Transesophageal Echocardiography Findings Research Articles

CLINICAL IMPORTANCE OF COMPLEX AORTIC PLAQUE IN THE CHA2DS2-VASC SCORING SYSTEM IN PATIENTS WITH NONVALVULAR ATRIAL FIBRILLATION

Although complex aortic plaque (≥4mm, mobile or ulceration) is a significant risk factor for thromboembolism and a component of CHA2DS2-VASc score, the clinical importance of complex aortic plaque in CHA2DS2-VASc score has not been well investigated. Transesophageal echocardiography finding of

Abstract TP218: Transoesophageal Echocardiography in the Diagnostic Work-up of Patients With Embolic Stroke of Undetermined Source: A Necessary Investigation That Should Not Be Overlooked

Background&Purpose: The currently proposed criteria for the definition of embolic strokes of undetermined source (ESUS) do not include investigation with transesophageal echocardiography (TEE) among the mandatory diagnostic work-up. We sought to evaluate the diagnostic yield of TEE in consecutive patients fulfilling ESUS criteria. Methods: We prospectively evaluated ischemic stroke (IS) patients fulfilling ESUS criteria from three tertiary care stroke centers during a twelve month period. All patients underwent additional diagnostic work-up with TEE to estimate both the diagnostic yield and the impact of TEE findings in the therapeutic management of patients with ESUS. Results: We identified 61 patients with ESUS who underwent investigation with TEE [mean age 44.3±11.5 years; 49.2% males; median NIHSS=5 (IQR, 3-8)]. TEE revealed additional findings in 52.4% (95%CI by the adjusted Wald method: 40.2%-64.5%) of the patients. Patent foramen ovale (PFO) and atrial septal aneurysm (ASA) were reported in 27.8% (95%CI: 18.1%-40.2%) and 13.1% (95%CI: 6.5%-24.1%) of the study population respectively. The concurrence of PFO and ASA was reported in 4 patients (6.5%, 95%CI: 2.1%-16.1%). The presence of valvular vegetations was documented in 2 patients (3.2%; 95%CI: 0%-11.8%), while thrombus was found in the left atrium of one patient (1.6%, 95%CI: 0%-9.5%). Complex aortic arch atheromatosis was reported in 6.5% (95%CI: 2.1%-16.1%) of the patients. Neither myxomas, nor ventricular septal defects were found in TEE examinations. TEE findings changed the management in 16.4% (95%CI: 8.9%-27.8%) of the patients. Anticoagulants were initiated in 5 patients, while the other 2 patients with endocarditis received treatment with intravenous antibiotics. Finally, 3 of the 61 patients underwent a PFO-closure procedure due to the large size of the shunt and the previous history of recurrent cryptogenic IS. Conclusions: Our findings suggest that ESUS patients should undergo investigation with TEE in search of potential cardioembolic or aortogenic sources. TEE findings may have a decisive impact on the selection of the appropriate therapeutic approach for these patients.

Abstract TP221: A Novel Ultrasound Probe Attached to the Cervix Can Precisely Detect Large Patent Foramen Ovale

Introduction: We developed a novel probe (paste-able soft ultrasound probe; PSUP) attached to the cervix for detection of right-to-left shunt (RLS), because insufficient temporal bone window interrupts the precise examination for diagnosis of RLS. Hypothesis: We assessed the hypothesis that diagnostic ability of PSUP for RLS detection is equal to those of transesophageal echocardiography (TEE). Methods: Subjects were patients with ischemic stroke and transient ischemic attack who underwent TEE. PSUP was a 2.0-MHz center frequency, which had an equal property with TCD, and the shape was thin, soft, and square modified for attachment to the neck. At first, we performed TEE with the echoscope at the level of the fossa ovalis after injection of saline agitated with air in the right antecubital vein. The procedure was performed with and without Valsalva maneuver. Visualization of microembolic signals (MES) induced contrast agent within the right atrium and crossing the interatrial septum was considered as positive patent foramen ovale (PFO). We divided PFO into two groups according to number of MES, such as small PFO (1-29 of MES) and large PFO (≥30 of MES). Then, monitoring using PSUP was performed at unilateral common carotid artery (CCA) using similar preparation and procedure to TEE. RLS by PSUP diagnosed when we found 1and more MES in CCA. We compared detectable rate by size of PFO between TEE and PSUP, and calculated accuracy of PSUP against TEE. Results: From May 2014 to July 2015, 62 patients (46 male, mean age of 61 years) were included in this study. We diagnosed 26 of 62 patients (42%) as PFO by TEE, whereas PSUP detected in 17 of them (27%). As a reference of TEE findings, diagnostic ability of PSUP was 58% of sensitivity, 94% of specificity, and 79% of accuracy. In TEE examination, large PFO was 11 patients and small was 15 patients. PSUP could evaluate large PFO (9 of 11 patients) more accurately than small one (6 of 15, 82% vs. 40%, p=0.05). Conclusion: PSUP should have a considerable accuracy of large PFO diagnosis. For patients with insufficient temporal bone window, PSUP may play an important role of detecting large PFO.

Variations of transesophageal echocardiography practices in India: A survey by Indian College of Cardiac Anaesthesia.

Context:Use of perioperative transesophageal echocardiography (TEE) has expanded in India. Despite attempts to standardize the practice of TEE in cardiac surgical procedures, variation in practice and application exists. This is the first online survey by Indian College of Cardiac Anaesthesia, research and academic wing of the Indian Association of Cardiovascular Thoracic Anaesthesiologists (IACTA).Aims:We hypothesized that variations in practice of intraoperative TEE exist among centers and this survey aimed at analyzing them.Settings and Design:This is an online survey conducted among members of the IACTA.Subjects and Methods:All members of IACTA were contacted using online questionnaire fielded using SurveyMonkey™ software. There were 21 questions over four pages evaluating infrastructure, documentation of TEE, experience and accreditation of anesthesiologist performing TEE, and finally impact of TEE on clinical practice. Questions were also asked about national TEE workshop conducted by the IACTA, and suggestions were invited by members on overseas training.Results:Response rate was 29.7% (382/1222). 53.9% were from high-volume centers (>500 cases annually). TEE machine/probe was available to 75.9% of the respondents and those in high-volume centers had easier (86.9%) access. There was poor documentation of preoperative consent (23.3%) as well as TEE findings (66%). Only 18.2% of responders were board qualified. Almost 90% of the responders felt surgeons respected their TEE diagnosis. Around half of the responders felt that new intraoperative findings by TEE were considered in decision-making in most of the cases and 70% of the responders reported that surgical plan was altered based on TEE finding more than 10 times in the last year. Despite this, only 5% of the responders in this survey were monetarily awarded for performing impactful skill of TEE. Majority (57%) felt that there is no need for overseas training for Indian cardiac anesthesiologists.Conclusions:In this survey of members of the IACTA, use of TEE has increased substantially, but still a lot of variations in practice patterns exist in India. There is urgent need for improving TEE certification and upgrade documentation standards, motivate use of TTE across all centers, promote awareness and usefulness of TEE use among surgical fraternity, monitor impact of TEE, and support separate remuneration policy in India.

Transesophageal echocardiography experience in thepediatric age group in a tertiary cardiac center.

The aim of this study was to evaluate the transesophageal echocardiography (TEE) findings of pediatric patients in a tertiary center where complex congenital heart surgery and interventional procedures have been performed. All TEE studies performed between December 2009 and December 2014 were reviewed retrospectively. Patients were divided into 3 groups: perioperative, during interventional procedures, and due to other reasons. Demographic features, transthoracic echocardiography (TTE) reports, TEE reports, change in decision after TEE evaluation, and related complications were recorded. A total of 703 patients who had TEE evaluation were included in the study; 51% were female and 49% were male. The median age was 90 months (2 months to 18 years). TEE was performed perioperatively in 430 patients (61%), during cardiac catheterization-angiography and electrophysiology studies in 181 patients (26%), and due to other reasons in 92 patients (13%). Mismatches between TTE and TEE or changes in decision after TEE evaluation were present in 45 patients (10.4%) who had perioperative TEE, in 10 patients (5.5%) who had TEE during interventional procedures, and 22 patients (24%) who had TEE evaluation due to other reasons. No major complications were detected. Information acquired by TEE increases the clarity of future plans for the patient and helps to decrease the mortality and morbidity caused by unnecessary procedures.

The value of transesophageal echocardiography in the investigation and management of cryptogenic cerebral ischemia: a single-center experience.

The diagnostic utility of transesophageal echocardiography (TEE) has often been challenged in patients with cryptogenic stroke (CS). We estimated the prevalence of different findings on TEE examination of CS patients, their impact on secondary stroke prevention and the presence of potential age or gender disparities. We reviewed all TEE examinations that were performed in a single echocardiography laboratory during a 7-year-old period to identify CS patients that underwent investigation with TEE. Of the 518 total TEE examinations, we identified 88 CS patients. TEE revealed abnormal findings in 69.3% of them. Patent foramen ovale (PFO) and atrial septal aneurysm (ASA) were identified in 30.6 and 22.7% of the patients. Ascending aorta and aortic arch atheromatosis was present in 26.1% of the patients, with complex atheromatosis diagnosed in 14.7% of them. Cardiac myxomas were uncovered in 2.3%. Thrombi in the left atrium and in cardiac valves were reported in 3.4 and 2.3% of the patients, respectively. Based on TEE findings, the therapeutic management would be very likely modified in 9.1% of the patients. Subgroup analysis revealed no gender disparities on the prevalence of TEE findings and in secondary stroke prevention, while linear regression analyses revealed significant associations of age with the prevalence of PFO, ASA, aorta atheromatosis and complex aorta atheromatosis. TEE examination should be included in the diagnostic work-up of all CS patients, irrespective of age and gender status, since it can reveal potential sources of embolism and has a significant impact for secondary stroke prevention.

Transesophageal Echocardiograph Findings in Patients with Cardiovascular Disorders at Al-Thawrah General Hospital, Sana’a, Yemen

ABSTRACT Objectives: To determine the frequency distribution of different cardiovascular disorders and to describe their associated morphological abnormalities by transesophageal echocardiography among patients referred to the Transesophageal Echocardiography Laboratory of Al-Thawrah General Hospital, Sana’a, in the period 2009– 2011. Methods: This was a retrospective descriptive study of 856 patients with suspected cardiovascular disorders and referred for transesophageal echocardiography over a two-year period. Data about patients’ sex, their refer- ral site and transesophageal echocardiography findings were collected and analyzed according to the type of cardiovascular disorders, valvular affections and lesions, complications and recommended treatments. Results: Of the 856 patients, 63.4% were females and 36.6% were males. The majority of patients diagnosed by transesophageal echocardiography (82.4%) were referred from outpatient departments. Rheumatic heart dis- ease was the most frequent cardiovascular disorder (87.1%), followed by tricuspid valve lesions (62.8%), of which 54% (329/606) were tricuspid regurgitation and 62.6% (114/182) were aortic valve regurgitation. Re- garding the type of valvular lesions detected, mitral valve disease was the most frequent, being found in 69.2% (214/309) of patients. Regarding the severity of valvular lesions, 73.1% (19/26) of mitral valve stenosis cases were severe while 83.3% (35/62) of aortic stenosis cases were mild. Moderate pulmonary hypertension was seen mostly secondary to rheumatic heart disease. The majority of cardiovascular disorder patients (33.6%; 284/844) were recommended for balloon mitral valvotomy. Mitral valve surgery was the most frequently per- formed surgical intervention for affected valves of patients with cardiovascular disorders; being used for the treatment of 31.4% (80/255) of valvular lesions. Conclusions: Transesophageal echocardiography revealed that rheumatic heart disease is the most frequent cardiovascular disorder among Yemeni patients and poses a major health problem. In addition, a high propor- tion of patients with cardiovascular disorders have valvular lesions of the mild degree that require surgical in- tervention.

Initial experience with percutaneous coronary sinus catheter placement in minimally invasive cardiac surgery in an academic center.

BackgroundPlacement of a percutaneous coronary sinus catheter (CSC) by an anesthesiologist for retrograde cardioplegia in minimally invasive cardiac surgery is relatively safe in experienced hands. However, the popularity of its placement remains limited to a small number of centers due to its perceived complexity and potential complications.MethodsWe retrospectively reviewed all cardiac cases performed by one surgeon between December 2009 and April 2012. The reviewed cases were divided into two groups: cardiac cases with percutaneous CSC placement (CSC group) and cardiac cases without placement (control group). Anesthesia preparation time (APT) was then compared between the CSC group and control group. In the CSC group, cases were further divided into two groups. One group contained cases with an APT of less than 90 min (success group) and the other contained cases with an APT greater than or equal to 90 min or cases with CSC placement failure (delay/failure group). Patients’ characteristics, type of surgery, and transesophageal echocardiography (TEE) findings were compared between the two groups (success group vs. delay/failure group) to identify variables associated with prolongation of the APT or CSC placement failure.ResultsPercutaneous CSC placement was required in 83 cases (CSC group). The catheter was successfully placed in 74 of those cases. We experienced one complication, coronary sinus injury after multiple attempts at placing the catheter. The mean APT was 102 ± 31 min in the CSC group (n = 81) and 42 ± 15 min in the control group (n = 285). We could not identify any variables associated with prolongation of the APT or catheter placement failure.ConclusionsThe success rate of the placement was 89.1 % in our academic center. On average, placing the CSC added approximately one additional hour to the APT. This time is not an accurate representation of true catheter placement time, as it included time for preparation of the CSC, TEE, and fluoroscopy. We experienced one documented complication (coronary sinus injury), which was immediately diagnosed by TEE and fluoroscopy in the operating room. No variables associated with prolongation of APT or CSC placement failure were identified.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0203-4) contains supplementary material, which is available to authorized users.

The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta‐analysis

The diagnostic utility of transesophageal echocardiography (TEE) in patients with cryptogenic ischaemic stroke (IS) or transient ischaemic attack (TIA) remains controversial. A systematic review and meta-analysis was performed according to PRISMA guidelines to estimate the pooled prevalence of potential cardioembolic causes detected by TEE in prospective observational studies of cryptogenic IS/TIA. Cardiac conditions causally associated with cerebral ischaemia were considered to be intramural thrombi and intracardiac tumors according to ASCO phenotyping of IS. Thirty-five eligible studies, comprising 5772 patients (mean age 53.6 years, 56.9% men) were identified. The most common TEE finding was ascending aorta and/or aortic arch atheroma [51.2% (27.4%-74.5%)], followed by patent foramen ovale (PFO) [43.2% (36.3%-50.4%)]. Complex aortic plaques and large PFOs were reported in 14% (10.2%-18.9%) and 19.5% (16.6%-22.8%) of TEE evaluations. The prevalence of atrial septal aneurysm was 12.3% (7.9%-18.7%) and was significantly higher in conjunction with PFO presence (risk ratio 2.04, 95% confidence interval 1.63-2.54, P < 0.001). The prevalence of left atrial thrombus [3.0% (1.1%-8.3%)] and spontaneous echo contrast [3.8% (2.3%-6.2%)] was low. The prevalence of intracardiac tumors was extremely uncommon [0.2% (0%-0.7%)]. Significant heterogeneity was identified (I(2) > 60%) in the majority of analyses. Heterogeneity was not affected by cryptogenic stroke definition (TOAST versus alternative criteria). After dichotomizing available studies using a cut-off of 50 years, PFO was significantly (P = 0.001) more prevalent in younger than in older patients. Routine TEE in patients with cryptogenic IS/TIA commonly identifies abnormal findings. However, the prevalence of cardiac conditions considered to be causally associated with cerebral ischaemia (intracardiac thrombi and tumors) is low.

Efficacy and Transesophageal Echocardiographic Findings of Short-term Dabigatran or Rivaroxaban Therapy for Electrical Cardioversion in Patients with Atrial Fibrillation

Efficacy and Transesophageal Echocardiographic Findings of Short-term Dabigatran or Rivaroxaban Therapy for Electrical Cardioversion in Patients with Atrial Fibrillation

Liver Transplantation: Intraoperative Transesophageal Echocardiography Findings and Relationship to Major Postoperative Adverse Cardiac Events.

The primary aim of the study was to describe the most common intraoperative transesophageal echocardiography (TEE) findings during the 3 separate phases of orthotopic liver transplantation (OLT). The secondary aim of the study was to determine if the abnormal TEE findings were associated with major postoperative adverse cardiac events (MACE) and thus may be amenable to future management strategies. Data were collected retrospectively from the electronic medical record and institutional echocardiography database. Single university hospital. A total of 100 patients undergoing OLT via total cavaplasty technique. Intraoperative TEE was performed in all 3 phases of OLT. TEE findings of 100 patients who had TEE during OLT during the dissection, anhepatic, and reperfusion phases of transplantation were recorded after blind review. Findings then were analyzed to see if those findings were predictive of postoperative MACE. Intraoperative TEE findings varied among the different phases of OLT. Common TEE findings at reperfusion were microemboli (n = 40, 40%), isolated right ventricular dysfunction (n = 22, 22%), and intracardiac thromboemboli (n = 20, 20%). Intraoperative echocardiography findings during liver transplantation varied during each phase of transplantation. The presence of intracardiac thromboemboli or biventricular dysfunction on intraoperative echocardiography was predictive of short- and long-term major postoperative adverse cardiac events.

Predischarge Transthoracic Echocardiography after Surgery for Congenital Heart Disease: A Routine withaReason?

Predischarge (pre-d/c) transthoracic echocardiography (TTE) is routine after surgery for congenital heart disease, but how it affects clinical care is unknown. The aim of this study was to test the hypothesis that pre-d/c TTE frequently reveals findings associated with short-term clinical course through a systematic review of findings on pre-d/c TTE and clinical events that followed. Clinical outcomes of mortality, hospitalization, catheterization, and surgery at 1year were examined for pediatric patients undergoing pre-d/c TTE between June 2010 and June 2012. Using logistic regression, a multivariate model was generated associating clinical, pre-d/c transthoracic echocardiographic, and demographic variables with unplanned postdischarge cardiac events (UCEs) within 1 year. Of 462 patients who underwent pre-d/c TTE, there were 265 male patients (57%) and 197 female patients (43%); the median age was 0.8years (range, 0-33years). Two hundred thirty-seven patients (51%) had findings (valve regurgitation, hemodynamic obstruction, ventricular dysfunction, unintended shunt, or pericardial effusion) on pre-d/c TTE, 57 of which were of more than mild severity. Agreement between pre-d/c TTE and postoperative transesophageal echocardiographic findings was only fair to moderate (κ= 0.27-0.43). Sixty-four patients (14%) had UCEs. Univariate analysis revealed that UCE were more frequent in patients with diagnoses and surgical procedures of high complexity. After accounting for these confounding nonechocardiographic variables, pre-d/c transthoracic echocardiographic findings, specifically valve regurgitation of more than mild severity, and ventricular dysfunction and obstructions of any severity were independently associated with UCEs (odds ratios, 1.90, 1.99, and 1.85, respectively). Findings on pre-d/c TTE are frequent, commonly discordant with postoperative transesophageal echocardiographic results, and associated with adverse clinical events after surgery for congenital heart disease. These data would strongly support the practice of pre-d/c TTE after surgery for congenital heart disease.

Abstract W P204: Diagnostic Ability of a Novel Probe Attached to the Cervix for the Detection of Right-to-left Shunt Is Similar to Transesophageal Echocardiography

Introduction: Although transcranial Doppler (TCD) plays an important role of detecting right-to-left shunt (RLS) in order to diagnose patients as a paradoxical brain embolism, insufficient temporal bone window interrupts the precise examination. So, we developed the novel probe (PSUP) attached to the cervix for the detection of RLS. Our hypothesis is that diagnostic accuracy of RLS by PSUP is comparable to those of transesophageal echocardiography (TEE) as a gold standard. . Methods: Subjects were patients with ischemic stroke and transient ischemic attack who underwent TEE. PSUP was a 2.0-MHz center frequency and had an equal property with TCD transducer. The shape was thin, soft, and square modified for adequate attachment to the neck. At first, we performed TEE with the echoscope at the level of the fossa ovalis after injection of saline agitated with air in the right antecubital vein. The procedure was performed with and without Valsalva maneuver. Visualization of microembolic signals (MES) induced contrast agent within the right atrium and crossing the interatrial septum was considered positive for RLS. Then, monitoring using PSUP was performed at unilateral common carotid artery (CCA) using similar preparation and procedure to TEE. RLS by PSUP was diagnosed as having 1and more MES in CCA. After compared RLS detectable rate between TEE and PSUP, accuracy parameters for RLS detection of PSUP against TEE were calculated. Results: From May to August 2014, 21 patients were included in this study. RLS was 5 (24%) of 21 on TEE, and 5 (24%) on PSUP, respectively (table). As a reference of TEE findings, diagnostic power of PSUP was 84% of sensitivity, 94% of specificity, 84% of positive predictive value, 94% of negative predictive value, and 91% of accuracy. Conclusion: RLS detection by PSUP is substantially correct. PSUP may be useful for patients with insufficient temporal bone window, such as elder Asian women.

Abstract T MP49: Should Transesophageal Echocardiography (TEE) be the Initial Diagnostic Modality of Choice in Young Ischemic Stroke (IS) Patients?

Background&amp;Purpose: Current data is limited regarding the comparative utility of Transthoracic echocardiography (TTE) vs. TEE in diagnosing potential sources of cardioembolism (PSOC) in patients with cryptogenic stroke, particularly in young stroke patients. We sought to evaluate the comparative diagnostic yield of these two echocardiographic modalities in young IS patients. Methods: We conducted a retrospective chart review of consecutive young (18-45 yrs) IS patients admitted to a tertiary care stroke center over a study period of 42 months. All patients underwent both TTE and TEE during their standard diagnostic work-up. Stroke classification at discharge was performed according to TOAST criteria by treating physicians. Results: The study population consisted of 83 IS patients (mean age 38±5years, 40% men, 86% blacks, median admission NIHSS-score 3 points, IQR 1-8) who underwent both echocardiographic examinations. Cardioembolic stroke (CS) was the discharge diagnosis in 22 cases (27%). EF calculated by TEE strongly correlated to EF calculated by TTE (r=0.846; p&lt;0.001). Left atrial enlargement was detected more frequently by TEE than TTE (27% vs. 11%; p&lt;0.001). The overall yield of TEE for detecting PSOC was higher than TTE (23% vs 4%; p=0.011). TTE diagnosis of a PSOC was not associated with CS discharge diagnosis in univariate analyses (OR: 6.0, 95%CI: 0.5-69.8; p=0.152). TEE diagnosis of PSOC was associated with CS in univariate analyses (OR: 13.2, 95%CI: 4.0-43.8; p&lt;0.0001). After adjustment for demographics, vascular risk factors, admission NIHSS-score, admission SBP and DBP levels, admission blood glucose and abnormal TTE, TEE diagnosis of a PSOC was independently associated with a higher likelihood of CS diagnosis at hospital discharge (OR: 24.3, 95%CI: 5.9-100.0; p&lt;0.0001). Conclusions: Our study showed that the yield of TEE for detecting PSOC was higher than that of TTE, while abnormal TEE findings were independently associated with a higher likelihood of CS diagnosis. TEE should be considered as the initial echocardiographic modality for evaluating young IS patients, since it may expedite workup and early detection of stroke etiopathogenic mechanism.

Emergent transesophageal echocardiography in hemodynamically unstable obstetric patients

BackgroundThe obstetric population has an increasing incidence of comorbid conditions. These, coupled with the possibility of acute embolic events involving air, amniotic fluid, and thrombus, increase the likelihood of hemodynamic instability. Although the utility of transesophageal echocardiography to guide management in cardiac and high-risk, non-cardiac surgical populations has been well established, the emergent use in critically-ill parturients has not been comprehensively evaluated. MethodsUsing our departmental transesophageal echocardiography database of 28 293 examinations, parturients were identified who underwent emergent transesophageal echocardiography for evaluation of hemodynamic instability, including cardiac arrest, between January 1999 and March 2014. Transesophageal echocardiography findings and their impact on patient management were analyzed. ResultsTen peripartum patients were evaluated. Six patients became unstable during dilation and evacuation procedures; one after a forceps delivery; one during and one after cesarean delivery; and one during a postpartum laparotomy. Six patients proceeded to cardiac arrest; however, all women survived their initial operation and resuscitation. Transesophageal echocardiography was instrumental in determining the etiology and guiding resuscitation in all 10 patients including emergent cardiac surgical intervention with cardiopulmonary bypass (n=2). Seven patients survived to hospital discharge, but three died after experiencing neurologic complications. ConclusionsSevere hemodynamic instability and cardiac arrest can occur in previously healthy parturients in pregnancy. Our data suggest that emergent transesophageal echocardiography is a valuable tool in determining the etiology and directing therapy of refractory hypotension or cardiac arrest in obstetric patients.

Comment on "Dual Prosthetic Heart Valve Presented with Chest Pain: A Case Report of Coronary Thromboembolism".

We have recently read with great interest the case report by S. Wongrakpanich et al. describing a patient with a history of dual prosthetic heart valves and atrial fibrillation who developed coronary embolism (CE) due to inadequate anticoagulation [1]. Thanks are due to the authors for their contribution of the present report including a rare complication of prosthetic valve thrombosis (PVT). On the other hand, we want to make essential criticism regarding some major drawbacks in the management of the patient. CE is a rare cause of acute coronary syndrome (ACS) in patients with prosthetic heart valves. The majority of patients with prosthetic heart valve who were admitted with ACS had non-ST elevation ACS rather than ST segment elevation ACS [2]. The information in the literature about this complication is scarce and mainly based on case reports. There is a controversy regarding the treatment of patients with CE. In the current literature, intracoronary or intravenous thrombolytic therapy (TT), stent implantation, and embolectomy were performed as reperfusion strategies, but there is no consensus regarding the optimal treatment. In the case report presented by S. Wongrakpanich et al. a 54-year-old man with two ball-caged metallic prosthetic valves in mitral and aortic position was admitted with ACS. He had a history of left embolic stroke 15 years ago and international normalized ratio on the last admission was subtherapeutic. The authors performed emergent coronary angiography (CAG) before evaluation of the prosthetic valve with transthoracic (TTE) or transesophageal echocardiography (TEE). CAG revealed a thrombus image in the middle segment of the circumflex coronary artery which was aspirated successfully. The underlying vessel structure was normal which was consistent with a coronary embolism. So they performed TTE which revealed acceptable pressure gradients across both mechanical prostheses. First of all, the major concern regarding the management of this patient is that, even with the gradients and orifice area being within normal limits, TTE is usually uncapable of demonstrating the presence of nonobstructive thrombus on the prosthetic valves, necessitating TEE examination. Since the patient had aortic prosthesis, urgent conventional CAG without TEE examination carried a high risk of new potential thromboembolism due to catheter manipulation during CAG. Although the patient was not complicated with new thromboembolism, it would be better if they performed CAG just after TEE findings suggested that catheter intervention would be safe. Another noteworthy issue regarding the management of the patient is that, when a patient with prosthetic valve was admitted with ACS, PVT was needed to be excluded by TEE before CAG. This strategy helps the clinician to decide what to do during percutaneous interventions. If there is no PVT, you may focus on solving the coronary problem only; however if there are signs of PVT, you should find solutions for two problems. In such situations TT may be a favorable treatment strategy which aims to lyse both valvular and coronary thrombi in the absence of contraindications. The fresh nature of the embolic thrombus may play a role in the successful outcomes of TT. In our recently published case series TT was considered as an initial therapy in the management of PVT and related CE with successful outcomes for both prosthetic and coronary thrombosis [3]. Treatment modalities for PVT include heparin treatment, TT, and surgery. Guidelines lack definitive class I recommendations due to lack of randomised controlled trials and usually leave the choice of treatment to the clinician's experience. Surgery is suggested as a first line strategy in most situations of left sided PVT; however, TT has been recently used with successful outcomes [4, 5]. We have previously reported that low dose (25 mg) and slow infusion (6 hours) of tPA is very safe and associated with very high thrombolytic success in this regard [4]. As a result, we can conclude that CAG should be deferred after TEE due to risk of thromboembolism during catheter manipulation in aortic PVT patients and also in order to decide the best treatment strategy for PVT patients who were admitted with ACS. TT should be considered as an initial treatment modality in these patients. Low dose and prolonged infusion of tPA is an effective regimen which can be safely performed in the absence of contraindications.

Increased Incidence of Transfusion-Related Acute Lung Injury During Orthotopic Liver Transplantation: A Short Report

Intractable severe pulmonary edema during Orthotopic Liver Transplant (OLT) can be a fatal perioperative complication. We sought to characterize the incidence, timing, and related risk factors of severe pulmonary edema during OLT. We performed a retrospective observational survey of OLT cases performed between 2007 and 2011 at Miami Transplant Institute. Of all 632 OLT patients, a total of 9 patients (1.4%) had severe pulmonary edema during OLT. All these patients received blood transfusions before and after reperfusion (Packed red blood cell 8.9 ± 2.6 units, Fresh frozen plasma 12 ± 3.7 units, Platelets 5.4 ± 8.6 units). Eight episodes occurred after reperfusion (89%) and 1 before reperfusion (11%). Median time interval from last blood transfusion to severe pulmonary edema was 79 min (25–257 min). In the 8 patients that developed severe pulmonary edema post reperfusion, median time interval from reperfusion to severe pulmonary edema was 34 min (15–85 min). Perioperative mortality among severe pulmonary edema cases was 11% (1 in 9). Incidence of severe pulmonary edema was 1.4% in our patient population, and this number is much higher than that reported for TRALI in other large series (0.075 to 0.12%). Despite a large dose of steroids given at reperfusion, 89% of pulmonary edema episodes occurred within 2.5 hours of reperfusion. Also, heart failure and pulmonary embolism were unlikely based on intraoperative transesophageal echocardiography findings. These results may suggest an association between TRALI and the post reperfusion syndrome during liver transplantation that warrants further investigation.

Intraoperative three-dimensional transesophageal echocardiography for assessing the defect geometries of mitral prosthetic paravalvular leak during transcatheter closure

BackgroundParavalvular leaks (PVLs) are a common complication of prosthetic valve replacement. Use of the transcatheter intervention technique is a suitable alternative in high-risk patients who may not tolerate repeat surgery. Common reasons for failure of this demanding intervention include poor imaging quality and unsuitable anatomy. The purpose of this study was to assess the usefulness and the incremental value of real-time three-dimensional (RT 3D) transesophageal echocardiography (TEE) over two-dimensional (2D) TEE findings in the evaluation of the geometry and track of mitral PVLs during transcatheter closure. MethodsFive patients with six mitral PVLs at high risk for repeat surgery underwent transcatheter leak closure. Intraoperative RT 3DTEE was used to assess the location, shape, number, and size of the defects. Transapical approaches were used in all cases with fluoroscopic and RT 3D TEE guidance of the wire and catheter, device positioning, and assessment of residual leak after the procedure. ResultsIn all of the cases, defects with irregular crescent shapes and distorted tracks were clearly delineated by RT 3D TEE. This was compared to those results obtained through 2D TEE, which was unable to characterize the defects. Three cases showed small leaks, which were completely occluded with a patent ductus arteriosus (PDA) device in two cases, and a muscular ventricular septal defect (mVSD) occluder combined with coil devices in one case. One case involved a large leak and early device embolization of the muscular VSD occluder, which was removed surgically, and demonstrated a crescent–shaped defect. One patient had two releaks 2 months subsequent to the procedure due to two new extended leaks at the tails of the crescent–shaped defect. ConclusionRT 3D TEE can clearly delineate the geometries of defects in their entirety, including shape, size, and location of the defect and track canal. It would also appear that RT 3D TEE is superior to 2D TEE in the process of guiding the wire through the difficult canal anatomy, facilitating the overall procedure. The small mitral PVLs can be completely occluded, but subsequent complications occurred with large defect closures because of embolization or releak. Therefore, transcatheter closure of PVLs seems to be an attractive alternative for these patients, but newer occluder designs that better conform to leak geometry will be required to improve outcomes.

Abstract 15876: The Safety of Transesophageal Echocardiography in Patients With Gastroesophageal Varices

Introduction: The presence of gastroesophageal varices (GEV) is considered a relative contraindication to performing Trans esophageal echocardiography (TEE) however; the safety of TEE in patients with GEV is unknown. Hypothesis: Bleeding complications related to TEE in patients with GEV are dependent on the severity of the GEV. Methods: 55 patients (G1) with GEV undergoing clinically indicated TEE were studied. Each patient was matched by age and gender to a control subject (C). GEV were graded using esophagogastroduodenoscopy (EGD). There were 39 males and 16 females in either group. Complications related to TEE were defined as upper gastrointestinal (GI) bleed, decline in hemoglobin by more than 2 g/dl, esophageal perforation, aspiration, respiratory compromise requiring intubation and/or need for sedative reversal agents that occurred within 48 hours of the procedure. Results: In G1 grade 1, grade 2, and grade 3 GEV were present in 21, 24, and 12 patients, respectively. Of the 12 patients with grade 3 GEV, one patient had GI bleed. TEE findings included vegetation in 8 patients of G1 and in — patients of C and thrombus in 3 patients of G1 and 3 patients of C. Conclusions: TEE appears safe in patient with grade 1 or 2 GEV. However, caution should be advised when performing TEE in patients with grade 3 GEV. TEE showed significant findings of vegetation or thromus in at least 20% of the patients with GEV.

Use of mobile tablet devices and reduction in time to perioperative transesophageal echocardiography reporting: a historical cohort study.

Timely communication of intraoperative transesophageal echocardiography (TEE) findings to the postoperative care team is critical to optimizing patient care. We compared the use of a personal computer (PC) system with the use of a mobile tablet device (MTD) system for point-of-care TEE data entry and hypothesized that the MTD-based system would reduce the time to preliminary TEE reporting and decrease the incidence of delinquent reporting by 50%. In this historical cohort study, we reviewed 508 perioperative TEE reports entered by cardiothoracic anesthesia fellows. Reports were grouped based on whether data were entered on a PC (PC group) or a MTD (MTD group). Time to TEE reporting was defined as the time from the patient leaving the operating room to the time the TEE report was generated. Delinquent reports were defined as those generated >24 hr after the initial exam. Time to TEE reporting and incidence of delinquent reports were compared between the two groups. Mean (SD) time to TEE reporting was significantly improved with MTD data entry vs PC data entry [233 (676) min vs 1,103 (3,830) min, respectively; mean difference 870 min; 95% confidence interval (CI) 293 to 1,448; P = 0.003], and median (IQR) time was also significantly improved [46 (163) min vs 126 (1,000) min, respectively; median difference 80 min; P = 0.0002]. The incidence of report delinquency with MTD data entry vs PC data entry was also significantly reduced [2.1% vs 6.8%, respectively; mean difference 2.2%; 95% CI 0.5 to 9.0; P = 0.02]. Implementation of a MTD system for data entry leads to improved TEE reporting time and reduces TEE reporting delinquency. Further studies are required to determine whether this strategy enhances quality of reporting, optimizes communication between care teams, and improves outcomes without increasing costs.