Indication For Transesophageal Echocardiography Research Articles

Prevalence of non-infectious masses on intracardiac devices as incidental finding during transoesophageal echocardiography

Abstract Background Incidentally detected masses on the leads of cardiac implantable electronic devices (CIED) present a clinical dilemma and often raise the question whether they should be treated as a device infection. Indeed, they are considered as one of the major Duke criteria for the diagnosis of infectious device endocarditis. However, rather often incidental lead masses are detected in a routine transesophageal echocardiography (TOE) in patients without any signs of infection. Data on the prevalence of such findings are scarce and outdated. Purpose In this study, we aimed to determine the current prevalence and predisposing clinical factors of incidental non-infectious lead masses. Methods In this retrospective single center study, we analyzed all TOE examinations performed between 2020 and 2021 for the indications other than suspected infectious endocarditis. Patients with nonsuspicious leads and the ones with incidental non-infectious lead masses were compared with regard to clinical characteristics, presence of anticoagulation and indication for TOE. Results In total, 1361 TOE examinations were performed within the study period. From those 141 patients with CIED were selected. Thirty-nine patients (27.6%) presented with non-infectious CIED masses. The clinical characteristics of study patients and the TOE indications are listed in Table 1. Patients with incidental CIED mass showed a higher prevalence of dilated cardiomyopathy (38.5%) compared to patients with no CIED mass (16.7%), p=0.004 Table 1. The presence of laboratory sings of infection and cardiovascular risk factors, such as arterial hypertension, diabetes mellitus or chronic kidney disease did not differ significantly between both groups (Table 1). Also, incidental lead masses were less prevalent in patients with oral anticoagulation (Odds ratio 0.33, 95% CI: 0.11–1.00; p=0.048; Figure 1), whereas the distribution of CHA2DS2-VASc Scores did not show any differences. Conclusion The prevalence of incidental non-infectious CIED lead masses in TOE in our study was 27,6%, which is higher, than previously reported 5–10%. We did not observe any association between the incidental CIED lead masses and cardiovascular comorbidities. The absence of the oral anticoagulation seems to be the only clinical risk factor for such findings in our study, suggesting possible thrombogenic genesis. The high prevalence of incidental non-infectious lead masses should be kept in mind in order to avoid the overdiagnosis of CIED infection and unnecessary lead extraction. Funding Acknowledgement Type of funding sources: Public hospital(s).

Bubble Test and Carotid Ultrasound to Guide Indication of Transesophageal Echocardiography in Young Patients With Stroke

Background and PurposeIndication of transesophageal echocardiography (TEE) in patients ≤60 years with brain ischemia is uncertain.MethodsThis prospective double-blinded study included patients with cryptogenic acute ischemic stroke or transient ischemic attack (TIA) ≥18 and ≤60 years. After routine diagnostics, all patients underwent patent foramen ovale (PFO) screening by transcranial Doppler (TCD) bubble test, carotid ultrasound for atherosclerosis screening (intima-media-thickness >0.90 mm or plaques), and TEE. We calculated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) of the combined non-invasive ultrasound to predict therapy-relevant TEE findings.ResultsWe included 240 consecutive patients (median 51 years, 39% women) of which 68 (28.3%) had both a negative bubble test and no carotid atherosclerosis. Of these, 66 (97.1%) had unremarkable TEE findings; in one patient a small PFO was found and closed subsequently, in another patient a 4.9 mm thick aortic atheroma was found, and double platelet inhibition initiated. Of the other 172 (71.7%) patients, 93 (54%) had PFO and 9 (5.2%) complex aortic plaques. No other therapy-relevant findings were present in both groups. Non-invasive ultrasound had a sensitivity of 98.0%, specificity of 47.8%, NPV of 97.1%, and PPV of 58.1% for therapy-relevant TEE findings.ConclusionsBubble test and carotid ultrasound could be used for the individual decision for/against TEE in patients with cryptogenic stroke ≤60 years. If they are unremarkable, TEE can be omitted with high safety regarding secondary prevention. If bubble test is positive and/or carotid ultrasound shows atherosclerosis, TEE should be carried out if PFO or aortic atheroma are potentially relevant for further patient management.

Who Should Rather Undergo Transesophageal Echocardiography to Determine Stroke Etiology: Young or Elderly Stroke Patients?

Introduction: The indication of transesophageal echocardiography (TEE) in acute stroke is unclear. Thus, we systematically studied the impact of TEE on determining stroke etiology and secondary prevention in patients of different age-groups with cryptogenic stroke.Methods: Four hundred and eighty five consecutive patients with acute retinal or cerebral ischemia were prospectively included and underwent routine stroke workup including TEE. Stroke etiology was identified according to the TOAST classification and patients were divided in those with determined and cryptogenic stroke etiology without TEE results. Then, the frequency of high- and potential-risk sources in TEE was evaluated in <55, 55–74, and ≥75 year-old patients with cryptogenic stroke etiology.Results: Without TEE, stroke etiology was cryptogenic in 329(67.8%) patients and TEE determined possible etiology in 158(48.4%) of them. In patients aged <55, 55–74, ≥75, TEE detected aortic arch plaques ≥4 mm thickness in 2(1.2%), 37(23.0%), and 33(40.2%) and plaques with superimposed thrombi in 0(0.0%), 5(3.1%), and 7(8.5%); left atrial appendage peak emptying flow velocity ≤30cm/s in 0(0.0%), 1(0.6%), and 2(2.4%), spontaneous echo contrast in 0(0.0%), 1(0.6%), and 6(7.3%), endocarditis in 0(0.0%), 0(0.0%), and 1(1.2%) and patent foramen ovale (PFO) plus atrial septum aneurysm (ASA) in 18(20.9%), 32(19.9%), and 14(17.1%), respectively. TEE changed secondary prevention in 16.4% of these patients following guidelines of 2010/11 and still 9.4% when applying the guidelines of 2020.Conclusions: TEE was highly valuable for determining stroke etiology and influenced individual secondary prevention based on available treatment guidelines and expert opinion in most cases. In young patients the impact of TEE was limited to the detection of septal anomalies. By contrast, in older patients TEE detected high numbers of complex aortic atheroma and potential indicators of paroxysmal atrial fibrillation.

Where is the Effective Mitral Orifice? Echocardiographic Divergence Between Mitral Inflow Volume and Left ventricular Outflow Tract Volume

Two-dimensional transthoracic echocardiography (2DTTE) is not a reliable methodfor estimating regurgitatant volume in mitral insufficiency due to inadequate measurementof the mitral annulus (MA). Three-dimensional transesophageal echocardiography(3DTEE) offers better tools for measuring the MA.ObjectivesThe aim of this study was to compare the MA area and the difference in mitral inflow(MI) volume and left ventricular outflow tract (LVOT) volume determined by2DTTE and 3DTEE in normal hearts, and to evaluate at what level of the mitralvalve apparatus the mitral effective orifice is actually located.MethodsA total of 13 consecutive and prospective patients with indication of transesophagealechocardiography (9 to rule out cardioembolic source and 4 due to febrile syndrome)were included in the study. Their mean age was 42 (29-47) years and 7 were women.All the patients had normal 2DTTE, were in sinus rhythm and had normal bloodpressure at the moment of the study. 2DTTE and 3DTEE were simultaneously performed.LVOT area and MA area were calculated by 2DTTE and 3DTEE. Mitralvalve (MV) area distal to the MA was estimated by 3DTEE. Mitral inflow and LVOTvolume were calculated as the product between the area and flow velocity time integral(VTI). The effective mitral valve area (EMVA) was hypothetically estimated bydividing the LVOT (3DTEE) volume by MI VTI.ResultsCorrelation (rs), concordance and 95% CI between MA area by 2DTTE vs. 3DTEEwere: 0.506, 1.97 (-0.40 to 4.34), EMVA vs. 3DTEE: 0.549, 2.41 (-4.03 to -0.79) andEMVA vs. MV at 11 mm (8-12) of the MA: 0.982, 0.079 (-0.26 to 0.42). The differencebetween MI volume and LVOT volume (ml) was: 2DTTE: 12.8 (7.5-19), 3DTEE: 32.8(25.9-48) and 3DTEE (from the MV distal to the MA) 1.8 (1.25-3.6).ConclusionsThe better the technique for measuring the mitral annulus, the farther we are fromthe mitral effective orifice. The mitral valve area measured at one centimeter of thehighest point of the mitral annulus is the best approximation to the effective mitralorifice.

Comprehensive Textbook of Perioperative Transesophageal Echocardiography, Second Edition.

Edited by Robert M. Savage, M.D., F.A.C.C., Solomon Aronson, M.D., F.A.C.C., F.C.C.P., F.A.H.A., F.A.S.E., and Stanton K. Shernan, M.D. Philadelphia, Lippincott Williams &amp; Wilkins, 2011. Pages: 770. Price: $229.00.As the foreword indicates, the breadth of the second edition of Comprehensive Textbook of Perioperative Transesophageal Echocardiography is expansive, aptly mirroring the growth of echocardiography in perioperative medicine. For those of us striving to improve our echocardiography skills and improve patient care, this book will serve as a must-read, must-have reference. To reduce the burden of lugging around a heavy textbook, purchasers of each book gain access to an online version accessible from anywhere! The book covers everything a reader could want in an organized, well-thought-out manner. Filled with vibrant color illustrations and an extensive topic list, the text has a wonderful flow.Section 1 details the basics of perioperative echocardiography, starting with physics. This often-maligned topic is covered in detail, yet remains easy to read. Comprehensive illustrations help the reader along as the complex physics of echosonography are unwoven. Although the illustrations in this chapter are slightly busy, they appropriately convey the information needed. The text builds nicely on this basic knowledge by correlating the physical principles of ultrasound with real-life image pitfalls and artifacts in chapter 2 and image optimization in chapter 3. A section called Key Points at the end of each chapter succinctly summarizes important concepts. The book transitions smoothly from “machine” to “man” as the subsequent chapters of section 1 outline the anatomy of the heart, transesophageal echocardiography indications, and both the comprehensive and abbreviated transesophageal echocardiography examination before delving deeper into each area of the heart.Section 2 discusses the use of transesophageal echocardiography and transthoracic echocardiography in the critical care setting. Detailed evaluation of the patient with endocarditis and the use of rescue echocardiography in the intensive care unit are added to this edition as new chapters.Advanced applications of echocardiography are examined in section 3. From a new chapter on epiaortic imaging to chapters on congenital heart disease, as well as surgical considerations in valve and heart failure surgery, this section builds heavily on the basics. The level of detail and precision shines through as each chapter offers a wealth of information, clinical data, and images to support the echocardiographer through tough clinical scenarios. New chapters on strain echocardiography and three-dimensional echocardiography complete this section. It is a must-read for those working toward advanced certification in transesophageal echocardiography.With a text version, online version, 3 sections, 39 chapters, more than 60 contributing authors, 770 pages, and thousands of referenced articles, this text truly lives up to its name. It is comprehensive in every sense of the word. Yet, despite such a vast number of contributors and broad scope, it reads in a singular, focused manner. Topic after topic, it builds on the basics before advancing to an expanse of clinical application. I expect its readership will range from beginner to expert. For beginners, it is simple and easy to follow. For those already skilled, it is detailed and comprehensive. It is clearly informative for those seeking transesophageal echocardiography certification and those certified long ago. In short, it is well worth the asking price.*University of Chicago, Pritzker School of Medicine, Chicago, Illinois. jmarymont@northshore.org

Chiari's network: Normal anatomic variant or risk factor for arterial embolic events?

This study was performed to assess the prevalence of Chiari's network in patients undergoing transesophageal echocardiography and to determine whether this anomaly is associated with other cardiac lesions or is characterized by typical clinical findings. Chiari's network is a congenital remnant of the right valve of the sinus venosus. It has been found in 1.3% to 4% of autopsy studies and is believed to be of little clinical consequence. Video recordings of 1,436 consecutive adult patients evaluated by transesophageal echocardiography over a 30-month period were reviewed for the presence of Chiari's network. Echocardiographic contrast studies had been performed in all patients with Chiari's network and were compared with those of 160 consecutive patients without a Chiari net, serving as a control group. Chiari's network was present in 29 of 1,436 patients (prevalence 2%). A frequently associated finding was a patent foramen ovale in 24 (83%) of the 29 patients with Chiari's network versus 44 (28%) of 160 control patients (p < 0.001). Intense right-to-left shunting occurred significantly more often in patients with Chiari's network than in control patients (16 [55%] of 29 patients vs. 19 [12%] of 160 control patients, p < 0.001). Another frequent association was an atrial septal aneurysm in 7 (24%) of 29 patients. The indication for transesophageal echocardiography was a suspected cardiac source of arterial embolism in 24 (83%) of 29 patients with a Chiari net, 13 of whom (54%) had recurrent embolic events. Chiari's network was significantly more common in patients with unexplained arterial embolism than in patients evaluated for other indications (24 [4.6%] of 522 patients vs. 5 [0.5%] of 914 patients, p < 0.001). Potential causes for arterial embolism were present in 9 of the 24 patients with a Chiari net and embolic events (atrial septal aneurysm in 7, cerebrovascular lesion in 2). In 15 (62%) of 24 patients only a patent foramen ovale could be identified. Three patients had deep venous thrombosis and pulmonary embolism at the time of arterial embolism; none had a thrombus detected within the network. In patients undergoing transesophageal echocardiography, the prevalence of Chiari's network was 2%, which is consistent with autopsy studies. By maintaining an embryonic right atrial flow pattern into adult life and directing the blood from the inferior vena cava preferentially toward the interatrial septum, Chiari's network may favor persistence of a patent foramen ovale and formation of an atrial septal aneurysm and facilitate paradoxic embolism.

Transesophageal echocardiography for study of bioprostheses in the aortic valve position

Transesophageal echocardiography is a relatively new imaging modality with unequivocal advantage over precordial echocardiography in a significant number of conditions.*-3 The importance of transesophageal echocardiography in the assessment of aortic valve disease (native or prosthetic) has not been clearly shown. There is some evidence from anecdotal case reports4v5 and small series of patients that it may be superior to transthoracic imaging.6 The present study was undertaken to evaluate the use of transesophageal echocardiography in the setting of bioprosthetic aortic valve disease and to define the clinical situations in which its use is superior to the precordial approach. Between July 1987 and July 1990, 33 patients (19 men and 14 women, mean age 61 f I3 years) were studied by transesophageal echocardiography for suspected bioprosthetic aortic valve disease, and the recordings were reviewed retrospectively. The indication for transesophageal echocardiography was based on a strong clinical suspicion of aortic valve abnormalities, yet with a normal aortic valve by the transthoracic approach, or when there was a suspicion, but not definite, of an abnormality of the aortic valve on the transthoracic study. Sixteen patients were referredfor suspected infective endocarditis, 12 for aortic prosthesis assessment, and 5 for suspected prosthetic dysfunction. Twenty-seven patients were inpatients and 6 were ambulatory. Thirteen patients underwent subsequent cardiac surgery. All ultrasound recordings were obtained using a

Transesophageal echocardiography for congenital heart disease.

Surface echocardiographic imaging of small children is routinely successful in defining anatomical details and Doppler flow patterns with even the most complex congenital cardiac malformations. However, in larger children or adults, imaging is frequently limited. A recent expansion of the role of echocardiography is intraoperative epicardial imaging. Epicardial and postoperative imaging, however, have significant limitations. To avoid some of these limitations, transesophageal echocardiography has increasingly been used in the arena of congenital heart disease. The more recent development of small sized gastroscopic probes has allowed transesophageal echocardiographic assessment of congenital heart disease in children down to newborn size. As detailed studies of individual lesions are reported, it has become clear that the mere presence of a congenital heart defect is not an indication for transesophageal echocardiography in most children if imaging can be accomplished by surface examination. However, transesophageal echocardiography may be indicated for the intraoperative or postoperative assessment of that defect, particularly when repair has been difficult or is known to be associated with significant residual abnormalities. Cardiac structures encountered with horizontal and vertical imaging plane transducers have been described and should be completely familiar to the examining echocardiographer.