Assessment of successful valve reconstruction by intraoperative transesophageal echocardiography (TEE)

Usefulness of intraoperative transesophageal echocardiography in predicting the degree of mitral regurgitation secondary to atrioventricular defect in children

The objectives of this study were to determine the validity of the grade of mitral regurgitation (MR) as imaged by intraoperative transesophageal echocardiography (TEE) in predicting the grade of MR at follow-up. Intraoperative TEE and corresponding follow-up transthoracic studies were retrospectively reviewed and the regurgitant jet area to left atrial area ratio was used to quantify the MR. Patient records were reviewed to identify factors contributing to the development of a certain grade of MR. Intraoperative TEE was useful in detecting severe MR that required further repair at the same time. However, discrepancy in the grade of MR at follow-up was noted in 47% of patients (21 of 47) and unchanged grade of MR was found only in 53% of patients (26 of 47). Blood pressures were significantly lower and heart rates higher intraoperatively. Initial preoperative grade of MR and type of atrioventricular canal defect did not predispose for a particular grade of MR at follow-up. The grade of MR by intraoperative TEE does not predict the grade of MR at follow-up as imaged by transthoracic echocardiography.

Transoesophageal echocardiography in neonates, infants and children: applicability and diagnostic value in everyday practice of a cardiothoracic unit

OBJECTIVE

To determine the applicability of and information obtained by transoesophageal echocardiography in neonates, infants, and children in every day practice of a cardiothoracic unit.

DESIGN

Four month prospective study.

SETTING

Supraregional centre for paediatric cardiothoracic services.

PATIENTS AND METHODS

58 patients aged between four days and 16 years with a wide range of cardiovascular disease underwent transoesophageal echocardiography under sedation or general anaesthetic. One of two paediatric probes (6 or 7 mm diameter), or an adult probe (13 mm in diameter) was used. Whenever possible the investigation was immediately preceded by precordial echocardiography.

MAIN OUTCOME MEASURES

Success, failure, technical difficulties, and complications of probe introduction and, when possible, comparison of the information obtained with that obtained from precordial echocardiography.

RESULTS

Introduction of the probe was successful in 57 of the 58 patients. The only complication encountered was transient bradycardia during manipulation of the probe in a 2.2 kg baby. The adult (13 mm) probe was successfully used in children as small as 7.0 kg. Below this weight a smaller paediatric probe was required. In 56% of cases transoesophageal ultrasound provided information not obtained from the precordial approach. The technique was of particular value perioperatively and in the immediate postoperative period in neonates and infants and in the presence of valve prostheses and the investigation of mediastinal tumours in older children.

CONCLUSIONS

Transoesophageal echocardiography is a valuable additional investigative tool for children of all ages. It is of particular value when acquisition of precordial image is impaired around the time of and after operation and in children with prosthetic valves or mediastinal tumour. Image quality was superior with the adult probe and we recommend the use of this probe unless the patient's weight is below 7 kg, when a paediatric probe allows this technique to be used usefully and safely in babies as small as 2.2 kg.

Evaluation of mitral regurgitation by Doppler echocardiography

The diagnosis and assessment of mitral regurgitation has been one of the main challenges for cardiac ultrasound. Imaging techniques (M-mode and two-dimensional echocardiography) provide direct morphologic and etiologic information of the evaluation of patients with suspected mitral regurgitation. The advent of cardiac Doppler increased tremendously the ability to evaluate mitral regurgitation noninvasively. Continuous-wave and pulsed Doppler have been found to be sensitive and specific in the detection of mitral regurgitation. The introduction of color flow Doppler simplified enormously the assessment of patients with suspected mitral regurgitation. The maximal regurgitant area and maximal regurgitant area corrected for left atrial size have become the most commonly used parameters to evaluate mitral regurgitation by color flow Doppler in the clinical setting. However, the color regurgitant jet area is highly dependent on anatomical, hemodynamic, and equipment factors. A new method, based on the proximal isovelocity surface area, is being evaluated and appears to be relatively independent of equipment factors. Transesophageal echocardiography has been shown to be exquisitely sensitive in the detection of mitral regurgitation. Quantitation of mitral regurgitation by transesophageal echocardiography is currently based on the maximal regurgitant area and this parameter appears to correlate closely with the angiographic degree of mitral regurgitation. Pulmonary venous flow analysis had been used in conjunction with color flow mapping for the evaluation of mitral regurgitation by transesophageal echocardiography. The presence of reversed systolic flow has been shown to be sensitive and specific for the diagnosis of severe mitral regurgitation. Patients with clinically difficult surface studies, flail mitral valve leaflets, and prosthetic mitral valve are best evaluated by the transesophageal approach with interrogation of pulmonary venous flow.

Severe tricuspid regurgitation after mitral valve repair: diagnosis by intraoperative transesophageal echocardiography

Transesophageal echocardiography facilitates the evaluation of valvular repair in the operating room. The functional valvular morphology and degree of valvular regurgitation can be assessed before and after repair. This technique can also identify unsuspected findings--in this case, severe tricuspid regurgitation complicating cardiopulmonary bypass. We report a previously undescribed cause of traumatic tricuspid regurgitation.

Measurement of intracardiac dimensions and structures in normal young adult subjects by transesophageal echocardiography

Transesophageal echocardiography (TEE) has proven to be an excellent diagnostic means of diagnosing different cardiac diseases. To distinguish between normal and pathologic findings, standardized measurements of well-defined cross-sectional planes are necessary. Therefore, the 2-dimensional echocardiographic data of 25 healthy volunteers were obtained. In 13 men and 12 women, aged 19 to 30 years, recordings of the left ventricular short-axis view, the 2- or 4-chamber view with the left and right atria, the long axes of the left and right ventricles, the mitral and tricuspid valve ring and the atrial septum were analyzed. Furthermore, the aortic valve plane and the ascending and descending aorta were also measured. All data are given as mean values +/- 2 times the standard deviation. End-diastolic and end-systolic left ventricular anterior-to-posterior diameter of the left ventricular short axis was 2.5 +/- 0.3 cm/m2 and 1.7 +/- 0.3 cm/m2, with the fractional shortening ranging from 27 to 42%. The end-systolic lateral diameter was 2.4 +/- 0.5 cm/m2 for the left atrium and 2.4 +/- 0.4 cm/m2 for the right atrium, and the end-systolic anterior-to-posterior diameter was 1.5 +/- 0.6 cm/m2 for the left atrium and 2.1 +/- 0.6 cm/m2 for the right atrium. End-diastolic diameters of 3.4 +/- 0.6 cm/m2 and 2.8 +/- 0.4 cm/m2 were obtained for the long axis of the left ventricle and for the right ventricle. Measurements ranged from 1.5 to 2.2 cm/m2 for the end-diastolic diameter of the mitral ring and from 1.3 to 2.0 cm/m2 for the tricuspid ring.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of transesophageal color flow Doppler echocardiography in current cardiology practice

Of 3,480 patients who were referred for cardiac ultrasound evaluation, 230 patients (6.6%) underwent transesophageal echocardiography because the transthoracic study was not feasible, technically inadequate, or provided insufficient diagnostic information for optimal patient management. There were 149 inpatients and 81 outpatients. The majority (182 patients, 79%) had aortic or mitral disorders. In 166 patients (72%), transesophageal echocardiography played a significant role in patient management. Transesophageal echocardiography was most useful in evaluating diseases of the aorta (dissection, root abscess, or aneurysm), mitral prosthesis, complications of endocarditis, left atrial appendage thrombi, and in determining the cause of mitral insufficiency. Transesophageal echocardiography was useful in the evaluation of critically ill patients and those with severe lung disease.

Transesophageal echocardiography

Two-dimensional transesophageal echocardiography generally has superior sensitivity and image quality compared with precordial echocardiography. Its unique anatomic perspective posterior to the heart often provides important clinical information not obtainable by other imaging approaches and technologies. It is particularly useful in the diagnosis of mitral valve disease, left atrial masses, endocarditis and its sequelae, and aortic dissections. It is also useful for examination of the left main coronary artery, left ventricular outflow tract, atrial and ventricular septa, and congenital defects. In addition to its application as a diagnostic tool in conscious patients, it can be employed intraoperatively to evaluate and guide surgical intervention. Detection of ventricular wall motion abnormalities by transesophageal echocardiography has been shown to be the most sensitive indicator of myocardial ischemia available in the clinical setting. It has potential for wide application for safely monitoring left ventricular function in patients in intensive care or under anesthesia.