Search

MitraClip (MC) is the most common percutaneous treatment for severe mitral regurgitation (MR). An accurate two-dimensional and three-dimensional echocardiographic (3DTEE) imaging is mandatory for the optimal procedural result. Recently transillumination 3DTEE rendering (3DTr) has been introduced integrating a virtual light source into the dataset and with the addition of glass effect (3DGl) allows to adjust tissue transparency improving depth perception and anatomical structure delineation in comparison with the standard 3DTEE (3DSt). The aim of this retrospective study in 30 patients undergoing MC, was to compare 3DSt, 3DTr, and 3DGl in mitral valve (MV) evaluation and procedural result assessment. 3DTEE acquisitions obtained before and after MC were processed with 3DSt, 3DTr, and 3DGl rendering. Each reconstruction was scored for quality and for ability to recognize MV anatomy, MR origin, clip position, dimension and grasping. Imaging quality was judged good or optimal in 52%, 76%, and 96% in 3DSt, 3DTr, and 3DGl reconstructions respectively. In 26/30 patients a diagnostic incremental value was found with 3DTr vs. 3DSt and in 15/26 with 3DGl vs. 3DTr and 3DSt. Only 3DGl with perpendicular cropping of the clip allowed to visualize and measure the grasped portion of each mitral leaflets. 3DTEE imaging during MC may be improved by 3DTr and 3DGl providing a better evaluation of MV, of leaflet grasping and of residual MR jets after MC.

Introduction and Objectives: To investigate the incidence and clinical relevance of the presence of mobile echogenic images (MEI) during transesophageal echocardiography (TEE) for monitoring of transcatheter aortic valve implantation (TAVI). Methods: Consecutive patients referred to our center for transfemoral or transapical TAVI were included. The procedure was monitored by three-dimensional (3D) TEE and images were analyzed by two independent experts. In-hospital follow-up was carried out and correlated with imaging findings. Results: A total of 104 patients were included. MEI were visualized in 11 patients during the procedure (11%) and in over 50% of cases were identified as thrombi, however no differences in periprocedural stroke were found in follow-up. Conclusions: Visualization of MEI during 3D TEE monitoring of TAVI is relatively common (11%) and in over 50% of cases they are identified as thrombi. The clinical implications of this finding are uncertain, as despite their frequency, the incidence of clinical stroke in this patient population was no higher. 3D TEE is a useful tool for diagnosis of MEI and can alert the operator to their presence. Resumo: Introdução e objetivos: Investigar a incidência e relevância clínica da presença de imagens ecogénicas móveis (IEM), através de ecocardiografia transesofágica (ETE) durante a implantação valvular aórtica percutânea (TAVI). Métodos: Foram incluídos doentes consecutivos referenciados para o nosso centro para realização de TAVI por via transapical ou transfemoral. Foi realizada a monitorização da ETE 3 D e as imagens foram analisadas por dois peritos individualmente. O seguimento foi realizado no hospital e foi correlacionado com achados de imagem. Resultados: Foram definitivamente incluídos 104 doentes. Durante o procedimento foram visualizadas IEM em 11 pacientes (11%) e,em mais de 50% dos casos, foram identificadas como trombos, não tendo, no entanto, sido encontradas diferenças no seguimento dos doentes. Conclusões: A visualização das IEM através da monitorização por ETE 3 D durante a TAVI é relativamente comum (11%) e, em mais de 50% dos casos, são identificadas como trombos. As implicações clínicas deste achado são incertas, porque apesar da sua frequência não há maior incidência de acidente vascular cerebral clínico nesta população de doentes. A ETE é uma ferramenta útil para o diagnóstico e pode alertar o operador da sua presença. Keywords: Transcatheter aortic valve implantation, Three-dimensional, Aortic stenosis, Transaortic valve, Palavras-chave: Implantação valvular aórtica percutânea, 3 D, Estenose aórtica, Válvula transaórtica

An 89-year-old man with symptomatic severe aortic stenosis underwent 29-mm Evolut R (Medtronic, Minneapolis, Minnesota) implantation under general anesthesia. During the procedure, the Evolut R was deployed using the left subclavian artery approach. However, systemic hypotension persisted.

Aortic dissection is a rare but devastating complication of cardiac operations. The purpose of this investigation was to assess the occurrence of aortic dissection during elective cardiac operations and the usefulness of intraoperative transesophageal echocardiography for the diagnosis and management of this complication. Data of consecutive adult patients undergoing elective cardiac surgery with transesophageal echocardiographic monitoring during an 8-year period were studied retrospectively. Aortic dissection was identified in 7 (0.13%) of 5,247 patients, and diagnosed immediately by transesophageal echocardiography in 5 of them; 2 were diagnosed later by transesophageal echocardiography. All aortic dissections were type A and they occurred after completion of the primary procedure. Two patients treated conservatively died within 5 days. Four of the 5 patients who underwent immediate reoperation survived with serious postoperative complications. Transesophageal echocardiography should be carried out when there is a risk of aortic dissection during cardiac operations, especially in the posterior wall of the ascending aorta, to avoid missing the diagnosis and delaying treatment.

Objective Transesophageal echocardiography (TEE) is increasingly used in hemodynamic monitoring in the intensive care unit. This paper describes and validates a scoring system for assessing competence in TEE performed by intensivists for this indication.

OBJECTIVE The right-to-left shunt (RLS) is diagnosed by contrast-enhanced transesophageal echocardiographic monitoring of the bilateral atria (cTEE-BA). However, the procedure is often disturbed by nonsmoke spontaneous individual contrast (NSSIC) with fast motion, which appears in the left atrium after respiratory maneuvers without administration of a contrast medium and moves past in several seconds. We attempted to perform cTEE monitoring of the aortic arch (cTEE-AA) for evaluation of the RLS and compared the findings with those of cTEE-BA. METHODS Both cTEE-BA and cTEE-AA were performed in 168 patients with ischemic stroke (133 men and 35 women; mean age +/- SD, 62.0 +/- 14.4 years). The frequency of NSSIC in the left atrium was compared with that in the aortic arch during the respiratory maneuver. When contrast much brighter than the NSSIC was visualized in the left atrium and the aortic arch during the respiratory maneuver with administration of the contrast medium, we considered the RLS to be positive in the cTEE-BA and cTEE-AA, respectively. Findings were then compared between the 2 examinations. RESULTS Nonsmoke spontaneous individual contrast was more frequently observed in the left atrium than the aortic arch (61.3% versus 14.9%; chi2 test, P < .0001). The RLS was positive in 34 patients in the cTEE-BA and in 39 patients in the cTEE-AA. The sensitivity and specificity of the cTEE-AA for the cTEE-BA were 100% and 96.3%, respectively. CONCLUSIONS The cTEE-AA may be an alternative method for detection of an RLS, especially in patients with a large amount of NSSIC in the left atrium.

BACKGROUND The STARFlex (SF) device is a CardioSEAL (CS) double-umbrella device that has been modified by the addition of a self-centering mechanism comprised of nitinol springs connected between the two umbrellas and a flexible core wire with a pin-pivoting connection. This paper compares the results of atrial septal defect (ASD) closure with CardioSEAL and STARFlex devices. PATIENTS AND METHODS Between December 1996 and March 2000, 117 patients underwent ASD closure with CardioSEAL (n = 79) and STARFlex (n = 38). The mean age (17 years), weight (49 kg), and ASD size (15 mm) were similar in the two groups. The procedures were performed under general anesthesia with both fluoroscopic and transesophageal echocardiographic monitoring. IMMEDIATE RESULTS The devices were successfully implanted in all patients. Ten patients had multiple ASDs. A single device was used in four patients (CardioSEAL in three, STARFlex in one), while a simultaneous placement of two CardioSEAL (one patient) or two STARFlex (five patients) were performed in six patients. The results are summarized as follows: [table: see text] Follow-Up Results: On follow-up clinical exam, electrocardiograms, chest X-rays, and echocardiograms were obtained at 1, 6, and 12 months. [table: see text] During follow-up there were no deaths, endocarditis, rhythm disturbances, or other complications. Arm fractures were observed almost exclusively with large CardioSEAL devices (40 mm, less frequently with 33 mm), and only in one 33-mm STARFlex device. There were no clinical complications related to fractures. CONCLUSIONS The STARFlex device seems to offer better results than the CardioSEAL, with significantly lower rates of residual shunts and arm fractures.

A patient with familial amyloid polyneuropathy underwent a living, nonrelated orthotopic liver transplant and developed hypotension after induction of anesthesia. Causes of hypotension in patients with familial amyloid polyneuropathy are discussed. Transesophageal echocardiographic monitoring was invaluable in differentiating various causes of hypotension and in diagnosing peripheral vasodilation as the predominant cause of hypotension.

Percutaneous mitral commissurotomy (PMC) was successfully performed in a 48-year-old woman with dextrocardia and situs inversus and a severe mitral stenosis. After PMC, the valve area increased from 0.97 to 1.89 cm2, and no complication occurred. This case shows that PMC is practicable in a case of dextrocardia with situs inversus. The procedure appears to be safer and easier when carried out with the Inoue balloon, image inversion on the screen, and under transesophageal echocardiographic monitoring. © 1996 Wiley-Liss, Inc.

I NTRAOPERATIVE transesophageal echocardiography (TEE) is being used increasingly for monitoring of ventricular function and wall motion during coronary artery bypass grafting (CABG). Although the exact frequency of its use has not been well documented in the literature, a recent survey administered by the Society of Cardiovascular Anesthesiologists at their 1993 Annual Meeting indicated that nearly 39% of the respondents (n = 202) used TEE "routinely" during cardiac cases (although no distinction was made between CABG and valve surgery).* Although the respondents to this survey represent a biased sample of cardiovascular subspecialists, it appears that the intraoperative use of TEE has become popular. With the use of such a sensitive imagmg modality, the chance of detecting incidental abnormalities unrelated to the primary surgical procedure increases. A case is reported of an unsuspected finding on TEE that led to additional surgical intervention in an already high-risk patient undergoing CABG.

Objective: Transesophageal echocardiography is a diagnostic and monitoring modality. The objectives of our study were to compare the diagnoses obtained with continuous transesophageal echocardiography and hemodynamic monitoring in the intensive care unit, to determine interobserver variability of diagnosis obtained with both modalities, and to evaluate its impact. Design: Prospective cohort study. Setting: Surgical intensive care unit. Patients: Consecutive hemodynamically unstable patients after cardiac surgery. Interventions: At admission, unstable patients were monitored during 4 hrs with transesophageal echocardiography and standard hemodynamic monitoring. The critical care physician evaluated the patients based on all information except the transesophageal echocardiography at 0, 2, and 4 hrs and formulated a hypothesis on the most likely cause of hemodynamic instability. Transesophageal echocardiography information was provided after each evaluation. To evaluate interobserver variability, all the hemodynamic and echocardiographic information was gathered, randomized, and evaluated by five clinicians for the hemodynamic data and five echocardiographers for the transesophageal echocardiography data. The evaluators were blinded to all other information. Kappa statistics were used to evaluate agreement. Impact of transesophageal echocardiography was assessed retrospectively by using the Deutsch scale. Results: Twenty patients qualified for the study. The agreement between the hemodynamic and echocardiographic diagnosis showed a kappa at admission, 2 hrs, and 4 hrs of 0.33, 0.47, and 0.28. The interobserver agreement for the initial diagnosis (p = .014) and between all evaluators (p

IMPLICATIONS We present a case of systemic arterial embolism during wedge resection of the lung. The importance of transesophageal echocardiographic monitoring is described.

We created an atrial septal defect (ASD) using a Ferris-Smith-Kerrison bone punch under transesophageal echocardiographic monitoring for infants with complex congenital heart diseases, eg, transposition of the great arteries. We describe a safe and easy technique of ASD creation instead of Blalock-Hanlon operation.

To determine the utility of transesophageal echocardiographic monitoring during percutaneous balloon mitral valvotomy, we analyzed data from 40 consecutive patients who had been randomly assigned to undergo balloon mitral valvotomy under transesophageal echocardiographic guidance or without echo. All procedures were carried out under general anaesthesia. The completion rate (100% vs 73%), the procedure time (108 +/- 28 min vs 65 +/- 18 min), the X-ray exposure time (62 +/- 13 vs 33 +/- 12 min), resulted significantly (P less than 0.001) more favorable in the echo-monitored patients. Moreover, a lower rate of major complications (cardiac tamponade, large residual atrial shunting, and severe mitral regurgitation) was noted in the echo-monitored patients. The achieved final area of the mitral valve did not differ significantly between the two groups. From an evaluation of results as a whole, 96% of the echo-monitored procedures were successful, whereas only 40% of the procedures conducted without echocardiographic control achieved a satisfactory final result in absence of major complications. We conclude that transesophageal echocardiography is a safe, effective, and valuable tool to monitor each step of balloon mitral valvotomy in order to shorten the time of the procedure, and to improve the results of this complex interventional catheterization technique.

Unilateral cemented hip hemiarthroplasty was done on 16 dogs who subsequently had revision arthroplasty and who were divided into 1 control and 3 experimental groups: The first group had cement extraction using osteotomes; the second, using a high speed burr; the third, an ultrasonic tool. Hemodynamic and transesophageal echocardiographic monitoring were done. Postmortem pulmonary specimens were examined for differences in the quantity of fat emboli. There was a significant increase in emboli with the ultrasonic tool as compared with osteotomes and high speed burr. There was no significant difference in emboli between the osteotomes and high speed burr. Fat emboli syndrome is related to mechanical compression of the femoral canal. The ultrasonic instrument was unique in its tendency to cause large embolic showers, especially during extraction of the distal cement plug. In these young dogs, minimal hemodynamic changes and no cardiac dysrhythmias occurred, which in part may be attributed to their good health. These changes may remain subclinical for patients with good cardiorespiratory reserve, or may become life threatening for those with poor reserve. By outlining the mechanisms of fat embolism in revision total hip arthroplasty, it may be possible to decrease future morbidity, especially in patients who frequently have cardiopulmonary disease.

Balloon valvuloplasty is considered a palliative treatment for patients with severe aortic stenosis and in whom the risk of surgery would be unacceptably high (Cribier et al. 1986; Serruys et al. 1988; Pop et al. 1988). Apart from there being a high rate of restenosis, the procedure itself may be accompanied by cardiac and noncardiac complications (Serruys et al. 1988; McKay et al. 1987). Cardiac complications such as ventricular perforation, aortic insufficiency, and progressive heart failure have been described (McKay et al. 1987; Serruys et al. 1988). In a minority of patients, worsening of left ventricular contraction was observed after aortic balloon valvuloplasty in comparison with prevalvuloplasty conditions.