Transesophageal Echocardiography Examination Research Articles

Detection of atrial shunt lesions with asingle echocardiographic parameter.

SummaryBackgroundUnrepaired left to right atrial shunt lesions can cause significant right ventricular (RV) volume overload. The parameter pulmonary to systemic shunt volume ratio (Qp:Qs) has been shown to detect even small differences between left and right ventricular stroke volume; however, four parameters are needed for its calculation. This study was carried out to evaluate the accuracy of the single parameter right ventricular outflow tract (RVOT) velocity time integral (VTI) to identify atrial shunt lesions.MethodsAll patients who underwent transesophageal echocardiography (TEE) examination at this institution between 1 January 2013 and 1 January 2018 were retrospectively analyzed. The RVOT-VTI was measured in the transthoracic echocardiography performed immediately before each TEE. The diagnostic accuracy for detection of atrial shunt lesions was tested.ResultsA total of 2797 patients with a median age of 67 years (interquartile range, IQR 54–77 years) were included in the final analysis. A total of 113 (4%) patients had a relevant atrial shunt lesion. The mean RVOT-VTI of the shunt group was 25 cm (SD ± 8.1 cm) and was significantly higher than that of the non-shunt group with 17 cm (SD ± 4.8 cm) (p < 0.001). The area under the curve (AUC) was 0.81. A total of 106 patients (93.8%) of the shunt group had a VTI of ≥16 cm. If the RVOT-VTI was <16 cm, the negative predictive value was 99.3%. If the RVOT-VTI was ≥25 cm, 22% of patients proved to have a significant shunt lesion.ConclusionIn this large retrospective analysis it could be shown that a low RVOT-VTI predicted the absence of significant atrial shunt lesions, while a high RVOT-VTI predicted the presence. The parameter should be applied in all patients with suspected atrial shunt lesions where calculation of Qp:Qs is impossible.Electronic supplementary materialThe online version of this article (10.1007/s00508-020-01659-0) contains supplementary material, which is available to authorized users.

Atherosclerotic plaque detected by transesophageal echocardiography is an independent predictor for all-cause mortality

Atherosclerotic lesions in the great arteries are frequent findings in the elderly. Numerous studies have shown their strong predictive value for cardiovascular disease, embolic events, and mortality. We sought to determine the risk of all-cause mortality depending on the localization of plaques in the thoracic aorta evaluated by transesophageal echocardiography (TEE). A total of 2,054 patients (median age 65 years, interquartile range 52–73; 58% men) who underwent a TEE examination between 01/2007 and 03/2015 were retrospectively analyzed. For each patient, the presence of atherosclerotic lesions in the ascending aorta, the aortic arch, and in the descending aorta, as well as cardiovascular risk factors and survival were documented. Median follow-up period was 48 months (interquartile range 38–58). Multivariate Cox regression analysis indicated plaque in the ascending aorta (HR of 1.36, 95% CI 1.01–1.83, P = 0.046), the aortic arch (HR of 1.78, 95% CI 1.29–2.45, P < 0.001), the descending aorta (HR of 2.01, 95% CI 1.54–2.77, P < 0.001), and plaque in any part of the thoracic aorta (HR of 1.84, 95% CI 1.42–2.4, P < 0.001), as independent predictors for all-cause mortality after adjusting for age, sex, arterial hypertension, hyperlipidemia, smoking, and diabetes. In this study, we could demonstrate that more than mild plaque at any site of the thoracic aorta predicts all-cause mortality. Assessment of atherosclerotic lesions in all segments of the thoracic aorta should be part of every routine TEE examination.

Management of periprocedural anticoagulant therapy: a novel individualized approach-a transeusophageal echocardiographic study.

Patients with non-valvular atrial fibrillation who are under chronic oral anticoagulant therapy (OAC) treatment frequently require interruption of OAC treatment. By examining the presence of left atrial/left atrial appendage (LA/LAA) thrombus or dense spontaneous echo contrast (SEC) with transesophageal echocardiography (TEE) we aimed to develop an individualized strategy. To test the validity of CHA2DS2VASc score based recommendations was our secondary purpose. In this prospective study patients with non-valvular atrial fibrillation on OAC therapy were included. Patients' baseline characteristics, CHA2DS2VASc and HASBLED scores, medications, type of invasive procedures and clinical events were recorded.Each patient underwent to TEE examination prior to the invasive procedure. Bridging anticoagulation was recommended only to patients with LA/LAA thrombus. We included 155 patients and mean CHA2DS2VASc score of the study population was 3.4 ± 1.4. Seventy-one of them had LA/LAA thrombi or SEC on TEE examination and bridging anticoagulation was applied. OAC treatment was not bridged in 8 of 11 patients with prior cerebrovascular accident and 17 of 31 patients with CHA2DS2VASc score of > 4. 57 of 124 patients with CHA2DS2VASc score of ≤ 4 required bridging anticoagulation. There were 14 major bleedings decided according to ISTH bleeding classification. Major bleeding was observed only in patients underwent to high-risk bleeding procedure. In conclusion CHA2DS2VASc score by itself is not enough for decision-making regarding ischemic risk. Furthermore, since major bleedings occurred only in patients underwent to high-risk bleeding surgery, TEE-based individualisation may be a feasible approach particularly for those with high thromboembolic risk undergoing high-bleeding risk procedure.

Low vitamin D levels predict left atrial thrombus in nonvalvular atrial fibrillation

Background and aimsWe determined the association between left atrial (LA) thrombus occurrence and a non-classic risk marker, plasma levels of vitamin D, in atrial fibrillation (AF) patients on continuous non-vitamin K antagonist oral anticoagulant (NOAC) therapy for ≥4 weeks. Low levels of plasma 25-hydroxy vitamin D (25-OHD) are predictive of fatal stroke. Vitamin D has anticoagulant effects on the coagulation cascade, which are indirectly targeted by NOAC therapy. The impact of plasma levels of vitamin D on the rate of LA thrombus detected by transesophageal echocardiography (TEE) in AF patients is unknown. Methods and resultsWe enrolled 201 (133 female) AF patients who were using continuous NOAC therapy for ≥4 weeks. All patients underwent transthoracic and TEE examination. Serum concentrations of 25-OHD, C-reactive protein (CRP) levels, CHA2DS2-VASc scores and parameters, LA size, and left ventricle ejection fraction (LVEF) were examined before the TEE procedure. LA thrombus occurrence was independently associated with serum levels of 25-OHD (OR: 0.884; 95% CI: 0.839–0.932; P < 0.001), LA diameter (OR: 1.120; 95% CI: 1.038–1.209; P = 0.003), and LVEF(OR: 0.944; 95% CI: 0.896–0.995; P = 0.032). Dense spontaneous echo contrast (SEC) presence was also inversely associated with 25-OHD concentrations. ConclusionsLow 25-OHD levels, as a non-classic risk factor, were independently and significantly associated with dense SEC and LA thrombus occurrence in AF patients under NOAC therapy, as well as LA enlargement and decreased LVEF. Further large-scale studies are needed to explain the role of vitamin D deficiency, or efficacy of replacement, on LA thrombus occurrence.

A Practical Approach to Transesophageal Echocardiography, 4th ed

It is an exciting time for transesophageal echocardiography with a number of recent advancements in technology and software. Understanding their benefits and limitations depends on a sound basic understanding of ultrasound principles, particularly as many advancements are optimized for transthoracic echocardiography (TTE) in spontaneously breathing patients. This creates a dilemma for perioperative clinicians because the desire to embrace newer technologies is high but may not be valid for perioperative transesophageal echocardiography (TEE). While there are a number of books on TEE ranging from short pocket notes to extensive atlases, this book excels through a number of features: (1) its clear, concise writing style makes it easy to read for beginners, but also offers new information for more experienced echocardiographers; (2) its incorporation of novel technologies and expert opinion to more established, evidence-based techniques; and (3) its synthesis of book and eBook. Furthermore, it is well organized and can easily be read by individual chapters or by sections. This book is useful for beginners as well as for more advanced echocardiographers and echocardiography partners (eg, surgeons and intensivists), particularly for those who are active in the perioperative setting. This well-thought-out and revised fourth edition contains contributions from world-renowned clinicians in the field, whose experience is evident throughout the text by combining readily available information with personal tips and literature recommendations. This makes the book a pleasure to read and a highly useful teaching aid and reference work. The book is organized into 5 useful sections. The first section discusses the essentials of 2-dimensional (2D) imaging, including sufficient information on 2D image formation and information on a comprehensive TEE examination. The section on left ventricular systolic performance is an excellent review of established and novel methods of quantification, and the chapter on the diagnosis of myocardial ischemia provides a good resume, balancing theoretical concepts with practical advice. The second section discusses the essentials of Doppler echo, highlighting the differences of Doppler to 2D, limitations in TEE, and quantitative measurements. The third section focuses on bread-and-butter valvular disease explaining anatomy and pathophysiology. In a straightforward fashion, it reviews day-to-day issues from a pragmatic point of view. The main focus is on left-sided pathology, but the chapter on right-sided pathology, while rather condensed, is of high quality. The fourth section, our personal favorite, is a collection of clinical challenges, some of which may be less well known, ranging from echo for revascularization, aortic surgery, guiding interventions, anatomic anomalies, and congenital heart disease in the adult. The section on critical care echocardiography nicely rounds out the chapter. The final section offers a concise summary of 3-dimensional (3D) echo and illustrates artifacts and optimization tricks for the clinician. Additionally, the 6 appendices include information on echo views, cardiac dimensions, hemodynamic calculations, prosthetic valves, grading of valvular disease, and answers to multiple-choice questions (MCQs). While the sections are well organized, individual chapters may easily be read as stand-alone references. The chapters are by and large well referenced. All sections are divided into reasonable chunks with many high-quality figures and videos that are available online. Additionally, MCQs at the end of each section enable the reader to test and solidify knowledge. Reading the book, it is evident that this is an excellent fourth edition. Nonetheless, a potential fifth edition may include the following changes: (1) a section or subsection on assist devices; (2) a comparison/caveat of what technologies have been validated in TEE rather than solely using TTE; (3) an appendix or checklist along the lines of “what to tell the surgeon” before and after surgery; and (4) a section on what to expect or an outlook for the future. Furthermore, a brief justification of answers to MCQs (currently only available in some chapters) would be beneficial as would online case reports with images/clips of common complications. Both would offer less-experienced clinicians’ insight into typical complications. Finally, we particularly enjoyed comments based on personal preference and experience rather than solely relying on hard evidence, which is often lacking for perioperative TEE. As a book written by world-renowned experts in the field, further elaboration along these lines would offer additional added value. Overall, this book is very appealing and offers a great deal of information both online and offline. Although not a pocket guide, it has a reasonable size and is a great comprehensive asset to beginners as well as a useful reference guide to more experienced echocardiographers. Michael Vandenheuvel, MDDepartment of Anesthesia and Perioperative MedicineUniversity Hospital GhentGhent, BelgiumEckhard Mauermann, MD, MScDepartment of AnesthesiologyUniversity Hospital BaselBasel, SwitzerlandDepartment of Anesthesia and Perioperative MedicineUniversity Hospital GhentGhent, Belgium[email protected]

Acupuncture for Relief of Gag Reflex in Patients Undergoing Transoesophageal Echocardiography-A Protocol for a Randomized Placebo-Controlled Trial.

Background: Gagging during transesophageal echocardiography examination (TEE) can be distressing and even dangerous for patients. The needling of acupuncture point CV24 was described to be effective in reducing the gag reflex during TEE in patients with ischemic stroke or transient ischemic attack. Methods: We describe a proposal for a prospective, randomized, patient, practitioner and assessor-blinded, single-center trial with two arms/groups; real acupuncture will be compared to placebo acupuncture. A total of 60 (30 per group) patients scheduled for elective TEE in order to exclude a cardiac embolic source, endocarditis or for valve failure evaluation will be recruited according to patients’ selection criteria and receive either indwelling fixed intradermal needles at acupoints CV24 and bilateral PC6 or placebo needles at the same areas. Patients, the practitioners who will perform the TEE procedure, and the assessor of the outcome measures will be unaware of the group’s (real or placebo) allocation. Results: The primary outcome is the intensity of gagging, measured using verbal rating scale (VRS-11) from 0 = no gagging to 10 = intolerable gagging. Secondary outcomes include the incidence of gagging, the use of rescue medication, patients’ satisfaction with relief of unwanted side effects during TEE procedure, success of patients’ blinding (patients’ opinion to group allocation), heart rate and oxygen saturation measured by pulse oxymetry. Conclusions: To study the effects of acupuncture against gagging during TEE, we test the needling of acupoints CV24 and PC6 bilaterally. A placebo acupuncture is used for the control group. Trial registration number: NCT NCT0382142.

Application of Transesophageal Echocardiography in Observing Left Atrial and Left Atrial Appendage Before Radiofrequency Ablation in Patients with AF

Objective: To report and explain the significance of transesophageal echocardiography(TEE) in the observation of left atrium and left atrial appendage before radiofrequency ablation in patients with AF. Methods: 25 patients with AF were selected as the review objects who received echocardiography in our hospital during June 2018 to June 2019. They had routinely received transthoracic echocardiography (TTE) before preparing for radiofrequency ablation. Then TEE was selected to observe and compare the effect of two detection methods on left atrial and left auricular thrombosis. Results: TEE examinations were given to patients with atrial fibrillation before radiofrequency ablation. Compared with TTE examinations, the detection rate of left atrium and left atrial appendage thrombosis was significantly improved. The two detection methods are different and comparable(P&lt;0.05), which is of great significance in clinical application. Conclusion: The use of TEE has significantly improved the detection rate of left atrial and left atrial appendage thrombosis in patients with AF, and has become an important examination method before the implementation of radiofrequency ablation.

Short-term competency of aortic valve repair in Egyptian patients.

In recent years, repair techniques for diseased aortic valves have received increasing attention. This study reports the short-term outcome of aortic valve repair (AVr) for three pathologic categories: rheumatic heart disease, aortic regurgitations (ARs) from subarterial ventricular septal defect (VSD), and infective endocarditis in order achieve the valve competency. From January 2017 to March 2019, 30 patients underwent AVr with significant AR in the National Heart Institute (NHI) and Banha university. All patients underwent echocardiography before and after the procedure; 30 patients underwent AVr with significant AR, nine patients (30%) with juxta-arterial VSD, two patients (6.66%) with infective endocarditis (IE), and 19 patients (63.33%) with rheumatic aortic valve disease. For intraoperative transesophageal echocardiography and direct examination for better clarification of the anatomy and guidance of repair after cardiopulmonary bypass (CPB), annular repair, leaflet repair by shaving, plication, triangular resection, augmentation with the pericardium, and VSD closure were done. Only three patients developed aortic incompetence grade II, no in-hospital mortality; however, we had 3 months later mortality for one patient with IE, only one patient with rheumatic heart disease progressed from grade II to grade IV aortic incompetence (AI) and aortic valve replacement was done so AVr was successfully done for the subaortic VSD, rheumatic, and IE patients instead of replacement of the valve. In favor of AVr, good patient selection, amenable techniques for the suitable pathology will give a good target hence the aim of the work.

A Focused Transesophageal Echocardiography Protocol for Intraoperative Management During Orthotopic Liver Transplantation

The value of a simplified, focused intraoperative transesophageal echocardiography (TEE) protocol in patients undergoing liver transplantation (LT) is unknown. We sought to create and assess a 5-view LT TEE examination focused on 5 prespecified common causes of hypotension during LT. Retrospective cohort study. Single-center tertiary academic hospital. All patients undergoing LT with TEE from January 2010 through May 2019. None. A 5-view LT TEE protocol adapted from a published rescue TEE protocol was assessed retrospectively in a cohort of 106 patients. The primary outcome was the frequency with which the protocol would have detected a composite of 5 prespecified causes of hypotension if the TEE exam had been limited to those views. To assess potential influence on intraoperative care, management changes associated with TEE images were extracted from the medical record. The prespecified diagnoses occurred 24 times; the LT TEE protocol would have detected 22 of 24 of these (92%, 95% confidence interval [CI]: 74%-98%). Intraoperative management changes occurred in 15 of 16 patients (94%) with 1 of the prespecified TEE findings, compared with 1 of 27 patients (3.7%) with TEE findings outside those diagnoses (p < 0.0001). In a retrospective cohort study, a simplified LT TEE protocol would have detected 92% of prespecified TEE findings. Management changes occurred in 94% of those patients, while changes rarely occurred in patients with other TEE findings. A focused LT TEE protocol may diagnose critical pathology adequately and guide management during LT when standard monitors are insufficient.

Diagnosis of aortic dissection by transesophageal echocardiography during cardiopulmonary resuscitation.

Early identification of the causes of cardiac arrest is helpful in determining the resuscitation measures during cardiopulmonary resuscitation (CPR). We aimed to evaluate the feasibility of transesophageal echocardiography (TEE) during CPR in diagnosing aortic dissection and the influence of aortic dissection on resuscitation outcome in adult patients with prolonged non-traumatic cardiac arrest. Adult patients aged >20years with non-traumatic cardiac arrest who underwent prolonged CPR (>10min) and TEE examination during CPR were enrolled. The enrolled patients were grouped according to the presence of aortic dissection on TEE: the aortic dissection (AD) group and the non-AD group. Variables related to cardiac arrest event, CPR, and resuscitation outcome were compared between the two groups. Forty-five patients (median age, 71years; 26 men) were enrolled. Ten (22.2%) and 35 (77.8%) patients were included in the AD and non-AD groups, respectively. No patients in the AD group survived. Aortic dissection on TEE was inversely related to the rate of return of spontaneous circulation on multivariate analysis (odds ratio, 0.019; 95% confidence interval, 0.001-0.750; p=.035). TEE is a useful tool for diagnosing aortic dissection as a cause of cardiac arrest during CPR. Aortic dissection is associated with poor resuscitation outcomes.

A CLINICAL CASE OF LYSIS OF THROMBUS IN THE LEFT ATRIAL APPENDAGE IN A PATIENT WITH ATRIAL FIBRILLATION PREVIOUSLY TREATED WITH WARFARIN

The article describes the clinical observation of LAA thrombosis in a 46-year-old patient with atrial fibrillation that first occurred during taking warfarin; discusses further management of the patient. Due to inefficacy of medical cardioversion (CV) and the need to restore sinus rhythm, electric CV was planned. Before the planned restoration of the rhythm, transesophageal echocardiography was performed and a thrombus in the LAA was detected. Given that the patient had been on adequate warfarin therapy for a long time, it was decided to prescribe a drug from the direct oral anticoagulants group dabigatran etexilate at a dose of 150 mg BID for 8 weeks. The control transesophageal echocardiographic examination showed evidence of complete lysis of thrombus.

Perpendicular and turbulent flow after aortic valve replacement: paravalvular or transvalvular leakage? \u2013 a case report

BackgroundPerpendicular transvalvular leakage (TVL) is occasionally observed after aortic valve replacement (AVR) in biological valves with a stent post, often originating from the base of the stent post. However, an observed perpendicular jet flow is not always a TVL. In rare cases, paravalvular leakages (PVLs) can be perpendicular and are present behind a TVL. In the present case, both PVL and TVL existed simultaneously as unusual perpendicular jet flows that originated from sites in close proximity to the stent post.Case presentationA 73-year-old man underwent AVR with a biological valve in the supra-annular position using the non-everting mattress suture technique with pledgets. After weaning from cardiopulmonary bypass (CPB), transesophageal echocardiography (TEE) revealed an unfamiliar perpendicular turbulent flow, similar to reported TVL, originating from the anterior stent post. Further TEE examination revealed a PVL had originated from the site between the sewing ring at the anterior stent post and native annulus attached to a pledget. The space between the sewing ring and annular retained native portion caused the perpendicular turbulent jet. Consequently, two types of perpendicular turbulent flows, TVL and PVL, existed adjacent to each other.After reinstitution of CPB, inspection of the prosthesis itself indicated it to be normal, but there was a region adjacent to the anterior stent post near the right coronary ostium where the tip of the curved Pean forceps entered between the sewing ring and the native annulus. The region was consistent with TEE findings. AVR was performed with the same prosthesis again. After weaning from CPB, immediate TEE revealed that the unusual perpendicular turbulent flows had disappeared and only a few small TVLs were observed. Regarding the disappearance of TVL, we considered that the fabric region of the prosthetic valve was covered with cellular elements to prevent the leak, as it was already used in AVR once and soaked in blood.ConclusionsPerpendicular turbulent flow raises the possibility of both TVL and PVL in the case of AVR with stented bovine pericardial valves. For a differential diagnosis of TVL or PVL, it is important to know the surgical procedures and valve morphology.

P767 Imagiologic features and Prevalence of Cardiac Lesions detected in Transesophageal Echocardiography

Abstract INTRODUCTION Echocardiography plays a central role in the detection of intracardiac lesions, with transesophageal echocardiography (TEE) acquiring an outstanding role due to its increased sensitivity, improving diagnosis and evaluation of complications. PURPOSE To characterize clinically and echocardiographically the type of intracardiac masses mostly identified on TEE, in order to reflect about its prevalence, exam indication and echocardiographic criteria for correct diagnosis. METHODS Unicentric, retrospective observational analysis of TEE examinations performed between 01/2014 and 05/2019. Data collected from TEE registers and patient process assessment. Cardiac findings were classified according to its echocardiographic features as vegetations, thrombi or suspected tumoral masses. RESULTS 144 TEE examinations revealed the presence of intracavitary lesions, with 62% of them (89 exams) having imagiologic features suggestive of vegetations, with polypoid highly mobile lesions attached to valve leaflets, often leading to valvular insufficiency. More than one valve was affected in 21% and about 30% were prosthetic valves. Potential serious complications such as perforation and abscess formation were present in 13% and 7%, respectively. 35 examinations disclosed the presence of thrombi, 66% located on the left atrial appendage and 17% on the left atrium (LA). In 4 cases they were attached to prosthetic valves and 10 of the patients had not been anticoagulated previously. Some doubtful diagnosis were lately confirmed after disappearance of the lesion with anticoagulation therapy. Diagnosis of tumoral masses was made in 11%, some of them waiting for histologic confirmation. 50% had features resembling pappilary fibroelastomas (PF) (38% of the aortic valve, 25% of the mitral valve, 1 of the pulmonary valve and 1 the left ventricle pathologically confirmed), such as a filiform highly mobile pedunculated structure attached to a valve leaflet. Heterogeneous masses suggestive of myxomas were identified in 35%, 80% located on the LA. The most frequent reason for performing a TEE examination was a previous embolic event, a doubtful image on transthoracic echocardiogram or before electrical cardioversion. Except for PF which were increasingly detected by echocardiography, the prevalence of thrombi or vegetations remained similar across the years. Most presumptive diagnosis made by TEE were confirmed based on clinical evolution or histology. CONCLUSIONS In this cohort, most TEE examinations revealed the presence of vegetations, a major criterion for establishing the diagnosis of infective endocarditis. TEE enables more accurate evaluation of the lesions and although histologic confirmation is frequently necessary, some imagiologic features allow for a presumptive diagnosis which is often correct. This analysis also reflects the prevalence of cardiac lesions and the increased awareness of some conditions, such as PF.

P1377 Predicting the presence of coronary artery disease by transesophageal echocardiography

Abstract Introduction The accuracy of ultrasound signs as predictors for the presence of coronary artery disease (CAD) has been evaluated extensively in the 1990s and 2000s. Imaging quality has improved tremendously over the last decades. Hypothesis High-end ultrasound systems allow for accurate prediction of presence or absence of CAD. Methods We retrospectively evaluated all patients who received transesophageal echocardiography examination (TEE) between 2007 and 2016 and who had coronary angiography within 24 months before or after the TEE. Results A total of 242 patients fulfilled the inclusion criteria, 60% were male. Mean age was 70 (SD ±13) years. In multivariate regression analysis, plaque in the aortic arch (OR 2.53, 95%CI 1.01-6.35, p = 0.048), plaque in at least one of the thoracic aortic segments (OR 2.44, 95%CI 1.21-4.9, p = 0.012), the presence of mitral annular calcification (MAC) (OR 1.87, 95%CI 1.03-3.39, p = 0.038), and any two of the three (aortic stenosis (AS), MAC, aortic plaque) in combination (OR 2.05, 95%CI 1.08-3.88, p = 0.028) were predictors of significant CAD. The isolated findings MAC (OR 1.91, 95%CI 1.00-3.65, p = 0.049) and AS (OR 2.45, 95%CI 1.22-4.92, p = 0.012) were significant predictors for the absence of normal coronary arteries. Conclusion With a negative predictive value of 80%, the absence of MAC, AS, and aortic plaque makes the presence of significant CAD unlikely. If CAD must be excluded and MAC or AS are present, there is high likelihood for at least mild CAD. Coronary angiography rather than coronary CT angiography should be applied in these patients.

Biochemical markers for detection of intracardiac thrombosis

Aims: Intracardiac thrombus is known as the common cause of cardiogenic cerebral ischemia and a useful clinical marker of thrombogenesis. This study aimed to predict the presence of intracardiac thrombosis by noninvasive method using NT-pro-brain natriuretic peptide (BNP) and D-dimer evidenced by trans-esophageal echocardiography (TEE). Methods: A total of 200 patients were included and referred to TEE for the detection of intracardiac thrombi. Measurement of NT-Pro-BNP and D-dimer was done 2 h before the TEE examination. The patients were divided into two groups namely Group A with intracardiac thrombus and Group B without intracardiac thrombus. Results: There was an increased prevalence of intracardiac thrombus in diabetic hypertensive patients and transient ischemic attack patients. Intracardiac thrombus had significantly higher levels of Pro-BNP and D-dimer (P < 0.001). Using the receiver operating characteristic curve, the value of D-Dimer level >788 ng/ml and NT-Pro-BNP >683 ng/ml predicted the presence of intracardiac thrombus. Conclusion: High value of NT-Pro-BNP and D-dimer level can predict the presence of intracardiac thrombosis and its decreased value can predict the absence of thrombosis in patients with suspected intracardiac thrombi.

P699 Atrial septum tearing due to balloon sizing in percutaneous closure of ASD

Abstract INTRODUCTION Percutanous closure of atrial septal defect (ASD) has become an accepted ,reliable procedure and alternative to surgical treatment.Various complications associated with this procedure have been identified but tear of atrial septal rim is a very rare complication.We report a case of atrial septal rim tear due to balloon sizing and diagnosed at the same time by transesophageal echocardiography (TEE). CASE A 64-year-old female patient was admitted to our clinic with dyspnea.Transthoracic echocardiography (TTE) was performed.Ejection fraction was %60 .Moderate tricuspit regurgitation was observed and pulmonary artery pressure was 45 mmHg. TTE revealed a left to right shunt and TEE was planned.2D and 3D-TEE was performed.Two separate secundum type ASD were observed and diameters of defects were measured as 15 mm and 14 mm.Measurement of rim between two defects was 7 mm.(Figure 1 A-B-C) It was observed that the aortic rim was absent but the other rims were sufficient for percutaneous closure.Percutaneous closure was planned .Balloon sizing with a 34-mm AGA balloon resulted in a stretched defect diameter of 26 mm using the stop-flow technique.After the measurement of ASD with sizing balloon flail structure was observed in atrial septal rim.We evaluate this image from various echocardiographic window and we diagnosed the atrial septal rupture. (Figure 1-E ) The patient was hemodynamically stable during the intervention and the atrial septal rupture diameter did not increase. Therefore it was decided to continue the process.ASD diameter was measured again after the rupture of the atrial septum and it was measured 26 mm by TEE and sizing balloon. A 28-mm Amplatzer septal occluder (ASO) was selected.In the same session 28 mm ASO device was successfully placed in the defect.In the TEE examination, it was found that the device was in correct place, there was no shunt from left to right and the torn was between the two discs of the device.(Figure 1-F) The procedure was successfully completed without complications. DISCUSSION Rupture of the interatrial septum or rim during percutaneous ASD closure is a very rare complication. Possible causes of rupture in the interatrial septum when using sizing balloon may be the manipulation of the sizing balloon, passing the guide wire through a small atrial septum fenestration , and the over-stretching of the sizing balloon.There are very rare case reports in the literature about this subject. The rupture of the atrial septum can be enlarged, and therefore surgical treatment has to be performed in these cases in the literature. CONCLUSION In this case, we tried to present the rupture of the interatrial septum, which is a rare complication that may develop when using sizing balloon, and successful percutaneous closure of ASD in the same session. Abstract P699 Figure.

Fluid responsiveness to passive leg raising in patients with and without coronary artery disease: A prospective observational study.

Introduction:Hemodynamic stability and fluid responsiveness (FR) assume importance in perioperative management of patients undergoing major surgery. Passive leg raising (PLR) is validated in assessing FR in intensive care unit patients. Very few studies have examined FR to PLR in intraoperative scenario. We prospectively studied FR to PLR using transesophageal echocardiography (TEE), in patients with no coronary artery disease (CAD) undergoing major neurosurgery and those with CAD undergoing coronary artery bypass grafting (CABG).Methods:We enrolled 29 adult consenting patients undergoing major neurosurgery with TEE monitoring and 25 patients undergoing CABG. After induction of anesthesia, baseline hemodynamic parameters were obtained which was followed by PLR using automated adjustment of the operating table. Clinical and TEE-derived hemodynamic parameters were recorded at 1 and 10 min after PLR following which patients were returned to supine position.Results:A total of 162 TEE and clinical examinations were done across baseline, 1 and 10 min after PLR; and paired comparison was done at data intervals of baseline versus 1 min PLR, baseline versus 10 min PLR, and 1 min versus 10 min PLR. There was no significant change in hemodynamic variables at any of the paired comparison intervals in patients undergoing neurosurgery. CABG cases had significant hemodynamic improvement 1 min after PLR, partially sustained at 10 min.Conclusion:Patients undergoing CABG had significant hemodynamic response to PLR, whereas non-CAD patients undergoing neurosurgery did not. A blood pressure–left ventricular end-diastolic volume combination represented strong correlation in response prediction (Pearson's coefficient 0.641; P < 0.01).

P1564 Changes in coronary flow velocity measuring during coronary bypass grafting can predict elevation of cardiac troponin

Abstract Background Stenosis of a coronary artery results in an increase in flow velocity in the pathologic segment. Effective grafting should decrease the stenotic native coronary velocity according to a hemodynamic law. The range of decreased velocity can hypothetically reflect the effectiveness of a graft. Grafting effect insufficiencies often cause elevations in periprocedural cardiac troponin (cTn) elevation. The aim of the study is to determine, if measuring coronary flow velocity changes during coronary artery bypass grafting (CABG) can predict further cTn elevation. Methods and results Consecutive 68 patients (48 men, 64 ± 9 years old), who were referred for CABG, were included into the study. A standard basic perioperative transesophageal echocardiography (TEE) examination was performed with additional scans of the left main, left anterior descending (LAD), and circumflex (LCx) arteries’ proximal segments. Measurements of coronary flow velocities was performed before and after grafting in the same sites of the arteries. The maximal value of cTnI within 48 hours after CABG was accounted for in the analysis. All patients had arterial hypertension, 15 patients (22%) had diabetes mellitus, 12 patients (18%) was current smokers. Forty-one patients (60%) had prior myocardial infarctions, 18 persons (26%) had previous coronary stenting. The ejection fraction before the operation was 56 ± 13%. Before grafting the mean velocity in the left main artery was 79 cm/s (25th-75th quartile, 42-111), in LAD 98 cm/s (25th-75th quartile, 71-125), and in LCx 116 cm/s (25th-75th quartile, 68-156). There was a strong significant correlation between changes in coronary flow velocities and the value of cTnI (R = 0.56, p &amp;lt; 0.0004). The patients with and without significant elevations in cTnI had differences in coronary velocity changes before and after grafting (p &amp;lt; 0.009). Patients with elevated cTnI in more than 5 times, had, on average, an increase in the velocities for native arteries of 21 ± 19 cm/s. Conclusion Coronary flow velocity assessment during CABG could predict an elevation of cardiac troponins after cardiac surgery. Abstract P1564 Figure.

An interesting case of normal variant misinterpreted as left atrial mass

Coumadin ridge is a normal anatomical variant that is found in the left atrium (LA). We present a case of a LA mass in a 69-year-old patient, diagnosed during preoperative evaluation for total knee replacement and hence referred for surgical resection of the atrial mass. Detailed and meticulous transthoracic and transesophageal echocardiographic examination revealed it as a prominent Coumadin ridge between the left superior pulmonary vein and LA appendage with a bulbous tip, confused initially as an LA mass. The echocardiographic appearance of Coumadin ridge is described as “Q-tip sign.” It can be differentiated with other structures, such as thrombus/atrial mass, because of its property of being at a specific location, lack of mobility, and unique linear structure with a rounded bulbous tip. This case highlights the importance of proper knowledge and the need for careful evaluation of normal structural variants to avoid unnecessary workup and treatment.

Portal venous pulsatility fraction, a novel transesophageal echocardiographic marker for right ventricular dysfunction in cardiac surgical patients.

Background:Right ventricular (RV) has a vital role in maintaining optimal tissue perfusion. Assessment of portal venous flow characteristics can be alternative and emerging technique to assess RV function.Aims:To investigate if portal venous pulsatility fraction (PF) could serve as effective and complementary tool in identifying RV dysfunction.Materials and Methods:Thirty adult patients aged 18-65 years undergoing cardiac surgery under general anesthesia were enrolled in study. Intraoperative transesophageal echocardiographic examination was performed. Tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), RV ejection fraction (EF), and portal vein flow pulsatility were assessed. Portal vein PF was used to quantify degree of pulsatility.Results:Portal vein was demonstrated in 27 patients (90%). 27 values of portal vein PF, RV EF, FAC, and TAPSE were analyzed. Portal vein PF demonstrated significant linear correlation with TAPSE (r = −0.55, P = 0.003), RV FAC (r = −0.44, P = 0.02), and RV EF (r = −0.53, P = 0.004). ROC curve was constructed to calculate sensitivity and specificity of portal vein PF for assessing RV function. Portal vein PF value of ≥45% indicated RV dysfunction with sensitivity of 92.3%, specificity of 71.4%, positive predictive value of 75%, and negative predictive value of 90.9%. Area under ROC curve was 0.819 (95% confidence interval = 0.624 – 0.939, P = 0.0006).Conclusion:Portal vein PF is simple and feasible method for assessment of RV function. It complements the existing echocardiographic measures to diagnose RV dysfunction.