Use Of Transesophageal Echocardiography Research Articles

Assessment of the Characteristics of Patent Foramen Ovale Associated with Cryptogenic Stroke.

This study aims to comprehensively assess the characteristics of patent foramen ovale (PFO) in relation to Cryptogenic Strok (CS) by utilizing transesophageal echocardiography (TEE) and contrast transthoracic echocardiography (c-TTE) and to identify high-risk factors associated with PFO-related CS. Transcatheter PFO closure has demonstrated its effectiveness in preventing PFO-related CS. Therefore, understanding the specific structural attributes of PFO associated with CS is imperative. Enrollment comprised 113 test patients who experienced CS in conjunction with PFO and 117 control patients diagnosed with migraine with PFO but without a history of stroke. The characteristics of the PFO were observed by TEE and c-TTE. A comparative analysis was undertaken to assess the variations in PFO characteristics between the test patients and controls, and to uncover the independent factors relevant to CS. The patients in the test group were older than the controls. Both the height and length of the PFO during Valsalva exhibited greater dimensions in the test group when contrasted with controls. Notably, the test group presented higher incidence rates of low-angle PFO (defined as an angle between the inferior vena cava (IVC) and PFO ≤ 10°) and atrial septal aneurysm (ASA) as contrasted with the control group. Right-to-left shunt (RLS) III during Valsalva demonstrated a significantly elevated occurrence within the test group as opposed to the controls. Conversely, RLS II during Valsalva exhibited a significantly higher frequency in the controls in contrast to the tests. No significant disparities were observed between the two groups with respect to RLS I during Valsalva and all grades of RLS at rest. Multivariate analysis revealed that the length of the PFO during Valsalva, the presence of ASA, RLS III during Valsalva and low-angle PFO were independent relevant factors associated with CS. The length of the PFO tunnel, low-angle PFO, RLS III during Valsalva and the presence of ASA were independent risk factors for CS. The combined utilization of TEE and c-TTE may prove valuable in identifying PFO patients at a heightened risk of CS and in facilitating the screening process for transcatheter PFO closure.</p>.

Anaesthetic Management of a Large Atrial Septal Defect with Severe Tuberculous Constrictive Pericarditis: A Case Report

The combination of constrictive pericarditis (CP) and atrial septal defect (ASD) is a rare medical condition. Surgical intervention is typically considered the superior treatment option for patients with this condition. In this report, we present a rare case where a patient presented both a large ASD and severe tuberculous CP. The role of anesthesia is crucial in surgical procedures involving this complex cardiac conditions. Factors such as hemodynamic stability, fluid management, and preservation of cardiac function must be carefully considered. The utilization of transesophageal echocardiography (TEE) proved highly advantageous in this case, as it guided the medical team through various phases of treatment. By closely monitoring cardiac function with TEE, changes and improvements be accurately evaluated over time. This case report discusses the anesthetic management issues of this complex disease.

Transesophageal Echocardiography Utilization to Visualize Thrombi in the Pulmonary Vein Stump, Post Lung Lobectomy

Lung lobectomy can cause a cerebral infarction due to thrombus formation in the pulmonary vein (PV). While contrast-enhanced computed tomography (CT) has commonly been used to detect thrombi, the utility of transesophageal echocardiography (TEE) for thrombus visualization, in the PV stump, is less known. Herein, a series of cases are provided, in which TEE was able to detect a thrombus in the PV stump, as an embolic source of a cerebral infarction. Transesophageal echocardiography is a powerful imaging technique for evaluating thrombi mobility and properties, which are impossible with enhanced CT. Thus, TEE can contribute to identifying the cause of stroke when the embolic source is unknown.

Implementation of a Liver Transplant-Specific TEE Guide to Expand TEE Utilization and Improve Workflow During Orthotopic Liver Transplantation.

Transesophageal echocardiography (TEE) is being increasingly utilized during orthotopic liver transplantation to guide perioperative management. Obstacles of improving TEE utilization include the challenge of becoming familiar with the TEE machine, optimizing TEE images, and translating skills acquired in didactic or simulator center-based training into clinical use. In an effort to expand TEE utilization and improve workflow among the liver transplantation (LT) anesthesiologists at our institution, a LT-specific TEE guide was created to serve as a reference and educational tool during LT. A 26-question survey was distributed to all LT anesthesiologists before and 6 months after implementation of the LT-specific TEE guide. All seven LT anesthesiologists completed the survey questions during the study period. No statistically significant difference was detected in participant-reported confidence in optimizing targeted TEE views, performing technical aspects of the exam, navigating the knobs on the TEE machine, or in ability to identify abnormal cardiac pathology during the study period. One participant became basic-TEE certified during the study period. Implementing a liver transplant-specific TEE guide is a strategy to expand TEE utilization, encourage longitudinal TEE education and reinforce concepts learned from hands-on education sessions; however, we did not detect a difference in participant-reported confidence of performing a TEE exam, ability to identify abnormal cardiac pathology or altering workflow. Further studies with larger sample sizes will be needed to evaluate the effectiveness of a LT-specific TEE guide.

Is there a reduced confidence towards direct oral anticoagulants compared to vitamin K antagonists in patients scheduled for an elective electrical cardioversion? The results of the BLITZ-AF study

ObjectiveTo study the confidence of cardiologists in performing an electrical cardioversion in patients on oral anticoagulation (OA) with or without transoesophageal echocardiography (TOE). MethodsData about atrial fibrillation (AF) patients admitted to cardiology wards for elective cardioversion (ECV) were extrapolated from the BLITZ-AF study. Percentage of vitamin K antagonists (VKAs), direct oral anticoagulants (DOAC) and heparin prescription were analysed in relation to the use of TOE before ECV. ResultsOverall rate of TOE was 33.7% (240/713); it was used before ECV in 124/313 (39.6%) of DOACs patients and in 96/372 (25.8%) of the patients on VKAs, showing a significant reduced resort to TOE in VKAs patients (p = 0.0001). Among non-valvular patients TOE was more frequently performed in males, at younger ages and in patients on heparin when compared to patients treated with OA. TOE was also more frequently performed in tertiary hospitals and in hospitals with cardiology wards and electrophysiology labs, when compared to hospital provided only with cardiology wards. At multivariable analysis there was a significant less recourse to TOE in patients on VKAs (OR 0.47; 95% CI: 0.33–0.67) and higher recourse in the heparin group (OR: 3.85; 95% CI:1.59–9.28) with respect to patients on DOACs; a higher recourse to TOE was observed also in tertiary hospitals (OR 4.25; 95% CI 2.69–6.69) and in hospitals with cardiology wards and electrophysiology (EP) labs (OR 1.87; 95% CI 1.23–2.82). Conclusionour study shows the reluctance in cardioverting patients on DOACs respect to VKAs without a previous TOE, despite adequate anticoagulant treatment.

Assessment of regional wall motion abnormality using transesophageal echocardiography in patient undergoing off pump coronary artery bypass grafting – An observational study

Context: Transesophageal echocardiography (TOE) has been widely used intraoperatively in cardiovascular surgeries. Its influence on perioperative decision-making in both surgical and pharmacological planning has been well recognized. A study was undertaken to establish the fact that the routine use of TOE not only reduces the complications of Coronary artery bypass grafting procedures, but also helps in better surgical decision-making. Aims: To compare the regional wall motion abnormality (RWMA) using TOE at pre and postgrafting Off-pump coronary artery bypass (OPCAB) procedure. Settings and Design: The study design involves institutional setting and observational study. Subjects and Methods: Seventy-two adult patients undergoing elective OPCAB procedures were included between January 2019 and June 2020. RWMA and ejection fraction (EF) were assessed before grafting and postgrafting using intraoperative TOE (IOTOE) to quantify the improvement of wall motion, if no improvement then the need for graft revision or additional grafting was suggested. Statistical Analysis Used: Quantitative outcomes were compared using paired t-tests. SPSS 20.0 was used to analyze the data collected. P < 0.05 was considered to be statistically significant. Results: Sixty-five (90%) patients had RWMA and EF improvement after the grafting and 3 (4%) patients had improvement after graft revision as suggested by IOTOE. So, 68 (94%) patients out of 72 had good surgical outcomes. The comparison between pre and postgrafting EF showed a statistically significant difference i.e., P < 0.05. Conclusions: IOTOE can be used routinely as a definitive mandatory monitoring tool to help in appropriate intra-operative surgical decision-making in patients undergoing OPCAB to enable better surgical outcomes and thereby reduce the morbidity and mortality associated with the procedure.

Utility of transesophageal echocardiography during orthotopic liver transplantation: A narrative review.

Orthotopic liver transplantation (OLT) is the standard of care for patients suffering from end stage liver disease (ESLD). This is a high-risk procedure with the potential for hemorrhage, large shifts in preload and afterload, and release of vasoactive mediators that can have profound effects on hemodynamic equilibrium. In addition, patients with ESLD can have preexisting coronary artery disease, cirrhotic cardiomyopathy, porto-pulomary hypertension and imbalanced coagulation. As cardiovascular involvement is invariable and patient are at an appreciable risk of intraoperative cardiac arrest, Trans esophageal echocardiography (TEE) is increasingly becoming a routinely utilized monitor during OLT in patients without contraindications to its use. A comprehensive TEE assessment performed by trained operators provides a wealth of information on baseline cardiac function, while a focused study specific for the ESLD patients can help in prompt diagnosis and treatment of critical events. Future studies utilizing TEE will eventually optimize examination safety, quality, permit patient risk stratification, provide intraoperative guidance, and allow for evaluation of graft vasculature.

Transesophageal echocardiography guided transseptal puncture and nadir temperatures in cryoballoon pulmonary vein isolation.

IntroductionCryoballoon (CB) guided pulmonary vein isolation (PVI) is an established procedure in the treatment of atrial fibrillation (AF). Transseptal access is an indispensable step during PVI and may be associated with severe complications. For specific interventions, specific puncture sites of the fossa ovalis are advantageous. Here, we analyzed the potential impact of a transesophageal echocardiography (TOE) guided transseptal puncture on nadir temperatures in CB PVI.Methods and ResultsWe retrospectively analyzed 209 patients undergoing CB PVI in our hospital. The use of TOE had been at the operator’s discretion. No TOE‐related complications such as perforation of the pharynx or esophagus or loss of teeth were noted. Concerning the applied freezes, we found significantly lower nadir temperatures in all PVs in the TOE group than in the non‐TOE group. Procedure time and fluoroscopy time and complications were similar in both groups.ConclusionTOE‐guided TSP in CB PVI is safe and feasible. Our study found significantly lower nadir temperatures of CB freezes after TOE‐guided TSP which potentially underscores the value of a more infero‐anterior puncture site.

Suggested modification of the recommendations for echocardiography in patients with clinical suspicion of infective endocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Infective endocarditis (IE) is a serious condition that requires prompt diagnosis and treatment. Transthoracic echocardiography (TTE) is usually the initial imaging modality, however transoesophageal echocardiography (TOE) is often necessary because of its higher sensitivity for IE compared with TTE. Yet, TOE has an increased risk of complications. The European Society of Cardiology (ESC) has established guidelines for the management of IE with recommendations for the use of TOE in patients with clinical suspicion of IE. Purpose This project aims to evaluate the ESC recommendations for the use of TOE in patients with clinical suspicion of IE. The purpose of the study is further to examine whether the ESC recommendations for TOE among patients with clinical suspicion of IE result in an unnecessarily large number of negative TOE examinations. Methods All TOE examinations performed due to referrals of patients with clinical suspicion of IE between 1 May 2019 and 30 April 2020 at a university hospital in our city were analysed. The variables included for analysis were age; sex; cardiac comorbidities; prosthetic valves; blood culture results; results from TTE and TOE; number of TOEs during the inclusion period; Duke criteria. The TOE and TTE results were compared in relation to the ESC guidelines. Results In total 195 TOE examinations from 160 patients were included, of which 61 (31%) TOEs were positive for IE. All examinations were of patients with clinical suspicion of IE, of which 37 (19%) had negative TTE. Of the 37 patients with negative TTE, 13 had prosthetic valve or intracardiac device of which 5 had positive TOE. All the 24 (12%) examinations with negative TTE and no prosthetic valve or intracardiac device had negative TOE. Conclusions The ESC recommendations for TOE in patients with clinical suspicion of IE are probably broad enough not to miss patients with IE, but there might be an unnecessarily large number of patients that get referred for TOE with negative results. To avoid this, we propose a modification of the recommendations for TOE in patients with clinical suspicion of IE. Negative TTE examination with good image quality and no indications for TOE according to Fig 1, could result in avoiding unnecessary TOE examinations without jeopardizing the IE diagnosis. Abstract Figure. Fig 1

Utility of transesophageal echocardiography in the identification and treatment of occult mechanisms of cerebral infarction

Cryptogenic stroke comprises approximately 25% of all cases of ischemic stroke. The diagnostic evaluation of these patients remains a challenge in clinical practice. Transesophageal echocardiography (TEE) has been shown to have superior diagnostic accuracy in identifying potential cardioembolic sources of ischemic stroke when compared to transthoracic echocardiography (TTE). However, there has been inconsistent data on the management implications of these new cardiac findings. The addition of TEE to the comprehensive stroke evaluation will better identify potential cardiac sources of embolism (CSE) and will result in significant management changes. A prospective registry of consecutively admitted patients with acute ischemic stroke (1/1/2015–8/10/2020) was retrospectively queried. Patients 18 to 60 years of age with stroke due to mechanisms other than large or small vessel disease, or atrial fibrillation were eligible for inclusion. The primary outcome was any high-risk CSE identified on TEE following unrevealing TTE. Of the 2,404 consecutive stroke patients evaluated during the study period, 263 (11%) met inclusion criteria and the median age was 53 (IQR 46–57). TEE was performed in 108 patients (41%). A high-risk CSE was identified in 36 patients (33%), the majority of which were PFOs (n = 29). TEE led to a clinical management change in 14 patients (39%) after identification of a high-risk CSE; 6 underwent PFO closure and 8 had adjustment to their antithrombotic therapy. The addition of TEE to the comprehensive stroke evaluation led to the identification of a high-risk CSE in one in three patients resulting in significant management changes.

UTILIZATION OF TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN INFECTIVE ENDOCARDITIS DIAGNOSIS: A SINGLE CENTRE EXPERIENCE

<h3>BACKGROUND</h3> Echocardiography plays a key role in the diagnosis of infective endocarditis (IE). Although transesophageal echocardiography (TEE) has a higher sensitivity in identifying the presence of vegetations than transthoracic echocardiogram (TTE), it is a more invasive investigation with higher risk to the patient and higher cost to the healthcare system. Owing to a high prevalence of intravenous drug use (IVDU), Saskatchewan has a large number of suspected IE cases. The American Society of Echocardiography (ASE) and the European Society of Cardiology (ESC) have published recommendations regarding the appropriate use of TEE. The objective of this study is to evaluate the utilization of TEE in Regina, Saskatchewan, in the diagnosis of IE. <h3>METHODS AND RESULTS</h3> Patients aged ≥ 18 who received a TEE for the diagnosis of IE from January 1 to December 31, 2019 were identified. A retrospective chart review collected demographic and clinical information, as well as clinical outcomes. Primary outcome included the percentage of TEEs that complied with ASE and ESC recommendations. Factors associated with the inappropriate use of TEE were identified. Data analyses were carried out using Excel and IBM SPSS version 22. 204 admissions of 188 patients involved a TEE performed for the diagnosis of IE within the study period. The mean age was 53 ±17 years, with 41% females. 41.4% of patients had a history of active or past IVDU, 11.8% had prosthetic valves, and 9.8% had intracardiac devices. TEE confirmed the presence of a vegetation in 24.5% of cases. 13.2% of patients died during the same admission, and 33.3% died within 1-year of discharge. 30-day readmission rate was 26.0%. Only 30.9% of TEEs were appropriately used. Two criteria emerged as common reasons for inappropriately used TEEs. 46.6% of TEEs were performed without a prior TTE. 31.9% of TEEs were ordered for patients with a low pre-test probability in the absence of positive blood culture. Patients with a history of active or past IVDU was associated with more inappropriately used TEEs (74.4% vs. 61.2%, p=0.046). <h3>CONCLUSION</h3> Patients who undergo TEE for the diagnosis of IE represent a high-risk population, with a high prevalence of IVDU, and high readmission and mortality rates. Only a small proportion of TEEs were appropriately used. Clinician education and a more protocolized approach towards the use of TEE in IE diagnosis may help reduce inappropriate usage.

The clinical role of transesophageal echocardiography during transvenous lead extraction.

Transesophageal echocardiography (TEE) is commonly used during cardiothoracic procedures. TEE has also become standard during transvenous lead extraction (TLE) procedures, but its effect and role have not been optimally defined. The goal of this study is to identify how TEE was used during TLE at our institute and review its utility. We retrospectively reviewed high-risk patients undergoing TLE, for whom more complications during extraction procedures, from June 2012 to September 2020. The patients were divided into TEE group and non-TEE group according to real-time TEE monitoring. We compared the rate of procedural success, complications between two groups and concluded the clinical utility of TEE during TLE. A total of 195 patients were included (105 in TEE group vs 90 in non-TEE group), the rate of procedure success (97.8%vs 96.5%, p=0.41) and complications during extraction (8.6%vs 12.2%, p=0.40, major complication 5.7%vs 12.2%, p=0.11, minor complication 2.9%vs 0%, p=0.30) were comparable. In TEE group, 12 patients (11.4%) received following benefits: altering surgical plans, guiding subsequent therapy strategies, and rapidly diagnosing complications, moreover no complications occurred from TEE. This study demonstrates that real-time monitoring by TEE cannot change the rate of procedural success and complication during TLE; however, TEE provides valuable information to instruct clinical therapy and improves the safety of TLE.

Utility of Transesophageal Echocardiography in the Identification and Treatment of Occult Mechanisms of Cerebral Infarction (4844)

Utility of Transesophageal Echocardiography in the Identification and Treatment of Occult Mechanisms of Cerebral Infarction (4844)

280. Description of Transesophageal Echocardiography Prescribing Practices in non-Staphylococcus aureus Bacteremia with Application of Scoring Systems

BackgroundIn non-S. aureus gram-positive bacteremia (non-SAB), practices of obtaining transesophageal echocardiography (TEE) are mixed despite the availability of scoring systems in certain organisms (DENOVA for E. faecalis, HANDOC for non-beta hemolytic streptococci) that provide recommendations for TEE with scores 3 or higher. This study aimed to analyze the application of DENOVA and HANDOC scoring systems to coagulase-negative Staphylococci (CoNS), Enterococcus spp. and Streptococcus spp. in relation to TEE prescribing practices.MethodsA retrospective, observational study was conducted at two tertiary care hospitals including patients with ≥1 positive blood culture for Enterococcus spp. or Streptococcus spp., or ≥2 positive blood cultures for CoNS with matching susceptibilities between November 2017 and November 2019. The primary outcome compared DENOVA and HANDOC scores in patients who received TEE vs. those who did not. Secondary outcomes included DENOVA and HANDOC scores in subgroup populations, adherence to DENOVA/HANDOC scoring systems, treatment characteristics, and patient outcomes.ResultsOf the 310 patients included, 96 (31%) underwent TEE and 214 (69%) did not. Fewer patients in the TEE group underwent transthoracic echocardiography: 29.2% vs. 69.9%, p< 0.01. Infectious Diseases providers were involved in all patients that underwent TEE. Median scores were significantly higher in all patients who underwent TEE; DENOVA: 2 (1–3) vs. 1 (1–2), p< 0.01; HANDOC: 3 (3–4) vs. 3 (2–3), p< 0.01. DENOVA and HANDOC scores were significantly higher in the TEE group in Enterococcus spp. and Streptococcus spp., respectively; overall adherence to scoring system recommendations in these groups was less than 60%. HANDOC score was higher in the TEE group for patients with CoNS and 87.5% of these patients with score ≥3 had endocarditis (versus 50% with DENOVA score). More patients in the TEE group had endocarditis 46.9% vs. 6.5%, p< 0.01.ConclusionDENOVA and HANDOC scores were significantly higher among TEE patients, but areas of improvement exist in relation to overutilization of TEE and development of scoring system for CoNS. Efforts to improve TEE utilization should be coordinated with Infectious Disease providers.Disclosures All Authors: No reported disclosures

Transesophageal echocardiography for perioperative management in thoracic surgery.

Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures. Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion. Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.

Cost-effectiveness of routine transoesophageal echocardiography during cardiac surgery: a discrete-event simulation study

BackgroundThe aim of this study was to simulate and compare the healthcare and economic outcomes associated with routine use of intraoperative transoesophageal echocardiography (TOE) in patients undergoing cardiac surgery with those associated with a scenario where TOE is not routinely used. MethodsThe impact of TOE on surgical decision-making was estimated through a systematic literature review. Individual short-term morbidity and mortality estimates were generated by application of the Society of Thoracic Surgeons risk calculator. Long-term event rates, unit costs, and utility weights were sourced from published literature and expert opinion. A discrete-event simulation model was then constructed to simulate both the in-hospital and post-discharge outcomes for patients undergoing cardiac surgery. Robustness of the base case results was examined through deterministic and probabilistic sensitivity analyses. An incremental cost–effectiveness ratio of €30 000 per quality-adjusted life-year gained was assumed to represent acceptable cost-effectiveness. ResultsRoutine use of intraoperative TOE was associated with lower costs and higher benefits per patient, which indicates that use of TOE is a dominant strategy. The intervention resulted in the avoidance of 299 cardiac complications, 20 strokes, and 11 all-cause deaths per 10 000 patients. Routine intraoperative TOE was associated with an increased occurrence of bleeding owing to more valvular surgery and subsequent long-term anticoagulation. ConclusionsRoutine intraoperative TOE is a cost-effective procedure for patients undergoing cardiac surgery, leading to lower overall costs. It was associated with a decrease in long-term complications including stroke, cardiac complications, and death, although there was a slight increase in extracranial bleeding events.

P6489Preoperative determination of artificial chordae length by transesophageal echocardiography

Abstract The use of artificial chordae is one of the main techniques used in mitral valve repair to treat prolapsing leaflets, especially in anterior and bileaflet prolapse. With the use of PTFE sutures to replace elongated or ruptured chords mitral valve repair rates have significantly improved. The main difficulty with this technique is to determine the optimal length of the artificial chordae. Intraoperative transoesophageal echocardiography (TOE) is mandatory in mitral valve repair in order to determine the type of lesion of the mitral valve but also to evaluate the quality of the repair. We examined the accuracy of preoperative prediction of artificial chordae length by the preoperativeTOE. Patients and methods Twenty-one consecutive patients (7 females) underwent mitral valve repair with artificial chordae for significant mitral valve prolapse in our department during the last year. The median age of the patients was 62 y. (range 25 - 87) and the mean EuroSCORE II 3,36% (SD 4,61%). During the prep TOE we determined the predicted length of the required replacement chordae for the repair using mainly the 4 chamber view to calculate the distance between the tip of the papillary muscle and the coaptation point of the two leaflets and we subtracted 5mm which is the minimum of the desired coaptation length (top right part of the Figure). All the patients underwent totally endoscopic mitral repair through a 3 cm right periareolar incision. 14,3% of the patients had anterior leaflet (AML) prolapse, 23,8% bileaflet and 61,9% posterior (PML). The appropriate length of the required chordae was measured intraoperatively. Results We used on average 3 loops of artificial chordae size 23,3 mm (SD 1,15mm) to treat the AML prolapse, 5 loops size 23,2 mm (SD 2,28mm) to treat the bileaflet prolapse and 2,23 loops size 18mm (SD 2mm) to treat the PML prolapse (bottom part of the figure). The predicted size of the artificial chordae had a positive correlation to the length used (Pearson correlation, p&lt;0,001) as demonstrated in the top left part of the Figure. An annuloplasty band was implanted to all the patients. All the patients had no mitral regurgitation in the postoperative TOE. The mean valve area was 3,54cm2 (SD 0,57) and the mean peak gradient 5,6 mmHg (SD 1,82). There was no mortality. Chordae length predicted by echo Conclusion The length of artificial chordae can be predetermined with great accuracy with the use of TOE, making TOE an important tool not only for the determination of the mitral lesion and quality of the repair but also for the planning of the operation.

TEE for Lung Transplantation: A Case Series and Discussion of Vascular Complications

Summary Stenosis at either the pulmonary artery (PA) or pulmonary vein (PV) anastomosis during lung transplantation (LTx) is a serious complication that requires an accurate and timely diagnosis for optimal clinical management. Transesophageal echocardiography (TEE) can play an essential role in making these diagnoses, both intraoperatively and postoperatively. However, it is important to recognize the limitations of TEE in this setting, including the lack of official guidelines to diagnose PA or PV stenosis. In this series, we describe four cases of vascular complications associated with LTx. We highlight the utility of TEE in the perioperative management of these patients, and discuss the diagnostic considerations when using this tool to assess the PA and PV anastomoses. As experts in perioperative echocardiography, anesthesiologists can employ TEE to enhance surgical success and improve patient outcomes after LTx. We therefore advocate the use of TEE during all cases of LTx, and encourage further efforts into the development of official echocardiographic guidelines specific to this patient population.

Determinants of left atrium thrombi in scheduled cardioversion: an ENSURE-AF study analysis.

AimsENSURE-AF (NCT 02072434) was the largest prospective randomized clinical trial of anticoagulation for cardioversion in atrial fibrillation (AF), which also provides the largest prospective dataset for transoesophageal echocardiography (TOE) prior to cardioversion. This ancillary analysis investigated determinants of TOE-detected left atrium thrombi (LAT) in patients scheduled for electrical cardioversion (ECV).Methods and resultsThe ENSURE-AF multicentre PROBE evaluation trial compared edoxaban 60 mg once daily (QD) with enoxaparin/warfarin in 2199 subjects undergoing ECV of non-valvular AF. Patients were stratified by the use of TOE, anticoagulant experience, and selected edoxaban dose. Electrical cardioversion was cancelled or deferred when TOEdetected LAT. In total, 1183 subjects were stratified to the TOE arm and LAT was reported in 91 (8.2%). In univariate analysis, age ≥75 years (26.4% vs. 16.9%, P = 0.0308), lower weight (86.5 ± 15.0 vs. 90.7 ± 18.0 kg, P = 0.0309), lower creatinine clearance (80.1 ± 30.6 vs. 93.2 ± 33.9 mL/min, P = 0.0007), heart failure (59.3% vs. 43.0%, P = 0.0029), and diuretic treatment (53.9% vs. 40.1%, P = 0.0141) were more prevalent in the LAT group. Non-significant trends were seen for higher mean CHA2DS2-VASc score (3.0 ± 1.41 vs. 2.7 ± 1.48, P = 0.0571) and more prevalent anticoagulation use prior to enrolment (60.4% vs. 50.3%, P = 0.0795) in the LAT group. In logistic regression analysis, age (P = 0.0202) and heart failure (P = 0.0064) were independently associated with LAT.ConclusionElective ECV is commonly cancelled or deferred due to TOE-detected LAT in patients with non-valvular AF. Age ≥75 years and heart failure were associated with the presence of LAT.

Role of Intraoperative Transesophageal Echocardiography in Cardiac Surgery: an Observational Study.

AIM:This study is based on the hypothesis that the routine use of transesophageal echocardiography in cardiac surgery will influence the surgical decision taken by the surgeon intra-operatively in Kasr-Alainy hospitals.METHODS:Patients were examined with intraoperative transesophageal echocardiography (TEE) before and after cardiopulmonary bypass. Complete and comprehensive intraoperative TEE examinations will be performed by TEE certified cardiac anesthesiologists. Data that will be collected from the intraoperative examination and will be compared with preoperative transthoracic echocardiography, and the surgical decision that was taken preoperatively will be revised again with the cardiothoracic surgeon before the start of surgery. Also, TEE will be used again after weaning from bypass for revision and assessment of our decision.RESULTS:We examined the utility of TEE in 100 patients undergoing different types of cardiac procedures in Kasr Al-Ainy hospital. This prospective clinical investigation found that the pre- and post-CPB TEE examinations influenced surgical decision making in 10% of all evaluated patients.CONCLUSION:Intraoperative TEE has the potential to influence clinical decision making for cardiac surgical patients significantly. It is useful in surgical planning, guiding various hemodynamic interventions, and assessing the immediate results of surgery. Thus, IOTEE should be used routinely in all patients undergoing all types of cardiac surgeries.