Transesophageal Echocardiography Imaging Research Articles

Valvulitis: un nuevo criterio ecocardiográfico para el diagnóstico de endocarditis infecciosa de bioprótesis de válvula aórtica

Introduction and objectivesDiffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. MethodsFrom 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. ResultsThe prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. ConclusionsValvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Proteomic biomarkers for noninvasive left atrial appendage thrombus prediction in patients with atrial fibrillation

IntroductionThe CHA2DS2-VASc score, used to assess the risk of left atrial appendage thrombus (LAAT) formation in patients with atrial fibrillation (AF), has limited predictive value. Moreover, transesophageal echocardiography imaging, the gold standard diagnostic method to identify thrombi, is semi-invasive. Consequently, there is a need for alternative and noninvasive diagnostic methods for LAAT risk assessment. MethodsDeep proteomic analysis was conducted in plasma samples from 8 patients with nonvalvular AF, divided into thrombus and control groups (4 patients in each group) based on the presence or absence of LAAT. Biomarkers associated with LAAT were validated using an enzyme-linked immunosorbent assay in a cohort of 179 patients with available clinical, transthoracic, and transesophageal echocardiography data. Predictive models were developed to assess the improvement in LAAT identification. ResultsThe LAAT group had higher CHA2DS2-VASc scores, larger LA diameter, and lower LAA flow velocities. Deep proteomic analysis identified 30 differentially expressed proteins, including myosin light chain 4, prenylcysteine oxidase 1 (PCYOX1), and decorin as potential diagnostic biomarkers of LAAT. The model showed that PCYOX1 and decorin provided an area under the curve (AUC) of 0.970 for LAAT prediction compared with 0.672 in a model including the CHA2DS2-VASc score and LAA cauliflower morphology. The incremental value of proteomic biomarkers for LAAT in patients with nonvalvular AF was further confirmed with the net reclassification improvement and integrated discrimination improvement indices. ConclusionsProtein levels of PCYOX1 and decorin improve the predictive performance for LAAT in patients with nonvalvular AF.

Transesophageal Echocardiography Improves Precision in Transseptal Puncture Compared to Fluoroscopy in Left Atrial Electrophysiological Procedures.

Background: Complex arrhythmias often arise from the left side of the heart, necessitating established electrophysiological (EP) procedures like 3D-mapping-assisted radiofrequency (RF) ablations or pulmonary vein isolation (PVI). These procedures typically require transseptal access, emphasizing the critical role of achieving an optimal catheter position through a precise transseptal puncture (TSP). Commonly employed imaging methods for TSP guidance include fluoroscopy and interventional echocardiography. Despite their routine use, there is limited evidence on which imaging modality offers superior catheter positioning for EP procedures, and safety concerns regarding transseptal punctures with imaging remain underexplored. This study aims to systematically evaluate the feasibility, safety, and accuracy of echo-guided TSP compared to fluoroscopy-guided TSP. Methods: In this prospective study, 150 consecutive patients undergoing left atrial EP procedures were enrolled between October 2023 and February 2024 at the Ulm University Heart Center. Following optimal fluoroscopy-guided transseptal needle positioning at the interatrial septum, the catheter placement was further verified using transesophageal echocardiography (TEE). Adjustments were made in cases of suboptimal needle positioning observed in TEE. The fluoroscopically achieved septal positions were categorized based on TEE images as optimal, suboptimal, poor, or dangerous. Results: Among the 150 patients included (58.0% male), fluoroscopy achieved optimal, suboptimal, and poor/dangerous positions in 32.7%, 43.3%, and 24.0%, respectively. After TEE-guided adjustments, optimal and suboptimal positions were achieved in 59.3% and 40.7% of patients, respectively. No instances of poor or dangerous transseptal needle positions were observed under TEE guidance. Conclusions: TEE-guided TSP emerges as a feasible, more accurate, and safer imaging method for transseptal punctures in EP procedures.

Imaging of congenital heart defects with a focus on magnetic resonance imaging and computed tomography

Due to advances in diagnostics and therapy, the survival rate of patients with congenital heart defects is continuously increasing. The aim of this review is to compare various imaging modalities that are used in the diagnosis of congenital heart defects. Transthoracic echocardiography is the imaging method of choice in the presence of acongenital heart defect because of its wide availability and non-invasiveness. It can be complemented by transesophageal echocardiography, cardiac catheterization, computed tomography (CT), and magnetic resonance imaging (MRI) of the heart and vessels close to the heart. The radiation exposure of CT examinations of the heart is continuously decreasing because of improved technologies. MRI is also being continuously optimized, e.g., by the acquisition of MR angiographies without contrast medium application or athin three-dimensional (3D) visualization of the entire heart with the possibility of reconstruction in all spatial planes (whole-heart technique) as well as 2D to 4D flow. Due to the complexity of congenital heart defects and the variety of possible pathologies, the choice of imaging modality and its exact performance has to be coordinated in an interdisciplinary context and individually adapted.

RL-TEE: Autonomous Probe Guidance for Transesophageal Echocardiography Based on Attention-Augmented Deep Reinforcement Learning

Ultrasound image acquisition in conventional transesophageal echocardiography (TEE) requires complex manual operation of the probe in the esophagus based on the interpretation of ultrasound images and in-depth knowledge of the cardiac anatomy. In this work, we formulate the TEE probe guidance task as a reinforcement learning (RL) problem, and present the first learning-based solution to 3-DOF control of a TEE probe based on the ultrasound image feedback, named RL-TEE, in order to mimic the visual search and navigation strategies of expert echocardiographers. The probe-tissue interaction in TEE is carefully modeled in our framework by considering both the requirements for navigation towards the standard views and compliance in the esophageal environment. Furthermore, we propose a hybrid deep Q-network model that augments a convolutional neural network backbone with self-attention mechanisms to better capture spatial information in ultrasound images to guide navigation decisions. The presented methods are preliminarily validated in a TEE simulation environment built with data from 25 subjects to acquire four standard views of the heart. Our results show that the proposed method can effectively learn to accurately and compliantly guide the probe movement for TEE standard view acquisition tasks and has a good generalization ability to unseen patient data. <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">Note to Practitioners</i> —The motivation of this paper is to realize 3-DOF movement guidance of a TEE probe to acquire the standard views of the heart based on the real-time images, which can be applied to existing robotic control systems or used to assist novice echocardiographers in TEE examination, thereby relieving operator workload and improving ease of use. This paper suggests a novel approach that uses the deep RL technique to achieve automatic interpretation of TEE images and intelligent guidance of the probe movement. The RL framework is designed to take into account both the navigation efficiency and compliance with the esophageal environment for the targeted intracorporeal application. A hybrid deep Q-network model that augments a convolutional neural network with attention mechanisms is designed to better capture spatial information from ultrasound images to predict the probe movement. The effectiveness of the framework is preliminarily validated in extensive experiments in a simulation environment built with real patient data. The proposed method can be applied in clinical use to provide real-time TEE probe guidance for novice echocardiographers, and can be integrated with a robotic system to fully automate the TEE acquisition, thereby relieving the doctors from tedious manual operation to focus on the diagnosis and treatment.

Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis

Introduction and objectivesDiffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. MethodsFrom 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. ResultsThe prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. ConclusionsValvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Comparison of left atrial appendage measurements between conventional transesophageal echocardiography and "Virtual TEE" reconstructed from computed tomography for pre-procedural planning of device closure.

For pre-procedural planning of left atrial appendage (LAA) closure, sizing is crucial. Although transesophageal echocardiography (TEE) is a standard modality, cardiac computed tomography (CT) is also widely used. The virtual TEE (V-TEE) that our group developed enables us to reconstruct images similar to TEE images from CT images. The software should be helpful to understand and plan the procedure strategy. Accordingly, we investigated the utility of V-TEE. Sixty-six patients at 4 participating sites who completed both CT and TEE prior to LAA closure were included. The LAA diameter at the landing zone (LZ) for WATCHMAN™ device implantation was statistically compared at 0°, 45°, 90°, and 135° between V-TEE and TEE. Among 66 cases, only 3 cases were excluded due to poor imaging quality, and 63 cases were analyzed. The device LZ diameters based on V-TEE were strongly correlated with those based on TEE, despite the significantly greater diameter based on V-TEE with mean differences of 2.4 to 3.0mm (all of them: P < 0.001). The discordances (V-TEE/TEE ratio) at most angles were significantly larger in the elliptical LAAs. V-TEE provides a valuable method for the evaluation of the LAA diameters. V-TEE-based measurements were larger than conventional TEE-based measurements, especially in cases of elliptical LAAs. The assessment by V-TEE has the potential benefit of ensuring proper device sizing regardless of the LAA morphology.

Transthoracic and transoesophageal echocardiography for tricuspid transcatheter edge-to-edge repair: a step-by-step protocol

Abstract Tricuspid regurgitation (TR) carries an unfavourable prognosis and often leads to progressive right ventricular (RV) failure. Secondary TR accounts for over 90% of cases and is caused by RV and/or tricuspid annulus dilation, in the setting of left heart disease or pulmonary hypertension. Surgical treatment for isolated TR entails a high operative risk and is seldom performed. Recently, transcatheter edge-to-edge repair (TEER) has emerged as a low-risk alternative treatment in selected patients. Although the experience gained from mitral TEER has paved the way for the technique’s adaptation to the tricuspid valve (TV), its anatomical complexity necessitates precise imaging. To this end, a comprehensive protocol integrating 2D and 3D imaging from both transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) plays a crucial role. TTE allows for an initial morphological assessment of the TV, quantification of TR severity, evaluation of biventricular function, and non-invasive haemodynamic evaluation of pulmonary circulation. TOE, conversely, provides a detailed evaluation of TV morphology, enabling precise assessment of TR mechanism and severity, and represents the primary method for determining eligibility for TEER. Once a patient is considered eligible for TEER, TOE, alongside fluoroscopy, will guide the procedure in the catheterization lab. High-quality TOE imaging is crucial for patient selection and to achieve procedural success. The present review examines the roles of TTE and TOE in managing patients with severe TR eligible for TEER, proposing the step-by-step protocol successfully adopted in our centre.

Deep learning for transesophageal echocardiography view classification

Transesophageal echocardiography (TEE) imaging is a vital tool used in the evaluation of complex cardiac pathology and the management of cardiac surgery patients. A key limitation to the application of deep learning strategies to intraoperative and intraprocedural TEE data is the complexity and unstructured nature of these images. In the present study, we developed a deep learning-based, multi-category TEE view classification model that can be used to add structure to intraoperative and intraprocedural TEE imaging data. More specifically, we trained a convolutional neural network (CNN) to predict standardized TEE views using labeled intraoperative and intraprocedural TEE videos from Cedars-Sinai Medical Center (CSMC). We externally validated our model on intraoperative TEE videos from Stanford University Medical Center (SUMC). Accuracy of our model was high across all labeled views. The highest performance was achieved for the Trans-Gastric Left Ventricular Short Axis View (area under the receiver operating curve [AUC] = 0.971 at CSMC, 0.957 at SUMC), the Mid-Esophageal Long Axis View (AUC = 0.954 at CSMC, 0.905 at SUMC), the Mid-Esophageal Aortic Valve Short Axis View (AUC = 0.946 at CSMC, 0.898 at SUMC), and the Mid-Esophageal 4-Chamber View (AUC = 0.939 at CSMC, 0.902 at SUMC). Ultimately, we demonstrate that our deep learning model can accurately classify standardized TEE views, which will facilitate further downstream deep learning analyses for intraoperative and intraprocedural TEE imaging.

Implementation of a Liver Transplant-Specific TEE Guide to Expand TEE Utilization and Improve Workflow During Orthotopic Liver Transplantation.

Transesophageal echocardiography (TEE) is being increasingly utilized during orthotopic liver transplantation to guide perioperative management. Obstacles of improving TEE utilization include the challenge of becoming familiar with the TEE machine, optimizing TEE images, and translating skills acquired in didactic or simulator center-based training into clinical use. In an effort to expand TEE utilization and improve workflow among the liver transplantation (LT) anesthesiologists at our institution, a LT-specific TEE guide was created to serve as a reference and educational tool during LT. A 26-question survey was distributed to all LT anesthesiologists before and 6 months after implementation of the LT-specific TEE guide. All seven LT anesthesiologists completed the survey questions during the study period. No statistically significant difference was detected in participant-reported confidence in optimizing targeted TEE views, performing technical aspects of the exam, navigating the knobs on the TEE machine, or in ability to identify abnormal cardiac pathology during the study period. One participant became basic-TEE certified during the study period. Implementing a liver transplant-specific TEE guide is a strategy to expand TEE utilization, encourage longitudinal TEE education and reinforce concepts learned from hands-on education sessions; however, we did not detect a difference in participant-reported confidence of performing a TEE exam, ability to identify abnormal cardiac pathology or altering workflow. Further studies with larger sample sizes will be needed to evaluate the effectiveness of a LT-specific TEE guide.

Feasibility of contrast-free left atrial appendage closure with WATCHMAN FLX device for patients with chronic kidney disease.

Contrast media are generally necessary for transcatheter left atrial appendage closure (LAAC), however, it should be avoided in patients with chronic kidney disease (CKD). The objective of this study was to evaluate the safety and feasibility of contrast-free LAAC with WATCHMAN FLX device for patients with CKD. Among 141 patients undergoing LAAC using the WATCHMAN FLX between May 2021 and March 2023, we performed LAAC without contrast media in 10 patients. Procedural and follow-up results were evaluated. The device size was selected based on the transesophageal echocardiographic (TEE) measurements. The device shape was assessed by fluoroscopy, and the device position was adjusted by TEE images. The mean age was 78 ± 4.9years, CHADS2 score was 3.2 ± 1.1, and the estimated glomerular filtration rate (eGFR) was 28 ± 12mL/min/1.73m2. The procedure was completed without contrast media in ten patients. Partial recapture of the device was required in four patients, but the initially selected device was finally implanted in all patients. Mean procedure time was significantly shorter in the contrast-free LAAC than in the contrast-use LAAC (41.6 ± 14.1min vs 30.3 ± 7.6min, p = 0.01). Postprocedural eGFR did not change from baseline, and there were no adverse events during the hospital stay. Follow-up TEE or cardiac computed tomography performed within 3months after the procedure revealed no device-related thrombus or peri-device leak > 3mm, and oral antithrombotic therapy was discontinued in all patients. Our experience shows that contrast-free LAAC using the WATCHMAN FLX device was safe and feasible. Non-contrast LAAC is one of the therapeutic options for patients with severe CKD.

Use of Transesophageal Echocardiography for Enhanced Safety During Bar Removal Procedures After Minimally Invasive Repair of Pectus Excavatum.

Background: Minimally invasive repair of pectus excavatum involves placement of retrosternal support (Nuss) bars. Hardware removal has been rarely associated with life-threatening hemorrhage from the heart, aorta, internal mammary arteries, and/or lung. There is no accepted standard intraoperative monitoring technique used during removal. We hypothesized that the use of transesophageal echocardiography (TEE) during Nuss bar removal would enhance safety of the procedure and be cost-effective. Methods: IRB-approved retrospective review of patients who underwent Nuss bar removal with intraoperative TEE monitoring over a 4-year period, from March 2013 to May 2017, was completed. Bar removal procedures were performed supine, under general anesthesia. TEE images were monitored and any distortion of the cardiac silhouette, new pericardial effusion, and/or cardiac arrhythmias would be considered evidence of possible bar adherence, triggering possible conversion to sternotomy or thoracotomy. Results: In total, 87 consecutive patients, mean age of 20 years, were identified. Bars had been in place for a mean of 30 months. Average procedure time was 67 minutes. No patients experienced arrhythmias, cardiac injury, or significant hemorrhage during removal. TEE gave excellent visualization of the cardiac silhouette and pericardium in all cases. No patient required insertion of an arterial line, a postoperative chest X-ray, or overnight hospitalization. Patients were discharged from the recovery room an average of 89 minutes postprocedure. Conclusion: TEE offers a minimally invasive safe way to visualize the pericardium and its contents during Nuss bar removal. Significant cardiac/mediastinal injuries should be immediately visible. The use of TEE is cost-effective and allows safe discharge the day of surgery.

The predictive value of compression rate on residual leak after left atrial appendage occlusion with watchman FLX

Abstract Background Incomplete left atrial appendage (LAA) occlusion due to residual leaks may occur after percutaneous closure procedure with Watchman FLX. Before release of device PASS (position, anchor, size and seal) criteria must be verified. Optimal compression rate for watchman FLX device is between 10-30% according to company recommendations. Purpose The aim of this study is to evaluate the correlation between compression rate and leak presence after left atrial appendage closure. Methods This is an observational retrospective study including patients that underwent LAA closure under transesophageal echocardiography (TEE) with at least one follow-up where complete LAA closure was assessed by TEE in our center between January 2021 and August 2022. TEE images were reviewed by the first author. Compression rate was calculated based on intraprocedural TEE images using the following formula: (original device size—size after deployment)/original device size*100. Patients were divided into 2 groups based on the compression rate: group 1: 10-30%; group 2: &amp;gt;30%. The rate of leak between groups was compared using the Chi-square test. Results 203 patients (mean age 79± 8 years) were included in the study. The implanted device size was 20 mm in 7 (3.4%), 24 mm in 30 (14.8%), 27 mm in 49 (24.1%), 31 mm in 75 (36.9%) and 35 mm in 42 (20.7%) patients. Based on the compression rate, patients were classified into group 1: &amp;gt;30% [n=37 (18.2%)] and group 2: ≤30% [n=166 (81.8%)]. Mean compression rate was 38.5% and 21.3% in group 1 and 2 respectively. At follow-up TEE, 1 (2.7%) patient in group 1 and 32 (19.3%) patients in group 2 were found to have a residual leak of &amp;gt;1 mm. When comparing leaks between the two groups, there was 1 leak in group 1 whereas in group 2 there were 32 leaks (1/37 vs 32/166, p value 0.01, RR 0.14, 95% CI, 0.02-0.74). Conclusion Devices with compression rate ≤30% were associated with significantly higher risk of residual leak.

Valvulitis: a new echocardiographic criterion for the diagnosis of prosthetic valve infective endocarditis

Abstract Background Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been previously described in some patients with aortic bioprosthetic valve endocarditis (PVE). This echocardiographic finding has been termed valvulitis. Objectives Our aim was to estimate the prevalence of valvulitis, to precisely describe its echocardiographic characteristics, and to determine their clinical significance in patients with aortic bioprosthetic valve endocarditis. Methods From 2011 to 2022, 388 consecutive patients with IE admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with aortic bioprosthetic valve endocarditis (n=86) were selected, and their TEE images were thoroughly evaluated by three independent cardiologists to identify all potential cases of valvulitis. The diagnosis of valvulitis was considered to be present when all three were in complete agreement. Results Prevalence of isolated valvulitis in the total cohort was 12.8%, and 20.9% of patients had valvulitis accompanying other classical echocardiographic findings of IE. A description of the main clinical and imaging findings of 11 patients with valvulitis and no other echocardiographic signs of IE is shown at the Table. Diagnosis status corresponds to the criteria for the diagnosis of IE according to the ESC 2015 IE guidelines, including 18F-FDG PET/CT. TEE long-axis and short-axis views of a patient with bioprosthetic valvulitis (homogeneous and hypoechoic thickening of the aortic leaflets) resulting in severe aortic stenosis are shown at the Figure, Panel A. At Panel B, abnormal FDG uptake (white arrow) at the prosthetic valve is seen on PET/CT scan of the same patient. At Panel C, histology of the aortic bioprosthetic leaflet of the same patient with valvulitis is presented (hematoxylin and eosin stain of the aortic leaflet; granulation tissue is well demonstrated (red bracket) covering the aortic fibrosa (red asterisk)). Moderate or severe valve stenosis was more common in those with valvulitis (81.8 vs 34.9%, p&amp;lt;0.001). Patients with isolated valvulitis tended to have a lower IE-related in-hospital mortality (9.1 vs 23.3%, p=0.219) and cardiac surgery was less frequently performed than in the other subjects with aortic PVE (27.3 vs 58.1%, p=0.17), but these results were not statistically significant. Conclusions Valvulitis can be the only echocardiographic finding in infected biological aortic prosthesis and needs to be recognized by imagers for early patient diagnosis. The identification of this sort of lesion is important since the clinical profile and management of these patients is different from that of patients with classical PVE.TableFigure

Catheter ablation of atrial fibrillation: three-dimensional transesophageal echocardiography versus magnetic resonance imaging for pre-interventioal pulmonary vein imaging (8-year follow-up)

Abstract Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation (AF). However, it is still challenging because of the high degree of variability of the pulmonary vein (PV) anatomy. Three-dimensional transesophageal echocardiography (TEE) is a promising new technique for cardiac imaging. Therefore, we have evaluated the usefulness of 3-D TEE for analysing the left atrial anatomy prior to an ablation procedure in comparison to magnetic resonance imaging (MRI). Methods In 240 patients, 3-D TEE and cardiac MRI were performed immediately prior to an ablation procedure (paroxysmal AF: 110 patients, persistent AF: 130 patients). The image quality provided by 3-D TEE and by cardiac MRI was compared in all patients. Two different ablation strategies were used. In patients with paroxysmal AF, the cryoablation technique was used. In the other patients, a circumferential pulmonary vein ablation was performed using a three-dimensional mapping system. Results A 3-D TEE and a cardiac MRI could be performed successfully in all patients prior to the ablation procedure. Several variations of the PV anatomy could be visualized precisely by 3-D TEE and cardiac MRI (e.g. accessory PVs, common PV ostia, varying diameter of the left atrial appendage and its distance to the left superior PV). The image quality was good in the majority of patients even if AF with rapid ventricular response was present during the examination. The image quality provided by 3-D TEE was acceptable in 230/240 patients (95.8 %). The TEE findings correlated well with the PV angiographies performed using cardiac MRI. There was a good correlation with regard to the diameter of the PV ostia assessed by these two imaging techniques. All ablation procedures could be performed successfully (mean number of completely isolated PVs: 3.9 (cryo group), 3.9 (radiofrequency catheter ablation group)). At 96-month follow-up, 64.6 % of all patients were free from an arrhythmia recurrence (cryo group: 70.0 %, Carto group: 60.0 %). There were no major complications. Conclusions AF ablation procedures can be performed safely and effectively based on prior 3-D TEE imaging. The image quality was acceptable in the vast majority of patients.

Influence of device generations on alternations of mitral annulus after transcatheter edge-to-edge repair: a real-time three-dimensional transesophageal echocardiography study

Abstract Background Alternation of the mitral annulus (MA) after transcatheter edge-to-edge mitral valve repair (TEER) is reported to be associated with a reduction of mitral regurgitation (MR). However, the influence of the new device system with 4 device size options (MitraClip G4) on MA geometry compared to the conventional device (G2) remains unknown. Methods and results A total of 129 patients (mean age 79±10 years, male 66%) including 38 primary MR and 91 secondary MR who underwent TEER guided with three-dimensional (3D) transesophageal echocardiography (TEE) were included. MA area, anterior-posterior (AP) diameter, inter-commissure (CC) diameter, and MA ellipticity before and after MitraClip implantation were measured using 3D TEE images assessed by dedicated software. MitraClip G4 was used in 54 cases (42%). In patients with secondary MR, greater changes in MA area, AP diameter, and MA ellipticity were observed in patients treated with G4 compared to G2 (P=0.001, 0.003, and 0.39, respectively). In contrast, patients with primary MR had no differences in the change of MA parameters between G2 and G4. Patients with significant residual MR had less increase of MA ellipticity after device implantation in secondary MR (P=0.014), but not in primary MR (P=0.062). Conclusion In patients with secondary MR, MitraClip G4 made greater changes in MAA, AP diameter, and MA ellipticity compared to MitraClip G2, but not in CC diameter. The change of ellipticity was associated with a reduction of MR after device implantation in secondary MR. These findings indicated that MitraClip G4 may lead favorable MA alternation than G2, especially in secondary MR.

Abstract 349: Deep Learning Detection of Chest Compression Location Using Transesophageal Echocardiography

Background: Recent work evaluating intra-arrest transesophageal echocardiography (TEE) in cardiac arrest (CA) has demonstrated that chest compression (CC) location is a strong predictor of return of spontaneous circulation. However, advanced skills to interpret images during resuscitation represent an important barrier to implementation of this modality. Deep Learning (DL) models have been increasingly used to perform the automated interpretation of TEE images. Given the unique challenges during the interpretation of images, DL-based automation represents an attractive adjunct to facilitate the use of intra-arrest TEE. We sought to evaluate the feasibility of a DL model to identify CC location in TEE images obtained during CA resuscitation. Methods: We analyzed videos from out-of-hospital and in-hospital CA patients evaluated with TEE collected through the Resuscitative TEE Collaborative Registry (NCT04972526). We reviewed and selected images for the DL algorithm, using midesophageal long axis clips. Videos were selected based on the visualization of anatomical structures necessary to identify the CC location. Images were annotated by an expert classifying them in CC over the LV (CC-LV) vs CC over the left ventricular outflow tract (CC-LVOT). We used TEENet, an end-to-end DL approach with input of TEE clips containing single compression cycles, to classify clips in CC-LV and CC-LVOT. The TEENet architecture includes two 3D convolution layers, followed by a global average pooling layer, and then appends a fully connected layer with a sigmoid layer. We used the F1-score as the evaluation metric for the model's performance. Results: Ten videos containing a total of 47 single CC cycle clips were selected for inclusion in the model, each clip with an average of 25 frames. The model was trained using 80% of the data (37 clips) and tested using the remaining 20% (10 clips). The model achieved an F1-score of 0.7273 in classifying CC-LV from CC-LVOT. Conclusion: We report the creation of a novel DL-model with acceptable precision and recall performance in the detection of CC location using intra-arrest TEE videos. This work is a proof-of-concept for future research aimed to evaluate the potential of DL-assisted TEE-guided CA resuscitation.

Abstract 18187: Scoring System to Predict Reduced Left Atrial Appendage Emptying Velocity

Introduction: Left atrial appendage emptying velocity (LAAev) as assessed on transesophageal echocardiography (TEE) is a surrogate for propensity for LAA thrombus and cardioembolic stroke. Identifying patients with decreased LAAev is important for risk stratification. CHA 2 DS 2 -VASc score is used to stratify stroke risk in atrial fibrillation (AF) but does not incorporate rhythm, type of atrial fibrillation or transthoracic echocardiography (TTE). Objective: To create a composite scoring system using clinical and TTE variables to predict reduced LAAev. Methods: We searched TEE reports of unique patients from 2016-2022 at the University of Kansas Medical Center. Additional information was extracted from review of TEE imaging, TTE reports and detailed medical chart review. Significant univariate predictors of reduced LAAev (&lt;30 cm/s) were added to a stepwise selection multivariable logistic regression model with significance level for entry and stay 0.15. Based on their respective odds ratios, selected variables were assigned different point values to create a risk score. Results: We included 995 patients (women 38.1% men, age 71.3±12.7 yrs, white 89.3%, LAAev 41.6±21.0 cm/s). The derived score includes different points assigned for long-standing persistent/permanent AF, persistent AF, paroxysmal AF, current rhythm AF, coronary artery disease, congestive heart failure, female sex, age ≥70 yrs and negative points for &gt;moderate mitral regurgitation; categorized into high, intermediate and low risk (see Figure). The rate of reduced LAAev &lt;30 cm/s was respectively 55.7%, 35.2% and 9.0%. Conclusions: Our scoring system was able to stratify risk of reduced LAAev and needs to be validated in independent datasets.

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.

Biomechanical characterization of normal and pathological human ascending aortic tissues via biaxial testing Experiment, constitutive modeling and finite element analysis

BackgroundAortic dissection and atherosclerosis are two common pathological conditions affecting the aorta. Aortic biomechanics are believed to be closely associated with the pathological development of these diseases. However, the biomechanical environment that predisposes the aortic wall to these pathological conditions remains unclear. MethodsSixteen ascending aortic specimens were harvested from 16 human subjects and further categorized into three groups according to their disease states: aortic dissection group, aortic dissection with accompanied atherosclerosis group and healthy group. Experimental stress-strain data from biaxial tensile testing were used to fit the anisotropic Mooney-Rivlin model to determine material parameters. Computed tomography images or transesophageal echocardiography images were collected to construct computational models to simulate the stress/strain distributions in aortas at the pre-dissection state. Statistical analyses were performed to identify the biomechanical factors to distinguish three groups of aortic tissues. ResultsMaterial parameters of anisotropic Mooney-Rivlin model were fitted with average R2 value 0.9749. The aortic diameter showed no significant difference among three groups. Changes of maximum and average stress values from minimum pressure to maximum pressure (△MaxStress and △AveStress) had significantly difference between dissection group and dissection with accompanied atherosclerosis group (p = 0.0201 and 0.0102). Changes of maximum and average strain values from minimum pressure to maximum pressure (△MaxStrain and △AveStrain) from dissection group were significant different from healthy group (p = 0.0171 and 0.0281). ConclusionChanges of stress and strain values during the cardiac cycle are good biomechanical factors for predicting potential aortic dissection and aortic dissection accompanied with atherosclerosis.