Transesophageal Echocardiography In Diagnosis Research Articles

The role of transoesophageal echocardiography in diagnosis and management of patients with embolic stroke of undetermined source

Abstract Funding Acknowledgements Type of funding sources: None. Introduction About 25–30% of the cases of ischemic stroke have no established etiology after standard diagnostic evaluation and are classified as embolic strokes of undetermined source (ESUS). Transoesophageal echocardiography (TOE) may provide additional information in the evaluation of patients with ESUS and change the secondary prevention management. Purpose In this retrospective study we examined the role of TOE in diagnosis and further management of patients with ESUS. Methods Patients with ESUS (18 to 60 years old) with no comorbidities were examined at the echocardiography laboratory of our hospital, from April 2018 until August 2022. All patients were thoroughly assessed with transthoracic echocardiography and had no abnormal findings. Atrial fibrillation was excluded by ambulatory electrocardiography. All patients were examined for presence of patent foramen ovale (PFO), aortic atheromatosis and left atrial appendage thrombus. The size of PFO shunt was classified based on the number of microbubbles seen in the left atrium during the first three cardiac cycles after the infusion of agitated saline. The presence of 1–5 microbubbles was classified as small shunt, 6–25 as moderate and >25 as large. Patients with large shunts and RoPE score >6 were referred to occlusion. Τ - test was used to compare the means of the variables and a p value 0.05 was considered statistically significant. Results In this study, 200 patients with ESUS (134 males), of mean age 52.6 (SD=9.8 ears), were enrolled. In 52 of them TOE determined the etiology of stroke. The presence of PFO was found in 70 (35.0%) patients. Of those, 17 (24.3%) had a small shunt, 20(28.6%) a moderate and 32 (45.7%) had a large shunt and were referred to occlusion. Patients with PFO were younger (mean age 47.2 years, SD 11.2, p<0.001) than those without PFO (mean age 54.8 years, SD 8.6) (Diagram 1). Furthermore, 20 (10.0%) patients were diagnosed with atheromatosis of ascending aorta and aortic arch ≥grade 2. Patients with aortic atheromatosis were older (mean age 58.1 years SD 7.6) than those without atheromatosis (mean age 51.9 years, SD 9.8, p = 0.008) (Diagram 2). Finally, TOE did not reveal left atrial appendage thrombus in any of the examined patients. Conclusion TOE revealed the etiology of stroke in about 25% of our patients, which consequently changed their secondary prevention management.

Three-dimensional transesophageal echocardiography in diagnosis of intermediate atrioventricular septal defect in the adult: case report and literature review

BackgroundIntermediate type atrioventricular septal defect is less frequent than complete or partial atrioventricular septal defect, and is rarely encountered in the elderly and the utility of three dimensional transesophageal echocardiography in the diagnosis has not been reported to date.Case presentationIn this case report, we described a rare case of an intermediate atrioventricular septal defect in an adult patient and we showed the valuable utility of real time 3D transesophageal echocardiography in the diagnosis and future surgical planning. The patient was referred to a tertiary center for an elective surgical repair. Finally, we provided a detailed review of the literature concerning the intermediate type of atrioventricular septal defect.ConclusionAlthough 2D transthoracic and transesophageal echocardiography enables diagnosis of the intermediate type atrioventricular septal defect, precise assessment of anatomy of atrioventricular septal defects and common atrioventricular valve was enabled only by real time 3D echocardiography.

Aortic Paravalvular Leaks. The Role Of Intraoperative Transesophageal Echocardiography In Diagnosis And Correction Guidance

Objective: Paravalvular leak (PVL) is a known and undesirable complication of prosthetic valve replacement. The presence of significant PVL is associated with comorbidities such as hemolysis, heart failure, and decreased long-term survival. The role of intraoperative transesophageal echocardiography (IOTEE) is the standard of care for valve repair surgery. However, its use in valve replacement is not universal. Methods: We performed a retrospective analysis of Aortic Valve Replacement (AVR) surgeries with IOTEE, from 2018-2020. Primary outcomes were the incidence of intraoperative PVL pre and post echocardiography guided correction. Secondary outcomes were PVL predictors factors, cardiopulmonary bypass time and cross clamp time. PVL was defined, according to circumferential extent of the regurgitant jet, as mild (<10%), moderate (10-20%) and severe (>20%). A PVL greater than mild was considered significant. Results: A total of 194 patients underwent surgical AVR (table 1); 73(37.6%) underwent minimally invasive aortic valve replacement and 121(62.4%) conventional aortic valve replacement. Of them, 87(4.8%) were isolated AVR and 107(55.1%) combined procedures. The overall incidence of significant PVL was 2.6% (n=5). All of them underwent echocardiography guided correction. Post correction IOTEE showed none significant PVL. Mild PVL was diagnosed in four of them. Cardiopulmonary bypass time was 119±37.9 minutes and cross clamp time was 81±26.1 minutes. There were no significant differences in these times between patients with PVL that needed correction and patients who did not. Diagnosis, etiology, bicuspid aortic valve, type of prosthesis and size number were not associated with PVL incidence. Conclusions: IOTEE allows early diagnosis of PVL. This enables intraoperative correction, without significant extension of surgical times, resulting in non-significant PVL. IOTEE should be the standard of care in AVR surgery. Table 1. Patients characteristics Patients n 194 Age (Mean±SD) 69.9 ± 11.4 Sex n (%) Male, Female 113(58.2%), 81(41.8) Diagnosis n (%)Aortic StenosisAortic InsufficiencyConcomitant stenosis and insufficiencyInfectious Endocarditis 146 (76%)28 (14.6%)16 (8.3%)2 (1%) Etiology n (%)CalcificationRheumatic diseaseAnulectasisProlapseInfectious EndocarditisProsthetic DysfunctionFibroelastomaOthers 160 (82.5%)3 (1.5%)6 (3.1%)10 (5.2%)6 (3.1%)2 (1%)2 (1%)5 (2.6%) Bicuspid valve n (%) 31 (16.1%) NYHA Functional Class n (%)No Heart failureIIIIIIIV 24 (13.6%)10 (5.6%)112 (63.3%)29 (16.4%)2 (1.1%) Angina 76 (40.9%) Left Ventricle Ejection Fraction (LVEF) n (%)Normal>50%30-50%<30% 143 (76.5)18 (9.6%)11 (5.9%)15 (8%) Euro Score II n (%)Low RiskIntermediate RiskHigh Risk 173 (89.6%)19 (9.8%)1 (0.5%)

Mid-esophageal bicaval versus short-axis view of interatrial septum in two-dimensional transesophageal echocardiography for diagnosis and measurement of atrial septal pouches.

Recent studies suggest that the left-sided septal pouch (SP) may increase the risk of cryptogenic stroke and act as an arrhythmogenic substrate. The aim of this study was to compare two transesophageal echocardiography (TEE) projections of the interventricular septum: mid-esophageal bicaval and short-axis views toward evaluating their ability to detect SPs. A total of 146 patients with both bicaval and short-axis TEE views were included in this study. The presence of SPs was determined, and they were evaluated for morphology. Irrespective of TEE projection view, the left SP was detected in 74 cases (50.7%), right SP in 16 cases (11.0%), and double in one case (0.7%). Agreement between both projections occurred in 119 cases (81.5%) with a weighted kappa coefficient of 0.68 (good agreement). We detected more left SPs from the bicaval view compared to the short-axis view; however, the observed difference was statistically insignificant (72 vs 59, P=.13). The detection of right SPs was higher in the short-axis view, but also statistically insignificant (9 vs 13, P=.38). Bland-Altman analysis revealed a significant difference in the left SP depth with higher values in the bicaval than short-axis view (systematic difference=1.17mm, LoA: -4.88-7.22mm, P=.02, ICC=0.58). The mid-esophageal bicaval view should be preferable over mid-esophageal short-axis view of interatrial septum for the diagnosis and measurement of the left SP.

Comparative Sensitivity of Transthoracic and Transesophageal Echocardiography in Diagnosis of Infective Endocarditis Among Veterans With Staphylococcus aureus Bacteremia.

Echocardiography is fundamental for diagnosing infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB), but whether all such patients require transesophageal echocardiography (TEE) is controversial. We identified SAB cases between February 2008 and April 2012. We compared sensitivity and specificity of transthoracic echocardiography (TTE) and TEE for evidence of IE, and we determined impacts of IE risk factors and TTE image quality on comparative sensitivities of TTE and TEE and their impact on clinical decision making. Of 215 evaluable SAB cases, 193 (90%) had TTE and 130 (60%) had TEE. In 119 cases with both tests, IE was diagnosed in 29 (24%), for whom endocardial involvement was evident in 25 (86%) by TEE, vs only 6 (21%) by TTE (P < .001). Transesophageal echocardiography was more sensitive than TTE regardless of risk factors. Even among the 66 cases with adequate or better quality TTE images, sensitivity was only 4 of 17 (24%) for TTE, vs 16 of 17 (94%) for TEE (P < .001). Among 130 patients with TEE, the TEE results, alone or with TTE results, influenced treatment duration in 56 (43%) cases and led to valve surgery in at least 4 (6%). It is notable that, despite vigorous efforts to obtain both tests routinely, TEE was not done in 86 cases (40%) for various reasons, including pathophysiological contraindications (14%), patient refusal or other patient-related factors (16%), and provider declination or system issues (10%). Patients with SAB should undergo TEE when possible to detect evidence for IE, especially if the results might affect management.

Transesophageal Echocardiographic Diagnosis and Imaging of Cardiac Situs and Malposition

ABSTRACT Dextrocardia (DC) is a rare cardiac anomaly that can be associated with other congenital abnormalities. Transesophageal echocardiographic imaging for evaluating these patients requires modification of the omniplane angle from the standard angles used. We describe the imaging technique in this condition when it is associated with situs solitus (SS) and situs inversus. How to cite this article Kumar MG, Ganesan R, Puri GD. Transesophageal Echocardiographic Diagnosis and Imaging of Cardiac Situs and Malposition. J Perioper Echocardiogr 2017;5(2):64-69.

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

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

Perioperative Transesophageal Echocardiographic Diagnosis of Membranous Interventricular Septal Aneurysm in Two Patients

ABSTRACT Aneurysms of interventricular septum are a rare anomaly usually seen as an incidental finding on echocardiography. Rarely, they can cause right ventricular outflow tract obstruction. They can present in patients having other cardiac lesions. Diagnosis of interventricular septal aneurysm is not straightforward. They can be confused with sinus of valsalva aneurysm or ventricular septal defect on transthoracic echocardiography. Transesophageal echocardiography (TEE) provides a better alternative to delineate the interventricular septal aneurysm. We describe the TEE diagnosis of membranous interventricular septal aneurysm in two dissimilar patients who presented for cardiac surgery at our cardiac center. How to cite this article Dutta V, Negi SL, Puri GD, Singh RS. Perioperative Transesophageal Echocardiographic Diagnosis of Membranous Interventricular Septal Aneurysm in Two Patients. J Perioper Echocardiogr 2016;4(1):14-16.

Abstract 19214: Echocardiographic Diagnosis of Chiari's Network and Arterial Embolic Events

Background: The clinical significance of Chiari’s network identified by echocardiogram is not yet established. A few authors have hypothesized that Chiari’s network may be associated with a patent foramen ovale, atrial septal aneurysm and paradoxical embolism. We set out to better understand the relationships of arterial embolic events and echocardiographic diagnosis of Chiari’s network in our adult population. Methods: We reviewed unique subject-adult transesophageal echocardiograms (TEE) performed at UIHC between November 2010 and March 2015 (n=3,703); we identified subjects with transesophageal echocardiographic diagnosis of Chiari’s network. Chiari’s network was observed in 6.2% of all TEE studies (n=229); males represented 59.8% with mean age of 61.5±16.3 years and mean left ventricular ejection fraction 53.8% ± 13.6%. Retrospective chart review was then performed to evaluate clinical variables encompassing a median [IQR] follow up of 8 months [2-19]. Results: Patent foramen ovale and atrial septal aneurysm were present in 22.3% and 11.4% subjects respectively. Approximately one half of patients (n=115, 50.2%) experienced at least one systemic embolic event by the end of the follow up period. Of these, 84 (36.7%) and 30 (13.1%) patients suffered stroke and transient ischemic events respectively. The all-cause mortality rate was high at 13.5%. Atrial tachyarrhythmia was present in 59 subjects (25.8%). The rate of systemic embolic events was higher in those without atrial tachyarrhythmia compared to those with atrial tachyarrhythmia (58.2% vs. 27.1%, p=0.000; OR (95% CI),0.267 (0.139-0.511). Antithrombotic therapy was prescribed in 79% of all subjects, 86.4% of patients with atrial tachyarrhythmia and 95.5% of patients with systemic embolic events. Conclusions: Patients with Chiari’s network have a high incidence of atrial tachyarrhythmia and systemic embolic events, primarily embolic stroke and transient ischemic events. Systemic embolic events occurred at significantly higher rates in subjects with Chiari’s network and no atrial tachyarrhythmia than those with atrial tachyarrhythmia. Future studies are warranted to further elucidate the risk of thromboembolic events in patients with Chiari’s network.

Role of Four‐Dimensional Transesophageal Echocardiography in Diagnosis of Mechanical Tricuspid Valve Obstruction Due to Thrombus

Role of Four‐Dimensional Transesophageal Echocardiography in Diagnosis of Mechanical Tricuspid Valve Obstruction Due to Thrombus

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

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

Clinical application of real-time three-dimensional transesophageal echocardiography in diagnosis of mitral valve prolapse

Objective To evaluate the clinical application value of real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) in diagnosis of mitral valve prolapse(MVP).Methods Twenty patients with MVP with more than moderate mitral regurgitation referred for mitral valve repair (MVR) were studied.All patients underwent RT-3D-TEE and mitral valve quantification(MVQ) before MVR.The location of scallop lesions and ruptured mitral chordae tendineae for mitral valve were evaluated,and compared with surgical findings.Carpentier's nomenclature was applied to the mitral valve anatomic localization either RT-3D-TEE or surgery.There were three anterior leaflet scallops defined as A1,A2 and A3,and three posterior leaflet scallops defined as P1,P2 and P3.Results ① The shape and spatial structure of the scallop lesions and ruptured mitral chordae tendineae of mitral valve were clearly displayed by RT-3D-TEE,also could be observed through left atrium view and left ventricular view.② Compaired with surgical findings,RT-3D-TEE was of high sensitivity (100 ％),higher specificity (95.46 ％) and crude agreement (95.83％) in the location of P2,the positive likelihood ratio of location of P2 (22.03) was the biggest,the negative likelihood ratio (0) was the smallest.③ RT-3D-TEE had lower sensitivity (66.67％),specificity (83.76 ％) and crude agreement (83.33 ％) in the diagnosis of location of P1 than other locations,the positive likelihood ratio(4.11) was the smallest,the negative likelihood ratio (0.40) was the biggest.④ The sensitivity,specificity,crude agreement,positive likelihood ratio and negative likelihood ratio of RT-3D-TEE in diagnosis of ruptured mitral chordae tendineae accompanied by MVP were 100％,91.67％,95.00％,12.00,0 respectively.Conclusions RT-3D-TEE could clearly display the three-dimensional structure of the lesions of mitral valve.It was of better accuracy in diagnosis of the location of scallop lesions of mitral valve and the rupture of chordae tendineae,and was of important clinical application value in MVR. Key words: Echocardiography, real-time three-dimensional; Echocardiography, transesophageal; Mitral valve prolapse

Abstract 13031: Real-Time Three-Dimensional Transesophageal Echocardiography for Diagnosis of Pannus Formation in Mechanical Aortic Valves: Comparison with Multi-detector Computed Tomography and Surgical Findings

Introduction: Pannus formation is a rare but important complication that can be missed in patients with prosthetic valves. However, currently available methodologies are not sufficient to diagnose subvalvular pannus formation especially in mechanical aortic valves. Hypothesis: In this study, we explored a series of experiences with three-dimensional transesophageal echocardiography (3D-TEE) for the visualization and accurate assessment of subvalvular pannus in patients with mechanical aortic valve. Methods: We enrolled 11 patients (mean age 64±8.6 years, 10 patients with either double or triple valve replacement) who had previously implanted mechanical aortic valve, with transaortic mean pressure gradient &gt;40mmHg or transaortic maximal velocity &gt;4m/sec despite normal occluder motion. All patients underwent 3D-TEE examination to rule out pannus formation and these findings were compared with multi-detector computed tomography (MDCT) images and/or surgical findings. Results: In 10 patients, 3D-TEE allowed good visualization of subaortic pannus formation whereas there was no significant pannus ingrowth in one patient. Through cropping full-volume 3D-TEE images, subaortic pannus formation could be visualized well in en face view, which was confirmed by MDCT images. The 3D-TEE images of the pannus were also matched with intraoperative findings in 7 patients undergoing reoperation of the mechanical aortic valve (Figure). Quantitative measurement of geometric subvalvular area using 3D planimetry was feasible and correlated well with the area measured by MDCT and with transaortic mean pressure gradient on transthoracic echocardiography (Spearman’s ρ=0.761 and -0.726, all p-value&lt;0.05). Conclusions: Real-time 3D-TEE is a useful diagnostic tool for the anatomical assessment of subvalvular pannus formation in mechanical aortic valves.

Incremental utility of Live/Real time three-dimensional transesophageal echocardiography in diagnosis of a unique type of subaortic membrane: a case report

Incremental utility of Live/Real time three-dimensional transesophageal echocardiography in diagnosis of a unique type of subaortic membrane: a case report

“Adhesive Pericarditis:” Intraoperative Transesophageal Echocardiographic Diagnosis of Combined Impairment of Systolic and Diastolic Function Secondary to Mycobacterium Tuberculosis

Mycobacterium tuberculosis is a well known cause of pericarditis.1 The disease may manifest echocardiographically as effusion with or without tamponade, constriction, effusion-constriction, and associated cardiomyopathy.2 Constrictive pericarditis is characterized by normal or enhanced early diastole followed by abrupt termination of ventricular filling as the maximum intrapericardial capacity is reached.3 The term effusive-constrictive pericarditis refers to pericarditis and associated effusion causing tamponade upon which drainage of the compressing fluid reveals pericardial constrictive physiology.

Intraoperative Transesophageal Echocardiography Diagnosis of Rare Source of Right Ventricular Failure After Heart Transplant

Intraoperative Transesophageal Echocardiography Diagnosis of Rare Source of Right Ventricular Failure After Heart Transplant

Evaluation of the location of mitral valvular prolapse by transthoracic and transesophageal echocardiography

Objective To evaluate the localization of mitral valvular(MV)prolapse by transthoracic echocardiography(TTE),transesophageal echocardiography(TEE)and explore the interrelationship between the different subregions of MV prolapse and mitral regurgitation(MR).Methods Total of thirtythree patients with MV prolapse and more than moderate MR were included.TEE was used to further judge the location of scallop lesions and the result of both TTE and TEE were compared with the surgical findings respectively.The relationship between the different subregions of MV prolapse and MR was analyzed.Results Compared with the surgery findings,the accuracy rate of TTE and TEE in diagnosis of MV prolapse was 100％ qualitatively,80％ for TTE and 94％ for TEE in localizing the diseased region with the anterior and posterior MV,the result of TEE was significantly different from TTE(P＜0.05).MR level was related to the location of MV prolapse.Conclusions Compared with the TTE,TEE had more advantages in localizing the position of the MV prolapse.Mitral regurgitation is related to the location of MV prolapse. Key words: Echocardiography; Echocardiography,transesophageal; Mitral valve prolapse; Anatomical regions

Transesophageal echocardiography for diagnosis of inadvertant closure of Inferior Vena Cava opening during minimally invasive atrial septal defect closure

Transesophageal echocardiography (TEE) is widely used in cardiac surgery. TEE provides important diagnostic and functional information before and after cardiopulmonary bypass thereby having a very important impact on perioperative clinical outcomes. We describe a case in which intraoperative TEE was instrumental in the timely diagnosis of inadvertant closure of the inferior vena cava (IVC) opening during minimally invasive surgical closure of atrial septal defect.

Spontaneous Echocardiographic Contrast in an Obstructed Coronary Sinus Because of a Perforated Membrane

CORONARY SINUS (CS) obstruction impedes the drainage of coronary veins, thereby increasing the coronary venous pressure and decreasing the coronary perfusion pressure, leading to possible myocardial dysfunction. 1 Ulma G. Stevenson J.G. Lupirretti F.M. et al. Transesophageal echocardiographic diagnosis of iatrogenic coronary sinus stenosis: A case report. J Thorac Cardiovasc Surg. 1997; 114: 493-495 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The authors report intraoperative transesophageal echocardiographic (TEE) detection of CS obstruction caused by a perforated membrane (attached to the Thebesian valve), covering its ostium, resulting in a dilated CS with spontaneous echocardiographic contrast.

Evaluation of Transmitral Pressure Gradients in the Intraoperative Echocardiographic Diagnosis of Mitral Stenosis after Mitral Valve Repair

ObjectiveAcute mitral stenosis (MS) following mitral valve (MV) repair is a rare but severe complication. We hypothesize that intraoperative echocardiography can be utilized to diagnose iatrogenic MS immediately after MV repair.MethodsThe medical records of 552 consecutive patients undergoing MV repair at a single institution were reviewed. Post-cardiopulmonary bypass peak and mean transmitral pressure gradients (TMPG), and pressure half time (PHT) were obtained from intraoperative transesophageal echocardiographic (TEE) examinations in each patient.ResultsNine patients (9/552 = 1.6%) received a reoperation for primary MS, prior to hospital discharge. Interestingly, all of these patients already showed intraoperative post-CPB mean and peak TMPGs that were significantly higher compared to values for those who did not: 10.7±4.8 mmHg vs 2.9±1.6 mmHg; p<0.0001 and 22.9±7.9 mmHg vs 7.6±3.7 mmHg; p<0.0001, respectively. However, PHT varied considerably (87±37 ms; range: 20–439 ms) within the entire population, and only weakly predicted the requirement for reoperation (113±56 vs. 87±37 ms, p = 0.034). Receiver operating characteristic curves showed strong discriminating ability for mean gradients (AUC = 0.993) and peak gradients (area under the curve, AUC = 0.996), but poor performance for PHT (AUC = 0.640). A value of ≥7 mmHg for mean, and ≥17 mmHg for peak TMPG, best separated patients who required reoperation for MS from those who did not.ConclusionsIntraoperative TEE diagnosis of a peak TMPG ≥17 mmHg or mean TMPG ≥7 mmHg immediately following CPB are suggestive of clinically relevant MS after MV repair.