Transgastric Short-axis View Research Articles

Deep Learning Based Automatic Left Ventricle Segmentation from the Transgastric Short-Axis View on Transesophageal Echocardiography: A Feasibility Study.

Segmenting the left ventricle from the transgastric short-axis views (TSVs) on transesophageal echocardiography (TEE) is the cornerstone for cardiovascular assessment during perioperative management. Even for seasoned professionals, the procedure remains time-consuming and experience-dependent. The current study aims to evaluate the feasibility of deep learning for automatic segmentation by assessing the validity of different U-Net algorithms. A large dataset containing 1388 TSV acquisitions was retrospectively collected from 451 patients (32% women, average age 53.42 years) who underwent perioperative TEE between July 2015 and October 2023. With image preprocessing and data augmentation, 3336 images were included in the training set, 138 images in the validation set, and 138 images in the test set. Four deep neural networks (U-Net, Attention U-Net, UNet++, and UNeXt) were employed for left ventricle segmentation and compared in terms of the Jaccard similarity coefficient (JSC) and Dice similarity coefficient (DSC) on the test set, as well as the number of network parameters, training time, and inference time. The Attention U-Net and U-Net++ models performed better in terms of JSC (the highest average JSC: 86.02%) and DSC (the highest average DSC: 92.00%), the UNeXt model had the smallest network parameters (1.47 million), and the U-Net model had the least training time (6428.65 s) and inference time for a single image (101.75 ms). The Attention U-Net model outperformed the other three models in challenging cases, including the impaired boundary of left ventricle and the artifact of the papillary muscle. This pioneering exploration demonstrated the feasibility of deep learning for the segmentation of the left ventricle from TSV on TEE, which will facilitate an accelerated and objective alternative of cardiovascular assessment for perioperative management.

Deep learning for transesophageal echocardiography view classification

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

Abstract 13679: Personalized Guidance of Edge-to-Edge Transcatheter Tricuspid Valve Repair

Introduction: Transcatheter edge-to-edge tricuspid valve repair (T-TEER) for tricuspid regurgitation (TR) is always guided by TEE. Hypothesis: Safety and efficacy of T-TEER can be increased by multimodality imaging (MMI) guidance. Methods: From December 2020 to January 2022, we performed T-TEER in 40 inoperable patients. All patients received TTE, TEE and cardiac CT screening, and were assigned to a MMI (n=17) guidance group, provided good TTE acoustic window, or otherwise classical TEE (n=23). Multimodality imaging employed the 4 right-sided chamber views. Accordingly, the 1-chamber view was obtained in the transgastric short-axis view on TEE, but also from a modified subcostal TTE short axis. The 2-chamber view was visualized from a low-esophageal position, or from a parasternal long axis view of the right ventricle. The 3-chamber view was seen on mid-esophageal TEE 50-100°, but also in the parasternal short axis view. Finally, the 4-chamber view was obtained on mid-esophageal 0-30°, or the classical four-chamber TTE view. CT derived fluoroscopic angulations of these views allowed interventionalists and imaging specialists to speak a common language. Results: Device success was achieved in all patients, with 1.5±0.6 implanted clips / patient in the MMI vs 1.5±0.5 in the TEE group (p=0.851). Device times were 66.1±35.1 vs 58.7±27.5 minutes (p=0.459). TR reduction was successful in 94% vs 95% of patients, p=1.000. Two- or more grade TR improvement occurred in 65% vs 52% of cases. There were no device associated complications but 3 TEE-related gastro-esophageal bleedings occurred in the 2 nd group. By 12 months, 4 vs 8 patients (p=0.504) were readmitted for acute heart failure, and 2 vs 4 (p=0.686) died. NYHA class decreased by one grade in all survivals. However, Kansas City Cardiomyopathy Questionnaire score and 6-minute walk distance significantly increased in each respective group, more with MMI ( Δ 29±21.4 vs 22±13.6 points, p=0.227; Δ 101±100.4 vs 85±64 meters, p=0.121). Conclusions: A patient-tailored MMI approach to T-TEER guidance, by using TTE in patients with good acoustic window and cardiac CT for fluoroscopic determination of the 4 right-sided chamber views, is feasible and improves safety, procedural success and, in turn, clinical outcomes.

Diagnostic, prognostic and clinical value of left ventricular radial strain to identify paradoxical septal motion in ventilated patients with the acute respiratory distress syndrome: an observational prospective multicenter study

BackgroundAcute cor pulmonale (ACP) is prognostic in patients with acute respiratory distress syndrome (ARDS). Identification of paradoxical septal motion (PSM) using two-dimensional echocardiography is highly subjective. We sought to describe feature-engineered metrics derived from LV radial strain changes related to PSM in ARDS patients with ACP of various severity and to illustrate potential diagnostic and prognostic yield.MethodsThis prospective bicentric study included patients under protective ventilation for ARDS related to COVID-19 who were assessed using transesophageal echocardiography (TEE). Transgastric short-axis view at mid-papillary level was used to visually grade septal motion, using two-dimensional imaging, solely and combined with LV radial strain: normal (grade 0), transient end-systolic septal flattening (grade 1), prolonged end-systolic septal flattening or reversed septal curvature (grade 2). Inter-observer variability was calculated. Feature engineering was performed to calculate the time-to-peak and area under the strain curve in 6 LV segments. In the subset of patients with serial TEE examinations, a multivariate Cox model analysis accounting for new-onset of PSM as a time-dependent variable was used to identify parameters associated with ICU mortality.ResultsOverall, 310 TEE examinations performed in 182 patients were analyzed (age: 67 [60–72] years; men: 66%; SAPSII: 35 [29–40]). Two-dimensional assessment identified a grade 1 and grade 2 PSM in 100 (32%) and 48 (15%) examinations, respectively. Inter-rater reliability was weak using two-dimensional imaging alone (kappa = 0.49; 95% CI 0.40–0.58; p < 0.001) and increased with associated LV radial strain (kappa = 0.84, 95% CI 0.79–0.90, p < 0.001). The time-to-peak of mid-septal and mid-lateral segments occurred significantly later in systole and increased with the grade of PSM. Similarly, the area under the strain curve of these segments increased significantly with the grade of PSM, compared with mid-anterior or mid-inferior segments. Severe acute cor pulmonale with a grade 2 PSM was significantly associated with mortality. Requalification in an upper PSM grade using LV radial strain allowed to better identify patients at risk of death (HR: 6.27 [95% CI 2.28–17.2] vs. 2.80 [95% CI 1.11–7.09]).ConclusionsIn objectively depicting PSM and quantitatively assessing its severity, TEE LV radial strain appears as a valuable adjunct to conventional two-dimensional imaging.

Comparison of visual estimation and quantitative measurement of left ventricular ejection fraction in untrained perioperative echocardiographers

BackgroundPerioperative evaluation of the left ventricular systolic function is essential information to help diagnose and manage life-threatening perioperative emergencies. Although quantifying the left ventricular ejection fraction (LVEF) is recommended to determine the left ventricular function, it may not always be feasible in emergency perioperative settings. This study compared the visual estimation of LVEF (eyeballing) by noncardiac anesthesiologists with the quantitative LVEF measured using a modified Simpson’s biplane method.MethodsTransesophageal echocardiographic (TEE) studies of 35 patients were selected and 3 different echocardiographic views (the mid-esophageal four chamber view, the mid-esophageal two chamber view, and the transgastric mid-papillary short axis view) were recovered from each study and displayed in random order. Two cardiac anesthesiologists certified in perioperative echocardiography independently measured LVEF using the modified Simpson method and categorized LVEF into five grades: hyperdynamic LVEF, normal, mildly reduced LVEF, moderately reduced LVEF and severely reduced LVEF. Seven noncardiac anesthesiologists with limited experience in echocardiography also reviewed the same TEE studies and estimated the LVEF and graded LV function. The precision of the LV function classification and the correlation between visual estimation of LVEF and quantitative LVEF were calculated. The agreement of measurements between the two methods was also assessed.ResultsPearson’s correlation between the LVEF estimated by the participants and the quantitative LVEF using the modified Simpson method was 0.818 (p < 0.001). Of a total of 245 responses, 120 (49.0%) responses were correct grading of the LV function. Participants were able to classify the LV function more accurately in the LV function grades 1 and 5 (65.3%). The 95% level of agreement of the Bland-Altman method was − 11.3-24.5. -21.9-22.6, − 23.1-26.5, − 20.5-22.0 and − 26.6-11.1 for LV grade 1 to 5, respectively.ConclusionVisual estimation of LVEF in perioperative TEE has acceptable accuracy in untrained echocardiographers and can be used for rescue TEE.

Collapsed Woman With a D-Shaped Left Ventricle on Echocardiogram

A 45-year-old woman presented to the emergency department with unwitnessed out-of-hospital cardiac arrest with asystole rhythm. After intubation, transesophageal echocardiography was performed to search for possible etiologies of cardiac arrest. It showed a D-shaped left ventricle at the midventricular level in the transgastric short-axis view (Figure A and Video, available at http://www.annemergmed.com). After the return of spontaneous circulation, transesophageal echocardiography revealed the resolution of the D-shaped left ventricle (Figure B). Dilated right ventricle because of cardiac arrest. The right ventricle to left ventricle ratio was described as an echocardiographic sign suggesting pulmonary embolism with high specificity in previous studies.1Fields J.M. Davis J. Girson L. et al.Transthoracic echocardiography for diagnosing pulmonary embolism: a systematic review and meta-analysis.J Am Soc Echocardiogr. 2017; 30: 714-723.e4Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar In our case, right ventricle dilation with septal flattening was also observed during resuscitation, which returned to normal size after the return of spontaneous circulation. In Aagaard's porcine studies,2Aagaard R. Caap P. Hansson N.C. et al.Detection of pulmonary embolism during cardiac arrest—ultrasonographic findings should be interpreted with caution.Crit Care Med. 2017; 45: e695-e702Crossref PubMed Scopus (27) Google Scholar,3Aagaard R. Granfeldt A. Bøtker M.T. et al.The right ventricle is dilated during resuscitation from cardiac arrest caused by hypovolemia: a porcine ultrasound study.Crit Care Med. 2017; 45: e963-e970Crossref PubMed Scopus (32) Google Scholar the right ventricle size showed no correlation with the causes of arrest. The right ventricle dilation might be inherent to cardiac arrest. Our case supported Aagaard’s studies; therefore, the dilated right ventricle noted on the echocardiography during resuscitation must be interpreted cautiously. Other differential diagnoses should be considered if the dilated right ventricle resolves after the return of spontaneous circulation. In patients with cardiac arrest, thrombus visualized in the proximal pulmonary arteries or right heart might be a more specific sign to diagnose pulmonary embolism and guide further treatment, such as thrombolytic therapy.4Konstantinides S.V. Meyer G. Becattini C. et al.2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).Eur Heart J. 2020; 41: 543-603Crossref PubMed Scopus (1340) Google Scholar Gastric ulcer perforation was diagnosed following the return of spontaneous circulation by computed tomography. Gastrorrhaphy and drainage of intra-abdominal abscess were done; however, the patient died the next day because of a profound septic shock. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0ODMwZGY4ZmNmZjg3MWZkNjRiYzVkNTgyMjQ1YTNhNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwOTg5Mzc1fQ.GE5j2RbdtAaHLdnx_AuVeAXfSftnIEpj1OAn9NZU9Stpu06w5LMVtZlgBhaB1tMFs6TOjMwr5LfsP17MhOD7AgBQr4O2BAy1vl0OVBHuhL5TuNK8RFAIVShVmQL_BYFiB4Py1xh8kiU5JsL9kuInpRDAEX4P1ANaxTL9CyTD4X3O9sFEHJLh6LgERT2fq6XjhXu3qODqLCmCDR5S7EOiP8HuU5Mt_PONO5bLGStTYYHOK1vIP7OlT_nLlacBrdeUxJqIHmLdtMZCEkZLFAPedhLGI0Tok-ncrbC-qlUnk1JI2PIYwPtgdKEJrxh6SHIK4D0haEmqAqE7Fbj6EggPDw Download .mp4 (2.92 MB) Help with .mp4 files VideoThe transesophageal echocardiography showing a D-shaped left ventricle at the midventricular level in the transgastric short-axis view during resuscitation, which turned back to a normal shape after the return of spontaneous circulation was achieved.

A Rare Cause of Severe Biventricular Dyssynchrony During Venoarterial Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Failure

A Rare Cause of Severe Biventricular Dyssynchrony During Venoarterial Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Failure

B-PO01-102 PATIENT SELECTION CONSIDERATIONS AND PROCEDURAL OUTCOMES FOR TRICUSPID TRANSCATHETER EDGE-TO-EDGE REPAIR IN PATIENTS WITH RIGHT VENTRICULAR LEADS: THE TRILUMINATE EARLY FEASIBILITY EXPERIENCE

Transcatheter edge-to-edge repair (TEER) for the treatment of isolated tricuspid regurgitation (TR) is emerging as an alternative to surgery. These patients commonly have right ventricular (RV) leads which must be evaluated on a patient-specific basis to determine the feasibility of TEER. To discuss selection criteria for tricuspid TEER in patients with RV leads and review procedural strategies and outcomes. 117 patients (18 with RV leads) were screened for enrollment into the TRILUMINATE feasibility study. Echocardiographic imaging was assessed to determine pacing lead location and mobility, potential procedural lead-to-device interaction, contribution to TR severity and appropriateness for TEER. Selection criteria were developed. Procedural strategy and core lab adjudicated outcomes are reported for the approved cases and compared between patients with and without RV leads. Twelve (out of 18) patients with RV leads were approved for enrollment. The reasons for exclusion were lead impingement (4), lead/leaflet interaction (1) and highly mobile lead (1). Transesophageal echocardiographic transgastric short axis views and mid esophageal right ventricle inflow/outflow views (with and without biplane imaging) were often used to make these assessments. Acute procedural success (APS) was achieved in 83% (10/12) of patients with RV leads. The two APS failures were due to the inability to achieve TR reduction at discharge. Both APS failures had RV leads located in the septal-posterior commissure and no complications were noted for either case. One single leaflet device attachment and no embolization occurred through 30-day follow-up. An average of 2.2 [1-4] clips were deployed per patient with 81%, 15% and 4% of clips in the anterior-septal, septal-posterior and anterior-posterior coaptation lines respectively. TR was reduced by 1.3 grades on average at 30-day follow-up with 75% of patients (9/12) achieving at least a one grade reduction. Outcomes were similar for patients with and without RV leads. Tricuspid TEER appears feasible and safe in appropriately selected patients with RV leads, with similar outcomes compared to patients without RV leads. These favorable results require further confirmation.

Assessment of tricuspid annulus: anatomic and echocardiographic correlation.

Tricuspid regurgitation is associated with a poor outcome and its quantification remains a challenge. Tricuspid annulus dilatation is one of the parameters that influences clinical decision-making. The aim of this study was to compare the use of 2D transoesophageal echocardiography with surgical assessment for the measurement of the tricuspid annulus. Sixty-one cardiac patients (median age 64years) were included in the study. Echocardiographic tricuspid annulus measurements were obtained from four chamber and transgastric short axis views and compared with the surgical measurements of this valve. The study was approved by the Ethics Committee of our institution. The tricuspid annulus measurements were obtained from the four chamber and the short axis views in 57 and 49 patients, respectively, while surgical measurement was performed in all 61 patients. Bland-Altman analysis of 49 tricuspid annulus-matched dimensions of the short axis view and surgical values showed a mean bias of 0.223mm/m2, with limits of agreement of -5.86 to 6.31mm/m2. Echocardiographic measurements of the tricuspid annulus dimension were accurate (90% sensitivity and 90% specificity for a four chamber view cut-off value ≥ 24.5mm/m2, and 89% sensitivity and 97% specificity for a short axis view cut-off value ≥ 37.6mm/m2, P < 0.0001; both cases) for detecting directly assessed annular dilatation by the surgeon in the operative field. Echocardiographic values of tricuspid annulus dimension have a good predictive value to detect surgically assessed annular dilatation and may help identify patients who require surgical tricuspid intervention.

Transesophageal echocardiography (TEE) in cardiac arrest: results of a hands-on training for a simplified TEE protocol

BackgroundIntegration of transesophageal echocardiography (TEE) with Focused Cardiac Ultrasound (FoCUS) can impact decision-making, assist in the diagnosis of reversible etiologies and help guiding resuscitation of patients with cardiac arrest.ObjectiveTo evaluate the ability of emergency physicians (EPs) to obtain and maintain skills in performing resusTEE after a course with clinical training in the cardiac surgery theatre.MethodsTen EPs without previous TEE experience underwent a resusTEE course, based on a 2-h workshop and an 8-h hands-on training. The training was performed in a cardiac surgery theatre tutored by cardiovascular anesthesiologists. The six taught views were mid-esophageal four-chamber (ME4CH), mid-esophageal long axis (MELAX), mid-esophageal two-chamber (ME2CH), mid-esophageal bicaval view (MEbicaval), transgastric short axis (TGSAX) and aorta view (AOview). The EPs were evaluated by a cardiovascular anesthesiologist at the end of the course as well as after 12 weeks according to a standardized evaluation method. Once the course was completed, resusTEE exams, performed by EPs in Emergency Department (ED), were monitored for a 12-week period.ResultsThe average assessment of the ten EPs by the tutors was higher than 4 points out of 5, both at the end of the course and after 12 weeks. Probe insertion, acquisition and interpretation of the different views scored on average more than 4 points out of 5 except for TGSAX that showed worsening after 12 weeks. Trainees performed twelve resusTEE exams in ED in patients with out-of-hospital cardiac arrest (OHCA) over 12 weeks after the course. EPs used only four out of six taught views in clinical practice, in the following order of frequency: ME4CH, AOview, MEbicaval and MELAX.ConclusionsEPs, after a course with clinical training in the cardiac surgery theatre, can successfully acquire and maintain the skills needed to perform resusTEE. However, among the six views learned in the course, EPs used only four of them (ME4CH, MEbicaval, MELAX and AOview).

Transesophageal echocardiography (TEE) found acute cor pulmonale in the transgastric midpapillary short-axis view. leading to adjustments of positive end-expiratory pressure (PEEP) to improve right ventricular function

Transesophageal echocardiography (TEE) found acute cor pulmonale in the transgastric midpapillary short-axis view. leading to adjustments of positive end-expiratory pressure (PEEP) to improve right ventricular function

Left ventricular aneurysm was found by transesophageal echocardiography (TEE) in the transgastric midpapillary short-axis view, which led to anticoagulation therapy

Left ventricular aneurysm was found by transesophageal echocardiography (TEE) in the transgastric midpapillary short-axis view, which led to anticoagulation therapy

Exaggerated Interventricular Dependence among Trauma and Burn Patients: A Relationship with Kidney Function—An Exploratory Study

Acute kidney injury (AKI) is a serious condition that affects critically ill patients admitted to the ICU. In this study, we report the association between right ventricle shape and AKI in a cohort of burn and trauma patients. This study is a retrospective review of trauma and burn patients who were admitted to our ICU between 2013 and 2016 who underwent hemodynamic transesophageal echocardiography. Left ventricular eccentricity index (LVEI) measurements were performed on still images obtained from transgastric short-axis view clips at end diastole. LVEI was used as a surrogate of right ventricular volume loading. There were 132 patients, the mean age was 50.8 years, and they were predominantly white and males. Using logistic regression and adjusting for age, race, gender, injury mechanism, and injury severity, higher LVEI was independently significantly associated with lower incidence of AKI (odds ratio 0.03, confidence interval 0.00-0.69). Higher LVEI is associated with a lower incidence of AKI in critically injured trauma and burn patients.

Focused transesophageal echocardiography for emergency physicians-description and results from simulation training of a structured four-view examination.

BackgroundTransesophageal echocardiography (TEE) offers several advantages over transthoracic echocardiography (TTE). Despite these advantages, use of TEE by emergency physicians (EPs) remains rare, as no focused TEE protocol for emergency department (ED) use has been defined nor have methods of training been described.ObjectiveThis study aims to develop a focused TEE examination tailored for the ED and to evaluate TEE skill acquisition and retention by TEE-naïve EPs following a focused 4-h curriculum.MethodsAcademic EPs were invited to participate in a 4-h didactic and simulation-based workshop. The seminar emphasized TEE principles and views obtained from four vantage points. Following the training, participants engaged in an assessment of their abilities to carry out a focused TEE on a high-fidelity simulator. A 6-week follow-up session assessed skill retention.ResultsFourteen EPs participated in this study. Immediately following the seminar, 14 (100 %; k = 1.0) and 10 (71.4 %, k = 0.65) successfully obtained an acceptable mid-esophageal four-chamber and mid-esophageal long-axis view. Eleven (78.6 %, k = 1.0) participants were able to successfully obtain an acceptable transgastric short-axis view, and 11 (78.6 %, k = 1.0) EPs successfully obtained a bicaval view. Twelve participants engaged in a 6-week retention assessment, which revealed acceptable images and inter-rater agreement as follows: mid-esophageal four-chamber, 12 (100 %; k = 0.92); mid-esophageal long axis, 12 (100 %, k = 0.67); transgastric short-axis, 11 (91.7 %, k = 1.0); and bicaval view, 11 (91.7 %, k = 1.0).ConclusionThis study has illustrated that EPs can successfully perform this focused TEE protocol after a 4-h workshop with retention of these skills at 6 weeks.Electronic supplementary materialThe online version of this article (doi:10.1186/s13089-015-0027-3) contains supplementary material, which is available to authorized users.

Selected Abstracts of the TEEPGI 2014 Workshop

ABSTRACT Mitral valve perforation is most commonly due to infective endocarditis. Iatrogenic mitral valve perforation following aortic valve replacement has not been described previously. A 57 years male patient presented with complaints of progressive dyspnea on exertion and occasional palpitations. A preoperative diagnosis of severe aortic stenosis, sclerodegenerative aortic valve with normal left ventricle function was made on transthoracic echocardiography. A coronary angiogram showed single vessel disease involving proximal left anterior descending artery causing 80% stenosis. The patient was planned for aortic valve replacement (AVR) and CABG. Pre bypass TEE showed bicuspid aortic valve, thick, calcified, severe aortic stenosis and normal left ventricle systolic function. Mitral valve was morphologically normal with mild central mitral regurgitation jet. Patient underwent CABG and AVR under cardiopulmonary bypass support. Post CPB TEE examination showed 2 jets of mitral regurgitation in midesophageal aortic long-axis view (Fig. 1). There was a mild central MR jet and an additional mild MR jet from the body of anterior mitral leaflet. Transgastric short axis view showed turbulence in the region of A1 scallop of anterior mitral leaflet. We present the intraoperative TEE images of the patient with a discussion on the role of TEE in detection of mitral valve perforation and surgical decision making.

A Heart in the Heart

A 65-year-old man with severe aortic stenosis was taken to the operating room for aortic valve replacement. After anesthetic induction and endotracheal intubation, a transesophageal echocardiography (TEE) probe was inserted and a transgastric basal short axis view was obtained as part of the standard comprehensive TEE examination.1 A slightly oblique imaging plane (omniplane angle of 10 degrees) of the transgastric basal short axis revealed a heart-shaped mitral valve orifice during the early left ventricular filling phase of diastole (Fig 1; Video clip 1) that resembled an epicycloid with one cusp during maximal diastolic opening.

Hemodynamic assessment of critically ill patients using a miniaturized transesophageal echocardiography probe

IntroductionHemodynamic management in intensive care patients guided by blood pressure and flow measurements often do not sufficiently reveal common hemodynamic problems. Trans-esophageal echocardiography (TEE) allows for direct measurement of cardiac volumes and function. A new miniaturized probe for TEE (mTEE) potentially provides a rapid and simplified approach to monitor cardiac function. The aim of the study was to assess the feasibility of hemodynamic monitoring using mTEE in critically ill patients after a brief operator training period.MethodsIn the context of the introduction of mTEE in a large ICU, 14 ICU staff specialists with no previous TEE experience received six hours of training as mTEE operators. The feasibility of mTEE and the quality of the obtained hemodynamic information were assessed. Three standard views were acquired in hemodynamically unstable patients: 1) for assessment of left ventricular function (LV) fractional area change (FAC) was obtained from a trans-gastric mid-esophageal short axis view, 2) right ventricular (RV) size was obtained from mid-esophageal four chamber view, and 3) superior vena cava collapsibility for detection of hypovolemia was assessed from mid-esophageal ascending aortic short axis view. Off-line blinded assessment by an expert cardiologist was considered as a reference. Inter-rater agreement was assessed using Chi-square tests or correlation analysis as appropriate.ResultsIn 55 patients, 148 mTEE examinations were performed. Acquisition of loops in sufficient quality was possible in 110 examinations for trans-gastric mid-esophageal short axis, 118 examinations for mid-esophageal four chamber and 125 examinations for mid-esophageal ascending aortic short axis view. Inter-rater agreement (Kappa) between ICU mTEE operators and the reference was 0.62 for estimates of LV function, 0.65 for RV dilatation, 0.76 for hypovolemia and 0.77 for occurrence of pericardial effusion (all P < 0.0001). There was a significant correlation between the FAC measured by ICU operators and the reference (r = 0.794, P (one-tailed) < 0.0001).ConclusionsEchocardiographic examinations using mTEE after brief bed-side training were feasible and of sufficient quality in a majority of examined ICU patients with good inter-rater reliability between mTEE operators and an expert cardiologist. Further studies are required to assess the impact of hemodynamic monitoring by mTEE on relevant patient outcomes.

Evaluation of Hepatic Structures by Transesophageal Echocardiography

A 52-year-old woman presented for orthotopic liver transplantation because of nonalcoholic steatohepatitis. She suffered hepatic encephalopathy, esophageal variceal bleeding, and Crohn’s disease. The TIPS procedure was performed 15 months ago with a VIATORR stent (W.L. Gore & Associates, Inc, Flagstaff, AZ) deployed through the right hepatic vein, intraparenchymal tract, and right portal vein to relieve portal hypertension. TEE showed a left ventricular ejection fraction of 50%, diastolic dysfunction, and ascites. From the transgastric short-axis view, the TEE probe was turned to the right and rotated to 53°. The right hepatic vein was found to be dilated to 2 cm. A 1-cm-wide tubular structure with echogenic walls was connected to the right hepatic vein anteriorly inside the hepatic parenchyma (Fig 1). Color-flow Doppler identified continuous flow into the right hepatic vein from this structure without significant turbulence. Pulse-wave Doppler revealed a flow velocity of 92.3 cm/s in systole and 70.1 cm/s in diastole (Fig 2). This structure was believed to e the metal stent placed during the TIPS procedure for two reasons: the chogenic wall and corrugated configuration are consistent with stent haracteristics, and continuous high-velocity forward flow rarely is oberved in native hepatic veins. Within TIPS stents, the high portal veino-hepatic vein pressure gradient exceeded the right atrial pressure (which s low because of intravascular depletion in liver failure patients) during oth systole and diastole, which resulted in persistent flow through the tent. The patient tolerated the liver transplantation well and was disharged home on postoperative day 10.

Massive Left Ventricular Pseudoaneurysm

A 50-year-old woman presented to the operating room for repair of a left ventricular pseudoaneurysm. She had a history of cardiac sarcoidosis which had manifested as dilated cardiomyopathy and recurrent ventricular tachycardia, which was treated with an endocardial/epicardial ablation six months ago. Transesophageal echocardiography at the transgastric basal short axis view demonstrated a 4 cm rupture of the basal inferolateral wall of the left ventricle close to the base of the posterior mitral valve annulus giving rise to a large (9.5 × 7 cm) pseudoaneurysm (Fig. 1). Three dimensional reconstruction (Fig. 2) as seen from within the pseudoaneurysm looking into the left ventricle shows the extent of the rupture. The mitral valve apparatus can be seen through the defect. The patient underwent a patch closure of the defect. Fig. 1 Transesophageal echocardiography. The transgastric basal short axis view demonstrated a 4 cm rupture of the basal inferolateral wall of the left ventricle close to the base of the posterior mitral valve annulus giving rise to a large pseudoaneurysm. The ... Fig. 2 Transesophageal echocardiography. Three dimensional reconstruction as seen from within the pseudoaneurysm looking into the left ventricle shows the extent of the rupture (see arrow). The mitral valve apparatus can be seen through the defect. The fundamental features that differentiate true aneurysms from false aneurysms are the presence of a continuous surrounding myocardial wall found in true aneurysms and the presence of a pericardial wall usually with mural thrombus found in false aneurysms.1) Due to its lack of structural myocardial support, a left ventricular pseudoaneurysm carries a significant risk of expansion and fatal rupture and therefore requires an urgent surgical intervention.2)

Initial Experience with a Disposable Transesophageal Echocardiography Monitoring System during Therapeutic Hypothermia following out of Hospital Cardiac Arrest

Objective: This investigation summarizes the initial clinical experience of trained echocardiographers who utilized a miniaturized disposable monoplane transesophageal echocardiography (TEE) system in patients undergoing therapeutic hypothermia following out of hospital cardiac arrest.Design: A retrospective, single-center, observational study. Setting: A tertiary care university hospital.Patients: We retrospectively reviewed the medical records of 13 consecutive patients undergoing therapeutic hypothermia following out of hospital cardiac arrest in which a disposable monoplane TEE probe was placed to observe myocardial recovery and potentially guide hemodynamic optimization. Measurements and Main Results: A total of 40 imaging sessions were performed. The success rate for obtaining the mid-esophageal four chamber and the transgastric mid-papillary short axis views were 92.5% and 100% respectively. Endocardial border definition was adequate in 90% of imaging sessions to measure left ventricular end diastolic and systolic areas enabling calculation of fractional area of change. Assessment of right ventricular function was possible in 92.5% of imaging sessions.A significant number of imaging sessions (12/40, 30%) provided information that clarified the patient’s biventricular function in the setting of ambiguous invasive pressure monitoring measurements.Conclusions: Acquisition of a mid esophageal four chamber and transgastric mid papillary view was possible with the miniaturized disposable TEE probe in the vast majority of imaging sessions. This information enabled the qualitative assessment of right ventricular function, measurement of left ventricular end systolic, and diastolic area with a high degree of success in patients during therapeutic hypothermia following cardiac arrest. The authors postulate that serial assessment of biventricular function and filling with serial TEE imaging provides information that cannot be reliably inferred from other advanced hemodynamic monitoring devices in routine clinical practice. This work was funded by the Department of Anesthesiology at Vanderbilt University Medical Center.