Transesophageal Echo Guidance Research Articles

Minimalist transcatheter aortic valve replacement misses paravalvular regurgitation:Incidence and echocardiographic distribution of missed paravalvular regurgitation.

Paravalvular regurgitation (PVR) may be missed intraoperatively with transthoracic echocardiography (TTE) guided minimalist TAVR. We sought to determine the incidence and echocardiographic distribution of PVR missed on intra-op TTE, but detected on predischarge TTE. From July 2015 to 2020, 475 patients with symptomatic severe native aortic stenosis underwent TTE-guided minimalist TAVR. Missed PVR was defined as predischarge PVR that was ≥1 grade higher than the corresponding intra-op PVR severity. PVR was classified as anterior or posterior on the four standard TTE views; parasternal short-axis (PSAX), parasternal long-axis (PLAX), apical 3-chamber (A3C), and 5-chamber (A5C). Location-specific risk of missed PVR was then determined. Mild or greater PVR was seen in 55 (11.5%) cases intra-op and 91 (19.1%) at predischarge, with no severe PVR. Among the 91 patients with ≥mild predischarge PVR, missed PVR was present in 42 (46.2%). Compared to the corresponding anterior jets, missed PVR rate was significantly higher for posterior jets in PLAX (62.5% vs. 25.0%, p = 0.005), A5C (56.9% vs. 25.0%, p = 0.009), PSAX (66.7% vs. 24.3%, 0.001), but not A3C (58.5% vs. 40.0%, p = 0.28). Intraoperative TTE-guided minimalist TAVR either misses nearly half of ≥mild PVR or underestimates PVR by ≥1 grade when compared to predischarge TTE. Posterior PVR jets are more likely to be missed. Transesophageal echo guidance may help minimize missing PVR. Further studies are warranted.

Successful Fenestration of an Extracardiac Conduit in a Fontan Patient With the Baylis NRG RF Transeptal Needle and Creation of Fontan Fenestration with a 20-mm 535 Formula Stent

Successful Fenestration of an Extracardiac Conduit in a Fontan Patient With the Baylis NRG RF Transeptal Needle and Creation of Fontan Fenestration with a 20-mm 535 Formula Stent

Averted Catastrophic Transseptal Puncture: Percutaneous Transseptal Mitral Commissurotomy in a Patient With Undiagnosed Azygous Continuation of the Inferior Vena Cava

A case is presented of a patient requiring percutaneous mitral balloon commissurotomy. During positioning of the transseptal needle, an unusual needle position on the lateral projection prompted the physician to abandon the puncture and do an angiogram of the inferior vena cava. This revealed an azygous vein continuation. The valve was treated at a later date under general anesthesia with transesophageal echo guidance. This case illustrates how reliance on the posterior-anterior projection to find the optimal point for transseptal puncture can be very misleading and how crucial the lateral projection is.

The Impella 5.5 as a Short Term Mechanical Circulatory Support Device in High Risk Cardiac Surgery

Purpose Post-cardiotomy cardiogenic shock (PCCS) is a life-threatening condition characterized by severe myocardial contractile impairment and reduced end organ perfusion. PCCS has been reported to occur in up to 9% of all cardiac surgery cases with a mortality approaching 40%. The Impella 5.5 micro-axial, full support, surgical pump has emerged as a useful support device in the setting of weaning from cardiopulmonary bypass (CPB) and for the mitigation of a low cardiac output syndrome. Methods From July 2020 to September 2020, 7 consecutive patients underwent urgent cardiac surgery supported by the Impella 5.5 device. In all cases, the Impella 5.5 was implanted during the index cardiac surgery via the ascending aorta using a 10mm woven Dacron graft and positioned using transesophageal echo guidance. In this retrospective study, we evaluated short-term outcomes of hospital mortality, acute kidney injury, cerebrovascular events, and device-related adverse events. Results The mean age was 61 years (range 46-71). Mean preoperative LVEF was 31% (range 25-50). Six patients underwent coronary artery bypass grafting and one patient underwent redo sternotomy and mitral valve replacement. The Impella 5.5 was implanted prior to weaning from cardiopulmonary bypass in six patients and for the onset of post-cardiotomy shock in one patient. In all patients, hemodynamics improved and stabilized immediately after the initiation of Impella support. The mean duration of Impella support was 3.8 days (1.9-6.6 days). There were no in-hospital deaths, no reoperation for bleeding, and no patients suffered a neurologic complication or renal failure requiring dialysis. There was no incidence of hemolysis requiring device explantation. All patients experienced native heart recovery. Four patients (57%) were discharged home, and three patients were discharged to a skilled nursing facility or rehabilitation center. Conclusion The peri-operative use of the Impella 5.5 heart pump facilitates surgery on high‐risk patients with depressed left ventricular ejection fraction and helps to prevent post-cardiotomy shock. Prospective studies looking at the preemptive use of the Impella 5.5 in these patients are needed.

Percutaneous treatment of a ventricular septal defect caused by MINOCA

We present a case of a 78-year-old female with a history of hypertension, paroxysmal atrial fi brillation and ischemic stroke which was admitted due to an hour-long chest pain with ECG changes indicating sinus rhythm and a newly formed LBBB. Subsequently a ventricular septal defect (VSD) was discovered which we successfully treated percutaneously. At admission, echocardiography revealed septo-apical hypokinesis with an accompanying reduced left ventricular ejection fraction of 38%, in addition to the mid-ventricular septal defect (7/14 mm in size) causing a signifi cant left to right shunt (QP/QS = 1.8/1.0). Coronary angiography demonstrated lack of obstruction of the coronary vessels – MINOCA. Rapid response and Intensive care treatment, including Intra-Aortic Balloon Catheter insertion, lead to LV-functional improvement and hemodynamic stabilization. A dual access approach through the right jugular vein and right radial artery was used and eventual closure of the VSD was achieved with an Occlutech ASD occluder (20.5/16.5 mm), inserted via the venous introducer, while under constant angiographic and transesophageal echo guidance. Immediate VSD shunt elimination was disclosed by EchoCG and angiography. Overall, an uneventful in-hospital stay and six months event-free follow-up period were registered including further EchoCG which confi rmed lack of major cardio-vascular events and the stable position of the occluder, without a visible shunt.

Veno-arterial extracorporeal membrane oxygenation and prolonged use of mechanical compression device combine for good outcome after hypothermic cardiac arrest: a case report

The use of mechanical compression devices to deliver chest compressions in conjunction with veno-arterial extracorporeal membrane oxygenation (VA ECMO) in the setting of cardiac arrest is growing. Herein, we report a case of hypothermic cardiac arrest requiring VA ECMO and prolonged use of an external compression device. A 38-year-old morbidly obese male (BMI 66.5) was admitted after being found down by a river. The patient was hypothermic (27.4 ℃; outside temperature 4 ℃) and in active asystolic cardiac arrest. A LUCAS chest compression system (Jolife, Lund, Sweden) was placed and transesophageal echo (TEE) was performed. This revealed cardiac standstill and suboptimal placement of the LUCAS device which was repositioned under TEE guidance. After difficult VA-ECMO cannulation, LV venting was required but coagulopathy, hypothermia, and body habitus precluded immediate endovascular mechanical unloading device placement. Therefore, the LUCAS was continued. After 380 minutes of VA ECMO, 460 minutes of LUCAS device support, and gradual rewarming to normothermia, the patient was cardioverted to sinus tachycardia and an Impella CP was placed. Over the next 96 hours infusions were reduced and biventricular function normalized. The Impella CP was removed on day 7, VA ECMO on day 12, and extubation occurred on day 15. He discharged with no neurologic deficits on day 34, a right sided above knee amputation his only notable hospital complication. The combined support of an external compression device and VA ECMO allowed for return of spontaneous circulation despite a downtime greater than 100 minutes. Further, TEE guidance allowed for optimal LUCAS positioning.

Echocardiography in interventional cardiology

AbstractOver the last two decades, cardiology practice has experienced fast development of new interventional diagnostic and treatment procedures. While most procedures are cath lab based, the use of echocardiography as an imaging technique has become an integral part. In addition to the important use of transesophageal echocardiography in aortic and mitral valve surgery, it has now become an essential imaging technique for transcatheter aortic valve replacement and MitraClip procedures. Likewise, atrial septal procedures—whether hall closure or puncture for mitral valvuloplasty—are both performed under transesophageal echo guidance. Even ventricular procedures, for example alcohol septal reduction and pericardiocentesis, are performed under direct echo imaging. Thus, Doppler echocardiography has become an integral component of most cardiac procedures where operators need to have optimum skills as what to look for at different stages of the procedure.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/4193230/Activity.aspx

Right mini-thoracotomy for left maze with transesophageal echo guidance☆

Minimally invasive surgery (MIS) is widening with the development of new specialized instrumentation, allied with improved surgical experience and techniques, some of which have shown to be effective for the ablation of atrial fibrillation (AF). These developments enable us to achieve a so-called 'ideal procedure', epicardially on beating hearts, with less operative risk, high cure rates and rapid patient recovery. Epicor (St Jude Medical, Sunnyvale, CA, USA) low profile (LP) system is a device using high intensity focused ultrasound (HIFU). We describe the use of this technology for ablation of AF through MIS approach using transesophageal echocardiography (TEE) to pilot the ablation on mitral isthmus. Ten patients underwent monolateral small thoracotomy, through the 4th intercostal space. HIFU was carried out in all cases to create an epicardial box lesion of the pulmonary veins (PVs) and mitral isthmus. TEE was employed to guide the positioning of the ablation device on mitral isthmus, in all patients. There were no mortalities or major complications, including pacemaker implantation. One patient had postoperative atrial tachycardia and was cardioverted before hospital discharge. Three patients had a postoperative AF and were scheduled for cardioversion after three months, and one patient spontaneously revealed a normal sinus rhythm (SR). During the follow-up period, all patients recorded a normal SR. We consider Epicor LP system safe and effective for AF ablation through a single right minimal invasive approach.

Interventional closure of atrial septal defects with the Solysafe Septal Occluder — Preliminary results in children

Background To report usability, safety, and efficacy of the self-centering Solysafe Septal Occluder for transcatheter closure of secundum type atrial septal defect (ASD) in paediatric patients. Methods Retrospective observational clinical study in two tertiary care centers for congenital heart diseases. Patients: First 37 (median age 8.7 years, 68% female) consecutive patients with an ASD stretched diameter up to 22 mm in whom a Solysafe Septal Occluder was used to close a haemodynamically significant ASD. Interventions: Transcatheter closure of ASD was performed under general anaesthesia with trans-esophageal echo guidance. Stretched diameter of the ASD was assessed by balloon sizing. Main outcome measures: Rate of success, complete closure rate, and complications (defined as vascular complications, device-related complications such as embolism, thrombus formation, device erosions, infections, and arrhythmia) during follow up. Results 37 procedures were performed, success rate was 87% (32 of 37 pts.). A missing retroaortic rim was the main reason for device failure. Complete ASD closure rate was 78% immediately in cath lab (25 of 32 pts.), 90% after four weeks (28 of 31 pts.), 94% after three months (29 of 31 pts.), and 100% after six months (20 of 20 pts.). Procedure-related complication was femoral vein thrombosis in one patient. Conclusions The Solysafe Septal Occluder is a feasible, safe, and clinically efficient new device for interventional closure of small to medium sized ASDs less than 23 mm stretched diameter in childhood. Limitations for the Solysafe device are ASDs with absent retroaortic rims and very small children with a body weight < 10 kg.

Catheter closure of atrial septal defects with deficient inferior vena cava rim under transesophageal echo guidance

To describe the case selection, imaging considerations, technique, and results of catheter closure of atrial septal defects (ASD) with deficient inferior vena cava (IVC) rim. Transcatheter closure with Amplatzer septal occluder (ASO) has become standard treatment for most secundum ASDs. Defects with deficient IVC rim continue to be challenging to image and close in the catheterization laboratory. Records of 12 patients with deficient IVC rim (<5 mm), who underwent catheter closure (April 2007 to June 2008) were reviewed. General anesthesia and transesophageal echo (TEE) guidance was used in all. The IVC rim was imaged at 70 degrees-90 degrees with retroflexion of the TEE probe, in addition to the conventional views. Devices 1-4 mm > maximal ASD size were selected. Deployment was accomplished either from the left atrium, left upper or from the right pulmonary veins. The median age was 5.5 (2.5-27) years and median weight was 19.5 (9-65) kg. The defects measured 16-32 mm and 18-36 mm septal occluders were used. The median fluoroscopic time was 13.1 (4.2-32.7) min. Initial device selection was revised in four patients. Two patients had residual flows at IVC margin. The device embolized to right ventricular outflow tract in one patient. This was retrieved, and a larger device was deployed. No other complications were observed immediately or on follow-up (median 6; range 1-14 months). Transcatheter closure of ASDs with deficient IVC rim is feasible under TEE guidance. The modified retroflexed view allows adequate imaging of IVC rim through TEE.

Transnasal transesophageal echocardiography: A new approach for the PFO occlusion in awake patients

To reduce risks, discomfort, cost, and operative time for percutaneous patent foramen ovale (PFO) closure, we propose to perform this procedure under transesophageal echo-guidance using a 10 Fr. catheter introduced through nasal way (TEENW). Transesophageal or intracardiac echocardiography is commonly used to guide percutaneous PFO closure. Sedation needed quite frequently during transesophageal echocardiography, increased patients' discomfort, procedure prolongation, costs, use of both femoral veins, and additional intracardiac manipulations are the main limitations of standard techniques. We enrolled 20 consecutive patients with a history of cerebral ischemia and PFO with right-to-left shunt. In 15 patients Amplatzer PFO occluder was used, whereas in five patients with longer PFO tunnel (>10 mm) Cardia Intrasept was selected. Without sedation, a multifrequency monoplane probe, developed for intracardiac echocardiography, was introduced into the nostril and advanced forward the esophagus. Then under echo guidance, the closing device was presented, opened and released. Procedure lasted for an average of 33.3 min, and no complications were seen. At procedure's completion, six patients showed persistence of reduced shunt during Valsalva manoeuvre. At six-month follow-up, shunts disappeared in all patients. TEENW is safe and well tolerated, and images' quality is high enough to deserve widespread adoption of this technique for PFO closure.

Percutaneous closure of an aorta to left atrium fistula with an Amplatzer duct occluder

We describe percutaneous closure of an unusual paravalvular leak, with a communication from the noncoronary cusp of the aortic valve to the left atrium adjacent to a St. Jude mitral valve prosthesis, in the absence of an infection. The patient presented with worsening dyspnea and edema. The anatomic location of the valve annulus adjacent to the noncoronary cusp underlies the etiology of this communication. Outcomes from surgical repair are associated with high mortality. We performed percutaneous closure of the defect, using general anesthesia and transesophageal echo guidance. An Amplatzer duct occluder was placed in the fistula, with immediate and complete closure of the shunt. While no devices specific for closure of paravalvular leaks have been designed, growing experience with a variety of devices and the use of echo guidance have allowed successful therapy in many complex cases.

Percutaneous introduction of left atrial cannula for left heart bypass: Effectiveness of transesophageal echo guidance for transatrial cannulation

Percutaneous introduction of left atrial cannula for left heart bypass: Effectiveness of transesophageal echo guidance for transatrial cannulation