight into the prognosis and management of these patients. Detection of these fragile-appearing strands may affect a patient’s suitability for operative resection or necessitate meticulous techniques for removing any fragmented tumor from the IVC before restoring flow to that vessel.