Three-dimensional Transesophageal Echocardiogram Research Articles

A Very Rare Case of Primary Mural Endocarditis of the Right Atrium due to Candida Albicans

Right-sided infective endocarditis accounts for 5-10% of all infective endocarditis cases. Fungal endocarditis represents 1-3% of all of infective endocarditis cases, with Candida spp. being the most common microbiological cause. Primary mural endocarditis is defined by the absence of valvular vegetations together with the presence of vegetations on the endocardial free wall that are not associated with myocardial abscesses, cardiac structural abnormalities, devices, prosthetic material, thrombi or tumors. It constitutes a very rare entity and only 63 cases have been published the literature. C. albicans is the microbiological cause in only nine of these cases, none of which involves the right atrium. We report the case of a frail 84-year-old female patient with a pacemaker presenting with fever. In the transthoracic and three-dimensional transesophageal echocardiograms, a mobile mass was found attached on the free wall of the right atrial base. Blood cultures were positive for C. albicans and the modified Duke criteria were fulfilled for a definite diagnosis of infective endocarditis. After evaluation from a heart team the patient was managed with transvenous lead extraction and intravenous high-dose caspofungin, according to the 2023 Guidelines of the European Society of Cardiology for the management of endocarditis. Pacemaker lead cultures were negative leading to the diagnosis of primary mural endocarditis. The patient responded well to treatment with significant clinical and laboratory improvement. Long-term oral fluconazole was initiated after hospital discharge with a close follow-up plan. To our knowledge this is the first case of primary mural endocarditis of the right atrium due to C. albicans.

Mitral prosthetic valve dehiscence: Role of three-dimensional transesophageal echocardiogram in management

Mitral prosthetic valve dehiscence: Role of three-dimensional transesophageal echocardiogram in management

Mitral valve prolapse in patients with atrial septal defect: A quantitative three-dimensional echocardiographic analysis.

Mitral valve (MV) prolapse is highly prevalent in patients with atrial septal defect (ASD). Abnormal left ventricular geometry has been proposed as the main mechanism of MV prolapse in ASD, however, the changes in the morphology of the MV apparatus remain to be clarified. Our aim was to assess the MV geometry in patients with ASD and MV prolapse. We evaluated 99 patients (73% female, median age 40 years) with ASD who underwent a three-dimensional transesophageal echocardiogram. Three-dimensional analysis of the MV was done using dedicated automated software. Transthoracic echocardiographic parameters were assessed post ASD closure in 28 patients. MV prolapse was found in 39% of patients. Although smaller left ventricular dimensions and greater interatrial shunt were found in patients with MV prolapse compared with those without prolapse, there was no difference in the subvalvular parameters. MV prolapse was associated with larger mitral anterior-posterior diameter, anterolateral-posteromedial diameter, anterior perimeter, posterior perimeter, total perimeter, and anterior leaflet area (all p<0.05). Mitral regurgitation was more frequent in patients with MV prolapse (80vs. 48%, p=0.002). In patients with ASD, the main mechanism of MV prolapse is the presence of an organic primary process of the MV apparatus (excessive anterior mitral leaflet tissue and mitral annular enlargement).

Fatal Infective Endocarditis in a Patient with Cardiac Resynchronization Therapy

A 71-year-old man who underwent cardiac resynchronization therapy with a defibrillator (CRT-D) implantation five years ago, was admitted by a lengthy febrile illness. An initial transthoracic echocardiogram identified a unique vegetation of 10 mm adhered to device cables. Triple antibiotic was started with initial favorable clinical response, but the control transesophageal echocardiogram (TEE) at ten days showed several large mobile vegetations adhered to CRT-D leads and partially occupying the tricuspid annulus (A-B). Three-dimensional TEE confirmed these findings (C). Accordingly, emergent cardiac surgery for device removal was indicated (D). The patient died within 48 hours because of septic multiple organ dysfunction syndrome.

Real Time Three‐Dimensional Echocardiography and Endovascular Stenting

A 52-year-old male with HIV and chronic renal failure presented with 2-day history of fever and chills. He had recent superior vena cava (SVC) stent placement for SVC stenosis following multiple dialysis-catheter insertions. Patient's blood cultures grew methicillin-resistant staphylococcus aureus. Two-dimensional (2D) echocardiography showed no vegetations. With high clinical suspicion, 2D transesophageal echocardiogram (TEE) was obtained and confirmed no endocarditis and patent stent at SVC right atrial junction; however, entire stent was not visualized. Simultaneous three-dimensional TEE provided superior views of SVC stent in cross-sectional and longitudinal planes, clearly demonstrating patent stent without vegetations, stenosis, migration, or thrombosis.

Ventricular Assist Device–Associated Thrombus

HomeCirculationVol. 124, No. 7Ventricular Assist Device–Associated Thrombus Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessBrief ReportPDF/EPUBVentricular Assist Device–Associated Thrombus Daniel B. Sims, MD, Hiroo Takayama, MD, Nir Uriel, MD, Linda D. Gillam, MD, Yoshifumi Naka, MD, PhD and Ulrich P. Jorde, MD Daniel B. SimsDaniel B. Sims From the Division of Cardiology, Department of Medicine (D.B.S., N.U., L.D.G., U.P.J.) and the Division of Cardiothoracic Surgery, Department of Surgery (H.T., Y.N.), Columbia University Medical Center, New York, NY. Search for more papers by this author , Hiroo TakayamaHiroo Takayama From the Division of Cardiology, Department of Medicine (D.B.S., N.U., L.D.G., U.P.J.) and the Division of Cardiothoracic Surgery, Department of Surgery (H.T., Y.N.), Columbia University Medical Center, New York, NY. Search for more papers by this author , Nir UrielNir Uriel From the Division of Cardiology, Department of Medicine (D.B.S., N.U., L.D.G., U.P.J.) and the Division of Cardiothoracic Surgery, Department of Surgery (H.T., Y.N.), Columbia University Medical Center, New York, NY. Search for more papers by this author , Linda D. GillamLinda D. Gillam From the Division of Cardiology, Department of Medicine (D.B.S., N.U., L.D.G., U.P.J.) and the Division of Cardiothoracic Surgery, Department of Surgery (H.T., Y.N.), Columbia University Medical Center, New York, NY. Search for more papers by this author , Yoshifumi NakaYoshifumi Naka From the Division of Cardiology, Department of Medicine (D.B.S., N.U., L.D.G., U.P.J.) and the Division of Cardiothoracic Surgery, Department of Surgery (H.T., Y.N.), Columbia University Medical Center, New York, NY. Search for more papers by this author and Ulrich P. JordeUlrich P. Jorde From the Division of Cardiology, Department of Medicine (D.B.S., N.U., L.D.G., U.P.J.) and the Division of Cardiothoracic Surgery, Department of Surgery (H.T., Y.N.), Columbia University Medical Center, New York, NY. Search for more papers by this author Originally published16 Aug 2011https://doi.org/10.1161/CIRCULATIONAHA.111.035337Circulation. 2011;124:e197–e198IntroductionA 51-year-old man presented to an outside hospital after a witnessed cardiac arrest. The patient was in ventricular fibrillation and was defibrillated multiple times. ECG revealed anterolateral ST elevations. An intra-aortic balloon pump was placed, and catheterization revealed 100% proximal left anterior descending artery and 99% first obtuse marginal artery occlusion. Bare metal stents were placed in the left anterior descending artery, but the patient remained in cardiogenic shock and was transferred to our institution for a ventricular assist device. He had a short-term CentriMag biventricular assist device (Levitronix, Waltham, MA) placed with stabilization of his hemodynamics. The inflow cannula on the left side was placed in the left atrium and across the mitral valve into the left ventricle. He was maintained on aspirin and a heparin infusion. The patient's condition improved, and he was evaluated for a long-term ventricular assist device. On the 16th hospital day, hematochezia occurred. Colonoscopy revealed a necrotic ulcer in the cecum thought to be caused by a thromboembolism. A transesophageal echocardiogram revealed the left-sided inflow cannula ensheathed in clot with mobile thrombus (Figures 1 and 2 and Movies I and II in the online-only Data Supplement). There was considerable thrombus along the lateral and apical wall of the left ventricle (Figure 3 and Movie III in the online-only Data Supplement). Thrombectomy was performed emergently, and the cannula was removed and replaced with a cannula at the left ventricular apex. The following day, the patient developed mesenteric ischemia and multiorgan dysfunction syndrome and died.Download figureDownload PowerPointFigure 1. Two-dimensional transesophageal echocardiogram with clot on the left-sided inflow cannula of the ventricular assist device in the left atrium. Mobile thrombus is present in the left atrium and on the mitral valve.Download figureDownload PowerPointFigure 2. Three-dimensional transesophageal echocardiogram with clot ensheathing the left-sided inflow cannula of the ventricular assist device in the left atrium. Mobile thrombus is present.Download figureDownload PowerPointFigure 3. Two-dimensional transesophageal echocardiogram with thrombus present at the left ventricular apex and lateral wall.Cardiogenic shock in the setting of an acute myocardial infarction is associated with a 50% mortality rate despite early reperfusion of the infarct-related artery and intra-aortic balloon counterpulsation.1 In these patients, mechanical circulatory support with a ventricular assist device is necessary to support hemodynamics and end-organ perfusion. Even with adequate anticoagulation, a thrombus can form on the left ventricular assist device apically placed inflow cannula.2 In this particular case, stasis in the left atrium and left ventricle created by the transatrial cannulation likely led to the extensive thrombus formation.DisclosuresDr Naka has received consulting fees from Terumo Heart Inc and Thoratec Co. Dr Jorde has received consulting fees from Thoratec Co and Jarvick Heart Inc. The other authors report no disclosures.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.111.035337/-/DC1.Correspondence to Ulrich P. Jorde, MD, Division of Cardiology, Columbia University Medical Center, 630 W 168th St, New York, NY 10032. E-mail [email protected]edu

Three-dimensional transesophageal echocardiography: diagnosing intraoperative pulmonary artery thrombus

A 61-year-old patient with the diagnosis of acute heart failure based on severe mitral valve insufficiency due to chordae rupture was scheduled for surgery. Intraoperatively, a standard two-dimensional transesophageal echocardiogram (2D-TEE) examination, revealed severe mitral valve regurgitation due to a prolaps with chordal rupture and an echo dense structure in the pulmonary artery (PA). Because it was not possible to visualize this echo dense structure fully with 2D-TEE we performed a three-dimensional transesophageal echocardiogram (3D-TEE). On the basis of the clear demonstration on 3D-TEE of an at least 6-cm thrombus in the PA we decided to remove the thrombus prior to proceeding with the mitral valve repair. We conclude that 3D-TEE can alter surgical management and provide more valuable information on PA thrombus than that obtained by 2D-TEE.

Severe Aortic Regurgitation After Transradial Percutaneous Coronary Intervention

A 60-year-old man presented to a community hospital with new-onset shortness of breath after a 2-hour episode of typical chest pain. The ECG showed anteroseptal and inferior wall Q-waves. Serum troponin T levels were negative. An echocardiogram revealed anterior wall hypokinesia with left ventricular ejection fraction of 40% and no signs of valvular disease. The patient was transferred to our center for coronary angiography. Arterial access was obtained from the right radial artery. The angiogram showed mild disease of the left coronary artery and a right coronary artery (RCA) arising from the left coronary sinus. The RCA was extremely difficult to cannulate; nonselective injections revealed a long and severe stenosis of the mid segment (Figure 1 and Movie 1). After many unsuccessful attempts to cannulate the RCA with different guiding catheters, the operator decided to engage first the left coronary artery with an Amplatz 2 guiding catheter. A BMW Universal II guide wire was advanced into the left anterior descending artery (LAD) for better stability. This approach …

Echodetection of Disseminated Endocardial Vegetations in a Patient with Active IV Drug Abuse

Infective endocarditis is a known complication of intravenous (IV) drug abuse and typically involves cardiac valves, sparing the myocardial endocardium. We present the case of a young IV drug using patient who developed sepsis. Although cardiac symptoms and signs were minimal, an echocardiogram was done as patient had a history of IV drug abuse and was in sepsis. Echocardiogram demonstrated disseminated vegetations involving the left ventricular and right ventricular endocardium while sparing the valves. Although diagnosis of infective endocarditis was made on two-dimensional transthoracic echocardiogram, two-dimensional and three-dimensional transesophageal echocardiograms demonstrated the pattern of endocarditis with clarity. This patient had severe sepsis and bacteremia with Methicillin sensitive Staphylococcus aureus.

Ischemic Mitral Regurgitation: A Quantitative Three-Dimensional Echocardiographic Analysis

A comprehensive three-dimensional echocardiography based approach is applied to preoperative mitral valve (MV) analysis in patients with ischemic mitral regurgitation (IMR). This method is used to characterize the heterogeneous nature of the pathologic anatomy associated with IMR. Intraoperative real-time three-dimensional transesophageal echocardiograms of 18 patients with IMR (10 with anterior, 8 with inferior infarcts) and 17 patients with normal MV were analyzed. A customized image analysis protocol was used to assess global and regional determinants of annular size and shape, leaflet tethering and curvature, relative papillary muscle anatomy, and anatomic regurgitant orifice area. Both mitral annular area and MV tenting volume were increased in the IMR group as compared with patients with normal MV (mitral annular area=1,065±59 mm2 versus 779±44 mm2, p=0.001; and MV tenting volume=3,413±403 mm3 versus 1,696±200 mm3, p=0.001, respectively). Within the IMR group, patients with anterior infarct had larger annuli (1,168±99 mm2) and greater tenting volumes (4,260±779 mm3 versus 2,735±245 mm3, p=0.06) than the inferior infarct subgroup. Papillary-annular distance was increased in the IMR group relative to normal; these distances were largest in patients with anterior infarcts. Whereas patients with normal MV had very consistent anatomic determinants, annular shape and leaflet tenting distribution in the IMR group were exceedingly variable. Mean anatomic regurgitant orifice area was 25.8±3.0 mm2, and the number of discrete regurgitant orifices varied from 1 to 4. Application of custom analysis techniques to three-dimensional echocardiography images allows a quantitative and systematic analysis of the MV, and demonstrates the extreme variability in pathologic anatomy that occurs in patients with severe IMR.

Successful Repair of a Traumatic Ventricular Septal Defect Using an Amplatzer Occluder Guided By Three-Dimensional Transesophageal Echocardiography

Transesophageal echocardiogram (TEE) guided perventricular cardiac intervention has gained popularity in recent years. We present a special case of perventricular closure conducted for a traumatic apical muscular ventricular septal defect (mVSD) under the guidance of three-dimensional (3D) TEE with an Amplatzer mVSD occluder and further discuss the important role of 3D TEE in perventricular cardiac intervention.

Novel three-dimensional transesophageal echocardiography imaging of a highly mobile left atrial thrombus associated with stroke

A 71-year-old woman initially presented with increasing dizziness and numbness, as well as a mild fever. Her medical history included atrial fibrillation and a mechanical mitral valve replacement (MVR) surgery eight years previously for severe rheumatic mitral stenosis. A transthoracic echocardiogram was unable to rule out a clinical suspicion of endocarditis on the mitral prosthesis, due to inherent shadowing artifact from the valve. Therefore, a transesophageal echocardiogram (TEE) was scheduled to obtain a better image of the valve. In the days preceding the TEE, the patient had a severe stroke with pronounced right-sided paralysis. The subsequent TEE did not show any signs of endocarditis; however, a large, highly mobile thrombus (labelled ‘X’) was detected in the left atrium (LA) (Figure 1 and Video 1). Spontaneous contrast was also noted in the left atrial appendage (LAA), indicating slow-moving blood. The addition of three-dimensional (3D) TEE imaging allowed for unique views of the thrombus compared with standard two-dimensional TEE, and allowed for determining its 3D size, shape and spatial orientation within the chamber (Figure 2 and Video 2). This relatively new imaging modality also helped identify a thin strand of fibrin that loosely attached the thrombus to the LAA, which was unclear from multiple two-dimensional TEE views. The 3D images revealed that the thrombus’ large size prevented it from fitting through the mitral valve prosthesis; however, it was seen repeatedly striking against the valve. The patient was aggressively managed with antithrombotic medication and closely monitored over the course of one month. Due to complaints of severe leg pain, the patient underwent computed tomographic angiography, revealing that the thrombus had embolized into the femoral artery. After the thrombus was surgically removed from the leg, a follow-up TEE showed no residual left atrial thrombus. Figure 1 Figure 2

Three-Dimensional Transesophageal Echocardiogram Provides Real-Time Guidance During Percutaneous Paravalvular Mitral Repair

A 65-year-old woman with severe paravalvular mitral regurgitation and chronic hemolytic anemia was referred for surgical consultation. Her medical history included rheumatic heart disease with mitral valve replacement in 1977, aortic valve replacement in 1988, and repeat mechanical mitral valve replacement in 2002. Predominant symptoms were New York Heart Association function class III dyspnea and fatigue. The patient was considered at high risk for surgical complication because of the 3 previous valve surgeries and significant pulmonary hypertension (systolic pulmonary pressure, 70 mm Hg). The Figure demonstrates repair of the significant paravalvular …

Semirigid partial annuloplasty band allows dynamic mitral annular motion and minimizes valvular gradients: an echocardiographic study

Background Traditional mitral annuloplasty devices include both rigid rings, which restrict annular motion, and soft rings and bands, which can locally deform. Conflicting data exist regarding their impact on annular dynamics. We studied mitral annuloplasty with a semirigid partial band and with a nearly complete rigid ring. Methods Intraoperative three-dimensional transesophageal echocardiograms (n = 14) and predischarge transthoracic echocardiograms were retrospectively analyzed in patients undergoing mitral valve repair for degenerative disease with either a rigid ring (n = 77) or a semirigid partial band (n = 38). Each transesophageal echocardiogram was analyzed with TomTec three-dimensional software to produce cardiac cycle frame planimetry and to measure device geometry. Actual device sizes provided reference dimensions. Blinded analysis of Doppler data from transthoracic echocardiograms was performed. Results Validation of the quantitative transesophageal echocardiogram methodology revealed a 1.3% ± 0.3% (mean ± standard error of the mean) underestimation of actual linear dimension. With the semirigid partial band, systolic valve orifice area and intertrigonal distance decreased from 6.14 ± 0.37 to 5.55 ± 0.24 cm 2 (−9.6%; p = 0.01) and from 2.69 ± 0.08 to 2.55 ± 0.13 cm (−5.2%; p = 0.03), respectively. Systolic anterior-posterior distance decreased from 2.1 ± 0.10 to 1.95 ± 0.06 cm (−7.1%; p = 0.01) compared with diastole. In contrast, rigid ring orifice area was unchanged (4.12 ± 0.15 to 4.10 ± 0.16 cm 2; −0.5%; p = 0.48) during the cardiac cycle. Transthoracic echocardiography revealed significantly lower mitral inflow gradients with semirigid partial band (mean gradients compared with rigid ring, 4.0 ± 0.3 versus 5.0 ± 0.3 mm Hg; p = 0.02; peak gradients, 8.9 ± 0.5 versus 11.1 ± 0.5 mm Hg; p = 0.01). Conclusions Three-dimensional transesophageal echocardiographic measurements of annular dynamics are valid and reliable when discrete annuloplasty devices are present. In contrast to the rigid ring, the semirigid partial band permits more physiologic geometric changes and is associated with lower postoperative mitral valve gradients.