To Transesophageal Echocardiography Research Articles

A comparison of intracardiac echocardiography and transesophageal echocardiography for guiding device closure of ostium secundum atrial septal defect: A 15-year experience.

Our aim was to evaluate the fluoroscopy time (FT), procedure time (PT) safety and efficacy when using intracardiac echocardiography (ICE) in comparison to transesophageal echocardiography (TEE) guidance for transcatheter closure of Ostium Secundum Atrial Septal Defect (OS-ASD). Ninety patients (n=90) diagnosed with OS-ASD underwent transcatheter closure between March 2006 and October 2021. Fifty-seven patients were treated under ICE guidance, while 33 patients were treated under TEE guidance. Mean age was 43±15 years and 42±10 years in the ICE and TEE groups, respectively. The majority of patients had a centrally placed defect. Median FT was 8.40 min versus 11.70 min (p<.001) in the ICE group compared to the TEE group, respectively. Median PT was 43 min versus 94 min (p<.001) in the ICE group compared to the TEE group, respectively. Both ICE and TEE provided high quality images. All interventions were completed successfully, except for one patient in the ICE group who experienced a device migration, the development of atrial tachycardia in one patient and atrial fibrillation in two patients in the ICE group which spontaneously cardioverted. There were no other complications. This study on a consistent cohort of patients with OS-ASD undergoing percutaneous closure suggests that use of ICE is safe and efficacious. Compared to TEE, ICE demonstrated significantly shorter FT and PT, decreasing the entire duration of the procedure and x-ray exposure. No relevant differences were observed in terms of success rate and complications.

Advanced 3D-TEE tools for mitral annular calcification characterisation. Correlation with CT scan

Abstract Background Mitral annular calcification (MAC) is a degenerative process that leads to development of mitral regurgitation (MR). Its presence is associated with worse therapeutic results, due to technical challenges and risk of complications. The precise characterization has gained special importance in recent years. Due to the accuracy of the CT to detect calcium compared to transesophageal echocardiography (TEE), different prognostic scores based on this technique have been proposed. Purpose Our objective was to assess the usefulness of new tools based on 3D-TEE to determine the severity of MAC compared to CT in patients with MR. Methods Between 2019 -2022, patients with severe MR with different degrees of MAC were selected and evaluated by 3D-TEE and CT. Two independent expert observers blindly performed a quantitative standardized characterization of severity (1-10), applying the score proposed by Guerrero et al. based on four parameters: Calcium thickness, radial extension, involvement of trigones and leaflets both by CT (Figure 1, A) and advanced 3D-TEE tools (transillumination/True-Vue (Figure 1, B-C) and multiplanar/iSlice reconstruction (Figure 1, D). The agreement and correlation of both techniques were compared for each of the categories, as well as for the final classification of severity (Mild: 0-3, Moderate: 4-7, Severe 8-10). Results 38 patients were included (Mean age: 80±5.7 years), 76% women. The MAC score measured by TEE was 6.1±0.4 vs. 8±0.4 by CT (p=0.03) with a very good agreement between both techniques estimated by the ICC (r=0.9) with an average difference of 1.2±1.4. Regarding the qualitative estimation, the concordance was good except for the estimation of the of the leaflet’s calcification (Table 1). Conclusions The use of advanced 3D-TEE imaging tools provides an excellent estimation and extension of the severity of MAC compared to CT, slightly overestimating the severity. These tools not only bring qualitative but also quantitative information and could be a first approximation before performing CT. This result highlights the usefulness and necessity of using multimodality imaging in the evaluation of degenerative mitral regurgitation.Figure 1Table 1

Impact of intracardiac echocardiography versus transesophageal echocardiography guidance on left atrial appendage occlusion procedures: A meta-analysis.

Intracardiac echocardiography (ICE) is increasingly used during left atrial appendage occlusion (LAAO) as an alternative to transesophageal echocardiography (TEE). The objective of this study is to evaluate the impact of ICE versus TEE guidance during LAAO on procedural characteristics and acute outcomes, as well the presence of peri-device leaks and residual septal defects during follow-up. All studies comparing ICE-guided versus TEE-guided LAAO were identified. The primary outcomes were procedural efficacy and occurrence of procedure-related complications. Secondary outcomes included lab efficiency (defined as a reduction in in-room time), procedural time, fluoroscopy time, and presence of peri-device leaks and residual interatrial septal defects (IASD) during follow-up. Twelve studies (n = 5637) were included. There were no differences in procedural success (98.3% vs. 97.8%; OR 0.73, 95% CI 0.42-1.27, p = .27; I2 = 0%) or adverse events (4.5% vs. 4.4%; OR 0.81 95% CI 0.56-1.16, p = .25; I2 = 0%) between the ICE-guided and TEE-guided groups. ICE guidance reduced in in-room time (mean-weighted 28.6-min reduction in in-room time) without differences in procedural time or fluoroscopy time. There were no differences in peri-device leak (OR 0.93, 95% CI 0.68-1.27, p = 0.64); however, an increased prevalence of residual IASD was observed with ICE-guided versus TEE-guided LAAO (46.3% vs. 34.2%; OR 2.23, 95% CI 1.05-4.75, p = 0.04). ICE guidance is associated with similar procedural efficacy and safety, but could result in improved lab efficiency (as established by a significant reduction in in-room time). No differences in the rate of periprocedural leaks were found. A higher prevalence of residual interatrial septal defects was observed with ICE guidance.

The Emerging Role of Intracardiac Echocardiography (ICE) in Left Atrial Appendage Closure (LAAC).

Intracardiac echocardiography (ICE) has emerged as a powerful imaging tool to guide percutaneous left atrial appendage closure (LAAC). Herein, we review an imaging protocol for ICE-guided LAAC and discuss the evidence for its use. Standardized imaging protocols have been proposed but have not been fully validated. ICE imaging yields similar procedural and clinical outcomes when compared to transesophageal echocardiography (TEE) to guide LAAC. Despite benefits of avoiding general anesthesia, TEE, and multiple physicians for LAAC procedures, ICE imaging remains under-utilized. Novel ICE catheters with 3D imaging capabilities may improve accuracy and efficiency of LAAC device implantation. ICE guidance is feasible, safe, and effective for LAAC. As the field evolves, further studies will be necessary to assess this technological advancement in imaging guidance.

Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization.

Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.

CT-criteria for left atrium appendage thrombus detection

&lt;b&gt;Objective: &lt;/b&gt;Atrial fibrillation is strongly associated with stroke and accounts for 60% of cardioembolic stroke. Assessing thromboembolic risk is important for patients with atrial fibrillation. Approximately 90% of all thrombus are localized in the left atrium appendage (LAA). This study aimed to determine the efficacy of cardiac computed tomography (CT) for LAA thrombus detection.&lt;br /&gt; &lt;b&gt;Material and methods:&lt;/b&gt; This retrospective study included 292 patients. LAA thrombus was confirmed or excluded by cardiac CT with the reference to transesophageal echocardiography (TEE). We excluded patients with allergic reactions to iodide, increased creatinine levels, thyroid disease (hyperthyroidism), pregnancy, and age &amp;lt;18 years.&lt;br /&gt; &lt;b&gt;Results:&lt;/b&gt; According to the cardiac CT, 103 of 292 people had LAA thrombus, while according to TEE, only 48 of patients had LAA thrombus. The sensitivity and specificity of CT were 97.7% and 77%, respectively. The sensitivity and specificity of the CT was higher in 2016–2020, when the delayed phase was added to the standard protocol, compared to 2012–2015 years. Older age, higher BMI, higher CHA&lt;sub&gt;2&lt;/sub&gt;DS&lt;sub&gt;2&lt;/sub&gt;-VASc and HAS-BLED scores, and larger LA and LVESV were significantly associated with LAA thrombus detection on cardiac CT. Higher LVESV and LVEDV indexes (LVESVI and LVEDVI) and lower LV ejection fraction measured by TEE were also predictors of LAA thrombus detection by cardiac CT.&lt;br /&gt; &lt;b&gt;Conclusion:&lt;/b&gt; Our findings show that cardiac CT has high sensitivity and specificity for excluding or confirming LAA thrombus, and can also be exclusively used to determine the presence or absence of a thrombus.

Left atrial appendage thrombus in acute stroke: diagnostic accuracy of CT angiography compared to transesophageal echocardiography

ObjectivesTo evaluate the value of an extended emergency computed tomography angiography (CTA) including cardiac imaging in patients with acute ischemic stroke for the detection of left atrial appendage (LAA) thrombus compared to transesophageal echocardiography (TEE) as a reference standard. Materials and MethodsWe conducted a retrospective case-control study of patients with presumed acute ischemic stroke who had undergone non-ECG-gated CTA for the craniocervical vessels with an extended coverage including the heart in the context of emergency stroke evaluation and for whom TEE was available as part of the routine stroke diagnostic. We selected cases with evidence of LAA thrombus in TEE and controls without LAA thrombus in TEE in a 1:3 ratio. Two independent observers analyzed CTA images for presence of LAA thrombus and were blinded to the presence of thrombus in TEE. ResultsTwenty-two patients with LAA thrombus in TEE, and 66 patients without LAA thrombus in TEE were included. The detection of LAA thrombus using CTA showed a sensitivity of 63.6%, a specificity of 81.8%, a positive predictive value of 53.9% and a negative predicted value of 87.1%. Interobserver agreement was only moderate (Cohen´s κ = 0.43). ConclusionsAn extended emergency CTA including cardiac imaging can be helpful in early risk stratification in patients with stroke of cardioembolic origin. However, our data show that a standard CTA of craniocervical vessels with extended coverage of the heart is of limited value when compared to TEE, the standard method of detecting LAA thrombi.

Predictors of sinus rhythm restoration in patients with long-term episodes of persistent atrial fibrillation

The aim – to compare clinical, laboratory and instrumental characteristics of patients with persistent atrial fibrillation (AF) and duration of AF episode ≥ 90 days, undergoing direct current (DC) cardioversion, in groups with or without further sinus rhythm (SR) restoration, for the purpose of determining the predictors of SR restoration.Materials and methods. The cohort single-center study analyzed clinical, laboratory and instrumental data from 115 persistent AF patients with duration of its episode ≥ 90 days, who underwent an elective direct current cardioversion. Patients were subdivided into the groups depending on SR restoration effectiveness: 59 (51.3 %) and 56 (48.7 %) patients with restored and non-restored SR, respectively.Results and discussion. The group of patients with non-effective DC cardioversion was characterized more severe heart failure (HF) and more frequent percutaneous coronary intervention (PCI) cases, as opposed to the group with restored SR. The studied groups differed significantly by the certain echo parameters, characterizing the structure and function of left heart chambers. The transthoracic echocardiography (TTE) revealed a higher left ventricular (LV) dilatation and more frequent pulmonary hypertension (PH) cases in non-restored SR group. According to transesophageal echocardiography (TEE) data, both groups demonstrated the deterioration of left atrial (LA) function, namely the decrease of LA appendage flow velocity ≤ 40 cm/s in more than 60 % of patients. Additionally, the LA spontaneous echo contrast (SEC) was visualized in vast majority of non-restored SR patients (94.6 %). At the same time, only 2 (3.6 %) patients with non-effective DC cardioversion were free from SEC, as compared to 44 (74.6 %) restored SR patients (р &lt; 0.001). The multivariable logistic regression analysis revealed SEC as an independent predictor of SR restoration.Conclusions. Persistent AF patients with duration of its episode ≤ 90 days and non-effective elective DC cardioversion demonstrated higher stage of HF, more frequent demand for PCI, the higher LV dilatation, and presence of PH (TTE) and LA SEC (TEE). Among other associated factors, the freedom from LA SEC appeared to be the only independent predictor of SR restoration in such patients.

Intracardiac echocardiography as transesophageal echocardiography replacement in percutaneous intervention imaging: a systematic review and meta-analysis

Abstract Background Intracardiac echocardiography (ICE) has become more popular as an alternative to transesophageal echocardiography (TEE), the current gold standard modality of intraoperative imaging in percutaneous closure of interatrial communications, despite the limited three-dimensional capabilities and operational learning curve. ICE's primary strength is the lack of general anaesthesia, thus reducing the risk from airway intervention. Studies have shown that the successful device deployment rate assisted with ICE was similar to TEE. In addition, the optimal use of ICE has been suggested to lower procedural and fluoroscopy time, leading to better outcomes. However, there is currently limited evidence in this area to support ICE as the better option for imaging in percutaneous atrial septal intervention. Purpose To compare the total procedural time and fluoroscopy exposure between ICE versus TEE for the guidance of percutaneous atrial septal intervention. Methods We performed a comprehensive literature search using PUBMED and Google Scholar from inception to December 2020. Publications that compared ICE and TEE in the atrial septal intervention in adult patients were screened according to our eligibility criteria. The primary outcome of the study was procedural time. Analysis was performed using Revman 5.4. Results Five studies were included in this study, providing a total of 332 (ICE=169 VS TEE=163) patients. The mean procedural time was shorter in the ICE group compared to the TEE group (mean differences −8.67 minutes, 95% CI: −10.48 to −6.86, p&amp;lt;0.0001, I2=95%). The mean fluoroscopy exposure was also shorter in the ICE group (mean differences −3.22 minutes, 95% CI: −3.73 to −2.71, p&amp;lt;0.0001, I2=87%). There was no difference in term of success rate of the closure nor significant complications during peri-procedural reported in all studies. Conclusion ICE-assisted intervention was shown to be more efficient and associated with statistically significant shorter procedure time and fluoroscopy time than TEE, reducing the possible risk for side effects. Therefore, our analysis suggested that ICE could replace TEE as primary guidance of percutaneous atrial septal intervention. Funding Acknowledgement Type of funding sources: None.

S624 Role of Esophagogastroduodenoscopy Before Transesophageal Echocardiography

Introduction: As per American Society of Echocardiography (ASE) guidelines, esophageal varices, dysphagia, thrombocytopenia, symptomatic hiatal hernia, active esophagitis, are relative contraindications to transesophageal echocardiography (TEE). It is not uncommon for gastroenterologists to get consulted to perform an esophagogastroduodenoscopy (EGD) to determine any lesions that will preclude performing a TEE. The evidence behind this recommendation is scant. We aim to determine whether an upper endoscopy before TEE changes patient management. Methods: This is a retrospective chart review of patients who underwent a diagnostic EGD to assess for clearance before TEE. All the EGDs were done 3 weeks prior to TEE. The primary outcome was preclusion of TEE based on EGD findings. Secondary outcomes were overt GI bleeding or drop in hemoglobin post TEE requiring endoscopic intervention. Results: A total of 26 patients met the inclusion criteria. Bacteremia and fungemia are the indications for TEE in 23 patients and cardioversion for Atrial fibrillation, mitral valve disease are the indications in the others. Variceal screening is the indication in 11 patients and anemia with overt GI bleeding is the indication in the rest. Of the 11 patients in the variceal screening group only 4 were known to have cirrhosis, and the rest were requested to have EGD for variceal screening due to elevated AST and thrombocytopenia with an APRI Score >1. All the consult requests are from cardiology team. 15 patients had EGD due to concerns for GI bleeding in the setting of anemia and overt GI bleeding. Of these 15, 2 patients had Grade D esophagitis and they underwent TEE 2-3 weeks after EGD (Figure). None of the patients experienced primary or secondary outcomes. Conclusion: Based on our findings upper GI endoscopy before TEE for risk stratification has limited utility. However, we agree with ASE guidelines of consulting gastroenterology when there is a question as to whether gastrointestinal symptoms or pathology present poses a risk for TEE. Our study is limited by small sample size, however, adds to the limited literature available on this subject.Figure 1.: Breakdown of indication for EGD and EGD findings.

Use of a Video Laryngoscope to Reduce Complications of Transesophageal Echocardiography Probe Insertion: A Multicenter Randomized Study

The objective of this multicenter study was to test the hypothesis of whether the use of a video laryngoscope (VL) reduces complications related to transesophageal echocardiography (TEE) probe insertion. A multicenter randomized control study. At 5 tertiary care level hospitals. Three hundred sixty-three adult patients undergoing elective cardiac surgery. The patients were randomized into 2 groups-the conventional group (C group; n=177) and the VL group (n=186) for TEE probe insertion. The primary endpoint of the study was the incidence of oropharyngeal injury, which was defined as blood at the tip of the TEE probe at the end of surgery and/or evidence of injury on VL examination at the end of surgery. The secondary endpoints of the study were the number of attempts required for successful TEE probe insertion and the relation between the esophageal inlet and the larynx. There was a higher incidence of injuries in the C group (n=26; 14.7%) compared to the VL group (n=14; 7.5%; p=0.029). The number of attempts for probe insertion was significantly lower in the VL group (p=0.0023). The most common relation between the esophageal inlet and the larynx was posterolateral (n=88; 47%), followed by posterior (n=77; 41%) and lateral (n=21;12%). The use of VL was associated with a lesser incidence of injury compared to the conventional technique, and its use for this purpose is recommended. The use of VL for probe insertion resulted in fewer attempts compared with the conventional technique. Significant variations do exist in the relation between the esophageal inlet and the larynx, and direct visualization with VL may contribute to better safety.

Systematic review with meta-analysis: incidence of variceal hemorrhage in patients with cirrhosis undergoing transesophageal echocardiography.

The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by cardiology professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis. To perform a systematic review to quantify the risk of bleeding complications in patients with cirrhosis following TEE. Two reviewers searched Ovid MEDLINE, MEDLINE In-Process and EMBASE databases from January 1992 to May 2021 for studies reporting bleeding complications from TEE in patients with cirrhosis. We calculated the pooled incidence rate of bleeding events using the metaprop command with a random effect model. We identified 21 studies comprising 4050 unique patients with cirrhosis; 9 studies (n=3015) assessed the risk of intraoperative TEE during liver transplant (LT) and 12 studies (n=1035) assessed bleeding risk in patients undergoing TEE for other indications. The pooled incidence of bleeding post-TEE was 0.37% (95% CI 0.04-0.94%) across all studies. Bleeding complications were low among patients undergoing TEE during LT as well as those undergoing TEE for other diagnostic reasons (0.97% vs. 0.004%) and among studies with mean MELD >18 compared to those with mean MELD <18 (0.43% vs. 0.08%). Few studies had a comparator arm, and data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were limited across studies. The risk of bleeding complications following TEE is low in patients with cirrhosis, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.

Assessing patent foramen ovale on coronary computed tomographic angiography: a comparison with transesophageal echocardiography.

This study was undertaken to determine if coronary computed tomographic angiography (CCTA) can help to assess patent foramen ovale (PFO) with high accuracy and reproducibility when compared to transesophageal echocardiography (TEE). In total, 75 suspected PFO cases (31 men, 44 women; mean age, 45 ± 9years) were evaluated by coronary CTA and TEE. PFO tunnel length (TL) and the opening diameter of the left atrial entrance (ODLAE) and right atrial entrance (ODRAE), as well as contrast shunt (if present due to PFO), were measured by both modalities. PFO was detected in 68 patients with TEE. The sensitivity for the detection of PFO with CCTA was 85.3%; specificity, 71.4%; positive predictive value, 96.7%; and negative predictive value, 33.3%. Both modalities demonstrated good agreement in measuring TL and ODLAE of PFO. However, the ODRAE of TEE was different from that of CCTA (1.14 ± 0.4mm and 1.45 ± 0.5mm, respectively, p = 0.04). The intra-observer and inter-observer variability and agreement for TL, ODRAE, and ODLAE of PFO were excellent between the two measurements. CCTA provided a method for detection of PFO with high accuracy and reproducibility compared with TEE. Therefore, CCTA is a practical and efficient alternative to TEE for PFO diagnosis.

A Wireless Wearable Doppler Ultrasound Detects Changing Stroke Volume: Proof-of-Principle Comparison with Trans-Esophageal Echocardiography during Coronary Bypass Surgery.

Background: A novel, wireless, ultrasound biosensor that adheres to the neck and measures real-time Doppler of the carotid artery may be a useful functional hemodynamic monitor. A unique experimental set-up during elective coronary artery bypass surgery is described as a means to compare the wearable Doppler to trans-esophageal echocardiography (TEE). Methods: A total of two representative patients were studied at baseline and during Trendelenburg position. Carotid Doppler spectra from the wearable ultrasound and TEE were synchronously captured. Areas under the receiver operator curve (AUROC) were performed to assess the accuracy of changing common carotid artery velocity time integral (ccVTI∆) at detecting a clinically significant change in stroke volume (SV∆). Results: Synchronously measuring and comparing Doppler spectra from the wearable ultrasound and TEE is feasible during Trendelenburg positioning. In two representative cardiac surgical patients, the ccVTI∆ accurately detected a clinically significant SV∆ with AUROCs of 0.89, 0.91, and 0.95 when single-beat, 3-consecutive beat and 10-consecutive beat averages were assessed, respectively. Conclusion: In this proof-of-principle research communication, a wearable Doppler ultrasound system is successfully compared to TEE. Preliminary data suggests that the diagnostic accuracy of carotid Doppler ultrasonography at detecting clinically significant SV∆ is enhanced by averaging more cardiac cycles.

The role of cardiac CT throughout the full cardiac cycle in diagnosing patent foramen ovale in patients with acute stroke.

We explored the hypothesis that the diagnostic performance of cardiac computed tomography (CT) throughout the full cardiac cycle would be superior to single-phase CT and comparable to transesophageal echocardiography (TEE) in diagnosing patent foramen ovale (PFO). From May 2011 to April 2015, 978 patients with stroke were diagnosed with PFO by TEE. In patients with stroke, cardiac CT was performed if the patients had more than two cardiovascular risk factors. We prospectively enrolled 70 patients with an indication for cardiac CT. Cardiac CT images were reconstructed at 10% increments of the R-R interval. The sensitivity of cardiac CT throughout the full cardiac cycle in diagnosing PFO was compared to that for TEE and single-phase cardiac CT. To evaluate the specificity of cardiac CT, we analyzed patients without PFO confirmed by TEE who underwent cardiac CT within 1 month of pre-cardiac surgery. Sixty-six patients with cardiac CT and TEE were included in the final analysis. Throughout the full cardiac cycle, cardiac CT had a sensitivity of 89.4% and a specificity of 92.3% in diagnosing PFO, compared to TEE as a reference. PFO was primarily detected in the 60% and 70% intervals in 10-phase reconstructed images. The sensitivity of PFO diagnosis with cardiac CT was 81.8% when analyzing both the 60% and 70% intervals instead of the full cardiac cycle. Cardiac CT throughout the full cardiac cycle outperforms single-phase cardiac CT in detecting PFO. Cardiac CT can be used as an alternative method to TEE for detecting PFO in stroke patients. • Throughout the full cardiac cycle, cardiac computed tomography (CT) had a sensitivity of 89.4% and a specificity of 92.3% in diagnosing patent foramen ovale (PFO), compared to transesophageal echocardiography. • The sensitivity of diagnosing patent foramen ovale with cardiac CT was 81.8% when analyzing 60% and 70% R-R intervals instead of the full cardiac cycle. • Cardiac CT with retrospective electrocardiographic gating throughout the full cardiac cycle can increase the detectability of PFO, compared to single-phase cardiac CT.

Chapter 31 - Clinical utility of echocardiography in secondary ischemic stroke prevention

Echocardiography employs ultrasound to evaluate cardiac function, structure and pathology. The clinical value in secondary ischemic stroke prevention depends on identification of associated conditions for which a change in treatment from antiplatelet agents and risk factor intervention leads to improved outcomes. Such therapeutically relevant findings include primarily intracardiac thrombus, valvular heart disease and, in highly selected patients, patent foramen ovale (PFO). Echocardiography in unselected patients with ischemic stroke has a very low yield of therapeutically relevant findings and is not cost-effective. With the exception of PFO, findings on echocardiography that are therapeutically relevant for secondary stroke prevention are almost always associated with history, signs or symptoms of cardiac or systemic disease. Choice of specific echocardiographic modalities should be based on the specific pathology or pathologies that are under consideration for the individual clinical situation. Transthoracic echocardiography (TTE) with agitated saline has comparable accuracy to transesophageal echocardiography (TEE) for PFO detection. For other therapeutically relevant pathologies, with the possible exception of left ventricular thrombus (LVT), TEE is more sensitive than TTE. Professional societies recommend TTE as the initial test but these recommendations do not take cost into account. In contrast, cost-effectiveness studies have determined that the most sensitive echocardiographic modality should be selected as the initial and only test.

Intraoperative Focused Cardiac Ultrasound for Assessment of Hypotension: A Systematic Review.

Focused cardiac ultrasound (FoCUS) has become a valuable tool to assess unexplained hypotension in critically ill patients. Due to increasing availability of transthoracic echocardiography (TTE) equipment in the operating room, there is a widespread interest in its usefulness for intraoperative diagnosis of hypotension as an alternative to transesophageal echocardiography (TEE). The objective of this systematic review is to evaluate the utility of intraoperative FoCUS to assess patients experiencing unexplained hypotension while undergoing noncardiac surgery. We performed a systematic literature search of multiple publication databases for studies that evaluated the utility of intraoperative FoCUS for assessment and management of unexplained hypotension in patients undergoing noncardiac surgery, including retro- and prospective clinical studies. A summary of the study findings, study quality, and assessment of level of evidence is presented. We identified 2227 unique articles from the literature search, of which 27 were potentially relevant, and 9 were included in this review. The number of patients pooled from these studies was 255, of whom 228 had intraoperative diagnoses with the aid of intraoperative FoCUS. The level of evidence of all studies included was very low according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. This systematic review has demonstrated that FoCUS may be a useful, noninvasive method to differentiate causes of intraoperative hypotension and guide correcting interventions, although the quality of evidence is very low. Further prospective high-quality studies are needed to investigate whether intraoperative FoCUS has a diagnostic utility that is associated with improved outcomes.

Bleeding Outcomes Following Transesophageal Echocardiography in Patients With Cirrhosis and Esophageal Varices.

Despite scant evidence, current guidelines indicate that esophageal varices are a relative contraindication to transesophageal echocardiography (TEE). The aim of this study is to compare the risk of gastrointestinal bleeding following TEE among cirrhotic patients with and without endoscopically‐documented esophageal varices. This is a retrospective analysis of patients with cirrhosis who underwent upper endoscopy within 4 years of TEE at five institutions between January 2000 and March 2020. Primary outcome was overt gastrointestinal bleeding. Secondary outcomes were hemoglobin decline by at least 2 g/dL or blood transfusion within 48 hours following TEE. Of the 191 patients, 79 (41.4%) had esophageal varices (30.4% large). No patient experienced a primary outcome. Secondary outcomes occurred in 52 (27.2%): 28 (35.4%) with esophageal varices and 24 (21.4%) without varices. After propensity‐score covariate adjustment, the odds ratio for a secondary outcome in patients with esophageal varices was 1.49 (95% confidence interval 0.74‐2.99). Restricting analysis to those who underwent endoscopy within 1 year of TEE did not significantly alter results. The risk of a secondary outcome was identical between patients who had upper endoscopy prior (27.5%) versus subsequent (26.7%; P = 1.00) to TEE. Conclusions: Among patients with cirrhosis, there was no overt gastrointestinal bleeding after TEE. The likelihood of a 2 g/dL decline in hemoglobin or blood transfusion within 48 hours following TEE was not significantly higher in patients with esophageal varices after controlling for confounders. Patients who underwent upper endoscopy before TEE did not manifest a lower risk of secondary outcomes versus those who had endoscopy after TEE, suggesting that routine preprocedural endoscopy is of marginal utility.

942 Low Incidence of Bleeding Complications in Patients With Cirrhosis Undergoing Transesophageal Echocardiography: A Systematic Review and Meta-Analysis

INTRODUCTION: The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by some professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis. Our study’s aim was to perform a systematic review and meta-analysis to quantify the risk of bleeding complications in cirrhosis patients following TEE. METHODS: Two reviewers searched MEDLINE and EMBASE databases from January 1992 to January 2019 for studies reporting bleeding complications following TEE in patients with cirrhosis. Data was extracted by two authors using standardized forms. The pooled incidence rate was calculated using the DerSimonian and Laird method for a random-effects model. The modified Newcastle-Ottawa Scale (NOS) was used to assess study quality. This study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. RESULTS: We identified 16 studies meeting inclusion criteria comprising 3415 unique cirrhosis patients. Nine studies (n = 3009) assessed risk of intraoperative TEE during LT and 7 studies (n = 406) included cirrhosis patients undergoing TEE for other indications; upper endoscopy was performed prior to TEE in 3 out of 9 and 7 out of 7 of those studies, respectively. The pooled risk of bleeding complications post-TEE was 1.0% (95%CI 0.0 – 2.0%) across all studies. The proportion of patients with bleeding complications was similar among patients undergoing intraoperative TEE during LT compared to those undergoing TEE for other reasons (1.1% vs 2.2%, P = 0.06). Further, bleeding rates were similar among patients in the subgroup of studies with mean MELD &gt; 18 compared to studies with mean MELD &lt; 18 (1.9% vs 1.3%, P = 0.31). Three studies had NOS quality scores &lt; 5, 6 had a score of 5–7, and 7 studies had quality scores &gt;7. Overall, the cohorts were representative and included patients with various etiologies of cirrhosis, though most were retrospective in design and lacked a control group. Detailed data on patient-level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were inconsistently reported and limited across studies. CONCLUSION: There is a low risk of bleeding complications in cirrhosis patients following TEE, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary.

A recurrent and transesophageal echocardiography\u2013associated outbreak of extended-spectrum \u03b2-lactamase\u2013producing Enterobacter cloacae complex in cardiac surgery patients

BackgroundWe report a recurrent outbreak of postoperative infections with extended-spectrum β-lactamase (ESBL)–producing E. cloacae complex in cardiac surgery patients, describe the outbreak investigation and highlight the infection control measures.MethodsCases were defined as cardiac surgery patients in Ghent University Hospital who were not known preoperatively to carry ESBL-producing E. cloacae complex and who postoperatively had a positive culture for this multiresistant organism between May 2017 and January 2018. An epidemiological investigation, including a case-control study, and environmental investigation were conducted to identify the source of the outbreak. Clonal relatedness of ESBL-producing E. cloacae complex isolates collected from case patients was assessed using whole-genome sequencing–based studies.ResultsThree separate outbreak episodes occurred over the course of 9 months. A total of 8, 4 and 6 patients met the case definition, respectively. All but one patients developed a clinical infection with ESBL-producing E. cloacae complex, most typically postoperative pneumonia. Overall mortality was 22% (4/18). Environmental cultures were negative, but epidemiological investigation pointed to transesophageal echocardiography (TEE) as the outbreak source. Of note, four TEE probes showed a similar pattern of damage, which very likely impeded adequate disinfection. The first and second outbreak episode were caused by the same clone, whereas a different strain was responsible for the third episode.ConclusionsHealth professionals caring for cardiac surgery patients and infection control specialists should be aware of TEE as possible infection source. Caution must be exercised to prevent and detect damage of TEE probes.