Transesophageal Echocardiography Findings Research Articles

Cardiopulmonary Resuscitation Without Aortic Valve Compression Increases the Chances of Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Prospective Observational Cohort Study.

Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA. Prospective observational cohort study. Single center. This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings. None. The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Etco2) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Etco2, post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups. Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear.

Abstract 217: Chest Compression on Aortic Valve Decreases Chance of Return of Spontaneous Circulation for Patients Experiencing Out-of-Hospital Cardiac Arrest

Background: Current CPR guidelines recommend applying chest compression at "the center of the chest" for patients undergoing out-of-hospital cardiac arrest (OHCA). However, studies revealed that following this recommendation, around half of OHCA patients would receive compressions on the aortic valve (AV), potentially obstructing blood flow and worsening prognosis. Hypothesis and Aim: We aimed to use transesophageal echocardiography (TEE) during cardiopulmonary resuscitation (CPR) to test the hypothesis of the impact of AV compression vs AV non-compression on adult OHCA patients' outcomes. Methods: This prospective cohort study included OHCA patients receiving TEE exams during CPR. Exclusion criteria were the return of spontaneous circulation (ROSC) before TEE, unidentifiable compression site, or unqualified TEE image. Patients were divided into AV-compressed or non-compressed groups based on initial TEE findings. Patient characteristics, TEE recordings, resuscitation data, and critical time points were analyzed. Primary outcome was sustained ROSC. Secondary outcomes included any ROSC, survival to admission, survival to discharge, and favorable neurological outcomes upon discharge defined by MRS ≤ 2. The sample size was pre-estimated as 37 patients per group. Results: A total of 76 patients from October 2020 to January 2023 were enrolled for analysis, with 39 in the AV non-compressed group and 37 in the AV-compressed group. Baseline characteristics were similar between groups. Compared to the compressed group, the non-compressed group had a better chance of sustained ROSC [adjusted odds ratio (aOR) 4.72, p=0.010], any ROSC (aOR 3.30, p=0.033), and survival to admission (aOR 6.74, p=0.010). The main results were tabulated as below. Conclusions: CPR with compressed AV decreased the chances of ROSC among OHCA patients.

Transcatheter aortic valve-in-surgical aortic valve for a patient with repeated healed endocarditis: a case report

BackgroundTranscatheter valve replacement is contraindicated in patients with active infective endocarditis. However, few reports suggest that it could be beneficial for high-risk surgical patients with healed infective endocarditis. Here, we report a case of a surgical transcatheter aortic valve in a patient with healed repeated prosthetic valve endocarditis using a stentless valve.Case presentationA 79-year-old female who underwent the Bentall procedure using a stentless valve and coronary artery bypass grafting for annuloaortic ectasia 22 years ago was hospitalized for stage II bioprosthetic valve failure. The patient had a history of prosthetic valve endocarditis three times: the first and second prosthetic valve endocarditis occurred 15 years ago, and the third prosthetic valve endocarditis occurred 3 years ago. The causative organisms were Campylobacter fetus and Enterococcus faecalis. With appropriate antibiotic therapy, the lesion was localized and healed completely without valve destruction; however, the patient developed rapid aortic regurgitation. Based on a review of the patient’s history of prosthetic valve endocarditis, the absence of signs of infection, and clinical findings of transesophageal echocardiography and computed tomography, a diagnosis of structural valve deterioration with healed infective endocarditis was made. Subsequently, a transcatheter aortic valve in a surgical aortic valve using a balloon-expandable type was performed, because the patient had a high surgical risk of 12.7%. The patient’s postoperative course was uneventful. At the 1-year follow-up, there were no signs of infection or valve abnormalities.ConclusionsTranscatheter valve replacement can be a treatment option for high-risk surgical patients with healed limited lesions in infective endocarditis.

Systemic Immune-Inflammation Index as a Predictor of Left Atrial Thrombosis in Nonvalvular Atrial Fibrillation.

The systemic immune-inflammation index (SII) has recently been investigated for cardiovascular diseases. We aimed to evaluate the relationship between SII and left atrial thrombosis (LAT). This retrospective, case-control study recruited patients with nonvalvular atrial fibrillation (NVAF) who underwent transesophageal echocardiography (TEE) for LAT detection before cardioversion or catheter ablation at a tertiary hospital between 2012 and 2021. Demographic characteristics were obtained from the hospital data system. According to TEE findings, the patients were categorized into LAT (+) and (-) groups. Age, gender, history of chronic diseases, urea, creatinine, albumin, hemogram parameters, the neutrophil-lymphocyte ratio (NLR), the platelet-lymphocyte ratio (PLR), SII, the CHADS2 score, the CHA2DS2-VASc score, echocardiographic parameters, antiaggregant-anticoagulant use, and nonparoxysmal atrial fibrillation were included and analyzed. The study population consisted of 403 patients, including 228 men (56.6%), at a mean age of 60.84±12.26 years. A high white blood cell count (WBC) (OR, 1.26; 95% CI, 1.05 to 1.51; P=0.013), a high SII (OR, 1.00, 95% CI, 1.00 to 1.00; P=0.003), and a low ejection fraction (OR, 0.95; 95% CI, 0.90 to 0.99; P=0.018) were independent predictors of LAT (+). A spontaneous echo contrast (OR, 2.43; 95% CI, 1.35 to 4.39; P=0.003) was associated with LAT (+). SII values above 693.6 predicted LAT (+) with 71.6% sensitivity and 71.7% specificity (AUC, 0.77; P<0.001). The predictiveness of SII was similar to that of NLR (0.77 vs 0.74, P=0.093) but higher than PLR (0.77 vs 0.67; P<0.001) and WBC (0.77 vs 0.69; P=0.031). SII is an independent predictor of LAT in patients with NVAF.

Right Ventricle Systolic Dysfunction: A Rare Cause of Right-To-Left Interatrial Shunt with Normal Pulmonary Artery Pressure

There is little information about right-to-left shunting with normal pulmonary artery pressure, which is produced as a consequence of right ventricle systolic dysfunction. We presented a case of unexpected transesophageal echocardiography findings of right-to-left shunting through an atrial septal defect despite normal pulmonary artery pressure, related to right ventricle systolic dysfunction in a 27-year-old young woman. Transesophageal echocardiography imaging revealed right ventricular systolic dysfunction and normal pulmonary artery pressure.

Iatrogenic injury of aortic valve leaflet during mitral valve replacement: A transesophageal echocardiographic finding

Iatrogenic aortic valve injury during non-aortic cardiac surgery is an infrequent complication. Iatrogenic aortic regurgitation (AR) has been reported after mitral valve repair, aortic valve repair, septal myomectomy, closure of the ventricular septal defect, and atrial septal defect repair. Various causes have been reported for AR after non-aortic cardiac surgery. Perforation of the aortic valve leaflet is a common cause of AR. Other causes of AR are leaflet tension and leaflet retraction due to inadvertent suture placement. A few previous case reports have presented severe AR as a complication of iatrogenic involvement of aortic valve leaflet during MV surgery. We report a case of severe AR and severe aortic stenosis occurring immediately after mitral valve replacement. This was diagnosed intraoperatively by Transesophageal echocardiography (TEE) and aortic valve replacement was done.

Relationship Between Transthoracic Echocardiography and Transesophageal Echocardiography in the Anatomic and Hemodynamic Assessment of Secundum Atrial Septal Defects in Children and Adults

Objective: To determine the relationship between transthoracic and transesophageal echocardiography in the anatomic and hemodynamic assessment of secundum atrial septal defects in children and adults.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Paediatric Cardiology, National Institute of Cardiovascular Diseases, Karachi Pakistan, from Jul 2020 to Jun 2021.&#x0D; Methodology: Seventy-seven patients above three years of age with secundum atrial septal defects were included. Linear regression was used to determine any statistically significant difference between transthoracic and transesophageal echocardiography approaches.&#x0D; Results: Of 77 patients, there were 37(48.1%) male and 40(51.9%) female. No significant difference was noted in terms of any of the clinical parameters during transthoracic echocardiography and transesophageal echocardiography. As per transthoracic echocardiography, 35(45.5%) were noted to be deviceable, while in transesophageal echocardiography, 36(46.8%) patients were found to be deviceable (p=0.872). No emergency exploration or deaths occurred. Linear regression showed no statistically significant difference between transthoracic echocardiogram and transesophageal echocardiography findings in terms of atrial septal defects size (p=0.226), total septal length (p=0.930), RV systolic pressure (p=0.440), RV functions and TAPSE (0.748) except LV ejection fraction function findings (p&lt;0.001).&#x0D; Conclusion: Anatomic and hemodynamic assessment of secundum atrial septal defects in children and adults correlated well with transthoracic and transesophageal echocardiography.

Unexpected TEE Findings During Rheumatic Triple-Valve Surgery: Incidental, Yet Impactful

This E-Challenge highlights an incidental prebypass transesophageal echocardiographic (TEE) finding of a right atrial membrane that impacted cardiac surgical management during triple-valve surgery. Two-dimensional and advanced 3-dimensional (3D) TEE were used in real-time to assist intraoperative decision-making. The findings, clinical course, discussion of the differential diagnosis, final diagnosis, and patient management are detailed here.

Detection of Atrial Fibrillation Using Insertable Cardiac Monitors in Patients With Cryptogenic Stroke in Japan (the LOOK Study): Protocol for a Prospective Multicenter Observational Study

Paroxysmal atrial fibrillation (AF) is a probable cause of cryptogenic stroke (CS), and its detection and treatment are important for the secondary prevention of stroke. Insertable cardiac monitors (ICMs) are clinically effective in screening for AF and are superior to conventional short-term cardiac monitoring. Japanese guidelines for determining clinical indications for ICMs in CS are stricter than those in Western countries. Differences between Japanese and Western guidelines may impact the detection rate and prediction of AF via ICMs in patients with CS. Available data on Japanese patients are limited to small retrospective studies. Furthermore, additional information about AF detection, including the number of episodes, cumulative episode duration, anticoagulation initiation (type and dose of regimen and time of initiation), rate of catheter ablation, role of atrial cardiomyopathy, and stroke recurrence (time of recurrence and cause of the recurrent event), was not provided in the vast majority of previously published studies. In this study, we aim to identify the proportion and timing of AF detection and risk stratification criteria in patients with CS in real-world settings in Japan. This is a multicenter, prospective, observational study that aims to use ICMs to evaluate the proportion, timing, and characteristics of AF detection in patients diagnosed with CS. We will investigate the first detection of AF within the initial 6, 12, and 24 months of follow-up after ICM implantation. Patient characteristics, laboratory data, atrial cardiomyopathy markers, serial magnetic resonance imaging findings at baseline, 6, 12, and 24 months after ICM implantation, electrocardiogram readings, transesophageal echocardiography findings, cognitive status, stroke recurrence, and functional outcomes will be compared between patients with AF and patients without AF. Furthermore, we will obtain additional information regarding the number of AF episodes, duration of cumulative AF episodes, and time of anticoagulation initiation. Study recruitment began in February 2020, and thus far, 213 patients have provided written informed consent and are currently in the follow-up phase. The last recruited participant (May 2021) will have completed the 24-month follow-up in May 2023. The main results are expected to be submitted for publication in 2023. The findings of this study will help identify AF markers and generate a risk scoring system with a novel and superior screening algorithm for occult AF detection while identifying candidates for ICM implantation and aiding the development of diagnostic criteria for CS in Japan. UMIN Clinical Trial Registry UMIN000039809; https://tinyurl.com/3jaewe6a. DERR1-10.2196/39307.

Prevalence, predictors and management of left atrial appendage thrombogenic milieu in atrial fibrillation with low thromboembolic risk

BackgroundThe present study aimed to investigate the prevalence, predictors, and management of left atrial appendage (LAA) thrombogenic milieu (TM) identified with transesophageal echocardiography (TEE) in non-valvular atrial fibrillation (NVAF) patients with low to moderate thromboembolic (TE) risk.MethodsWe retrospectively analyzed the baseline clinical data and TEE findings in 391 NVAF patients (54.7 ± 8.9 years, 69.1% male) with low to moderate TE risk according to the CHA2DS2-VASc score. LAA TM was defined as LAA thrombus (LAAT), sludge or spontaneous echo contrast (SEC). Management of LAA TM was at the discretion of the treating physician.ResultsA total of 43 patients (11.0%) were detected with LAA TM, including 5 with LAAT (11.6%), 4 with LAAT + Sect. (9.3%), 3 with sludge (7.0%), and 31 with Sect. (72.1%). In multivariate model, non-paroxysmal AF (OR 3.121; 95% CI 1.205–8.083, p = 0.019), and a larger left atrial diameter (LAD) (OR 1.134; 95% CI 1.060–1.213, p < 0.001) were significantly associated with the presence of LAA TM. All LAATs or sludges effectively resolved after mean duration of 117.5 ± 20.0 days for oral anticoagulant (OAC) medication. TE events occurred in 3 patients (18.8%) among those discontinuing OAC over a mean follow-up of 26.2 ± 8.8 months, while no TE events occurred in patients with continuous OAC.ConclusionsLAA TM could be identified in 11.0% in NVAF patients with low to moderate TE risk, especially in those with non-paroxysmal AF and enlarged LAD. Short-term OAC medication could effectively resolve the LAAT or sludge.

Successful bailout clipping for rare complication of anterior mitral leaflet dissection during transcatheter edge-to-edge mitral valve repair

A 91-year-old woman underwent transcatheter edge-to-edge mitral valve repair (TEER) due to severe mitral regurgitation (MR) with the central posterior mitral leaflet (PML) prolapse (Figure 1A; Supplementary data online, Movie S1). The XTW size of MitraClip G4 (Abbott Vascular, USA) was chosen considering the larger length of PML. Before inserting the MitraClip into left ventricle, a newly developed membranous structure was suddenly detected on the central anterior mitral leaflet (AML) by transoesophageal echocardiography (TEE) (Figure 1B). The structure appeared to spread widely from the tip of the central AML toward lateral side (Figure 1C; Supplementary data online, Movie S2) and colour jet flow of TEE penetrated in-between the AML and mobile layered structure (Figure 1D; Supplementary data online, Movie S3). Based on the TEE findings, we suspected AML dissection caused by the proximal edge of MitraClip during one of the procedural steps. The dissection area was localized in the central to lateral side of AML but did not advance further. Therefore, the bailout-TEER was performed to stabilize for both the PML prolapse and iatrogenic AML dissection. The clip was placed under the mitral valve and the clippers grasped both the leaflets (Figure 1E). After successful TEER, the part of AML dissection was minimized (Figure 1F; Supplementary data online, Movie S4). The abnormal colour jet disappeared and trivial amount of MR was present after the procedure (Figure 1G and H). Postprocedural enhanced computed tomography also confirmed absence of abnormal findings in the left atrium around mitral valve. Although extremely rare complication, caution against the occurrence of mitral leaflet dissection during TEER should be exercised.

Spontaneous Echo Contrast in the Left Atrium and Aortic-Arch Atheroma, Detected by Transesophageal Echocardiography, Was Negatively Correlated with Cognitive Function.

The relationship between transesophageal echocardiography findings and cognitive function. This study aimed to establish an association between transesophageal echocardiography findings and cognitive function in stroke survivors. A single-center study was conducted between April 1, 2017 and March 31, 2022. All subjects that were included had a past history of ischemic stroke and were admitted after >21 days from onset. The participants underwent cognitive function tests including a Mini-Mental State Examination, Revised Hasegawa Dementia Scale, Frontal Assessment Battery, and transesophageal echocardiography. The results of 126 participants were analyzed. The cognitive function of participants with a spontaneous echo contrast (+) in the left atrium including appendage or of those with an aorta-arch plaque with a maximum thickness ≥4 mm significantly worse while neither the patent foramen ovale nor the branch extending plaque influenced cognitive function (The median cognitive scores of the spontaneous echo contrast (-) versus (+) were 26 versus 22, p < 0.01**, 26 versus 21, p < 0.001***, and 14 versus 11, p < 0.01**. Those of the aortic-arch plaque max thickness (<4 mm) versus (≥4 mm) were 26 versus 25, p < 0.05*, 27 versus 24, p < 0.05*, and 15 versus 13, p < 0.05*). Our findings show that spontaneous echo contrast in the left atrium and aortic-arch atheroma detected by transesophageal echocardiography, were negatively associated with cognitive function.

Mitral Valve Replacement for Enlarged Libman-Sacks Endocarditis in a Patient with Persistent Primary Antiphospholipid Syndrome and Recurrent Stroke: A Case Report.

BACKGROUND Anticardiolipin antibodies in patients with Libman-Sacks endocarditis (LS) are indicative of comorbid antiphospholipid syndrome (APS) and can result in cerebral infarctions. We describe a case of LS and primary APS with recurrent cerebral infarctions despite anticoagulation treatment. The patient underwent surgery for enlarged LS vegetation with high titers of antiphospholipid antibodies. CASE REPORT A 41-year-old Japanese man was admitted to hospital for small cerebral infarction recurrence in a left parietal lesion. At age 35, the patient had suffered multiple cerebral infarctions. He was found to have high serum titers of all 3 antiphospholipid antibodies. Transesophageal echocardiography (TEE) findings were normal. Differential diagnosis ruled out other autoimmune diseases and a clinical diagnosis of primary APS was made. Warfarin anticoagulation was started. When cerebral infarction recurred 6 years after the first episode, serum titers of antiphospholipid antibodies remained high, and TEE showed a 7×8 mm area of mitral vegetation. A TEE results from his first admission revealed a 5×6 mm area of mitral vegetation, which was believed to be related to the current vegetation. As anticoagulation produced no improvement, the mitral valve was replaced with a mechanical valve. Examination of the excised vegetation found it to be consistent with LS. The patient made good progress within 3 years after surgery. CONCLUSIONS LS size can increase despite anticoagulation in cases with high titers of all 3 antiphospholipid antibodies and cerebral infarction. Such patients require ongoing TEE follow-up and surgical treatment should be considered.

Abstract 9383: Full versus Limited Transesophageal Echocardiography at the Time of Cardioversion for Atrial Fibrillation

Introduction: Transesophageal echocardiography (TEE) is frequently used to evaluate the left atrial appendage (LAA) prior to direct-current cardioversion (DCC) for atrial fibrillation (AF). Clinically relevant findings may be discovered prior to DCC. The optimal TEE study protocol at the time of DCC is unknown. Methods: One-hundred and fifty patients undergoing TEE-guided DCC for AF were retrospectively analyzed. Patients were separated into two groups based on the type of study performed. Comprehensive studies were defined as full TEEs (F-TEE). Studies focused on the LAA were defined as limited TEEs (L-TEE). The TEE findings between both groups were compared. Results: Among 150 patients included in the study (mean age, 66.9 ± 14.3 years; 31% female), 81 (54%) had an F-TEE and 69 (46%) had an L-TEE. Abnormal findings were significantly higher in the F-TEE group compared with the L-TEE group (76.5% versus 47.8%; P&lt;0.005). In patients with a prior study, a new finding was observed more often in the F-TEE versus L-TEE group (56.5% versus 22.0%; P&lt;0.005). In patients with a prior study performed within the previous 2 months, a new finding was observed in 55.3% versus 28.1% (P=0.022). F-TEE took longer to perform compared to L-TEE (7.9 ± 3.3 versus 4.3 ± 3.8 minutes; P&lt;0.005). Conclusions: Among patients undergoing TEE-guided DCC for AF, F-TEE reported significantly more cardiovascular pathology when compared to L-TEE. Among patients with prior echocardiographic studies, F-TEE reported significantly more new findings, regardless of whether the prior study was recent or remote. We believe our findings offer a convincing argument to adopt an F-TEE protocol for studies performed pre-DCC.

Abstract 200: Left-ventricular Outflow Compression During Cardiopulmonary Resuscitation Is Associated With Lower Return Of Spontaneous Circulation In Out-of-hospital Cardiac Arrest

Introduction: Transesophageal echocardiography (TEE) has been proposed as a tool ideally suited for imaging patients during cardiac arrest (CA) resuscitation, allowing for the evaluation of the area of maximal compression (AMC) during CPR. Previous work has shown that compression of the left-ventricular outflow tract (LVOT) or the aortic root during CPR (AMC-LVOT/Ao) occurs in over 50% of patients; animal trials and small single-center retrospective clinical study have linked this finding to lower rates of ROSC. We aimed to prospectively investigate the AMC and its association with ROSC. We hypothesized that patients who have AMC-LVOT/Ao have lower likelihood of ROSC. Methods: A prospective, observational, multicenter cohort study involving patients with out-of-hospital CA (OHCA) in whom TEE was performed during CPR. The study aimed to compare patients with AMC over the LV (AMC-LV) vs AMC-LVOT/Ao and was conducted through a collaborative research network involving 16 hospitals (NCT04972526). Data was collected on clinical and TEE characteristics and findings. Primary outcome was ROSC. We performed univariate analysis followed by multivariate regression model evaluating variables known to impact resuscitation outcomes. Results: Eighty-four patients were included in the analysis. Mean age 62 (46-72), 28% female, 71% had witnessed arrest, 60% had bystander CPR, 47% had mechanical CPR. Overall 26 patients (32%) had ROSC. Initial AMC during CPR was determined in 55/84 (65%) patients, of whom 33 (60%) had AMC-LV, 18 (33%) had AMC-LVOT/Ao, and 4 (7%) had other locations. There was no significant difference in AMC when analyzed by demographic characteristics, height, weight or between patients who received manual vs mechanical CPR. In multivariate regression controlling for age, race, gender, initial rhythm of arrest, level of TEE operator, doses of epinephrine, now-flow time, and total time of arrest, AMC-LVOT/Ao was significantly associated with lower ROSC probability (OR 0.06, 95% CI 0.01-0.4; p=0.009). Conclusion: In this multicenter, prospective study of patients with OHCA, TEE-guided resuscitation showed a strong association between the AMC and ROSC.

Adding troponin to echocardiography improves preoperative abscess detection in infective endocarditis. A REMOVE Trial analysis

Abstract Background Detection of cardiac abscess in patients with infective endocarditis (IE) is important for surgical planning and decision-making. While transesophageal echocardiography (TEE) is the method of choice for abscess detection, in many cases uncertainty remains. Since IE abscesses often affect ventricular muscle, biomarker release may be a helpful adjunct for abscess detection. Purpose We assessed the accuracy of TEE and the value of combining it with preoperative measurement of cardiac Troponin (cTn) in the diagnosis of abscess, using surgical inspection as a reference. Methods Data collected in the electronic clinical report form for patients included in the prospective, multicenter, randomized, controlled trial (REMOVE Trial) were analyzed. Continuous variables are presented as median (25th–75th percentile) and categorical data as absolute and relative frequencies. The diagnostic performance of TEE was identified by comparing preoperative TEE findings with intraoperative findings. The concordance rate is expressed as a percentage. Receiver operating characteristic (ROC) curve was used to assess the ability of cTn to predict the presence of abscess intraoperatively. Area under curve (AUC) with 95% confidence interval as well as sensitivity and specificity are provided as measures of accuracy. Youden index was used to estimate an optimal cut-off value for cTn. Results Among the 282 patients included, 84 had abscesses detected intraoperatively. The sensitivity and specificity of TEE to detect abscess were 58.3% and 86.4%, respectively. cTn-I and cTn-T were measured preoperatively in 113 and 96 patients, respectively. Median cTn-I in patients with abscess was 132 pg/ml (interquartile range (IQR): 54–1528) vs 53 pg/ml (IQR: 17–250) in patients without abscess, p=0.002. Median cTn-T in patients with abscess was 941 pg/ml (IQR: 387–1527) vs 697 pg/ml (IQR: 282–1423) in patients without abscess, p=0.353. The incidence of recent preoperative myocardial infarction was not different between patients with or without abscess (7.1% vs 5.6%, respectively, p=0.593). The AUC for predicting abscess was 0.69 (95% CI: 0.57 to 0.80, p=0.002) and 0.56 (95% CI: 0.43 to 0.69, p=0.353) for preoperative cTn-I and cTn-T, respectively. Optimal cut-offs according to the Youden index are 38 pg/ml for cTn-I and 1632 pg/ml for cTn-T. By adding preoperative cTn-I or cTn-T to the TEE findings, the AUC increased to 0.82 (95% CI: 0.73 to 0.91, p&amp;lt;0.001) and 0.72 (95% CI: 0.59 to 00.84, p=0.001), respectively. Conclusion The results suggest that using TEE alone is a poor method for abscess detection in IE. Adding preoperative troponin values to TEE findings significantly improved IE abscess detection. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Federal Ministry of Education and Research (BMBF), Germany

Transoesophageal echocardiography findings in young patients with cryptogenic ischemic stroke

Abstract Background and purpose The cause of ischemic stroke (IS) remains often unclear in young patients. Relevant structural heart abnormities with known embolic potential may represent cause of IS also in young population. The use of transoesophageal echocardiography (TEE) allows reliable detection of most relevant structural pathologies. The aim was to assess frequency and spectrum of relevant cardiac abnormities in young IS patients. Subjects and methods The study set consisted of young acute IS patients &amp;lt;50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study, registered on ClinicalTrials.gov NCT01541163). In all patients, the brain ischemia was confirmed on CT or MRI. Admission ECG, serum specific cardiac markers, TEE, 24-hour and 3-week ECG-Holter were performed in all patients. Results Out of 1284 patients enrolled in the HISTORY study, 135 (73 males, mean age 40.2±8.1 years) were &amp;lt;40 years. In total, the relevant TEE abnormities were present in 47 (35%) of these patients. Patent foramen ovale (PFO) with evident left to right shunt was detected in 38 (28%) patients, with significant right to left shunt in 25 (19%) patients, and other atrial septal defect with clinically significant bidirectional flow in 4 (3%) patients. Significant valvular heart disease was present in 2 (1%) patients (1 bicuspid aortic valve with moderate aortic regurgitation, 1 chronic severe mitral regurgitation), and 4 (3%) patients severe left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%) due to idiopathic dilated cardiomyopathy. Left atrial myxoma was detected in one patient. Conclusion The relevant structural abnormities with embolic potential were detected using TEE in 35% of young IS patients. Routine use of TEE to elucidate the causes of stroke, has a role especially in young patients who present with cryptogenic stroke and no cardiovascular risk factors, as well as in the setting of a PFO associated with a deep venous thrombosis. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): IGA LF UP, MH CZ - DRO

Diagnostic accuracy of cardiac computed tomographic angiography and transesophageal echocardiography in evaluation of patients with prosthetic paravalvular leakage.

Computed Tomography (CT) scan has been well addressed to provide diagnostic information for patients with prosthetic heart valve (PHV) dysfunction. However, its role in the assessment of patients with prosthetic paravalvular leakage (PVL) has not been studied thoroughly. So, this study was conducted to assess the feasibility, reproducibility, and accuracy of CT for diagnosis of prosthetic PVL using surgical findings as the reference standard. This was a prospective cohort study that was conducted on 26 consecutive patients with suspected prosthetic PVL who underwent both transesophageal echocardiography (TEE) and 64-slice ECG-gated CT. The gold standard was the intraoperative findings. Surgery was performed on 26 patients. There was an excellent degree of agreement between CT and intraoperative findings for diagnosis, localization of prosthetic PVL. The perimeter of prosthetic PVL measured by CT was strongly correlated with echocardiographic severity of PVL by TEE (Spearman's Correlation Coefficient, r=.83, p=.0014). This study demonstrates that cardiac CT showed comparable diagnostic accuracy to TEE and intraoperative findings for the detection, localization, and assessment of severity of prosthetic PVL. Moreover, CT was shown to be useful in detection of other findings related to prosthetic cardiac valves.

Detection of left atrial appendage thrombus by dual-energy computed tomography-derived imaging biomarkers in patients with atrial fibrillation.

AimsThis study aimed to assess the diagnostic performances of dual-energy computed tomography (CT)-derived iodine concentration and effective atomic number (Zeff) in early-phase cardiac CT in detecting left atrial appendage (LAA) thrombus and differentiating thrombus from spontaneous echo contrast (SEC) in patients with atrial fibrillation using transesophageal echocardiography (TEE) as the reference standard.Methods and resultsA total of 389 patients with atrial fibrillation were prospectively recruited. All patients underwent a single-phase cardiac dual-energy CT scan using a third-generation dual-source CT. The iodine concentration, Zeff, and conventional Hounsfield units (HU) in the LAA were measured and normalized to the ascending aorta (AA) of the same slice to calculate the LAA/AA ratio. Of the 389 patients, TEE showed thrombus in 15 (3.9%), SEC in 33 (8.5%), and no abnormality in 341 (87.7%) patients. Using TEE findings as the reference standard, the respective sensitivity, specificity, positive predictive value, and negative predictive value of the LAA/AA HU ratio for detecting LAA thrombus were 100.0, 96.8, 55.6, and 100.0%; those of the LAA/AA iodine concentration ratio were 100.0, 99.2, 83.3, and 100.0%; and those of the LAA/AA Zeff ratio were 100.0, 98.9, 79.0, and 100.0%. The areas under the receiver operator characteristic curve (AUC) of the LAA/AA iodine concentration ratio (0.978; 95% CI 0.945–1.000) and Zeff ratio (0.962; 95% CI 0.913–1.000) were significantly larger than that of the LAA/AA HU ratio (0.828; 95% CI 0.714–0.942) in differentiating the thrombus from the SEC (both P < 0.05). Although the AUC of the LAA/AA iodine concentration ratio was larger than that of the LAA/AA Zeff ratio, no significant difference was found between them (P = 0.259).ConclusionThe dual-energy CT-derived iodine concentration and the Zeff showed better diagnostic performance than the conventional HU in early-phase cardiac CT in detecting LAA thrombus and differentiating the thrombus from the circulatory stasis. However, these results need to be validated in large-cohort studies with late-phase images.

Transcatheter Closure of Atrial Septal Defect in Children: Single-Center Experience, Mid-Term Follow-up Results.

Objective:Atrial septal defect is a congenital heart disease usually diagnosed in childhood. This study aimed to evaluate the mid-term follow-up results of patients who underwent transcatheter closure of atrial septal defect by comparing the devices and methods used in the procedure and investigating the complications of this procedure in children.Materials and Methods:This study evaluated 232 patient files retrospectively. Of the 232 patients, 24 were excluded from the study due to missing files or data. Also, patients with multi-fenestrated atrial septal defect and aneurismatic septal tissue were excluded from the study. The following data were evaluated: follow-up time, patient complaints, symptoms, transthoracic echocardiography, and transesophageal echocardiography findings (if performed), the size of the defect as measured by balloon-sizing, the size of the device used in the procedure, and major and minor complications.Results:The study included 208 children who were diagnosed with atrial septal defect. The mean age of the patients was 88.0 ± 56.5 months. Of the patients, 170 (81.7%) had no complaints. The success rate of the procedure was found to be 95.7%. While device embolization was the most common major complication, arrhythmia was the most common minor complication. The complication rate was statistically different according to the device type used in the procedure.Conclusion:Transcatheter closure of atrial septal defect is a safe method for atrial septal defect closure in pediatric patients. The study found that defect diameters measured by different methods were not correlated with each other. The procedure complication rates differed according to device type.