Transesophageal Echocardiographic Study Research Articles

Analysis of risk factors for venous air embolism in the semisitting position and its impact on outcome in a consecutive series of 740 patients.

Routine use of the semisitting position, which offers several advantages, remains a matter of debate. Venous air embolism (VAE) is a potentially serious complication associated with the semisitting position. In this study, the authors aimed to investigate the safety of the semisitting position by analyzing data over a 20-year period. The incidence of VAE and its perioperative management were analyzed retrospectively in a consecutive series of 740 patients who underwent surgery between 1996 and 2016. The occurrence of VAE was defined by detection of bubbles on transthoracic Doppler echocardiography (TTDE) or transesophageal echocardiography (TEE) studies, a decrease of end-tidal CO2 (ETCO2) by 4 mm Hg or more, and/or an unexplained drop in systolic arterial blood pressure (≥ 10 mm Hg). From 1996 until 2013 TTDE was used, and from 2013 on TEE was used. The possible risk factors for VAE and its impact on surgical performance were analyzed. There were 404 women and 336 men with a mean age at surgery of 49 years (range 1-87 years). Surgery was performed for infratentorial lesions in 709 patients (95.8%), supratentorial lesions in 17 (2.3%), and cervical lesions in 14 (1.9%). The most frequent pathology was vestibular schwannoma. TEE had a higher sensitivity than TTDE. While TEE detected VAE in 40.5% of patients, TTDE had a detection rate of 11.8%. Overall, VAE was detected in 119 patients (16.1%) intraoperatively. In all of these patients, VAE was apparent on TTDE or TEE. Of those, 23 patients also had a decrease of ETCO2, 18 had a drop in blood pressure, and 23 had combined decreases in ETCO2 and blood pressure. VAE was detected in 24% of patients during craniotomy before opening the dura mater, in 67% during tumor resection, and in 9% during wound closure. No risk factors were identified for the occurrence of VAE. Two patients had serious complications due to VAE. Surgical performance in vestibular schwannoma surgery was not affected by the presence of VAE. This study shows that the semisitting position is overall safe and that VAE can be managed effectively. Persistent morbidity is very rare. The authors suggest that the semisitting position should continue to have a place in the standard armamentarium of neurological surgery.

Role of Echocardiography in the Diagnosis and Interventional Management of Atrial Septal Defects.

This review centers on the usefulness of echo-Doppler studies in the diagnosis of ostium secundum atrial septal defects (ASDs) and in their management, both in children and adults. Transthoracic echocardiography can easily identify the secundum ASDs and also differentiate secundum ASDs from other kinds of ASDs, such as ostium primum ASD, sinus venosus ASD and coronary sinus ASD, as well as patent foramen ovale. Preliminary selection of patients for device occlusion can be made by transthoracic echocardiograms while final selection is based on transesophageal (TEE) or intracardiac (ICE) echocardiographic studies with optional balloon sizing of ASDs. TEE and ICE are extremely valuable in guiding device implantation and in evaluating the position of the device following its implantation. Echo-Doppler evaluation during follow-up is also useful in documenting improvements in ventricular size and function, in assessing the device position, in detecting residual shunts, and in identifying rare device-related complications. Examples of echo images under each section are presented. The reasons why echo-Doppler is very valuable in diagnosing and managing ASDs are extensively discussed.

Procedural and short-term follow-up outcomes of Amplatzer Amulet occluder versus Watchman FLX device: A meta-analysis.

Procedural and short-term follow-up outcomes of Amplatzer Amulet occluder versus Watchman FLX device: A meta-analysis.

Mitral Annulus Geometry and Dynamic Motion Changes in Patients With Aortic Regurgitation: A Three-Dimensional Transesophageal Echocardiographic Study

The aim of the present study was to investigate the mitral annulus (MA) geometry and dynamic motion changes in patients with aortic regurgitation (AR) before and after aortic valve replacement (AVR). Moreover, the difference in the effect of the type of prosthetic aortic valve on MA was compared. Prospective observational study. Cardiac operating room at a single hospital. Eighty-two patients with isolated moderate-to-severe AR who underwent AVR. Forty patients with normal valves were enrolled as controls. None. The MA geometry and dynamic motion throughout the cardiac cycle were evaluated semiautomatically by three-dimensional transesophageal echocardiography. The severity of functional mitral regurgitation was intraoperatively evaluated. All patients were divided into 2 groups depending on the type of prosthetic valve (mechanical valve and bioprosthetic valve groups). Before AVR, compared with the control group without AR, the AR group demonstrated larger MA dimensions and the MA geometry was flatter. The contraction fraction of the MA area, perimeter, and height during the whole cardiac cycle were larger in the AR group (p < 0.05 for all). After AVR, most MA geometric and dynamic parameters decreased and functional mitral regurgitation also improved. In the postoperative subset analyses, the mechanical valve group showed a larger contraction fraction of the MA area and perimeter than the bioprosthetic valve group (p < 0.05 for both). The MA geometry and dynamic motion changed markedly in patients with AR. These spatial and dynamic changes were restored to a certain extent after surgical correction of the aortic valve. However, the effects produced by mechanical and bioprosthetic valves on MA were different.

A systematic transoesophageal echocardiography study of suture-mediated percutaneous patent foramen ovale closure.

A systematic transoesophageal echocardiography study of suture-mediated percutaneous patent foramen ovale closure.

Prospective national audit of major gastrointestinal complications of transesophageal echocardiography studies in children.

Background:Perioperative trans-esophageal echocardiography ('TEE') is widely used for the assessment of anatomy/repair of congenital cardiac defects. It is recognised that there are risks associated with its use.Aims:We wished, by means of a contemporaneous prospective national audit over a six-month period, to establish what proportion of TEE studies in children are complicated by major upper gastrointestinal or upper aerodigestive tract trauma.Methods:After obtaining appropriate local institutional ethics committee approval, a national prospective audit of the rate and severity of gastrointestinal complications of trans-esophageal echocardiography studies in anaesthetised adult cardiology and cardiac surgical patients was conducted by the Association of Cardiothoracic Anaesthesia and Critical Care in the United Kingdom and Ireland during the twelve months of 2017. During the second six months of the audit, the Congenital Cardiac Anaesthesia Network (an organisation including anaesthetists with a paediatric cardiac anaesthetic practice in all the United Kingdom cardiac surgical centres) prospectively audited the incidence of such complications of TEE studies in children.Results:A total of 1,059 studies were included in this six-month paediatric audit. There were no reports of the specified major complication.Statistical Analysis:The zero incidence of the major complication is consistent with a worst possible incidence of five per thousand TEE examinations.Conclusions:Such potentially reassuring information could be included in discussions with patients or families about the risk of trans-esophageal studies in children.

Interobserver Variation in Echocardiographic Measurements and Grading of Tricuspid Regurgitation Based on a Novel Web-Based Assessment Environment

The primary aim of this study was to assess interobserver variability in grading tricuspid regurgitation (TR) severity. The authors' secondary goals were to delineate which transesophageal echocardiographic (TEE) parameters best correlate with severity and how consistent the participants were at grading severity. This was a prospective cohort study of how clinicians evaluated previously acquired TEE images and videos. The 19 TEE studies of patients with TR were recorded by 4 senior echocardiographers across 4 US academic institutions. The participants evaluated these cases on a novel, web-based, assessment environment designed specifically for this study. Twenty-nine fellowship-trained and board-certified cardiologists and cardiothoracic anesthesiologists volunteered to participate in the study as observers from 19 different institutions. No interventions were performed on the participants. For each case, participants measured the vena contracta (VC), proximal isovelocity surface area (PISA), and jet area before giving a final classification on the severity of TR. Variation was highest for effective regurgitant orifice area and lowest for VC and PISA. The coefficient of variation, defined as the standard deviation from the mean divided by the mean, for all cases of trace, mild, moderate and severe TR were as follows: Jet Area-111%, 46%, 48%, 76%; VC-67%, 44%, 43%, 36%; PISA-52%, 48%, 31%, 35%; and effective regurgitant orifice area-127%, 95%, 66%, 58%. The interobserver variation in quantifying TEE parameters for TR is high, suggesting these may be difficult to measure reliably in a busy perioperative setting. Of the parameters assessed, VC and PISA radius had the highest interobserver agreement and the highest correlation with severity.

Temporal Changes and Clinical Implications of Delayed Peridevice LeakFollowing Left Atrial AppendageClosure.

The aim of this study was to assess temporal changes and clinical implications of peridevice leak (PDL) after left atrial appendage closure. Endocardial left atrial appendage closure devices are alternatives to long-term oral anticoagulation (OAC) for patients with atrial fibrillation. PDL >5mm may prohibit discontinuation of OAC. Patients included in the study had: 1) successful Watchman device implantation without immediate PDL; 2) new PDL identified at 45 to 90days using transesophageal echocardiography; 3) eligibility for OAC; and 4) 1 follow-up transesophageal echocardiographic study for PDL surveillance. Relevant clinical and imaging data were collected by chart review. The combined primary outcome included failure to stop OAC after 45 to 90days, transient ischemic attack or stroke, device-related thrombi, and need for PDL closure. Relevant data were reviewed for 1,039 successful Watchman device implantations. One hundred eight patients (10.5%) met the inclusion criteria. The average PDL at 45 to 90days was 3.2 ± 1.6mm. On the basis of a median PDL of 3mm, patients were separated into≤3mm (n=73) and >3mm (n=35) groups. In the≤3mm group, PDL regressed significantly (2.2 ± 0.8mm vs 1.6 ± 1.4mm; P=0.002) after 275 ± 125days. In the >3mm group, there was no significant change in PDL (4.9 ± 1.4mm vs 4.0 ± 3.0mm; P=0.12) after 208 ± 137days. The primary outcome occurred more frequently (69% vs 34%; P=0.002) in the >3mm group. The incidence of transient ischemic attack or stroke in patients with PDL was significantly higher compared with patients without PDL, irrespective of PDL size. New PDL detected by transesophageal echocardiography at 45 to 90days occurred in a significant percentage of patients and was associated with worse clinical outcomes. PDL≤3mm tended to regress over time.

Orifice Areas of Balloon-Expandable Transcatheter Heart Valves: A Three-Dimensional Transesophageal Echocardiographic Study

Accurate expected effective orifice area (EOA) values for balloon-expandable (BE) transcatheter heart valves (THV) are crucial for preventing patient-prosthesis mismatch (PPM) and assessment of THV function. Currently published reference EOAs, however, are based on transthoracic echocardiography (TTE), which may be subject to left ventricular outflow tract diameter underestimation and/or suboptimal THV Doppler interrogation. The objective of this study was to establish reference EOA values for BE THVs on the basis of Doppler and three-dimensional (3D) transesophageal echocardiography (TEE). Two hundred twelve intraprocedural transesophageal echocardiographic examinations performed during BE THV implantation with optimal postimplantation Doppler and 3D imaging were retrospectively reviewed. Continuity equation-derived EOAs were compared with geometric orifice areas by 3D planimetry (GOA3D). Performance indices (i.e., EOA normalized to valve size) and PPM rates were determined. TTE-based EOAs obtained within 30days were also calculated in a subset of 170 patients. The average EOA for all BE THV valves (77% SAPIEN 3) was 2.3±0.5cm2, while the average EOA was 1.6±0.2cm2 for 20-mm, 2.0±0.2cm2, for 23-mm, 2.5±0.3cm2 for 26-mm, and 3.0±0.3cm2 for 29-mm THV size (P<.001). Bland-Altman analysis demonstrated very good agreement between EOA and GOA3D (bias -0.04±0.15cm2). There were strong correlations between annular area and TEE-based EOA (R=0.84) and GOA3D (R=0.87). The mean performance index was 47±5% and was similar for all THV sizes (P=.21). EOAs based on TTE were smaller compared with those based on TEE, while the correlation with annular area (R=0.67) and agreement with GOA3D (bias -0.26±0.43cm2) was not as strong. The overall PPM rate was 2% in the TEE cohort and 12% in the TTE cohort. EOAs for BE THVs based on intraprocedural Doppler and 3D TEE suggest that previously published TTE-based reference values for EOA are underestimated, while PPM rates may be overestimated. Our findings have important clinical implications for preimplantation decision-making and for the evaluation of THV hemodynamics and function during follow-up.

Transesophageal echocardiography for cardiovascular risk estimation in patients with sepsis and new-onset atrial fibrillation: a multicenter prospective pilot study

BackgroundEchocardiographic parameters have been poorly investigated for estimating cardiovascular risk in patients with sepsis and new-onset atrial fibrillation. We aim to assess the prevalence of transesophageal echocardiographic abnormalities and their relationship with cardiovascular events in mechanically ventilated patients with sepsis and new-onset atrial fibrillation.MethodsIn this prospective multicenter pilot study, left atrial/left atrial appendage (LA/LAA) dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were assessed using an initial transesophageal echocardiographic study, which was repeated after 48–72 h to detect LA/LAA thrombus formation. The study outcome was a composite of cardiovascular events at day 28, including arterial thromboembolic events (ischemic stroke, non-cerebrovascular arterial thromboembolism, LA/LAA thrombus), major bleeding, and all-cause death.ResultsThe study population comprised 94 patients (septic shock 63%; 35% women; median age 69 years). LA/LAA dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were detected in 17 (19%), 22 (24%), and 27 (29%) patients, respectively. At day 28, the incidence of cardiovascular events was 46% (95% confidence interval [CI]: 35 to 56). Arterial thromboembolic events and major bleeding occurred in 7 (7%) patients (5 ischemic strokes, 1 non-cerebrovascular arterial thromboembolism, 2 left atrial appendage thrombi) and 18 (19%) patients, respectively. At day 28, 27 patients (29%) died. Septic shock (hazard ratio [HR]: 2.36; 95% CI 1.06 to 5.29) and left ventricular systolic dysfunction (HR: 2.06; 95% CI 1.05 to 4.05) were independently associated with cardiovascular events.ConclusionsTransesophageal echocardiographic abnormalities are common in mechanically ventilated patients with sepsis and new-onset atrial fibrillation, but only left ventricular systolic dysfunction was associated with cardiovascular events at day 28.

Assessing the left atrial appendage thrombus using 3D transesophageal echocardiography and pulse wave doppler

Abstract Background/Introduction In some patients, detecting and visualizing left atrial appendage (LAA) thrombus (especially at fundus level) seems to be challenging. Thus looking for indirect signs such as morphology, size and function may be of use. Purpose Finding echocardiographic signs suggesting presence of LAA thrombus using 3D TEE &amp; pulse wave doppler. Methods We collected data via transesophageal echocardiography (TEE) from different set of patients with diseased heart (valvular especially mitral stenosis, congenital, pre-cardiac conversion for atrial fibrillation). And that by using EPIQ7 echo machine by Phillips. With each patient, we acquired pulse wave doppler determining the maximum (telesystolic) emptying velocity at mid LAA (MEV-LAA), and maximum long axis surface area of LAA (LAA-SA) using Xplan modality or multiplanar reconstruction from gated 3D acquisitions of LAA. Doing so we tried to assess the relationship between LAA thrombus and its morphology (2D/3D) using the 04 shapes classification (windsock, cauliflower, chicken wing, cactus), measuring LAA-SA considering a cutoff of 6cm2 or above a dilated LAA. A MEV-LAA considered diminished if less than 25cm/s. Finally we calculated the ratio of LAA-SA/MEV-LAA. Results We assessed a group of 55 patients. LAA thrombus was visualized in 10 of them. The predominant morphology was windsock 50.9% then equally chicken wing and cauliflower 14.5%, cactus 11%. Thrombus occurred in major part with cauliflower type with 50% of all patients with the same shape. LAA was dilated in 25 patients in whom 7 had LAA thrombus (Se: 70% Sp: 60% PPV: 22%). LAA maximum emptying velocity was reduced in 18 patients in whom 10 had LAA thrombus (Se: 100% Sp: 82.2% PPV: 36%). We found that 7 patients with a ratio LAA-SA/MEV-LAA &amp;lt;1.7 had LAA thrombus (Se: 70% Sp: 97.8% PPV: 47%). Cauliflower morphology has the highest occurrence of thrombus as demonstrated in the literature. LAA-SA is the least reliable criteria associated with LAA thrombus. MEV-LAA is has the most sensible value of the three measurements. The ratio LAA-SA/MEV-LAA seems to have the highest specificity and positive predictive value in terms of association with thrombus (in cauliflower type this ratio seems to be less specific). Some limitations of this study was the limited number of patients assessed, no comparison in terms of sex (LAA size is different in men and women according to literature), sinus rhythm versus atrial fibrillation (LAA maximum emptying velocity), no correlation with CT-scan of LAA concerning dimensions and thrombus. Conclusion 3D transesophageal echocardiography and pulse wave doppler study of the LAA seems to be associated with thrombus formation especially indirect signs and indexed values (ratio LAA-SA/MEV-LAA), that tends to push the diagnostic power of TEE. Promptly this will lead to more investigations on a large scale number of patients in different sub-type groups. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Mustapha Pacha University Hospital Center, department of Cardiology A2 3D TEE of LAA and Mitral prosthesisXplan on LAA, cauliflower type

AN INTRA-OPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHIC STUDY TO COMPARE THE EFFECT OF SEVOFLURANE AND ISOFLURANE ON LEFT VENTRICULAR DYSFUNCTION IN PATIENTS WITH ISCHEMIC HEART DISEASE UNDERGOING CORONARY ARTERY BYPASS GRAFTING USING CARDIOPULMONARY BYPASS

An Intra-operative Transesophageal Echocardiographic Study to Compare The Effect of Sevourane and Isourane on Left Ventricular Dysfunction In Patients With Ischemic Heart Disease Undergoing Coronary Artery Bypass Grafting Using Cardiopulmonary Bypass Context : Diastolic dysfunction has been increasingly recognized as an important cause of congestive heart failure (CHF) and resultant morbidity. About 50% patients with CHF have 'diastolic heart failure' in spite of a normal systolic function with preserved ejection fraction. The widely used volatile anesthetic agents, Isourane and Sevourane, are considered important components of balanced anesthesia technique. However their effects on left ventricular (LV) systolic and diastolic function have not been precisely dened. This study was designed to quantify and compare their effects on left ventricular function by TEE before start of CPB. Aims : To compare the effects of Isourane and Sevourane on echocardiographic LVsystolic and diastolic parameters. Settings and design : After obtaining institutional ethics committee clearance and informed consent from 60 patients operated within my study period was included . Data were collected after induction and just before going on bypass. Materials and Methods : After inducing the patients with institutional protocol one group was given isourane(Group I) and another group was given sevourane(Group S), both at 1MAC. TEE parameters measuring LVsystolic and diastolic functions were done. Statistical analysis : Data were analysed by Epi Info (TM) 7.2.2.2. Result and conclusion :Isourane was better than sevourane in comparism of systolic and diastolic dysfunction.

Differences in mitral valve geometry between atrial and ventricular functional mitral regurgitation in patients with atrial fibrillation: a 3D transoesophageal echocardiography study.

This study investigated geometric differences in mitral valve apparatus between atrial functional mitral regurgitation (A-FMR) and functional mitral regurgitation (FMR) with left ventricular (LV) dysfunction in patients with atrial fibrillation (AF) using 3D transoesophageal echocardiography (TOE). In total, 135 moderate or greater FMR patients with persistent AF or atrial flutter underwent 3D TOE. Fifty-six patients had A-FMR, defined as preserved LV ejection fraction (LVEF) of ≥50% and normal LV wall motion. Seventy-nine patients had ventricular FMR (V-FMR), defined as LV dysfunction (LVEF of <50%) or LV wall motion abnormality. To evaluate mitral leaflet coaptation, the coapted area was calculated as follows: total leaflet area (TLA) in end-diastole - closed leaflet area in mid-systole. Although annular area (AA) did not significantly differ between the two groups, TLA was significantly smaller in A-FMR than in V-FMR (P = 0.005). TLA/AA, indicating the degree of the leaflet remodelling, was significantly smaller in A-FMR than in V-FMR (P < 0.001). A-FMR had significantly smaller posterior mitral leaflet tethering height and angle measured at three anteroposterior planes (lateral, central, and medial) than V-FMR (all P < 0.001). However, vena contracta width (VCW) measured on long-axis view on TOE and coapted area, which correlated with VCW (r = -0.464, P < 0.001), were similar between the two groups. Mitral leaflet remodelling may be less in A-FMR compared with V-FMR. However, leaflet tethering was smaller in A-FMR than in V-FMR, and this may result in a similar degree of mitral leaflet coaptation and mitral regurgitation severity.

Basic Transesophageal Echocardiography Education for Senior Anesthesiology Residents—Institutional Experience

The use of basic transesophageal echocardiography (TEE) in critically ill and older surgical patients can change patient management and improve outcomes after noncardiac surgery. The authors hypothesized that educating the future generation on basic TEE skills by an intense two-month rotation will help them achieve basic TEE certification by the National Board of Echocardiography (NBE) and facilitate good use of their skills for patient care during their practice. This is a descriptive report of graduating anesthesiology residents who completed two months basic TEE rotation at the authors' residency program between 2013 and 2019. The authors report the clinical training goals, NBE testamur and certification status, and a survey report on the use of basic TEE skills in their practice SETTINGS: University medical center. Residents who completed two months basic TEE rotation during their Clinical Anesthesia (CA)-3 year. None. Of a total of 115 residents, 67 (58%) elected basic TEE rotation. The NBE basic TEE certification and testamur status were achieved by 12 (21%) and 14 (24%) eligible residents, respectively. Residents (n = 43) personally performed 73 ± 21 (mean ± standard deviation) and reviewed 72 ± 28 (mean ± standard deviation basic TEE studies before graduation. The survey indicated that 63.4% of residents trained in basic TEE did not use their skills in their practice. Two months' basic TEE rotation was able to fulfill its educational goals (testamur status and clinical training) but fell short on achieving NBE certification rate and its ultimate impact on practice and patient care.

Comparative study of cardiac magnetic resonance imaging and transesophageal echocardiography in detection of left atrial and left atrial appendage thrombi

Abstract Funding Acknowledgements Type of funding sources: None. Background Left atrial (LA) thrombi are the most common intracardiac masses. Left atrial appendage (LAA) is the most common site for thrombus formation in patients with atrial fibrillation (AF), and in patients with valvular lesions. Transesophageal echocardiography (TEE) has been the conventional investigation for thrombus detection. However, because TEE is a semi-invasive technique; a completely non-invasive technique would be of great concern. Purpose The aim of this study is to evaluate the feasibility and diagnostic performance of cardiac magnetic resonance imaging (CMR), for the assessment of thrombi in the left atrium and left atrial appendage (LA/ LAA). Also whether CMR is comparable to TEE in identification and measurement of thrombus size. Methods We studied 43 patients who were diagnosed to have LA/LAA thrombus, or highly suspected thrombus by TEE. They underwent multisequence CMR for assessment of thrombus detection; within 7 days of TEE performance. Data collected from CMR study were statistically analyzed to evaluate for sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and overall accuracy of detection of LA/LAA thrombus using TEE as the gold standard. Also agreement between both imaging techniques was assessed using kappa agreement coefficient. We conducted a questionnaire where 10 questions were asked to every patient in the study. It aimed to obtain an idea about patients’ opinion of both tests. Results During the study period of 13 months, 43 patients were assessed. Twenty one patients had AF and 22 patients were in sinus rhythm. The median CHA2DS2VASc score of AF patients was 2.52 ± 1.12, and 76.7% of patients were undergoing anticoagulation therapy. In all subjects, the LAA was readily visualized with CMR. When evaluating the diagnostic performance of CMR results revealed overall sensitivity, specificity, PPV, NPV and accuracy of 97.44%, 75%, 97.44%, 75% and 95.35% respectively. Results of questionnaire was statistically significant p value yielding good overall opinion for the sake of CMR. There was an additional role for CMR regarding tissue characterization; where CMR detected 3 cases, diagnosed by TEE as thrombus, 1 case revealed Libman-Sacks Endocarditis and 2 cases revealed fibroelastoma. This made a paradigm shift in patient management. Conclusion CMR is a noninvasive, feasible and comparable modality for thrombus detection in the LA and LAA and could be a reasonable, more comfortable alternative to TEE.

Left ventricular outflow tract area after percutaneous transseptal transcatheter mitral valve implantation: A three‐dimensional transesophageal echocardiography study

Left ventricular (LV) outflow tract (LVOT) obstruction increases mortality in patients undergoing transcatheter mitral valve implantation (TMVI) in degenerated bioprostheses, annuloplasty rings, and native mitral valves. We aimed to evaluate the LVOT area after TMVI using 3-dimensional (3D) transesophageal echocardiography (TEE) and to investigate the preprocedural cardiac geometry that affects the LVOT area after TMVI. We retrospectively reviewed echocardiography data in 43 patients who had TMVI. A change in pressure gradient across LVOT from before to after TMVI (∆PG) and postprocedure 3D LVOT cross-sectional area at the level of the most distal portion of the mitral valve stent that was closest to the LV apex were assessed as evidence of LVOT narrowing. Transcatheter mitral valve implantation with the use of balloon-expandable valve system was performed for 24 bioprostheses, 7 annuloplasty rings, and 12 native valves. Compared to patients without increase in LVOT gradient (∆PG <10mm Hg; n=33), patients with increase in LVOT gradient (∆PG ≥10mm Hg; n=10) had smaller LV end-systolic volume (LVESV), greater LV ejection fraction (LVEF), and smaller aorto-mitral (AM) angle. The LVOT area at the valve stent distal edge showed strong association with ∆PG (r=-.68, P<.0001). Only a small AM angle was associated with a small LVOT area at the valve stent distal edge on multivariable analysis, independent of LVESV and LVEF. Small LV size, preserved LVEF, and small AM angle were associated with LVOT narrowing. 3D-derived AM angle might be independently associated with LVOT narrowing in patients undergoing transcatheter mitral valve-in-valve, valve-in-ring, and valve-in-native valve implantation, independent of LVESV and LVEF.

The Effect of Transesophageal Echocardiography Probe Insertion in Endotracheal Tube Cuff Pressure in Adult Cardiac Surgical Patients.

Background and Aims: Insertion of transesophageal echocardiography probe in cardiac surgical patient is a routine practice for surgical planning and decision making. However it may increase the endotracheal tube cuff pressure as it lies adjacent to the posterior wall of trachea. The aim of this study is to evaluate the changes in cuff pressure after insertion of the transesophageal echocardiography probe and after completion of initial manipulation of the transesophageal echocardiography probe during various examinations in adult cardiac surgical patients.&#x0D; Methods: Thirty six patients undergoing elective cardiac surgery requiring Transesophageal Echocardiography (TEE) monitoring were enrolled in the study. After induction of general anesthesia and endotracheal intubation cuff pressure were measured at 3 points of time; just after intubation (T1), after transesophageal probe insertion (T2) and after initial completion of TEE study (T3). The mean increase in cuff pressure at various point of time were compared.&#x0D; Results: The cuff pressure (mean±SD) at T1, T2 and T3 were 24.61±2.72, 30.22±5.61 and 32.25±4.45 cm of H2O respectively.The cuff pressure increased significantly from T1 to T2 (p&lt;0.001) and from T1 to T3 (p&lt;0.001). The cuff pressure was &gt; 30 cm of H2O in 18 (50%) of patients at T3 which was readjusted back to 25-30 cm of H2O by with drawing air from the cuff.&#x0D; Conclusion: Endotracheal tube cuff pressure should be routinely monitored either intermittently or continuously after transesophageal echocardiography probe insertion till it is in situ and pressure should be readjusted to avoid unwanted complications.

Propofol sedation administered by cardiologists in echocardiography studies

Introduction and objectivesThe advantages of sedation in patients undergoing transesophageal echocardiography (TEE) are well established, but the increasing number of TEE studies may limit the capacity of anesthesiology services. In this study we analyze the effectiveness and safety of a moderate sedation program carried out by non-anesthesiology professionals (NAP). MethodsDescriptive and prospective study that included all consecutive patients undergoing a TEE procedure under moderate sedation by NAP and by anesthesiology professionals (AP) from September 2018 to September 2019. Patients were selected according to a specific algorithm agreed upon with the Anesthesiology Department. We analyze current indications for TEE, complication rates, and recovery times associated with sedation. ResultsWe performed 267 procedures in 252 patients (54% male, 69 years). Main indications were screening or monitoring of surgical and percutaneous cardiac interventions (47.9%), endocarditis (28.5%) and stroke (20.6%). Patients in the NAP group were younger (59 vs 71 years), less hypertensive (43% vs 61%), with less lung disease (4% vs 24%), lower risk of difficult airway (1% vs 22%) and lower comorbidity (ASA scale≥III 13% vs 77%). Complications were more frequent in the AP group (26% vs 9%), mainly mild respiratory (19% vs 9%). Events were associated with the presence of lung disease and higher ASA degree. Recovery time was longer in the AP sedation group (20min vs 15min). ConclusionsTEE indications are changing and involve larger and more complex studies. Moderate sedation with propofol performed by NAP is safe in selected patients, with adequate recovery times.

Impact of ultrasound contrast agent during transoesophageal echocardiography on the sizing of the left atrial appendage

IntroductionInterventional closure of the left atrial appendage closure (LAAC) has been established as an alternative treatment in patients with atrial fibrillation (AF) and an increased risk of stroke. So far...

Transpericardial 3D Echocardiography in the Sheep Model, Facilitating Real Time Anatomical Assessment for Planning and Guiding Transcatheter Mitral Valve Replacement and Repair

Symptomatic mitral regurgitation (MR) is associated with high morbidity and mortality which can be ameliorated by surgical valve replacement or repair. Despite this, many patients are excluded from surgery. Transcatheter mitral repair and replacement has emerged as a promising therapeutic option for the treatment of severe MR. The majority of these procedures rely on high definition three dimensional (3D) transesophageal echocardiographic (TEE) real time imaging. The sheep model is the model of choice for preclinical studies of transcatheter mitral valve (MV) replacement and repair. However due to the thoracic conformation TEE studies in those animals are suboptimal. In this study we tested and compared the feasibility of conventional TEE and newly described transpericardial 3D echocardiography (TPE) for assessment of the MV as a tool to plan and possibly guide transcatheter/transapical procedures in the sheep model. The conventional TEE was challenging and produced incomplete data in all of the animals. In contrast, the TPE method clearly depicted the left atria and ventricle, MV apparatus, LVOT, aortic valve and proximal ascending aorta facilitating high resolution 3D rendering in all of the animals. The value of TEE in the sheep model is limited and could not be reliable for complete assessment of the LV and mitral valve apparatus. Whereas, TPE produce reliable and similar imaging to TEE in the human patients which could allow animal testing of devices designed to be delivered in humans.