Transesophageal Echocardiography Research Articles

Isolated pulmonary valve endocarditis.

Isolated pulmonary valve endocarditis (IPE) is arare form of infectious endocarditis. This article reports the case of a49-year-old patient with IPE who was initially admitted with suspected cholecystitis. After vegetations were detected by transthoracic (TTE) and transesophageal echocardiography (TEE), antibiotic therapy in accordance with the antibiogram was primarily attempted; however, due to persistently elevated infection parameters and structural valve damage apulmonary valve replacement was eventually performed.

The presence of spontaneous echo contrast didn't increase the risk for left atrial appendage closure: A propensity score matching analysis based on the CLACBAC study

BackgroundLeft atrial appendage closure (LAAC) was effective in preventing thromboembolic events and stroke in patients with atrial fibrillation (AF). However, whether left atrial spontaneous echo contrast (LA-SEC) poses a higher risk for thromboembolism is contradictory. We aimed to investigate whether LA-SEC is a risk factor for thromboembolic events in patients who underwent LAAC. Methods258 consecutive patients who underwent successful LAAC were enrolled and divided according to the presence or absence of LA-SEC detected by transesophageal echocardiography (TEE). Propensity score matching (PSM) was used to eliminate covariate imbalances. Baseline characteristics, periprocedural details, and clinical outcomes were compared between LA-SEC and non-LA-SEC groups and PSM-matched groups. ResultsOf the 258 patients enrolled, mean age was 71.8 ± 8.3 years and 59.3 % were male. LA-SEC group had a higher percentage of persistent AF and worse cardiac function. No significant difference in peri-procedure parameters was found. Through follow-up of 38.1 ± 10.7 months, the total incidence of thromboembolic events and stroke was 7.8 % and 6.6 %, respectively. Though the event-free survival rate of thromboembolic events (Log-Rank P = 0.042) and stroke (Log-Rank P = 0.010) was significantly lower in the LA-SEC group, multivariable COX regression analysis showed LA-SEC was not an independent predictor of thromboembolic events (Hazard ratio 2.073, 95 % Confidence interval 0.845–5.082, P = 0.111). Further survival analysis between PSM-matched groups with comparable baseline characteristics presented no significant difference in survival free from thromboembolic events (Log-Rank P = 0.616) and stroke (Log-Rank P = 0.312). ConclusionPatients with LA-SEC had worse condition, while LA-SEC per se did not increase the incidence of thromboembolic events and stroke for patients who underwent LAAC.

Exploring the Complexities of Non-Bacterial Thrombotic Endocarditis: Highlights from Literature and Case Studies.

Non-bacterial thrombotic endocarditis (NBTE) is a form of non-infective endocarditis characterized by the deposition of sterile fibrin and platelets on cardiac valves. Even though some studies have identified important pathophysiological features, many aspects remain poorly understood. Given its wide availability, transthoracic echocardiography is typically the initial diagnostic approach to the patient. Additionally, recent technological advancements in transesophageal echocardiography, such as three-dimensional and multiplanar reconstruction analysis, have significantly improved diagnostic accuracy over time. By presenting our case series and performing a literature review, we focused on the main pathophysiologic, diagnostic, and therapeutic aspects of this rare but potentially life-threatening disease.

Role of Intraoperative Left Ventricular Global Longitudinal Strain in Hemodynamic and Cognitive Outcomes in On-Pump Coronary Artery Bypass Surgery: A Prospective Observational Study

ABSTRACT Background: The role of left ventricular global longitudinal strain (LVGLS) in coronary artery bypass grafting (CABG) and outcomes such as low cardiac output syndrome (LCOS) is not well established. The authors investigated the relationship between LVGLS before and after induction of anesthesia, their differences, and their relationship with LCOS and other outcomes. Methodology: A prospective observational study was conducted in a public/private hospital with 50 adult patients scheduled for on-pump CABG with normal left ventricular ejection fraction (LVEF). Acoustic windows necessary to obtain the 2D-LVGLS were acquired with transthoracic echocardiography (TTE) before induction of anesthesia (LVGLSBI) and after with mechanical ventilation (LVGLSAI) using transesophageal echocardiography (TEE). LCOS was defined as the use of epinephrine, dobutamine, and/or milrinone at minimum IV doses of 1 μg/min-1, 2.5 μg/kg-1/min-1, and 0.375 μg/kg-1/min-1, respectively, for a minimum of 24 h after cardiopulmonary bypass. Results: A dedicated workstation (EchoPAC Software v203, GE) was used for offline calculation of LVGLS. LVGLSBI did not have a significant correlation with LCOS (mean difference, 1.66; 95% CI, −–3.63 to 3.05; P = 0.862), nevertheless, it was an independent risk factor of in-hospital mortality (OR, 0.74; 95% CI, 0.57–0.95; P = 0.02), 3-month mortality (OR, 0.80; 95% CI, 0.64–0.99; P = 0.05), and delirium (OR, 0.65; 95% CI, 0.43–0.97; P = 0.03) in the multivariate analysis. LVGLSAI was also an independent risk factor for 3-month mortality (OR, 0.78; 95% CI, 0.62–0.99; P = 0.04). Conclusions: In CABG surgeries, LVGLS was a predictor of adverse outcomes in both awake and anesthetized patients with normal LVEF.

Characteristics of patients diagnosed for cardiac cause of ischemic neurological events and prescreened with a transcranial Doppler examination.

Screening for patent foramen ovale (PFO) in patients with ischemic neurological events is becoming more common. This study aimed to evaluate clinical characteristics and atrial septum anatomy in relation to age and presence of PFO, as well as factors associated with a history of stroke in patients assessed for cardiac causes of ischemic neurological events. A total of 817 patients with a history of neurological episodes (stroke, transient ischemic attack [TIA], or migraine) were prescreened using transcranial Doppler ultrasound. Transesophageal contrast echocardiography (TEE) was employed to confirm PFO and assess the anatomy of the atrial septum and right atrium. Among the patients, 28% had ischemic stroke, 31% had TIA, and 49% had migraines. PFO was confirmed in 79% of the patients. Regardless of the analyzed age group, PFO was associated with higher prevalence of TIA, migraine and syncope history, atrial septal aneurysm (ASA), and Chiari network. There were fewer women in the PFO group, but only in the population aged 45 years or under. Patient age, male sex, typical cardiovascular risk factors, and the presence of ASA were associated with a history of stroke. In patients with ischemic neurological events who were prescreened for PFO, confirmation of PFO on TEE was associated with a higher prevalence of TIA, migraine, syncope, Chiari network, and ASA. Advanced age, typical cardiovascular risk factors, and ASA were associated with stroke history in the study population.

Impact of the Aortomitral Positional Anatomy on Atrioventricular Conduction Disorder Following Mitral Valve Surgery.

Variations in the aortomitral positional anatomy, including aortic root rotation appear to be related to variations in the location of the conduction system, including the bundle of His. However, little is known about their clinical significance. This study included 147 patients with normal ECGs who underwent mitral valve surgery. The aortomitral anatomy was classified using preoperative 3-dimensional transesophageal echocardiography, and postoperative conduction disorders, including atrioventricular block and bundle branch block, were analyzed. Variations classified as aortomitral appearance were designated as having a center appearance (85.7%, n=126/147) or lateral appearance (14.3%, n=21/147) on the basis of whether the aortic root was located at the center or was shifted to the left fibrous trigone side. Subsequently, those with a center appearance, aortic root rotation was classified as having a center rotation (83.3% [n=105/126]), in which the commissure of the left and noncoronary aortic leaflet was located at the center, lateral rotation (14.3% [n=18/126]), rotated to the left trigone side, or medial rotation (2.4% [n=3/126]), rotated to the right. The incidence of 3-month persistent new-onset conduction disorder was higher in the lateral appearance than the center appearance group (21.1% versus 5.0%; P=0.031) and higher in the lateral rotation than in the center or medial rotation groups (29.4% versus 1.0% versus 0.0%, respectively; P<0.001). Aortomitral variations can be classified using 3-dimensional transesophageal echocardiography. Lateral appearance and lateral rotation are risk factors for conduction disorders in mitral valve surgery.

Presentation of mitral valve cleft with concurrent atrial septal defect and ventricular septal defect detected by three-dimensional transesophageal echocardiography: a case report

BackgroundCleft in the mitral valve leaflet is a primary cause of congenital mitral regurgitation, stemming from developmental anomalies in the mitral valve and frequently associated with other congenital heart defects. Concurrent presence of cleft in mitral valve leaflet with atrial septal defect and ventricular septal defect is relatively rare. Echocardiography, especially transesophageal echocardiography, is essential in diagnosing cleft mitral valve leaflet and related congenital heart defects, providing critical, detailed imagery for accurate assessment. This study presents a young female patient whose anterior mitral cleft, along with atrial septal defect and ventricular septal defect, was revealed through three-dimensional transesophageal echocardiography.Case presentationA 25-year-old Iranian female, experiencing progressive dyspnea and diminished physical capacity over 3 months, was referred to our hospital. Initial examination and transthoracic echocardiography indicated severe mitral regurgitation. Further evaluation with transesophageal echocardiography corroborated these findings and identified a cleft in the anterior mitral valve leaflet, coupled with mild left ventricular enlargement and significant left atrial enlargement. The complexity of the patient’s condition was heightened by the diagnosis of cleft mitral valve leaflet in conjunction with atrial septal defect and ventricular septal defect, showing the complex nature of congenital defects.ConclusionThis case emphasizes the critical role of transthoracic echocardiography in diagnosing cleft of mitral valve leaflet and associated cardiac anomalies, showcasing its superiority over transthoracic echocardiography for detailed visualization of cardiac structures. The identification of multiple congenital defects highlights the necessity for a comprehensive diagnostic approach to manage and treat patients with complex congenital heart diseases effectively. Future research should aim to refine diagnostic methodologies to enhance patient outcomes for cleft of mitral valve leaflets and related congenital conditions.

From ECG to Imaging: Challenges in the Diagnosis of Adult Congenital Heart Diseases.

Congenital heart diseases (CHD) are one of the most common birth defects and the main leading cause of death in children. Many patients with CHD are reaching adulthood due to the success of improved contemporary surgical procedures. Understanding the etiology of CHD remains important for patient clinical management. Both genetic and environmental factors are involved in the development and progression of CHD. Variations in many different genes and chromosomal anomalies can be associated with CHD, by expression of different mechanisms. Sporadic cases are the most frequently encountered in these patients. Atrial septal defect is a common congenital heart disease that refers to direct communication between atrial chambers, found isolated or associated with other syndromes. Imaging techniques, especially transthoracic and transesophageal echocardiography (TOE) represent the key for diagnosis and management of ASD. The disease has a major incidence in adulthood, due to late symptomatology, but assessment and treatment are important to avoid time-related complications. Ebstein's anomaly is a rare congenital disease, with a dominant genetic participation, characterized by an abnormal displacement of the tricuspid valve and right ventricular myopathy, often requiring surgical intervention. Alongside echocardiography, cardiac magnetic resonance (CMR) imaging is the gold standard tool for the assessment of ventricular volumes. Early diagnosis and adequate treatment are mandatory to avoid possible complications of CHD, and thus, ECG, as well as imaging techniques, are important diagnostic tools. However, patients with CHD need a special healthcare team for the entire monitorization in various life stages.

Safety and effectiveness of left atrial appendage closure in atrial fibrillation patients with different types of heart failure

BackgroundBoth atrial fibrillation (AF) and heart failure (HF) are common cardiovascular diseases. If the two exist together, the risk of stroke, hospitalization for HF and all-cause death is increased. Currently, research on left atrial appendage closure (LAAC) in patients with AF and HF is limited and controversial. This study was designed to investigate the safety and effectiveness of LAAC in AF patients with different types of HF.MethodsPatients with non-valvular atrial fibrillation (NVAF) and HF who underwent LAAC in the First Affiliated Hospital of Army Medical University from August 2014 to July 2021 were enrolled. According to left ventricular ejection fraction (LVEF), the study divided into HF with reduced ejection fraction (LVEF < 50%, HFrEF) group and HF with preserved ejection fraction (LVEF ≥ 50%, HFpEF) group. The data we collected from patients included: gender, age, comorbid diseases, CHA2DS2-VASc score, HAS-BLED score, NT-proBNP level, residual shunt, cardiac catheterization results, occluder size, postoperative medication regimen, transthoracic echocardiography (TTE) results and transesophageal echocardiography (TEE) results, etc. Patients were followed up for stroke, bleeding, device related thrombus (DRT), pericardial tamponade, hospitalization for HF, and all-cause death within 2 years after surgery. Statistical methods were used to compare the differences in clinical outcome of LAAC in AF patients with different types of HF.ResultsOverall, 288 NVAF patients with HF were enrolled in this study, including 142 males and 146 females. There were 74 patients in the HFrEF group and 214 patients in the HFpEF group. All patients successfully underwent LAAC. The CHA2DS2-VASc score and HAS-BLED score of HFrEF group were lower than those of HFpEF group. A total of 288 LAAC devices were implanted. The average diameter of the occluders was 27.2 ± 3.5 mm in the HFrEF group and 26.8 ± 3.3 mm in the HFpEF group, and there was no statistical difference between the two groups (P = 0.470). Also, there was no statistically significant difference in the occurrence of residual shunts between the two groups as detected by TEE after surgery (P = 0.341). LVEF was significantly higher in HFrEF group at 3 days, 3 months and 1 year after operation than before (P < 0.001). At 45–60 days after surgery, we found DRT in 9 patients and there were 4 patients (5.4%) in HFrEF group and 5 patients (2.3%) in HFpEF group, with no significant difference between the two groups (P = 0.357). One patient with DRT had stroke. The incidence of stroke was 11.1% in patients with DRT and 0.7% in patients without DRT (P = 0.670). There was one case of postoperative pericardial tamponade, which was improved by pericardiocentesis at 24 h after surgery in the HFpEF group, and there was no significant difference between the two groups (P = 1.000). During a mean follow-up period of 49.7 ± 22.4 months, there were no significant differences in the incidence of stroke, bleeding, DRT and HF exacerbation between the two groups. We found a statistical difference in the improvement of HF between HFrEF group and HFpEF group (P < 0.05).ConclusionsLAAC is safe and effective in AF patients with different types of HF. The improvement of cardiac function after LAAC is more pronounced in HFrEF group than in HFpEF group.

Infective Endocarditis in Patients With Bicuspid Aortic Valves: Unique Clinical and Microbiologic Features

Patients with bicuspid aortic valves (BAV) are at increased risk of infective endocarditis (IE). Information of the clinical presentation and the microbiology of BAV-associated IE, however, is limited. Therefore, our study aimed to characterise the clinical features native valve endocarditis (NVE) in the setting of BAV and compared them to patients with prosthetic valve endocarditis (PVE) following BAV replacement. Adult patients with BAV or history of BAV with aortic valve replacement (AVR) and a definite or possible IE diagnosis within the Mayo Clinic Enterprise (USA) from January 2008 to December 2021, were included. BAV was confirmed by trans-oesophageal echocardiography. IE was defined according to the modified Duke criteria and only an initial episode was included. Statistical analyses were performed to compare clinical characteristics, microbiology, and IE complications. Overall, 161 patients with BAV and IE (NVE [n=60], 37.3%) and PVE [n=101, 62.7%) were included. Mean age±SD was 56.5±16.1 years, and 139 (86.3%) patients were males. PVE patients were older (p<0.01) and had a higher rate of hypertension (p<0.01), chronic heart failure (p<0.01), chronic kidney disease (p<0.01), and perivalvular abscess (p<0.01). BAV patients with NVE had a higher prevalence of isolated mitral valve IE (p<0.01), moderate to severe aortic valve regurgitation (p<0.01) and combined aortic with mitral valve IE (p<0.01). Streptococcus mitis was the most common pathogen in NVE (30.0%) while Staphylococcus aureus was the most common in PVE (15.8%). Patients with BAV are at risk of both NVE and PVE. Each syndrome has unique clinical features, including microbiologic findings, that should be appreciated in IE diagnosis and management.

Transesophageal echocardiography: Revolutionizing perioperative cardiac care.

Cardiovascular diseases (CVDs) are a major challenge in global health. Despite significant advances in treatment and management, the incidence and mortality rates of CVDs have been rising in recent years, particularly in the United States. With continuous advancements in medical technology, perioperative transesophageal echocardiography (TEE) has become a key technology in cardiac surgery, enhancing surgical success rates and patient safety. The application of TEE spans preoperative planning, intraoperative monitoring, and postoperative evaluation, especially in complex procedures such as mitral valve repair and aortic valve replacement, where it plays an indispensable role. Simultaneously, the introduction of artificial intelligence (AI) brings new prospects for TEE image analysis and diagnostic support, significantly improving diagnostic accuracy and real-time decision-making capabilities. However, the application of TEE technology faces challenges such as high costs, uneven technological diffusion, and the high skill requirements for medical personnel. Therefore, establishing standardized training protocols and strengthening multidisciplinary collaboration are crucial. This paper reviews the application of TEE in cardiac surgery and its path toward educational and practical standardization from a global perspective, emphasizing its importance in improving the postoperative quality of life for patients and exploring future directions in technological innovation and educational optimization.

Right-to-left shunt due to iatrogenic atrial septal defect manifested by aorto-caval fistula: a case report

BackgroundAn aorto-caval fistula is a rare but critical complication of abdominal aortic aneurysm (AAA) rupture, leading to high-output heart failure and increased venous pressure. The anesthetic management of such cases, particularly when complicated by an intraoperative right-to-left shunt, is seldom reported.Case presentationA 71-year-old man with a history of atrial fibrillation and catheter ablation presented with heart failure and abdominal pain, leading to cardiac arrest. Imaging revealed an AAA rupture into the inferior vena cava. During emergency surgery, severe venous bleeding was managed using intra-aortic balloon occlusion (IABO). Transesophageal echocardiography (TEE) identified a right-to-left shunt due to an iatrogenic atrial septal defect.ConclusionEarly TEE recognition and timely IABO intervention were crucial in managing this complex case, underscoring the importance of these techniques in similar emergency scenarios.

Application of a simplified transesophageal echocardiography examination sequence in high-risk cardiac surgery

BackgroundIn cardiac surgical procedures, patients carrying high-risk profiles are prone to encompass complicated cardiopulmonary bypass (CPB) separation. Intraoperative transesophageal echocardiography (TEE), a readily available tool, is utilized to detect cardiac structural and functional pathologies as well as to facilitate clinical management of CPB separation, especially in the episodes of hemodynamic compromise. However, the conventional TEE examination, always performed in a liberal fashion without any restriction of view acquisition, is relatively time-consuming; there appear its flaws in the context of critically severe status. We therefore developed the perioperative rescue transesophageal echocardiography (PReTEE), a simplified three-view TEE protocol consisting of midesophageal four chamber, midesophageal left ventricular long axis, and transgastric short axis.MethodsThis is a single-center and randomized controlled trial which will be implemented in Peking Union Medical College Hospital, Beijing, China. A total of 46 TEE scans are schemed to be performed by 6 operators participating in and randomly assigned to either the PReTEE or the conventional TEE group. This study is purposed to investigate whether the efficiency of discriminating leading causes of difficult CPB wean-off can be significantly improved via an abbreviated sequence of TEE views. The primary outcome of interest is the difference between the groups of PReTEE and the conventional TEE in the successful discrimination of etiologies in specified 120 s. Cox proportional hazards model will be further employed to calculate the outcome difference.DiscussionThe estimated results of this trial are oriented at verifying whether a simplified TEE exam sequence can improve the efficiency of etiologies discrimination during CPB separation in cardiac surgery.Trial registrationClinicalTrials.gov NCT05960552. Registered on 6 July 2023.

Early and Mid-Term Follow-up Results of Device Closure of Secundum Atrial Septal Defects Using Transesophageal Echocardiogram Guidance: A Comparison of Percutaneous Versus Peratrial Approaches

Background: Percutaneous closure of secundum atrial septal defects (ASDs) under only transesophageal echocardiogram (TEE) guidance is less invasive and avoids exposure to radiation, but the treatment of choice is controversial. Methods: One hundred and forty-four patients with a secundum ASD were included in this study. The patients received percutaneous device closure (PCDC/TEE) (n = 74) or peratrial device closure (PDC/TEE) (n = 70). A double-disk ASD occluder was used in both groups. The treatment was performed under only TEE guidance in both groups. Physical exams, electrocardiography, and echocardiography were performed immediately after device release, and at discharge, 3, 6, 12 months, and at yearly intervals after the procedure. Results: In ASD with a maximum diameter less than 20 mm, the successful closure rate was 100% for all PCDC/TEE and PDC/TEE. When the ASD diameter was between 20 mm and 25 mm, the success rate was 84% for PCDC/TEE and 100% for PDC/TEE. The average intracardiac manipulation time was 19.4 ± 6.4 minutes for PCDC/TEE and 5.7 ± 7.0 minutes for PDC/TEE (p &lt; 0.001). The average procedure time was 23.1 ± 6.8 minutes for PCDC/TEE and 51.1 ± 8.2 minutes for PDC/TEE (p &lt; 0.001). The postoperative hospital stay was 3 ± 1 days for PCDC/TEE and 5 ± 1 days for PDC/TEE (p &lt; 0.001). For the mean follow-up of 520 ± 256 days, there no cardiac deaths or significant residual shunts were documented in either group. Conclusions: In patients with an ASD less than 25 mm, PCDC/TEE is a safe and effective method of ASD closure. Additionally, PCDC/TEE is less traumatic, provides better cosmetic results, and decreases hospital stays. However, when the ASD diameter is greater than 20 mm and the aortic rim of ASD is less than 3 mm, the peratrial approach may be a better choice.

Perioperative Assessment and Clinical Outcomes of Percutaneous Atrial Septal Defect Closure with Three-Dimensional Transesophageal Echocardiography.

To close the atrial septal defect (ASD) with the transcatheter method, correctly defining the defect and selecting the appropriate closure device size are the most critical steps for the procedure's success. Although ASD can be successfully closed under the guidance of three-dimensional (3D) transesophageal echocardiography (TEE) and two-dimensional (2D) TEE, measurement comparisons between different types of defects are still needed. Our study was designed retrospectively. Sixty-one patients who underwent transcatheter ASD closure with 2D TEE and 3D TEE between 2020 and 2024 were included. The patients were divided into three groups according to the defect shape: circular, oval, and complex; and the measurement results, perioperative process, and clinical outcomes were compared in each group. The average age of the patients was 35.05 ± 13.87 years, and 41 (67.2%) were women. The average follow-up period of the patients was 15.3 ± 9.18 months. No statistical significance was observed in the comparison of measurements obtained with 3D TEE and 2D TEE in the circular and oval defect groups. The differences between the minimum defect diameters of complex defects measured by 2D TEE and 3D TEE (p: 0.037), IVC rims (p < 0.001), aortic rims (p: 0.012), and the differences between implanted device dimensions and the maximum defect diameters measured by both methods were compared; statistical significance was observed (p: 0.025). In circular and non-complex oval defects, it has been observed that the size of the closure device selected with 2D TEE or 3D TEE is optimal, and the procedure is practical and feasible. While the closure of complex ASDs with 3D TEE provides reliable and optimal results, using only 2D TEE in complex ASDs may lead to selecting a smaller-sized device.

Acute type B aortic dissection following transcatheter mitral valve edge-to-edge repair: a case report

Abstract Background Transoesophageal echocardiography is rarely reported as a possible cause of aortic dissection during the transcatheter edge-to-edge repair procedure. Herein, we present a case of type B aortic dissection following the transcatheter mitral valve edge-to-edge repair procedure, most likely related to the transoesophageal echocardiography probe. Case summary A 68-year-old Chinese man complained of exertional dyspnoea lasting over 2 years and had been diagnosed with severe mitral regurgitation. He was admitted to our hospital for the treatment of severe mitral regurgitation with transcatheter edge-to-edge repair. One MitraClip XTR (Abbott Vascular) was successfully implanted under the guidance of active transoesophageal echocardiography, and the mitral regurgitation became trace. However, the patient complained of persistent back pain after the treatment, and computed tomography angiography revealed a type B aortic dissection in the descending aorta. After 2 weeks of unsuccessful conservative treatment, he successfully underwent endovascular stenting and was discharged from the hospital. The patient recovered well and remained event free during the 6-month follow-up. Discussion Herein, we presented a rare complication following transcatheter mitral valve edge-to-edge repair that was most likely related to the transoesophageal echocardiography probe—type B aortic dissection. We postulated that repetitive flexion of the transoesophageal echocardiography probe led to compression-induced injury to the descending aorta wall at the mid-oesophageal level, which was the most probable aetiology of type B aortic dissection. Although this complication is rare, it is potentially fatal and therefore needs attention.

Atypical Presentation of a Cardiac Lipoma

Cardiac masses can have atypical presentations and diagnosis can be difficult because of limitations in imaging modalities. We report the case of a 69-year-old man with a history of hypertension and hyperlipidemia who presented with several months of dyspnea with exertion. There was a soft systolic murmur on exam. Transthoracic echocardiogram showed a large right atrial mass that appeared to be adherent to the interatrial septum. Considering the size and apparent attachment to the interatrial septum the suspicion was a myxoma. After further imaging however, including transesophageal echocardiogram, cardiac computed tomography (CT) and cardiac magnetic resonance imaging (MRI) the diagnosis changed to a lipoma. The patient had surgical resection of the mass which confirmed the diagnosis. A multi-imaging approach may be helpful and required to accurately diagnose cardiac masses.

Accuracy of mitral valve annulus measurements by two-and three-dimensional transesophageal echocardiography, compared to intraoperative measurements in patients undergoing mitral valve replacement surgery

Introduction: Transthoracic echocardiography (TTE) is the most beneficial diagnostic modality for mitral valve (MV) diseases. However, it is not accurate enough for MV annular sizing. Recent evidence has demonstrated the superiority of transesophageal echocardiography (TEE) over TTE. The present study aimed to evaluate the accuracy of two-dimensional TEE (2D-TEE) and three-dimensional TEE (3D-TEE) in preoperative measuring of MV size and specifications. Methods: This cross-sectional study evaluated patients with mitral valve replacement (MVR) surgery at Shahid Madani Heart Center of Tabriz university of Medical Sciences, Tabriz, Iran, in 2020. Thirty-eight patients admitted for MVR surgery were enrolled in this study. Demographic, electrocardiogram (ECG), and echocardiographic studies -including TTE, 2D, and 3D TEE- were performed preoperative for each patient. The accurate size and the specifications of the studied structure were measured by a surgical gauge caliper during the surgery, which was considered the gold standard value. The correlations between obtained parameters were evaluated using Pearson’s correlation coefficient. The data obtained from individual were entered into the SPSS software. Significance was set at P&lt;0.05. Results: The mean age of patients was 55.89±11.81 years, and 65.8% were male. Most patients (68.4%) had sinus rhythm. The strongest correlation with the gold standard was observed in mitral annulus circumference measured by the three-dimensional multiplanar reconstruction (3D MPR) method in all patients (r=0.758, P&lt;0.001), [(r=0.723, P&lt;0.001) for patients with sinus rhythm, and (r=0.825, P=0.001) for patients with atrial fibrillation (AF)]. The minor difference between the echocardiographic measurements and the surgical rule was related to the short axis (SA) in the 3D MPR method (3.3 mm). Conclusion: This study illustrated a high correlation between 3D-MPR TEE measured MV annulus and intra-operative measurements using a surgical gauge caliper as the gold standard.

Anesthesia Management of a Child with Severe Pectus Excavatum Complicated with Heart Compression Displacement

We report the anesthesia management of a severe pectus excavatum with cardiac compression displacement under thoracoscopic correction with general anesthesia. Preoperative chest computed tomography showed that the lower end of the sternum was significantly depressed, and the distance between the depressed sternum and the spine was less than 2cm. The heart was obviously compressed and shifted to the left thoracic cavity. During the intraoperative reversal of the orthopedic plate, the blood flow velocity of the tricuspid valve increased to 87.9cm/s and showed a single peak. The transesophageal echocardiography indicated mild tricuspid valve regurgitant flow, and the blood pressure dropped rapidly. After the surgeon was informed of the situation, the orthopedic plate was quickly turned to the convex side up, and the locally depressed anterior chest wall was lifted up. Satisfactory correction of chest wall malformations.

Severe Intraprosthetic Aortic Insufficiency Immediately After Implantation of an SAPIEN 3 Ultra RESILIA Valve with Spontaneous Resolution: Case Report

Abstract Background Aortic insufficiency(AI) is often encountered in Transcatheter Aortic Valve Replacement(TAVR) but is only rarely hemodynamically significant. Even more uncommon is the occurrence of intraprosthetic AI which often leads to hemodynamic compromise requiring additional therapeutic intervention. Case Summary An 85 year old female with severe aortic stenosis underwent elective TAVR with a size 23mm SAPIEN 3 Ultra RESILIA(S3UR) valve. After implantation, the patient developed hypotension. Transthoracic as well as transesophageal echocardiogram identified significant transvalvular AI. Persistence of AI led the team to consider a TAV-in-TAV strategy. Before a second valve system could be inserted, the patient’s blood pressure improved and AI resolved spontaneously. The patient was discharged recovered with no AI on follow up imaging studies. Discussion This is the first reported case of significant intraprosthetic AI with the new S3UR in our literature search as of writing. The new S3UR valve has several improvements from previous generations designed to increase valve area and durability as well as decreasing the incidence of paravalvular and intraprosthetic leaks. A stuck leaflet was inferred as the cause of the intraprosthetic AI and the improved design with excessive expansion may have led to this. Unlike previous case reports, intraprosthetic AI resolved without further intervention likely due to the turbulence of flow releasing the stuck leaflet. Cautious observation prevented the need for a TAV-in TAV for a rare and possibly catastrophic complication.