Transesophageal Echocardiography Probe Research Articles

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

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

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.

Radiation Exposure to the Interventional Echocardiographers and Sonographers: A Call to Action

Interventional echocardiography is a rapidly growing field within the disciplines of cardiology and anesthesiology, with the rise of advanced transcatheter procedures making skilled imagers more important than ever. However, these procedures also involve frequent manipulation of the transesophageal echocardiography probe, which means interventional echocardiographers (IEs) are at risk of long-term occupational radiation exposure. Studies have shown that radiation exposure is linked to various health issues, including cancer, cataracts, hypertension, hyperlipidemia, endothelial dysfunction, vascular aging, and early atherosclerosis. While there is increasing awareness of the occupational radiation dose limits and the need for better shielding methods, the importance of radiation safety for the IE is still not sufficiently prioritized in most cardiac catheterization laboratories/hybrid operating rooms. This is partly due to a paucity of studies looking at long-term radiation exposure to the IE, as this field is newer than that of interventional cardiologists.

Videolaryngoscope versus conventional technique for insertion of a transesophageal echocardiography probe in intubated ICU patients (VIDLARECO trial): A randomized clinical trial

BackgroundTransesophageal echocardiogram probe insertion in intubated critically ill patients can be difficult, leading to complications, such as gastric bleeding or lesions in the oropharyngeal mucosa. We hypothesised that the use of a videolaryngoscope would facilitate the first attempt at insertion of the transesophageal echocardiogram probe and would decrease the incidence of complications compared to the conventional insertion technique. MethodsIn this clinical trial, patients were randomly assigned the insertion of a transesophageal echocardiogram probe using a videolaryngoscope or conventional technique. The primary outcome was the successful transesophageal echocardiogram probe insertion on the first attempt. The secondary outcomes included total success rate, number of insertion attempts, and incidence of pharyngeal complications. ResultsA total of 100 intubated critically ill patients were enrolled. The success rate of transesophageal echocardiogram probe insertion on the first attempt was higher in the videolaryngoscope group than in the conventional group (90% vs. 58%; absolute difference, 32%; 95% CI 16%–48%; p < 0.001). The overall success rate was higher in the videolaryngoscope group than in the conventional group (100% vs. 72%; absolute difference, 28%; 95% CI 16%–40%; p < 0.001). The incidence of pharyngeal mucosal injury was smaller in the videolaryngoscope group than in the conventional group (14% vs. 52%; absolute difference, 38%; 95% CI 21%–55%; p < 0.001). ConclusionsOur study showed that in intubated critically ill patients required transesophageal echocardiogram, the use of videolaryngoscope resulted in higher successful insertion on the first attempt with lower rate of complications when compared with the conventional insertion technique. Trial registrationClinicalTrials.gov Identifier: NCT04980976.

Usefulness of perioperative transoesophageal echocardiography during paediatric cardiac surgery

BackgroundPaediatric transoesophageal echocardiography probes allow perioperative evaluation during paediatric congenital heart disease surgery. AimTo assess the usefulness of perioperative transoesophageal echocardiography in evaluating the severity of residual lesions, based on the type of congenital heart disease repaired in paediatric patients. MethodsA retrospective analysis was conducted on paediatric patients who underwent open-heart surgery at our tertiary centre over a four-year period. Perioperative transoesophageal echocardiography studies were performed, and residual lesions were classified as mild, moderate or severe. ResultsOverall, 323 procedures involving 310 patients with a median age of 13.8 (0.07–214.4) months and a median weight of 8.2 (2–96) kg at intervention were enrolled in the study. Twenty-one (6.5%) residual lesions led to immediate reintervention: severe right ventricular outflow tract obstruction (n=12); severe aortic regurgitation (n=3); superior vena cava stenosis (n=2); moderate residual ventricular septal defect (n=2); severe mitral regurgitation (n=1); and severe mitral stenosis (n=1). Three (0.9%) neonates had ventilation difficulties caused by the transoesophageal echocardiography probe having to be removed, but experienced no sequelae. ConclusionPerioperative transoesophageal echocardiography is a safe procedure, providing information on severe residual lesions, leading to the immediate revision of several paediatric congenital heart disease cases.

Advancing paediatric cardiac imaging: a comprehensive analysis of the feasibility and accuracy of a novel 3D paediatric transoesophageal probe.

Pediatric transoesophageal echocardiography (TOE) probes have remained two-dimensional (2D) limiting their use compared to adults. While critical in pediatrics for interventions and post-surgery assessments, technological advancements introduced a three-dimensional (3D) pediatric TOE probe. This study assessed the new 3D pediatric TOE probe (GE 9VT-D) for feasibility, handling, and imaging quality. At Children's Hospital of Toulouse, 2-month prospective study enrolled children undergoing TOE with the new probe. All imaging modalities were rated by 2 operators using a 5-point Likert-type scale from 1 (very poor) to 5 (very good) quality. Forty-five children, median age 3.7 (range: 2 months-14.7 years) median weight 7.8 kg (range: 4.3-48 kg) underwent 60 TOEs: 25% pre-surgery, 45% post-surgery, 28% during percutaneous procedures, and 2% in intensive care. Probe handling was "very easy" in all cases without adverse events. The median score of 2D, 2D colour, pulsed Doppler and 3D were noted 5 out of 5 and continuous Doppler and 3D colour 4 out of 5. The 3D image quality remained consistent irrespective of the patient weighing above or below 7.8 kg (p = 0.72). Postoperative TOEs identified two cases needing further interventions, emphasizing its value in evaluating surgical outcomes and also for guiding percutaneous interventions. Our comprehensive evaluation demonstrates that the new 3D pediatric TOE probe is feasible and provides high-quality imaging in pediatric patients. The successful integration of this novel probe into clinical practice has the potential to enhance diagnostic accuracy and procedural planning, ultimately optimizing patient outcomes in pediatric cardiac care.

A proposed rescue transesophageal echocardiographic protocol for anesthetized dogs.

To describe the acquisition and pitfalls of a 3-view transesophageal echocardiography (TEE) protocol in anesthetized, dorsally recumbent dogs. 8 beagles, 1 to 2 years old, 7.4 to 11.2 kg. Dogs were anesthetized, mechanically ventilated, and placed in dorsal recumbency. A TEE probe was advanced, and 3 views were performed: midesophageal 4-chamber and long axis (ME 4C and ME LAX) and caudal esophageal short axis (CE SAX) at the level of the papillary muscles. Probe insertion depth, flexion, omniplane angle, and image acquisition time were recorded. Two observers assessed 24 video clips each and identified anatomical structures. The ME 4C and ME LAX were obtained at 35 (30 to 40) cm insertion depth, omniplane at 0° and 103° (90 to 116), respectively. Views were obtained in ≤30 seconds once the TEE was in the cervical esophagus. Left-sided structures were identified in all cases, whereas right-sided structures were not always simultaneously obtained in the ME 4C, requiring further probe manipulation. All structures were identified on ME LAX. CE SAX was obtained at 40 (35 to 45) cm, omniplane at 0°, and in 15 (10 to 90) seconds. A true SAX view (circular left ventricle at the level of papillary muscles) could not be obtained in all dogs. A 3-view TEE protocol using core views as those described in humans may be applicable to dogs under general anesthesia and in dorsal recumbency. The CE SAX view at the level of the papillary muscles appears more difficult to obtain with consistency than midesophageal views.

In Situ Transesophageal Echocardiography During Electrical Cardioversion in Patients With Atrial Fibrillation—Safety and Echocardiographic Findings

Transesophageal echocardiography (TEE) can reliably detect left atrial (LA) and LA appendage (LAA) thrombus in patients with atrial fibrillation (AF) before electrical cardioversion (ECV). However, evaluating cardiac and valve function pre-ECV can be challenging due to the increased and irregular heart rate. Additionally, post-ECV atrial stunning increases the risk of LAA thrombosis. Therefore, post-ECV TEE may allow for useful appendage, ventricular, and valve function assessment. However, the safety and usefulness of leaving the TEE probe in situ during ECV for post-ECV cardiac evaluation in clinical practice have not been previously evaluated. We analyzed 37 out of 86 consecutive patients who had the TEE probe left in situ, for clinical reasons, during ECV by a single operator between February 20, 2019, and January 3, 2023. We examined changes in left ventricular (LV) function, dynamic changes in valvular regurgitation, electromechanical coupling of the left atrium, and qualitative spontaneous echo contrast. We also assessed the presence of any complications related to the periprocedural TEE exam. The mean age of the patients was 74±9.65years, and 29 (78%) were male. The periprocedural TEE time ranged from 7 to 55minutes, with an average of 20.78minutes. Immediately after ECV and restoration of normal sinus rhythm, there was an improvement in LV ejection fraction (47%±11.9% vs 40%±15.8%; P=.035). There was also a reduction in baseline mitral regurgitation of greater than moderate degree. However, spontaneous echo contrast worsened in the LAA in 11 (31.4%) patients. Additionally, 1 patient developed a new LAA thrombus, and 24 patients (72%) had evidence of electromechanical coupling with Doppler evidence of LA contraction. Clinically significant degenerative aortic and mitral stenosis were identified in 8% and mild or greater aortic regurgitation in 8% of patients post-ECV. No procedural complications were observed. In situ TEE before, during, and after ECV is safe and provides useful clinical information regarding immediate cardiac changes after ECV, with diagnostic and therapeutic implications.

A Cautionary Tale—Aortic Compression by Transesophageal Echocardiography Probe

A Cautionary Tale—Aortic Compression by Transesophageal Echocardiography Probe

Closed-Loop Magnetic Manipulation for Robotic Transesophageal Echocardiography

This article presents a closed-loop magnetic manipulation framework for robotic transesophageal echocardiography (TEE) acquisitions. Different from previous work on intracorporeal robotic ultrasound acquisitions that focus on continuum robot control, we first investigate the use of magnetic control methods for more direct, intuitive, and accurate manipulation of the distal tip of the probe. We modify a standard TEE probe by attaching a permanent magnet and an inertial measurement unit (IMU) sensor to the probe tip and replacing the flexible gastroscope with a soft tether containing only wires for transmitting ultrasound and IMU data and show that six-degree-of-freedom (DOF) localization and five-DOF closed-loop control of the probe can be achieved with an external permanent magnet based on the fusion of internal inertial measurement and external magnetic field sensing data. The proposed method does not require complex structures or motions of the actuator and the probe compared with existing magnetic manipulation methods. We have conducted extensive experiments to validate the effectiveness of the framework in terms of localization accuracy, update rate, workspace size, and tracking accuracy. In addition, our results obtained on a realistic cardiac tissue-mimicking phantom show that the proposed framework is applicable in real conditions and can generally meet the requirements for teleoperated TEE acquisitions.

Left Atrial Appendage Occlusion Under Miniaturized Transesophageal Echocardiographic Guidance and Conscious Sedation: Multicenter European Experience

BackgroundLeft atrial appendage occlusion (LAAO) procedures are widely guided by standard transesophageal echocardiography (TEE) probes, requiring general anesthesia in most patients. The use of miniaturized TEE probes allows for LAAO guidance under local anesthesia and offers an attractive imaging alternative to standard TEE probes. ObjectivesThe aim of this study was to assess the safety and efficacy of miniaturized TEE probes for procedural guidance of LAAO. MethodsMulticenter retrospective observational study of LAAO procedures performed under miniaturized TEE guidance and conscious sedation. The primary efficacy endpoint was technical success. The secondary efficacy endpoint was procedural success (technical success without major periprocedural complications). The safety outcome was a composite of major periprocedural complications. ResultsA total of 546 consecutive LAAO procedures were performed in 5 European centers. Technical success was achieved in 534 (98.0%) patients. Sixteen major periprocedural complications occurred in 15 (2.9%) patients, yielding a procedural success rate of 97.0%. Conversion to general anesthesia was required in 4 (0.7%) patients. Short-term imaging follow-up was available in 422 patients with an incidence of major (>5 mm) TEE-detected residual leaks of 0.7%, complete LAA occlusion of 82.2% on cardiac computed tomography, and device-related thrombus of 5%. As compared with procedural 2-dimensional imaging for device sizing, preprocedural assessment by 3-dimensional imaging resulted in improved technical success (100% vs 95.0%; P < 0.001). ConclusionsLAAO under conscious sedation and miniaturized TEE guidance is safe and feasible with a high rate of technical success and a low rate of periprocedural complications.

Temperature monitoring in cardiac surgery with transesophageal echocardiography probe: magic bullet or underutilization of a powerful tool?

Temperature monitoring in cardiac surgery with transesophageal echocardiography probe: magic bullet or underutilization of a powerful tool?

A novel useful 3D multiplanar reconstruction algorithm to detect the optimal transseptal puncture positioning in percutaneous mitral valve repair

Abstract Funding Acknowledgements Type of funding sources: None. Background in transcatheter edge to edge mitral repair (TEER), the use of transesophageal echocardiography (TEE) guidance is mandatory in every procedural step. The transseptal puncture (TPS) height is measured by TEE using a four chamber view (4CV) in mid-upper esophagus between the catheter tenting in fossa ovalis and the coaptation of the mitral valve (MV) and its correct positioning influence procedural outcome. However, TSP can represents a tricky step, because of poor images, challenging interatrial septa or a malalignment of TEE probe, catheter and mitral coaptation. Aim In this abstract we describe an alternative TEE 3D technique to measure TSP height. Methods Between August 2022 and December 2022 we performed 18 cases of TEER. In all cases we obtained a measure of the height of tenting (HT) with two different techniques: the 2D view (2DV) in 4CV and the 3D reconstruction algorithm (3DA) (fig.1). This 3DA starts with a real-time single-beat 3D volume acquisition from a mid esophagus at 0 degrees view. The 3D dataset should include IAS, aortic valve, and MV. In multiplanar reconstruction (MPR), three 2D planes are reconstructed from the 3D dataset. These MPR planes must be positioned in a predefined manner with the cursors correctly aligned on the catheter tip at the level of the fossa ovalis. The first plan (P1) is an off axis 4CV oriented perpendicular to the IAS exactly on the height of the catheter tip and serves as the orientation plane. This plane allows the exact location of the tenting point and the positioning of the other two MPR planes. The crossing of the axes should be positioned in all planes at the center of the left atrium. The second plane (P2) and the third plane (P3) are oriented perpendicular to the previous one (fig.1) and each other. Rotating and moving those two planes in a stepwise manner a 4CV, including the plane passing by catheter tip and MV coaptation is obtained in P1. In order to identify the exact plane of the coaptation, while in P1 the axis passing through the MV is positioned at the center of the MV, in P2 the axis is adjusted at the point of leaflet coaptation (fig.1). The HT is then measured in P1 thus avoiding the possible foreshortening affecting a simple 2DV. Results In all cases the 3D measure was accomplished but in 3 of 18 cases the 2DV was difficult to obtain because of loss of contact between the esophagus and the probe in retroflection, in those cases the HT was measured in a 0 degrees off axis view from the tenting of the fossa to a very anterior part of the coaptation line or to anterior leaflet. In all those cases the height of tenting was underestimated (fig.2). Conclusion The 3DA described can be useful in obtaining a more precise and reliable measure of the HT even in anatomical challenging patients. A comparative study that consents to investigate the correlation between the two methods and the inter and intra observer agreement is mandatory and planned at our institution.

Usos del videolaringoscopio C-MAC en una Unidad de Cuidados Intensivos. Estudio prospectivo, observacional

ObjectiveTo describe the main uses of the C-MAC video laryngoscope (VL) in an Intensive Care Unit (ICU) during a period of 29 months. Material and methodsProspective, observational study during a period of 29 months. All patients admitted to our ICU where the VL C-MAC was used were included. Indications, efficacy, and complications were recorded. ResultsThe VL C-MAC has been used 297 times in 250 patients. The mean age of the patients was 68 ± 13 years. The most frequent use of the VL C-MAC was orotracheal intubation (IOT), in 103 (34.7%) cases. 86.4% of the patients were intubated at the first attempt. Intubation with the VL C-MAC accounted for 60.6% (103/170) of all IOTs performed during the study period. The VL C-MAC was used in 76 (25.6%) cases to review the pharynx-larynx area, and in 68 (22.9%) cases to facilitate the introduction of the transesophageal echocardiography (TEE) probe. Other uses were facilitating percutaneous tracheostomy placement (10.1%), nasogastric tube placement (3%), orotracheal tube exchange (3.4%) and Sengstaken balloon placement (0.3%). ConclusionsThe IOT, the review of the pharynx-larynx area and the introduction of the TEE probe were the most frequent uses of the VL C-MAC in our ICU. The use of VL C-MAC in an ICU is broader than tracheal intubation and can facilitate the management of critical patients.

Pulmonary vein compression by transesophageal echocardiography probe demonstrated using epicardial echocardiography.

The authors declare no competing interests. Research data are not shared. Video S1: Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Structural and Electrical Integrity of Transesophageal Echocardiography Probes: Importance and Key Concepts

The clinical utility of transesophageal echocardiography (TEE) is well-established for patients undergoing cardiac surgery. With the increase in percutaneous structural heart disease procedures that rely on TEE for procedural guidance, the use of TEE probes is expanding. Although there are well-established protocols for routine cleaning and decontaminating TEE probes between patient use, there is a lack of awareness and misconceptions about maintaining TEE probes' structural and electrical integrity. The electrical leakage test (ELT) is routinely performed between patient use. From a patient safety standpoint, the ELT is necessary to ensure the longevity of this expensive equipment and prevent disruptions to the workflow in a busy department caused by TEE probes being decommissioned due to probe damage. This technical communication aims to highlight the importance of maintaining TEE probes' structural and electrical integrity. The article also highlights and discusses probe handling techniques between patient use, emphasizing the ELT to ensure patient safety and compliance with national and international standards.

Bend-insensitive fiber optic ultrasonic tracking probe for cardiovascular interventions.

Transesophageal echocardiography (TEE) is widely used to guide medical device placement in minimally invasive cardiovascular procedures. However, visualization of the device tip with TEE can be challenging. Ultrasonic tracking, enabled by an integrated fiber optic ultrasound sensor (FOUS) that receives transmissions from the TEE probe, is very well suited to improving device localization in this context. The problem addressed in this study is that tight deflections of devices such as a steerable guide catheter can result in bending of the FOUS beyond its specifications and a corresponding loss of ultrasound sensitivity. A bend-insensitive FOUS was developed, and its utility with ultrasonic tracking of a steerable tip during TEE-based image guidance was demonstrated. Fiberoptic ultrasound sensors were fabricated using both standard and bend insensitive single mode fibers and subjected to static bending at the distal end. The interference transfer function and ultrasound sensitivities were compared for both types of FOUS. The bend-insensitive FOUS was integrated within a steerable guide catheter, which served as an exemplar device; the signal-to-noise ratio (SNR) of tracking signals from the catheter tip with a straight and a fully deflected distal end were measured in a cardiac ultrasound phantom for over 100 frames. With tight bending at the distal end (bend radius<10mm), the standard FOUS experienced a complete loss of US sensitivity due to high attenuation in the fiber, whereas the bend-insensitive FOUS had largely unchanged performance, with a SNR of 47.7 for straight fiber and a SNR of 36.8 at a bend radius of 3.0mm. When integrated into the steerable guide catheter, the mean SNRs of the ultrasonic tracking signals recorded with the catheter in a cardiac phantom were similar for straight and fully deflected distal ends: 195 and 163. The FOUS fabricated from bend-insensitive fiber overcomes the bend restrictions associated with the FOUS fabricated from standard single mode fiber, thereby enabling its use in ultrasonic tracking in a wide range of cardiovascular devices.

Factors predicting difficulty in insertion of real-time-three-dimensional transesophageal echocardiography probe in adult patients undergoing cardiac surgery.

Transesophageal echocardiography (TEE) probe insertion may be associated with many complications. Demographic factors and airway conditions such as high Mallampati scores (MMC) and Cormack-Lehane grades (MCLG) are likely to have an impact on its ease of insertion. The primary aim of this study was to identify the predictive factors for difficult real-time-three-dimensional TEE probe insertion. A total of 153 adult patients undergoing cardiac surgery were prospectively evaluated. The upper airway manipulations required for TEE probe placement were jaw thrust, reverse Sellick's maneuver, and laryngoscopy. All the patients who required airway manipulations were grouped under difficult TEE probe placement group. We evaluated the patients' predictive factors such as demographic characteristics and factors related to difficult intubation. Out of 153 patients, 123 were males and 30 were females. Overall, 27.5% (n = 42) patients had difficulty in probe placement. About 31.7% (n = 39) males had difficulty in TEE probe placement against 13% (n = 4) females (P-value 0.045). Difficulty in TEE probe placement was found in 72.7% (n = 16) of obese patients (body mass index [BMI] > 30), compared to 18.6% (n = 17) in the patients with BMI less than 25 (P-value < 0.001). Probe insertion was significantly more difficult in the presence of MMC III and IV (50%, n = 18) compared to class I (19.2%, n = 10) (P-value 0.001) and MCLG III (73.3%, n = 22) compared to grade I (11.1%, n = 7) (P-value 0.001). Male gender, obesity, higher grades of MMC and MCLG were found to be the risk factors for difficult TEE probe placement in anesthetized patients.

Usefulness of perioperative transesophageal echocardiography during pediatric cardiac surgery

Pediatric transesophageal echocardiography (TEE) probes allow perioperative evaluation during pediatric congenital heart disease (CHD) surgery. To determine the usefulness of perioperative TEE for evaluation of residual lesions severity according to the type of repaired CHD. Retrospective review of patients who underwent a perioperative TEE study during open-heart surgery (excluding ostium secundum atrial septal defect closure) over 4 consecutive years in our center. Residual lesions were rated as mild, moderate or severe. Among 291 interventions (which may include multiple gestures) in 280 patients (pts), no complications related to TEE study occurred. Median weight was 8,1 kg (range 2–96) and size of probe (micro 2D TEE, mini-multi 2D TEE or 3D TEE) adapted to the weight. Twenty-one (7.2%) severe residual lesions required immediate reintervention. Eleven pts (9.7%) had severe residual stenosis and required immediate reintervention out of 113 right ventricular outflow tract obstruction (RVOTO) surgeries. Three pts (3.5%) required immediate reintervention for aortic regurgitation and two (2.3%) for mitral residual lesions out of 86 left heart surgeries. Two pts (1.1%) required immediate reintervention for severe residual VSD out of 188 ventricular shunt surgeries. Two pts (4.2%) required immediate reintervention for superior vena cava stenosis following Warden procedure out of 47 pretricuspid shunt surgeries. One immediate reintervention occurred after a “Cone surgery” for severe right ventricle dysfunction. Use of perioperative TEE is safe and provides accurate information of residual lesions leading to several immediate intervention. RVOTO, left valvular and shunt closure surgeries could most likely benefit of its use.

What flow is this!

A 38-year-old female with severe mitral regurgitation, severe aortic regurgitation, and moderate pulmonary hypertension was taken up for double-valve replacement surgery. After induction of anesthesia, transesophageal echocardiography (TEE) probe (Philips X7-2t, iE33 system) was inserted. Comprehensive TEE examination revealed an abnormal continuous color flow signal arising from the ascending aorta to the right pulmonary artery (RPA) [Figures 1 and 2, Video 1]. The direction of the color flow jet was perpendicular to the blood flow in the main PA. There was no history of a prior cardiac intervention except coronary angiography to rule out coronary artery disease. Suspecting a left to right shunt, blood samples from the right ventricle and RPA were taken for oximetry study, which showed a 7.3% step-up of oxygen saturation (73.3% vs. 80.6%). During surgery, excision of the pericardium superiorly showed a vascular structure extending from the left posterolateral aspect of the ascending aorta to the RPA. The vessel was doubly ligated with clips which resulted in cessation of its flow on TEE examination, as well as equalization of saturations in the right ventricle and RPA. The rest of the surgical procedure and postoperative course were uneventful.Figure 1: Upper esophageal ascending aorta short-axis view on transesophageal echocardiography showing ascending aorta (AA) to the right pulmonary artery (RPA) flow (arrow). MPA: Main pulmonary arteryFigure 2: Diagrammatic representation of the ascending aorta (AA) to the right pulmonary artery (RPA) flow (arrow). MPA: Main pulmonary artery, LPA: Left pulmonary artery {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_y3nnfi01"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} The most likely diagnosis of this communication is an aortopulmonary window or fistula. Aortopulmonary fistula is generally congenital in origin and may be associated with other congenital cardiac anomalies including patent ductus arteriosus, interrupted aortic arch, coarctation of the aorta, atrial septal defect, or coronary artery anomalies in about half of the patients.[1] Acquired aortopulmonary fistulae have either prior aortotomy, percutaneous endovascular procedure, or acute aortic dissection as the underlying pathology.[2,3] Aortopulmonary fistulae have also been described in chronic diseases of the aortic wall, such as aneurysm, giant cell aortitis, syphilitic or mycotic disease, or endocarditis.[4] After accurate delineation of the anatomy, location, and size of the fistula is achieved, the patient can be treated by either open surgery, hybrid procedure, or endovascular stenting.[5] The risks of pulmonary hypertension, Eisenmenger syndrome, and congestive heart failure remain high in patients with large aortopulmonary fistulae. Patients with very small shunt lesions, such as this patient, may remain asymptomatic, however. The case also highlights the importance of a comprehensive TEE examination to detect abnormal blood flow. DECLARATION OF PATIENT CONSENT The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.