Transesophageal Echocardiography Guidance Research Articles

Abstract 4131838: Heart’s Deception: A Venous Villain Hiding in the Heart

A 66-year-old male presented with 5 months of worsening left flank and lower back pain. Three weeks prior to this presentation, he was seen at an outside facility where he was found to have a left renal mass that was not further worked up. CT Abdomen and Pelvis showed an enhancing heterogenous lesion at the left superior renal pole, left adrenal gland lesion, and a pulmonary artery filling defect. This defect, along with concern for metastasis, led to a CT chest angiogram that reported small left upper and lower lobe pulmonary emboli. A transthoracic echocardiogram (TTE) was ordered and showed a linear highly mobile mass in the right atrium that was intermittently protruding into the right ventricle and into the main pulmonary artery through the pulmonic valve. There was no visible evidence of tumor extension of the renal mass into the inferior vena cava. Based on this, the highest differential was a clot-in-transit. After collaboration with the pulmonary embolism response team and echo team, the patient underwent aspiration thrombectomy via AngioVac system with transesophageal echocardiography (TEE) guidance. Most of the mass was removed, but there was a residual small portion adherent to the superior vena cava that was not amenable to aspiration. Grossly, the removed mass did not have the classic appearance of thrombus. The specimen was sent to pathology and returned as poorly differentiated carcinoma with spindle cell pattern positive for PAX8, CK7, CD10, pancytokeratin, and vimentin concerning for renal cell carcinoma. Post procedural transthoracic echo found to have new basal septal globular mass with vascularity seen on echo contrast imaging concerning for vascular involvement consistent with myocardial metastatic invasion. Cardiac magnetic resonance imaging could have aided in more precise tissue characterization to differentiate between clot or tumor prior to aspiration thrombectomy. This case demonstrates the significance of a detailed history and physical exam, use of multimodality imaging, and multidisciplinary collaboration to manage a rare cardiac condition.

Transesophageal Echocardiography Guidance during Transcatheter Mitral Valve Edge-to-Edge Repair for Severe Mitral Regurgitation Post–Mitral Annuloplasty: A Case Series

Transesophageal Echocardiography Guidance during Transcatheter Mitral Valve Edge-to-Edge Repair for Severe Mitral Regurgitation Post–Mitral Annuloplasty: A Case Series

Trans-femoral transcatheter intramyocardial septal radiofrequency ablation: a novel therapeutic approach for obstructive hypertrophic cardiomyopathy

Abstract Background Septal reduction techniques play a pivotal role in mitigating morbidity and mortality among patients with obstructive hypertrophic cardiomyopathy (oHCM). While trans-apical intramyocardial septal radiofrequency ablation (PIMSRA or LIWEN procedure) has shown promise in reducing left ventricular outflow tract (LVOT) gradients and improving symptoms in oHCM patients, it is associated with complications such as cardiac tamponade and atrioventricular block. Objective This study introduces a novel approach for transcatheter radiofrequency ablation of hypertrophic septum via femoral access, utilizing the DragonFire Transcatheter Myocardial Puncture and Radiofrequency Ablation System. We aim to evaluate its safety and medium-term outcomes in patients with oHCM. Methods A prospective, single-center, single-arm study of tf-PIMSRA was conducted in patients with drug-refractory oHCM. Ten patients were enrolled and underwent the procedure under the guidance of transesophageal echocardiography. The primary outcome was 30-day major adverse clinical events, with secondary outcomes including 90-day improvements in outflow obstruction and quality of life. Results All patients, with an average age of 57±10 years, including 4 males, underwent the procedure successfully without any complications, including major adverse clinical events or conduction abnormalities. The average duration of the procedure was 125.2±34.6 minutes, with an average ablation time of 38.69±18.29 minutes and ablation energy of 3.60±1.49KJ. At 90-day follow-up, significant reductions were observed in peak LVOT gradients (resting gradient: from 82.00 [56.00] mmHg to 14.00 [6.25] mmHg; p < 0.001; provoked gradient: from 102.00 [76.25] mmHg to 33.00 [16.50] mmHg; p = 0.002), and interventricular septum thickness (from 22.00 [19.00] mm to 17.00 [15.00] mm; p = 0.002). These improvements were associated with enhancements in NYHA functional classification (from 3.00 [2.75] to 1.00 [1.00]; p < 0.0001), Kansas City Cardiomyopathy Questionnaire scores (from 59.00 [44.50] to 80.00 [77.25]; p < 0.02), 6-minute walk distance (from 441 [400] m to 480 [465] m; p < 0.01), and pro B-type natriuretic peptide levels (from 1738.00 [1113.25] pg/ml to 252.00 [200.00] pg/ml; p = 0.002). All patients achieved New York Heart Association functional class I or II at follow-up. Conclusions Transfemoral PIMSRA appears to be a safe and effective procedure for relieving LVOT obstruction and symptoms in patients with drug-refractory oHCM. These findings support further investigation through randomized clinical trials comparing it with established septal reduction therapies.Patient-Level Outcomes for the trans-fem

Intracardiac vs transesophageal echocardiography for percutaneous LAA occlusion: a meta-analysis

Abstract Background Percutaneous left atrial appendage occlusion (LAAO) is typically performed under the guidance of transesophageal echocardiography (TEE) and fluoroscopy. Intracardiac echocardiography (ICE) appears to be a potential alternative to guide implantation. Purpose We sought to perform a meta-analysis comparing ICE and TEE for endocardial LAAO. Methods A comprehensive literature search was performed in PubMed and Google Scholar regarding published abstracts and manuscripts on July 1, 2023. Studies reporting clinical outcomes comparing ICE vs TEE for endocardial LAAO were included. Results A total of 16 studies with 123,444 patients (ICE-5,122 patients and TEE-122,667 patients) (mean age 75±4 years, 59%male) fulfilled the criteria. Five included Watchman, four included the Amplatzer Cardiac Plug/ Amulet device, and seven included both devices. There was no significant difference in CHA2DS2VASC or HAS-BLED scores between both groups. Outcomes assessed including procedural success between ICE vs TEE (risk ratio [RR], 1.01; 95% CI, 1.00-1.01), fluoroscopy time (mean difference [MD], 1.25 minutes; 95% CI, -1.63- 4.14) and total procedure time (MD, −3.74 minutes; 95% CI, − 13.42-5.94) were found to be similar between both groups. There was also no significant difference in complications including vascular complications, bleeding events, device embolization, and stroke between both groups. Of note, patients undergoing LAA closure under ICE guidance had higher risk for pericardial effusion and/or cardiac tamponade compared to those in the TEE group (RR 1.72; 95% CI, 1.32-2.23). Conclusions Although TEE is the gold standard for perioperative guidance of LAAO, imaging with ICE is a feasible alternative associated with similar efficacy outcomes in LAAO procedures. However, further studies needed to clarify safety of ICE as an alternative perioperative imaging technique.

Safety and efficacy of perventricular device closure of ventricular septal defects in children

Abstract Objectives To evaluate safety and efficacy of perventricular device closure techniques for the closure of ventricular septal defects (VSD) in children in United Arab Emirates. Methods In the year 2023-24, 13 children underwent per-ventricular device closures of VSD under the guidance of transesophageal echocardiography without cardiopulmonary bypass(CPB). The mean age at operation was 3.76 years (range 3 months-14 years). The ventricular septal defect sizes ranged from 2.7-6 mm. The device sizes ranged from 5-12mm. All patients except two required symmetrical device. Eight defects were peri membranous, 3 were sub-aortic and 2 were muscular. Ventricular septal defect occlusion device (Memoport, Beijing, China) were used through a 3-cm skin incision in the lower third of the sternum. Results All patients underwent VSD device closure successfully. The mean procedural duration was 42 minutes. None of the patients required CPB. The mean ventilation time and ICU stay was 3 hrs. and 24 hrs. respectively. None of the patients required inotropic support or blood transfusions. There were no residual shunt (except small shunt through the device), arrhythmias including heart block post operatively. At follow up, (3 months-7 months) there were no residual shunts, conduction disturbances, device dislodgement or major aortic or tricuspid valve complications. There was no mortality. Conclusions Perventricular device closure of VSD is highly successful, less invasive, safe and effective. It is associated with quick recovery, short length of stay and better cosmetic incision. Moreover, it avoids CPB.

Transcatheter closure of atrial septal defect (ASD) in adult and paediatric population without transoesophageal echocardiography/general anaesthesia

Abstract Background Transcatheter device closure is the preferred therapeutic option for ostium secundum atrial septal defect(OS-ASD). Standard practice is to perform it under transoesophageal echocardiography(TEE) guidance. However, TEE is performed under general anaesthesia (GA) and leads to increases in cost, procedural duration, ICU stay, total hospital stays, risk of oesophageal injury and complications of GA. Transthoracic echocardiography(TTE) is an excellent alternative and prior studies have shown it to be a safe alternative in paediatric population. In current study we analysed safety and efficacy of TTE-guided device closure of OS-ASD in all comer population irrespective of age, weight, defect size. Methods The study enrolled all patients who underwent device closure of OS-ASD between March 2017 and December 2023. All procedures were performed under LA for adults and conscious sedation for children. The device was placed under fluoroscopy guidance and position were confirmed on TTE. Procedural success, device, defect size ratio, procedural time, fluoroscopy time, complications, intensive care unit/hospital stay duration were analysed and compared with our own experience of 125 patients with TEE-guided closures before switching to complete TTE-guided procedure(before 2017). Results 340 patients underwent TTE-guided device closure of ASD. Procedure success was 97.4% with acceptable risk of major complications. Three(0.8%) had embolization into pulmonary artery, successfully operated surgically. Two had tamponade requiring drainage. In 9 patients, device could not be deployed despite multiple attempts and approaches. All of these had defect size of > 34mm and deficient IVC rim along with shorter (other than aortic) rim. Findings were compared with our own previous experience of TOE guided closure (practised before 2017). Compared to TOE group, TTE group had significantly lower total procedural duration (75±4 vs. 28 ±1 min; p < 0.01), intensive care unit stay (24±10 vs. 10.5±1 h; p < 0.01), and hospital (48±12 vs. 25.5±4h; p < 0.01) stay duration. Fluoroscopic time was similar in both. There was no mortality in either group. Major complications were comparable, TTE-guided group had less post-procedure complications of vomiting and headache. Additional findings of less pre-procedure fasting duration and early commencement of post procedure oral intake were noted in TTE group. Conclusion TTE-guided device closure of OS-ASD is a safe and feasible in all-comer population in experienced hands. It can definitely negate the use of TEE except in very poor echo window. The added advantages include utilization of physiological variations in PV/LV pressure during cough, Valsalva manoeuvres in awake patients. It definitely reduces the procedural duration, cost of procedure and dependence on GA and trained transoesophageal echocardiographer.

Anatomical classification of patent foramen ovale before percutaneous closure

Abstract Introduction Anatomical characteristics of patent foramen ovale (PFO) vary a lot, potentially impacting the embolic risk, selection of the device and the final sealing results of the closure procedure. Objective To categorize the different PFO anatomies and evaluate the consequence on the type of device used and the incidence of residual shunt. Methods 624 consecutive patients who underwent PFO percutaneous closure with transoesophageal echocardiography (TEE) guidance were retrospectively reviewed. Four types of PFO were identified once a rigid wire was in place using per-procedural TEE. This new classification was based on the PFO sheathed tunnel’s length and width, presence of concomitant atrial septal aneurysm (ASA) or additional defect (ASD), width of the septum secundum (SS) and aortic enlargement (Figure 1). Type I, or "single PFO" was defined by the absence of ASA or ASD, a tunnel width ≤ 4mm, SS’s width ≤ 10mm and no aortic enlargement (i.e., aortic root diameter <21mm/m², distorted anatomy or scoliosis). Type II or "dominant septal aneurysm" was defined by the presence of an ASA, with a distinction between subtype IIa (long PFO tunnel with length ≥10mm) and subtype IIb (short PFO tunnel with length <10mm). Type III or "modified PFO" was defined by SS’s width > 10 mm, aortic enlargement, or severe scoliosis, and type IV or "multi perforated" was defined by the presence of a concomitant ASD or a multifenestrated septal wall. In case of concomitant criteria, the predominant order was IV, then IIb, then III. For each category, the presence of residual shunt was evaluated after Valsalva manoeuvres with contrast echocardiogram 6 months after the procedure. Results Our population had a median age of 51 [41-59] years and included 43.8% women. The type II PFO was the most frequently encountered, with 42% of the patients (Table 1). A total of 44 (7.1%) patients presented multiple types concomitantly (mostly type II and III). PFO occluders were the most implanted devices overall, particularly with type I and IIb, while ASD occluder were more frequently used with types IV and IIb. Cribriform/Uni™ devices were more frequently used with type IV. Large devices (i.e., left disc’s diameter >25 mm) were predominantly used with type III and IV, but scarcely employed with type I and II. Within type II anatomies, large devices were significantly more frequently used with type IIb. Fluoroscopy duration was significantly higher with type IV. At 6 months ultrasound evaluation, large right-to-left residual shunt was significantly more frequent with type IV anatomy and with patients presenting multiple types concomitantly (18/34 - 40.9%). No significant differences were observed regarding clinical outcomes during follow-up. Conclusion Based on specific anatomical characteristics, four types of PFO may be identified, presenting with increasing procedural complexity, and requesting specific closure devices.

Intracardiac vs. transesophageal echocardiography guided transcatheter closure of patent foramen ovale and atrial septal defects

Transcatheter closure of atrial septal defects (ASD) and patent foramen ovale (PFO) can be performed with transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) guidance, but data comparing both modalities in contemporary practice is lacking. Using ICD-10 codes, patients who underwent transcatheter ASD/PFO closure between 2016 and 2020 using ICE or TEE in the Nationwide Readmissions Database (NRD) were identified. Propensity-score matching was performed to compare in-hospital adverse events, length of stay (LOS), cost, and 30-day non-elective readmissions. A total of 964 patients underwent ASD/PFO closure with ICE (38.3 %, n = 369) or TEE (61.7 %, n = 595) between 2016 and 2020. Propensity score matching yielded 327 patients in each group, which were well balanced. Median (IQR) age was 59.0 (46.0, 72.0) years and 54.7 % were female. No difference was observed in the rate of in-hospital major adverse events between groups. ICE guidance was associated with a lower median cost (ICE $20,140.1 (14,622.3, 25,027.0) vs TEE $20,740.4 (14,137.5, 33,045.3), p < 0.04). In conclusion, ICE guided ASD/PFO closure was associated with lower hospitalization cost without increasing in-hospital adverse events when compared with TEE guidance.

Clinical experience of pulmonary vein isolation via single transseptal puncture in atrial fibrillation patients: Comprehensive characterization and follow-up

BackgroundAtrial fibrillation is the most commonly observed cardiac rhythm disorder. Pulmonary vein isolation (PVI) is an effective treatment option to maintain sinus rhythm. This study evaluates the safety, efficacy, clinical outcomes and radiation exposures using a standardized single transseptal puncture (STP)-strategy. MethodsWe analyzed data from patients who underwent our STP-ablation technique with transesophageal echocardiography (TEE) guidance at a university hospital and a regional tertiary health center in Switzerland between January 1, 2017, and May 30, 2022. Collected data included demographics, symptoms, echocardiography results, procedural details, complications and outcomes. Mean follow-up time was 21.4 ± 16 months. ResultsThe study population included 304 patients with a median age of 67 years, who had at least one ablation using our STP-approach. Among these, 248 (82 %) patients underwent de novo PVI with this technique. Ablation was successful in all patients with isolation of all pulmonary veins, with an average procedure duration of 120 min and an average fluoroscopy time of 3 min, resulting in a mean X-ray dose of 252 cGy × cm2. TEE guidance was performed in 235 (95 %) patients. During the first intervention, 17 complications occurred in 13 patients (5 %). After the first PVI, 135 (54 %) patients experienced no recurrence during the follow-up period. The one-year recurrence rate for atrial fibrillation requiring therapy was 30 %. ConclusionOur STP- approach demonstrated comparable success rates to traditional methods, with similar procedural durations, low radiation exposure and a low complication rate. Therefore, this method may offer procedural, economic and safety benefits without compromising efficacy or safety.

Mitral valve repair in ventricular functional mitral regurgitation: a simplified technique of papillary muscles relocation.

Mitral valve repair techniques in ventricular functional mitral regurgitation are controversial due to ongoing debates about long-term repair durability in the setting of left ventricular remodelling. To address the limitations of conventional annuloplasty, subannular techniques, such as papillary muscle relocation, have been developed. However, the limited reproducibility of these techniques has hindered their widespread adoption. In this context, we introduce a simplified and reproducible method for papillary muscle relocation. This method utilizes transoesophageal echocardiographic guidance and premeasured polytetrafluoroethylene loops to streamline the procedure.

Acute type B aortic dissection following transcatheter mitral valve edge-to-edge repair: a case report

Abstract Background Transoesophageal echocardiography is rarely reported as a possible cause of aortic dissection during the transcatheter edge-to-edge repair procedure. Herein, we present a case of type B aortic dissection following the transcatheter mitral valve edge-to-edge repair procedure, most likely related to the transoesophageal echocardiography probe. Case summary A 68-year-old Chinese man complained of exertional dyspnoea lasting over 2 years and had been diagnosed with severe mitral regurgitation. He was admitted to our hospital for the treatment of severe mitral regurgitation with transcatheter edge-to-edge repair. One MitraClip XTR (Abbott Vascular) was successfully implanted under the guidance of active transoesophageal echocardiography, and the mitral regurgitation became trace. However, the patient complained of persistent back pain after the treatment, and computed tomography angiography revealed a type B aortic dissection in the descending aorta. After 2 weeks of unsuccessful conservative treatment, he successfully underwent endovascular stenting and was discharged from the hospital. The patient recovered well and remained event free during the 6-month follow-up. Discussion Herein, we presented a rare complication following transcatheter mitral valve edge-to-edge repair that was most likely related to the transoesophageal echocardiography probe—type B aortic dissection. We postulated that repetitive flexion of the transoesophageal echocardiography probe led to compression-induced injury to the descending aorta wall at the mid-oesophageal level, which was the most probable aetiology of type B aortic dissection. Although this complication is rare, it is potentially fatal and therefore needs attention.

Transesophageal echocardiography guidance for percutaneous closure of PFO and a new method to improve the diagnosis and safety during the procedures.

Percutaneous patent foramen ovale (PFO) closure is becoming more and more common for the treatment or prevention of PFO-associated right-to-left shunt (RLS). This study aims to investigate the value of transesophageal echocardiography (TEE) in percutaneous PFO closure, and to explore a new method that can improve intraoperative diagnosis and surgical safety. Based on our inclusion and exclusion criteria, we enrolled 73 patients between 16 and 70 years old (average age 43.25 ± 14.87 years) who underwent percutaneous PFO closure at the Department of Cardiac Surgery, Zhongshan Hospital (Xiamen), Fudan University, from January 2022 to December 2023. Out of the 73 enrolled patients, there were 28 males (38.36%) and 45 females (61.64%), 29 migraine patients (39.73%), 14 patients (19.19%) with headache and dizziness, 14 patients (19.18%) with a history of cerebral infarction (CI), and 25 patients (34.25%) with CI, lacunar infarction or ischemic focus on magnetic resonance imaging (MRI). All patients received routine transthoracic echocardiography (TTE) and agitated saline contrast echocardiography (ASCE) before operations. Percutaneous closure of PFO was completed under the guidance of TEE. In 12 patients, the method of "injection of heparinized sterile saline through the delivery sheath" was used to observe their RLS, and the anatomical characteristics of the PFO according to the shunt path were monitored and evaluated. This method was also applied to some patients to guide the conveyor to pass through the foramen ovale (FO) channel safely and effectively, thereby improving the success rate of PFO closure. The application of TEE during the procedure of percutaneous PFO closure, including preoperative evaluation, intraoperative guidance, and postoperative reevaluation, can offer further details about the anatomical and shunt characteristics of PFO, improve the diagnosis rate, and confirm the safety of the surgical path. It ensures the safety and reliability of the whole operation, greatly improving the success rate and reducing postoperative complications. TEE guidance of percutaneous PFO closure has the advantages of minimal trauma, no radiation and real-time visualization, while injecting heparinized sterile saline through the delivery sheath is safer and more effective in improving the success rate and reducing postoperative complications.

Dual-Lumen Extracorporeal Membrane Oxygenation Cannulation Technique Using Only Transthoracic Echocardiography - A Case Series.

Bicaval dual lumen cannula (DLC) is gaining popularity in veno-venous extracorporeal membrane oxygenation (V-V ECMO) for having less recirculation and facilitating mobilization. It is usually inserted under fluoroscopic or transesophageal echocardiographic guidance to prevent potentially fatal complications. Thus, their utilization was limited during the COVID-19 outbreak due to stringent quarantine policy and manpower shortage, especially when emergency insertion was required. To describe our experience on DLC insertion using transthoracic echocardiography alone during the pandemic, with a focus on safety considerations by using detail step-by-step procedural guide. Four patients were performed V-V ECMO using the transthoracic echocardiographic-guided DLC cannulation technique during the fifth wave of the COVID-19 outbreak, with no cannulation-related complications. Transthoracic echocardiographic guidance for DLC insertion is feasible and probably safe with a detailed guide, which can be adopted as a supplementary tool during future endemic outbreaks.

Fluoroscopy-only guided transcatheter patent foramen ovale closure: the importance of pre-procedural echocardiography.

Percutaneous closure of a patent foramen ovale (PFO) to prevent recurrent paradoxical thromboembolic events has become the standard of care. However, it remains uncertain if transesophageal echocardiography (TOE) guidance improves procedural success with an existing comprehensive pre-procedural TOE. The aim of the study was to compare the effectiveness of percutaneous PFO closure guided by fluoroscopy (FS) only vs TOE plus FS. Consecutive patients undergoing percutaneous PFO closure between February 2017 and April 2023 were analyzed. Based on pre-procedural echocardiography, patients were scheduled either for an FS-only or TOE/FS-guided procedure. The primary-endpoint was effective PFO-closure (residual-shunt grade 0/1 at 6-month follow-up). The secondary-endpoints included procedural safety/efficacy and major adverse cardiovascular events during hospital stay and at the 6-month follow-up. Two hundred-three patients (mean age 51.8 ± 12.5 years, 39.4% women, Risk of Paradoxical Embolism score = 7 [IQR = 6-7]) underwent PFO closure with FS-only guidance (88 patients, 43.3%) or TOE/FS guidance (115 patients, 56.7%). The main indications for PFO closure were cryptogenic stroke (179 patients, 88.2%) and peripheral embolism (13 patients, 6.4%). At baseline, a right-to-left shunt of grade 2 or higher was present in 199 patients (98%). The procedure time in the FS group was shorter (13 minutes in the FS group vs 16.5 minutes in the TOE/FS group, P = .002). The immediate procedural success was 99.5%. At 6 months, effective closure was achieved in 195 patients (96.1% [FS group: 97.7% vs TOE/FS group 97.8%, P = .29]). The rates of atrial fibrillation and recurrent thromboembolic events were not different among the procedural strategies (3.9% [P = .47] and 0.5% [P = .43]). After comprehensive pre-procedural echocardiography workup, PFO closure with FS guidance only seems equally safe and effective as TOE/FS guidance. A standardized pre-procedural echocardiography protocol facilitates procedural planning with excellent echocardiographic and clinical outcomes.

Perventricular device closure of the ventricular septal defects in children-first experience in the United Arab Emirates

BackgroundVentricular septal defect (VSD) is the most common congenital cardiac malformation, accounting for approximately 30% of congenital heart defects. Conventional surgical repair using cardiopulmonary bypass is invasive and associated with morbidities and prolonged hospital stay. With the advent of interventional approaches and availability of different occluding devices, the technique of perventricular device closure is evolving and being implemented successfully in larger groups of patients. We present herein, our initial experience of perventricular device closure for the ventricular septal defects in children to assess risks and benefits.MethodsFrom March, 2023 to February, 2024, we have performed perventricular closure of ventricular septal defects in 13 children, under guidance of transesophageal echocardiography without cardiopulmonary bypass support. The median age at operation was 2 year (range 1.3–10 years) with the median body weight 11 kg (range 8.7–16.6 kg). Sixty-nine percent were males. The ventricular septal defect sizes ranged from 2.7 to 6 mm (mean 4.7 mm). Seven defects were perimembranous, four sub-aortic and two were muscular. One patient also underwent pulmonary artery de-banding with pulmonary artery balloon angioplasty and other one patent ductus arteriosus ligation, concomitantly. For defect closure, we used ventricular septal defect occlusion device (MemoPart™, Lepu Medical Technology Company, China) through a 3-cm skin incision in the lower- third of the sternum. The device sizes ranged from 5 to 8 mm (mean 6.9+-1.8 mm) and all patients except for two required symmetrical devices.ResultsAll patients underwent device closure successfully. The procedural duration ranged between 32 and 52 min. None of the patients required cardiopulmonary bypass. The mean ventilation time and intensive care unit stay was 3 and 24 h, respectively. None of the patients required inotropic support or blood transfusions. Moreover, no patients developed any arrhythmias including heart block. The average length of hospital stay was 4.4 days. At the latest follow up, there were no residual shunts, conduction disturbances, device dislodgement or major aortic or tricuspid valve complications seen in any patients. There was no mortality.ConclusionsPerventricular device closure of ventricular septal defects is a less invasive, extremely safe and effective method in children. It is associated with very fast recovery, shorter hospitalization time and better cosmetic incision. Moreover, it avoids cardiopulmonary bypass. The modifications and refinements in the design, material and implantation techniques will help in expanding the indications and prevent complications in the long-term.

Comparison of Long-Term Clinical Outcomes and Costs Between Transesophageal Echocardiography-Guided and X-ray-Guided Percutaneous Atrial Septal Defect Closure in Children.

This study aimed to compare the long-term clinical outcomes and costs between using either transesophageal echocardiography (TEE) or X-ray fluoroscopy for Percutaneous atrial septal defect (ASD) closure in children. An analysis was conducted on clinical data from children undergoing TEE-guided (n = 168) and X-ray-guided (n = 139) percutaneous ASD closure. Demographic characteristics, technical indices, acute complications, follow-up outcomes, and costs were compared between the groups. The results are that TEE-guided closure demonstrated shorter surgical times (20.3 ± 7.6min vs. 32.8 ± 7.9min, P < 0.001) and lower procedural costs ($3093.3 ± 451.5 vs. $3589.1 ± 219.4, P < 0.001) compared to X-ray guidance. Initial successful closure rates were similar between the groups (TEE: 98.2%, XR: 97.1%, P = 0.691). TEE guidance also resulted in fewer acute complications and reduced radiation exposure. TEE-guided percutaneous ASD closure offers advantages in terms of shorter surgical times, lower procedural costs, and reduced radiation exposure compared to X-ray guidance. These findings support the preference for TEE guidance in pediatric ASD closure procedures, with potential implications for improving patient outcomes and reducing healthcare costs.

Clinical Results and Safety of Intracardiac Echocardiography Guidance for Combined Catheter Ablation and Left Atrial Appendage Occlusion.

The goal of this study was to compare the procedural safety and long-term outcome associated with a combined catheter ablation and left atrial appendage occlusion (LAAO) procedure utilizing intracardiac echocardiography (ICE) guidance versus transesophageal echocardiography (TEE) guidance. The study focuses on implementing LAmbre and Watchman devices in patients diagnosed with nonvalvular atrial fibrillation (AF). A total of 363 patients diagnosed with nonvalvular AF and who underwent a combined procedure were prospectively enrolled between November 2017 and May 2022. Following 1:1 propensity score matching, the TEE group (n = 132) and ICE group (n = 132) were systematically compared in terms of the combined procedure, imaging parameters, events related to the procedure, and subsequent outcomes during follow-up, including mortality, stroke, bleeding, device-related thrombus (DRT), and peri-device leaks (PDLs). The ICE group exhibited a significant reduction in total procedural duration (153.71 31.71 vs. 174.74 18.79 min), fluoroscopy radiation dosage (207.24 108.39 vs. 268.61 122.88 mGy), left atrial appendage occlusion procedure time (34.69 10.91 vs. 51.46 15.84 min), and contrast agent exposure (108.71 37.59 vs. 158.41 45.00 mL) compared to the TEE group. Angiography and ICE demonstrated a substantial correlation between the left atrial appendage (LAA) orifice and landing zone/LAA ostium (Pearson's correlation coefficient r = 0.808 and 0.536/0.697, two-tailed p 0.001). No occurrences of device-related embolism, thromboembolism, significant bleeding, or unexpected fatalities were observed in either group. Comparable rates of all-cause death (0.76% vs. 0.76%), stroke or transient ischemic attack (2.27% vs. 1.52%), severe bleeding (1.52% vs. 0.76%), PDL (23.81% vs. 24.62%), and DRT (1.52% vs. 1.52%) were noted after an average follow-up of 18.46 7.70 months in both groups, with no discernible differences. Multivariate logistic regression analysis identified a correlation between LAA velocity and the risk of PDL. The effectiveness and safety of ICE-guided combined treatment were demonstrated to be comparable to TEE guidance, accompanied by the additional advantages of decreased procedure time and fluoroscopy radiation exposure. NCT04391504, https://register.clinicaltrials.gov.

Real-world experience utilizing the nuvision 4D intracardiac echocardiography catheter for left atrial appendage closure

Transesophageal echocardiography (TEE) has been the preferred imaging modality to help guide left atrial appendage closure. Newer technologies such as the Nuvision 4D Intracardiac echocardiography (ICE) catheter allow for real-time 3D imaging of cardiac anatomy. There are no direct comparison studies for procedural imaging between TEE and 4D ICE. To evaluate the performance and safety of left atrial appendage (LAA) closure procedures with the Watchman FLX and Amulet, guided by the Nuvision 4D ICE Catheter. This retrospective observational analysis was conducted on institutional LAAO National Cardiovascular Data Registry from January 2022 to March 2023. Patients had undergone LAA closure procedures with the Watchman FLX or Amulet device guided by TEE or a 4D ICE Catheter. The primary outcome evaluated was successful LAAO device placement. A total of 121 patients underwent LAAO device placement with 46 (38.0%) patients guided by 4D ICE during LAAO implantation. The 4D ICE group had a shorter procedural time compared with TEE guidance. Post procedural 45-day TEE post implant was also comparable for both groups with no patients in either group having incomplete closure of the left atrial appendage and peri-device leak > 5 mm. No device related complications (device related access, stroke, or pericardial effusion) occurred in either group at follow-up. There was no significant difference in device implant success or post procedural outcomes at 45 days in either the TEE or 4D ICE group. However, there was a noticeable improvement in procedural time with the 4D ICE catheter.

SEVERE SYMPTOMATIC MITRAL REGURGITATION AFTER ANNULOPLASTY FAILURE: SUCCESSFUL TRANSCATHETER EDGE TO EDGE REPAIR

Abstract Surgical mitral valve repair is the most common, feasible and preferred procedure to treat primary and secondary mitral regurgitation (MR). However, 30% of patients suffer from residue severe regurgitation 10 years after surgical intervention, resulting in a considerable number of Redo procedures. In elderly and high–risk patients with major comorbidities medical treatment is the only and often insufficient option for symptoms’ relief. Percutaneous Transcatheter Edge to Edge repair technique (TEER) with MitraClip system is emerging as an off–label valid alternative to successfully treat severe mitral regurgitation after surgical valvuloplasty failure. Transesophageal echocardiography (TEE) is essential in diagnosis, planning, intraprocedural device placement, and follow up. In the peculiar setting of failed annuloplasty, with small residual valve area, the main risk is the creation of a gradient across the mitral valve. We present two cases of severe mitral regurgitation after surgical annuloplasty with ring placement, carefully evaluated for TEER and successfully treated with this procedure: 1) a 79–year–old man presented with exertional dyspnea and orthopnea in the setting of previous surgical mitral Annuloplasty (2003) with a 32–mm Carpentier Ring. Transesophageal echocardiography demonstrated severe mitral regurgitation due to P2 prolapse and central V–shaped cut of the valve, mean diastolic gradient 1.8 mmHg. 2) a 83 year–old woman presented with dyspnea (NYHA functional class III) and severe mitral regurgitation after previous Annuloplasty with a 34–mm Edwards Ring and placement of Goretex artificial Chordae (2016). TEE showed prolapse of P2 and P3 leaflets, mean diastolic gradient 2.17 mmHg, valvular area 3.5 cmq. Both patients underwent transfemoral and transseptal implantation of one MitraClip device (XTw and XT, respectively) under Transesophageal echocardiography guidance with successful reduction of mitral regurgitation to mild level and symptoms relief. In the first case post procedural mean diastolic gradient was 3.7 mmHg, in the second case it was 3.16 mmHg.

Personalized Guidance of Edge-to-Edge Transcatheter Tricuspid Valve Repair by Multimodality Imaging.

Background: Transcatheter edge-to-edge tricuspid valve repair (T-TEER) for tricuspid regurgitation (TR) is always guided by transesophageal echocardiography (TEE). As each patient has unique anatomy and acoustic window, adding transthoracic echocardiography (TTE) and cardiac CT could improve procedural planning and guidance. Objectives: We aimed to assess T-TEER success and outcomes of a personalized guidance approach, based on multimodality imaging (MMI) of patient-tailored four right-sided chamber views (four-right-ch), as depicted by CT, TTE, TEE and fluoroscopy. Methods: Patients were assigned to MMI or classical TEE guidance, depending on TTE acoustic window. In MMI patients, planning included cardiac CT, which determined the fluoroscopic angulations of the specific four-right-ch, while guidance relied heavily on TTE, with minimal intermittent TEE for leaflet grasping and result confirmation. Both TTE and TEE were matched to respective CT and fluoroscopy four-right-ch. TR severity and quality of life (QoL) parameters were assessed from baseline to 12 months. Results: A total of 40 T-TEER patients were included, with 17 procedures guided by MMI and 23 solely by TEE. Baseline characteristics were similar between groups, e.g., age (83.1 ± 4.1 vs. 81 ± 5.3, p = 0.182) or STS-Score (11.1 ± 7.4% vs. 10.6 ± 5.9%, p = 0.813). The primary efficacy endpoint of ≥one-grade TR reduction at 30 days was 94% (16/17) in MMI vs. 91% (21/23) in TEE patients, with two or more TR grade reduction in 65% vs. 52% (p = 0.793). Device success was overall 100%, with no device-related complications, but three TEE-associated cases of gastrointestinal bleeding in the TEE-only group. By 12 months, all 15 MMI and 19 TEE survivors improved NYHA functional class and QoL, e.g., Kansas City Cardiomyopathy Questionnaire Score Δ29.6 ± 6.7 vs. 21.9 ± 5.8 (p = 0.441) pts., 6-min walk distance Δ101.5 ± 36.4 vs. 85.7 ± 32.1 (p = 0.541) meters. Conclusions: In a subset of patients with good TTE acoustic window, MMI guidance of T-TEER is effective and seems to avoid gastroesophageal injuries caused by TEE probe manipulation. TR reduction, irrespective of guidance method, impacts long-term QoL.