Transesophageal Echocardiographic Assessment Research Articles

Con: All Off-Pump Coronary Artery Bypass Graft Surgeries Should Not Include Intraoperative Transesophageal Echocardiography Assessment

Con: All Off-Pump Coronary Artery Bypass Graft Surgeries Should Not Include Intraoperative Transesophageal Echocardiography Assessment

Pro: All Off-Pump Coronary Artery Bypass Graft Surgeries Should Include Intraoperative Transesophageal Echocardiography Assessment

HISTORICALLY, THE cardiopulmonary bypass machine was necessary for cardiac surgeons to perform complex operations on the heart. 1 Weir I. Coronary artery bypass. Ann R Coll Surg Engl. 2006; 88: 99-102 Crossref PubMed Google Scholar Cardiopulmonary bypass (CPB) allows for a stable operative site and a bloodless field while ensuring end-organ perfusion and cooling of the patient during cardiorespiratory arrest. 1 Weir I. Coronary artery bypass. Ann R Coll Surg Engl. 2006; 88: 99-102 Crossref PubMed Google Scholar CPB has been implicated as the cause of many adverse effects of cardiac surgery including a systemic inflammatory response and end-organ damage, especially neurologic injury and cognitive decline. 2 Roach G.W. Kanchuger M. Mangano C.M. et al. Adverse cerebral outcomes after coronary bypass surgery Multicenter study of perioperative ischemia research group and the ischemia research and education foundation investigators. N Engl J Med. 1996; 335: 1863-1875 Crossref Scopus (1670) Google Scholar , 3 Yacoub M. Off-pump coronary bypass surgery: In search of an identity. Circulation. 2001; 104: 1743-1745 PubMed Google Scholar , 4 Elahi M.M. Khan J.S. Matata B.M. Deleterious effects of cardiopulmonary bypass in coronary artery surgery and scientific interpretation of off-pump's logic. Acute Card Care. 2006; 8: 196-209 Crossref PubMed Scopus (33) Google Scholar In recent years, it has become possible to safely perform coronary artery bypass graft (CABG) surgery without the use of CPB. It was initially postulated that avoidance of cannulation and CPB would decrease the incidence of end-organ damage in all patients. Several clinical studies have not confirmed this, but off-pump CABG (OPCAB) surgery has been shown to be beneficial in a subset of patients that are at higher risk for developing neurologic complications. 5 Sharony R. Bizekis C.S. Kanchuger M. et al. Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: A case control study. Circulation. 2003; 108: II15-II20 PubMed Google Scholar , 6 Sharony R. Grossi E.A. Sounders P.C. et al. Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease. J Thorac Cardiovasc Surg. 2004; 127: 406-411 Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar

Neuroprotection during cardiac surgery

Cardiac surgery continues to be associated with significant adverse cerebral outcomes, ranging from stroke to cognitive decline. The underlying mechanism of the associated cerebral injury is incompletely understood but is believed to be primarily caused by cerebral embolism and hypoperfusion, exacerbated by ischemia/reperfusion injury. Extensive research has been undertaken in an attempt to minimize the incidence of perioperative cerebral injury, and both pharmacological and nonpharmacological strategies have been investigated. Although many agents demonstrated promise in preclinical studies, there is currently insufficient evidence from clinical trials to recommend the routine administration of any pharmacological agents for neuroprotection during cardiac surgery. The nonpharmacological strategies that can be recommended on the basis of evidence include transesophageal echocardiography and epiaortic ultrasound-guided assessment of the atheromatous ascending aorta with appropriate modification of cannulation, clamping or anastomotic technique and optimal temperature management. Large-scale randomized controlled trials are still required to address further the issues of optimal pH management, glycemic control, blood pressure management and hematocrit during cardiopulmonary bypass. Past, present and future directions in the field of neuroprotection in cardiac surgery will be discussed.

Transesophageal Echocardiographic Assessment of a Floating Thrombus Located in the Ascending Aorta

Transesophageal echocardiography (TEE) has become a unique imaging technique that provides improved visualization of aorta because of its proximity to the esophagus. It is a reliable method for the diagnosis of thoracic aorta diseases and detection of protruding atheromas or thrombi as sources of systemic emboli. We report a case in which TEE revealed a floating aortic thrombus located in the ascending aorta in a patient with chronic renal failure.

Dual Thrombosis of the Pulmonary Arterial and Venous Anastomotic Sites After Single Lung Transplantation: Role of Transesophageal Echocardiography in Diagnosis and Management

We present the case of a patient who developed severe respiratory and hemodynamic compromise shortly after single right lung transplantation. Transesophageal echocardiography showed a large intraluminal thrombus at the right pulmonary artery anastomosis resulting in severe obstruction to flow together with thrombosis of the right pulmonary veins extending into the left atrium. After thrombectomy and surgical revision of the vascular anastomoses, the patient made an uneventful recovery. This case illustrates the usefulness of transesophageal echocardiography in the diagnosis and treatment of patients who are hemodynamically unstable after lung transplantation.

Left Ventricle Apical–Aortic Conduit for Aortic Stenosis

Nativeaorticvalvereplacementistheprocedureofchoice for pure aortic valve stenosis. Occasionally, conventional surgery is deemed unacceptably high risk related to calcificationoftheaorticroot,multiplepreviousmediansternotomies, or patent retrosternal grafts. Implantation of a left ventricle apical‐aortic conduit (AAC) is an alternative approach in patients with these and other conditions that either preclude a median sternotomy or present a high risk for aortic cross-clamping and aortotomy. There are several imaging and postoperative concerns related to this situation. A 64-slice multidetector computed tomography (CT) scan of the chest and abdomen with and without contrast is usually performed to assess the degree of aortic root calcium, calcification of the descending thoracic aorta, and the lay of any retrosternal patent coronary artery bypass grafts. Intraoperative transesophageal echocardiographic assessment of the aortic valve is essential to rule out aortic insufficiency. An apical aortic conduit should be performed in the setting of isolated aortic stenosis. Mild aortic insufficiency can be tolerated but the procedure should be avoided in patients with greater than 1 aortic insufficiency. Intraoperative echocardiography is also valuable to further assess the degree of calcification of the descending aorta to help direct placement of the conduit-to-aorta anastomosis. We prefer to perform the operation with femoro-femoral cardiopulmonary bypass and mild hypothermia (34°C).

Role of Transesophageal Echocardiography in Assessment of Penetrating Heart Trauma

We report the case of a 38 year old man who received a stab wound on his chest. After admission at a Cardiothoracic Centre, a transthoracic echocardiogram showed pericardial effusion and a small ventricular septal defect. Due to poor transthoracic window and lack of improvement of his hemodynamic parameters the patient was transferred for transesophageal echocardiography in our Paediatric Cardiac Centre. The transesophageal echocardiography showed a 12 mm ventricular septal defect, In this case, the transthoracic echocardiography had a guide role but the transesophageal echocardiography procedure was conclusive. The patient tolerated transportation and the procedure well. We conclude that performing transesophageal echocardiography in the assessment of penetrating heart trauma may be useful in assisting management and that this procedure be done as soon as medically possible.

Intraoperative Assessment of Mitral Regurgitation: Role of Phenylephrine Challenge

We defined the effects of the operative (OP) state and phenylephrine challenge on the assessment of mitral regurgitation (MR) severity. In all, 57 patients underwent transesophageal echocardiographic assessment of MR severity pre-OP (PREOP) and intra-OP. MR severity was assessed PREOP under conscious sedation and intra-OP with general anesthesia, before and after hemodynamic manipulation with vasoactive agents, to match intra-OP and PREOP transesophageal echocardiographic mean arterial blood pressures. Intra-OP MR and mean arterial pressure were less than PREOP in 27 patients (both P < .001). When PREOP and OP blood pressures were matched using phenylephrine, there was no significant difference in MR severity between the two states (P = 1.0). Nonetheless, MR severity was still underestimated in 6 patients and overestimated in 7 patients intra-OP. Intra-OP transesophageal echocardiography underestimates MR severity. Phenylephrine reduces, yet does not eliminate, intra-OP underestimation of MR severity.

Transesophageal Echocardiographic Assessment of Right Atrial Appendage Anatomy and Function: Comparison with the Left Atrial Appendage and Implications for Local Thrombus Formation

We sought to define right atrial appendage (RAA) anatomic and functional parameters in a consecutive series of participants and to compare these measures with left atrial appendage (LAA) indices among patients with in sinus rhythm and atrial fibrillation (AF). With AF, both atria are fibrillating, yet the vast majority of thrombi are located within the LAA. Transesophageal echocardiography provides anatomic and functional information regarding both the LAA and the RAA. In a consecutive series of 92 patients (48 men; age 61 +/- 17 years) referred for transesophageal echocardiography, RAA and LAA anatomy (width, length, area) and ejection velocity were measured at two orientations (RAA, 90 and 135 degrees; LAA, 0 and 90 degrees). RAA anatomic measures were similar for both imaging planes, whereas LAA area was larger at 90 degrees. There was a modest correlation between RAA and LAA anatomic measures (area: r = 0.58, P = .001). RAA neck width was substantially greater than LAA neck width (P < .0001) whereas appendage area was similar (P = not significant) and RAA neck width/area was greater than LAA neck width/area (P < .0001). AF was associated with approximately 50% decline in ejection velocity for both the LAA and the RAA with an increase in LAA area (P = .006 vs sinus), but similar anatomic remodeling was not found for the RAA (P = not significant vs sinus). In this consecutive series of patients undergoing transesophageal echocardiography, RAA anatomic and functional parameters were found to be independent of imaging plane, with anatomic measures demonstrating a correlation with LAA measures. Although AF is associated with depressed RAA and LAA ejection velocities, anatomic RAA remodeling appears to be absent. The larger RAA width and lack of anatomic remodeling may partially explain the substantially lower prevalence of RAA thrombus found among patients with AF.

Transesophageal Echocardiography Assessment of Severe Aortic Regurgitation in Type A Aortic Dissection Caused by a Prolapsed Circumferential Intimal Flap

AORTIC REGURGITATION (AR) is a frequent complication of acute type A aortic dissection.1 A rare mechanism leading to this condition is intimal flap prolapse into the left ventricular outflow tract (LVOT) during diastole.2 Although transesophageal echocardiography (TEE) is becoming a routine diagnostic modality used by cardiac anesthesiologists for intraoperative evaluation of aortic dissection, its use in assessing AR due to the unusual displacement of a circumferential flap has not been described in the anesthesia literature.

Transesophageal Echocardiographic Assessment of Venous Carbondioxide Embolism during Laparoscopic Cholecystectomy

Background: Although major gas embolism has occurred rarely during laparoscopic cholecystectomy (LC), the incidence of less severe episodes of embolism is unknown. It is also possible that such gas embolism, if present, could affect to cardiorespiratory variables. This study was designed to assess the incidence of subclinical embolic events using transesophageal echocardiography (TEE) and to evaluate the related hemodynamic consequence during LC. Methods: With IRB approval, 20 patients undergoing LC were studied. The long axis four chamber view was obtained continuously, except for predetermined intervals where the transgastric short axis view was obtained to derive ejection fraction (EF). Heart rate, mean arterial pressure, O2 saturation, and end-tidal were monitored. Statistical analysis was performed using multivariated ANOVA and unpaired Student's t-test. P ＜ 0.05 was considered significant. Results: We observed gas embolism in 4/20 patients during insufflation and 20/20 patients during gallbladder (GB) dissection. There was no significant difference in cardiorespiratory variables between embolic and nonembolic patients during insufflation. Also there was no significant difference in cardiorespiratory variation in all patients with embolism between before and after GB dissection. EF decreased significantly after insufflation (P = 0.002) and was recovered after exsufflation (P = 0.001). This can be explained by increase in systemic vascular resistance (SVR). Conclusions: Embolic events commonly occur during insufflation and GB dissection without cardiorespiratory instability. Although embolic event itself didn't affect the hemodynamic variables, peritoneal insufflation increased SVR and decreased EF. We should pay attention to patients undergoing LC who have decreased cardiac function and also prepare for serious embolic event.

Perioperative diagnosis of mesenteric ischemia in acute aortic dissection by transesophageal echocardiography

Although computed tomography, angiography, or magnetic resonance imaging is most commonly used for diagnosing mesenteric ischemia caused by acute aortic dissection, use of these modalities is often limited in the perioperative period. Thus, we have introduced transesophageal echocardiography to cover this deficit. Purpose of this study is to report the feasibility and accuracy of transesophageal echocardiographic diagnosis on mesenteric ischemia. The consecutive 24 cases with acute aortic dissection which involved abdominal aorta and underwent surgery were examined. The celiac artery and superior mesenteric artery was visualized with 5 MHz biplane transesophageal echocardiography and was assessed for presence of dissection and blood flow in each of true and false lumen. The transesophageal echocardiographic findings were then correlated to the clinical course, computed tomographic findings, and laboratory data. The celiac artery and superior mesenteric artery was successfully visualized in 24 cases (100%) and 23 cases (95.8%), respectively. Perfusion patterns in superior mesenteric artery were categorized into four patterns: (1) intact artery with adequate perfusion (type A: 14 cases); (2) dissection in the artery but with adequate perfusion in true lumen (type B: 5 cases); (3) dissection in the artery with narrowed true lumen compressed by false lumen without detectable blood flow (type C: 1 case); and (4) obstruction of arterial orifice by the intimal flap with narrowed true lumen in the proximal aorta (type D: 2 cases). One case with immediate postoperative death and another case with unsuccessful visualization of superior mesenteric artery were excluded from the analysis. Clinically apparent intestinal ischemia was present in three cases: one case with type C and two cases with type D, but in none of the remaining 19 cases with type A or type B (both sensitivity and specificity were 100%). The superior mesenteric artery was opacified in all of these three cases with ischemia. The transesophageal echocardiographic assessment is feasible in nearly all patients and potentially provides correct diagnosis on intestinal ischemia in the perioperative period of acute aortic dissection. Types C and D indicate significant mesenteric malperfusion.

Transthoracic and Transesophageal Echocardiographic Assessment of Mitral Regurgitation Severity: Usefulness of Qualitative and Semiquantitative Techniques

In this report, we review the advantages, limitations, and optimal utilization of various transthoracic and transesophageal echocardiographic (TTE and TEE) methods used for assessing mitral regurgitation (MR) as published in full-length, peer-reviewed articles since the color Doppler era began in 1984. In addition, comparison is made to other imaging modalities including catheter-based, magnetic resonance and surgical assessment of MR. Although left ventricular (LV) angiography has been traditionally used for validation of various TTE methods and is time-honored, its considerable limitations preclude it from being a real "gold standard." Based on the reviewed literature, no clear "gold standard" for the assessment of MR can be identified at present, but newly emerging TTE and TEE techniques, such as three-dimensional color Doppler, may have the potential to overcome some of the limitations of the two-dimensional methods.

Transesophageal Echocardiographic Assessment of Left Atrial and Left Atrial Appendage Function after Radiofrequency Ablation of Atrial Fibrillation

Transesophageal Echocardiographic Assessment of Left Atrial and Left Atrial Appendage Function after Radiofrequency Ablation of Atrial Fibrillation

Giant Flow Reversal in Pulmonary Venous Flow as a Possible Mechanism for Asynchronous Pacing-induced Heart Failure

Mechanistic roles of the immediate increase in left atrial (LA) pressure in pacing-induced congestive heart failure have not been clearly understood. We evaluated the impact of asynchronous rapid ventricular pacing on LA hemodynamics in this model. Transthoracic and transesophageal echocardiography and hemodynamic assessment were performed in 23 healthy mongrel dogs. Data were acquired before and 5 minutes after initiation of rapid right ventricular pacing (200/min). At 5 minutes after initiation of the pacing, giant pulmonary venous (PV) flow reversal (-76 cm/s) was observed in association with 1:1 ventriculoatrial conduction or complete atrioventricular dissociation. This giant PV flow reversal corresponded to an inappropriately timed atrial contraction, especially during systole. Cardiac output (3.21 vs 2.00 L/min, P < .001) was decreased corresponding to the decrease in the forward blood volumes as described by decrease in the Doppler left ventricular (LV) outflow (8.99 vs 4.73 cm, P < .0001), mitral inflow (6.89 vs 3.19 cm, P < .0001), and PV flow (14.15 vs 7.22 cm, P < .0001) velocity integrals. As a result, there was a marked elevation of the mean pulmonary capillary wedge (9.1 vs 17.1 mm Hg, P < .001) and LV end-diastolic (8.2 vs 17.4 mm Hg, P < .01) pressures leading to congestive heart failure. The giant PV flow reversal seen during asynchronous rapid right ventricular pacing corresponds to an inappropriate atrial contraction, immediately elevates LA pressure, and may initially promote congestive heart failure. The increase in LV end-diastolic pressure associated with decreased LV ejection fraction caused decrease in the LV filling volume leading to further increase in the LA pressure. This sustained marked elevation in the LA pressure and LV end-diastolic pressure could contribute to the heart failure process.

80 Transesophageal echocardiographic assessment of pulmonary vein stenosis after radiofrequency ablation of atrial fibrillation

80 Transesophageal echocardiographic assessment of pulmonary vein stenosis after radiofrequency ablation of atrial fibrillation

Left atrial appendage assessment by second harmonic transthoracic echocardiography after an acute ischemic neurologic event

Although second harmonic (sh) imaging is widely available in most contemporary ultrasound systems, its accuracy to evaluate left atrial appendage (LAA) morphology and function remains poorly characterized. We conducted a cross-sectional survey of patients with acute ischemic neurologic conditions (n = 51) who underwent both transesophageal and transthoracic echocardiography (TTE) to explore the performance of sh in LAA assessment. Doppler and LAA area evaluation by sh TTE were feasible in most patients (98%). We observed positive and significant associations between sh TTE and transesophageal echocardiography assessment of LAA peak emptying velocities (r = 0.63, P < .001) and LAA maximum area (r = 0.73, P < .001). In addition, all patients (n = 7) with LAA thrombus or spontaneous contrast had peak emptying velocities less than 50 cm/s on sh TTE (negative predictive value of 100%). In multivariate analysis, LAA peak emptying velocity remained independently associated with LAA thrombus or contrast. In conclusion, sh TTE can provide valuable and clinically relevant information of LAA morphology and dynamics.

Left Internal Thoracic Artery Graft Assessed By Means of Intraoperative Transesophageal Echocardiography

We report a method of intraoperative assessment of left internal thoracic artery (LITA) graft with transesophageal echocardiography regarding patency, stenosis, and presence of remnant branch artery. In 52 consecutive coronary artery bypass grafting surgery patients, blood flow velocity was measured at the origin of the LITA after coronary artery bypass grafting by means of transesophageal echocardiography. The flow pattern and velocity change at temporary clamping of the graft was examined and was compared with the postoperative angiographic findings. The LITA was visualized in 47 of 52 cases (90.4%). The LITA flow was diastolic dominant, systolic dominant, or equivalent in 41, 3, and 3 cases, respectively. The anastomosis was stenotic in 2 of 6 cases of the latter two groups, but in none of the 41 cases with diastolic dominant flow (p = 0.0139). The branch artery was present in 4 of 6 cases of the latter two groups, but in only 2 of 41 cases with diastolic dominant flow (p = 0.0012). Remnant branch artery was found in all three cases with systolic dominant flow. The LITA flow was instantaneously reduced at clamping and recovered at declamping in every case with graft occlusion but one. The ratio of velocity change at clamping was less than 0.50 in all 41 cases without remnant branch, whereas it was more than 0.50 in 5 of 6 cases with a branch (p < 0.0001). The transesophageal echocardiographic assessment with the clamp test is feasible intraoperatively in the majority of patients, enabling us to assess LITA graft patency, stenosis, or presence of a remnant branch.

Atrial septal mass: Transesophageal echocardiographic assessment

Primary tumors are very rare, with the incidence in necroscopy series being between 0.0017% and 0.28%. Angiomas account for less than 5% of all these. Today, few reports discussing the clinical manifestation and pathologic appearance of cardiac angiomas have been published worldwide in the literature, and very few articles report surgical angioma excision. The angioma is a histologically benign tumor without infiltrative propensity, and it is mostly described in the subendocardial layers of the right atrium in adult female patients. Although these are incidental findings in the majority of cases because they are asymptomatic, such tumors might be associated with a wide range of atypical and different symptoms that are related to the cardiac chambers involved or to the specific cardiac site of origin. At gross examination, this tumor appears like a circumscribed mass in the subendocardial layer. Echocardiographic imaging techniques, either transthoracic or transesophageal, allow a differential diagnosis, whereas cardiac catheterization appears to be unnecessary. We report the case of a symptomatic patient undergoing successful surgical intervention for an interatrial septal angioma detected by means of 2-dimensional echocardiography.

Indices of Aortic Distensibility and Coronary Flow Velocity Reserve in Patients with Different Grades of Aortic Atherosclerosis

The purpose of this study was to evaluate the correlation of the elastic properties of the descending aorta, the coronary flow velocity reserve (CFR) and the grade of aortic atherosclerosis (AA) in patients who have undergone coronary angiography. A total of 113 consecutive patients (77 men and 36 women, aged 31-80 years) underwent stress transoesophageal echocardiographic (STEE) assessment of the CFR. The grade of AA and the indices of aortic distensibility were evaluated during the same session of STEE. All patients had chest pain without previous myocardial infarction. Coronary angiography was performed in all cases. The resting systolic and diastolic coronary flow velocities increased, while the coronary flow velocities measured at the peak of stress and the ratio Smax/Srest decreased in parallel with the aortic grade. The CFR and mean CFR were impaired in patients who exhibited aortic intimal thickening, but no further decrease was found in the event of aortic plaque. The elastic moduli E(p) and E(s) increased in parallel with the grade of AA. The occurance of a negative coronary angiogram was more common in patients without AA, but significant left anterior descending coronary artery disease or multivessel disease were more frequent at a higher grade of AA (in cases with aortic plaque). The CFR was decreased in patients with aortic intimal thickening, but no further decrease was observed in the presence of aortic plaque. The indices of aortic distensibility increased continuously in parallel with the aortic grade.