Biplane transesophageal echocardiography: clinical applications of the long-axis plane

Transesophageal echocardiography: a complementary view of the heart

Transesophageal echocardiography has been widely used as a diagnostic tool during the past two decades to detect cardiac abnormalities that are not visible or poorly visible with transthoracic echocardiography. At present, transesophageal echocardiography is a cornerstone of modern diagnosis of several cardiac diseases, providing diagnostic, prognostic and therapeutic information. In this review, the present status of transesophageal echocardiography not only as a diagnostic tool, underlining its effects on clinical decision making, but also as a monitoring adjunct for many interventional cardiac procedures is examined.

Improved Assessment of Pathological Regurgitation in Patients with Prosthetic Heart Valves by Multiplane Transesophageal Echocardiography

The aim of this study was to evaluate the diagnostic increment of individually optimized axes in the assessment of pathological prosthetic valve regurgitation. Forty-two patients with pathologically regurgitant prostheses in the aortic (n = 21), mitral (n = 15), and tricuspid (n = 6) positions were examined by multiplane transesophageal echocardiography. The investigation was performed utilizing the transverse axis first, the longitudinal axis second, and the intermediate axes afterwards. The presence of regurgitation, the differentiation between trans- and perivalvular origin, and the localization of perivalvular leakages at the sewing ring were evaluated. Findings in the biplane and intermediate axes were compared to surgery or autopsy in all patients. There was slightly higher detection rate for aortic prosthetic regurgitation using the intermediate axes than the biplane axes. The intermediate axes revealed significantly fewer differences to the morphological control than the biplane axes with regard to the differentiation of peri- and transprosthetic aortic regurgitation and to the localization of a periprosthetic aortic regurgitant origin. The intermediate axes provided significantly better agreement to surgery/autopsy than the biplane axes regarding the localization of the origin of mitral periprosthetic regurgitation. Morphological visualization of the perivalvular gap adds important information on the precise localization of the regurgitant origin. The pathological gap was visualized significantly more often using the intermediate than the biplane axes in all types of prostheses. The data in this study therefore suggest that multiplane transesophageal echocardiography is superior to biplane transesophageal echocardiography in the assessment of pathologic prosthetic regurgitation.

A prospective, randomized, blinded comparison of multiplane and biplane transesophageal echocardiographic techniques

Although multiplane transesophageal echocardiography has become an accepted diagnostic technique, there is a paucity of literature directly comparing the diagnostic yield of multiplane and biplane transesophageal examinations. This study was designed to compare the ability of multiplane and biplane transesophageal echocardiographic techniques to visualize intracardiac structures. Complete multiplane and biplane transesophageal studies were performed on each of 50 patients (100 total studies) referred to the echocardiography laboratory for elective transesophageal echocardiography. The biplane examinations were performed with a multiplane probe with angles only at 0 and 90 degrees. Images of 29 prospectively selected cardiac structures and valvular function parameters were scored as follows: 0 = not visualized, 1 = visualized well enough to identify structure, 2 = diagnostic quality, and 3 = exceptional quality. The scores for the individual structures were combined to identify total structure visualization quality scores for each of the imaging techniques. A separate subjective score was also determined to assess the overall adequacy of each study for addressing the clinical indication. The total structure visualization quality score was significantly higher for multiplane transesophageal echocardiography than for biplane transesophageal echocardiography (49 +/- 7 versus 45 +/- 7; p = 0.0001). Several individual structures were visualized significantly better (p < 0.05) by the multiplane technique, including the left upper pulmonary vein, fossa ovalis, left main coronary artery, and proximal ascending aorta. The subjective score of overall adequacy of the study for addressing the clinical indication showed a strong trend (p < 0.06) in favor of the multiplane technique, with higher scores in 11 of 50 multiplane studies versus three of 50 biplane studies when the two techniques were compared in individual patients. Therefore multiplane transesophageal echocardiography provides superior overall visualization of intracardiac structures compared with biplane studies, particularly for the left upper pulmonary vein, fossa ovalis, left main coronary artery, and ascending aorta.

A prospective comparison of the multiplane probe with the biplane probe in structure visualization and Doppler examination during transesophageal echocardiography

To compare the imaging capability of the multiplane probe with that of the biplane probe, 317 consecutive patients were randomized to undergo transesophageal echocardiography with either probe. Images of 24 cardiac structures and nine Doppler signals were graded prospectively on a three-grade system. Both multiplane and biplane probes provided excellent visualization of cardiac structures and Doppler signals, but the multiplane probe was significantly superior to the biplane probe. There were no differences in the number of attempts at esophageal intubation, the amount of sedation used, and the examination time. The number of complications was similar, although all failed intubations occurred with the multiplane probe.

Diagnosis in adolescents and adults with congenital heart disease. Prospective assessment of individual and combined roles of magnetic resonance imaging and transesophageal echocardiography

BACKGROUND

The inability to obtain complete diagnoses with transthoracic echocardiography in many adults with congenital heart disease provided the incentive to evaluate prospectively the individual and combined roles of magnetic resonance imaging (MRI) and transesophageal echocardiography (TEE) as "second-line" techniques for unresolved diagnostic problems.

METHODS AND RESULTS

Eighty-five patients were studied; 81 had MRI with a 0.5-T magnet to obtain spin-echo images, cine-MRI, and flow-velocity maps. Seventy-nine patients had TEE (37 biplane). A simple score (range, 0 to 1) was used for quantification of the results of MRI and TEE alone, for their comparison (in the 75 patients who had both), and for assessment of their combination. MRI, TEE, or their combination achieved a score of at least 0.75 in 18 of 25 diagnostic categories. A summary of the scores showed that for intracardiac anatomy. MRI scored 0.34, TEE scored 0.71 (P < .0001), and MRI plus TEE scored 0.84 (P < .003); for extracardiac anatomy, MRI scored 0.76, TEE scored 0.23 (P < .0001), and MRI plus TEE scored 0.84 (P = NS); and for hemodynamics and function, MRI scored 0.58, TEE scored 0.41 (P < .05), and MRI plus TEE scored 0.67 (P = NS). Total scores were MRI, 0.52; TEE, 0.50 (P = NS); and MRI plus TEE, 0.80 (P < .0001). MRI and TEE were inadequate for collateral and coronary arteries and pulmonary vascular resistance. Cine-MRI and flow-velocity maps comprised 43% of the MRI scores. Biplane TEE was better than single plane (scores of 0.59 versus 0.42, P < .0001).

CONCLUSIONS

MRI and TEE are important and complementary "second-line" investigations for congenital heart disease. Analysis of their performance in a wide range of diagnostic categories provides guidelines for their judicious application. Where both are available, diagnostic catheterizations are either obviated or simplified.

Intraoperative echocardiography: techniques and current applications

Intraoperative echocardiography has opened new dimensions in the evaluation of cardiac surgical patients, and has contributed significantly to the improved surgical results. The use of intraoperative echocardiography has enabled the surgeon to image the working heart, to define the operative anatomy and physiology, and to evaluate the results immediately before the patients leave the operating room. This review summarizes the current status and applications of intraoperative echocardiography in the practice of cardiac surgery.

The frequency of acquisition and quality of images obtained by transesophageal echocardiography: a prospective study of 100 consecutive cases

Although transesophageal echocardiography is capable of generating detailed images of the heart and aorta, the quality of these images and the frequency of their acquisition has not been previously defined. We performed monoplane transesophageal echocardiograms in 100 consecutive patients to determine the quality and frequency of acquisition of 10 standard, transverse views of the heart and aorta. Each image was graded for quality by ascribing a value from 0 (poor quality or not obtained) to 3 (excellent quality). The effect of age on image acquisition and quality was determined for patients less than or equal to 60 years (n = 54) versus greater than 60 years old (n = 46). For the 10 image planes, the average image quality score and the frequency of image acquisition (%) was (1) 2.23 and 100% for the four-chamber view, (2) 1.96 and 98% for the right ventricular inflow view and coronary sinus, (3) 2.17 and 99% for the five-chamber view, (4) 1.80 and 84% for the aortic valve short axis, (5) 1.54 and 82% for the mitral valve short axis, (6) 1.84 and 91% for the mid-left ventricular short axis, (7) 1.02 and 59% for the left ventricular apical short axis, (8) 1.79 and 93% for the ascending aorta, (9) 1.23 and 77% for the aortic arch, and (10) 1.88 and 92% for the descending thoracic aorta view. Ascending aorta and aortic valve short-axis views were obtained with a significantly higher frequency in patients less than or equal to 60 years old.(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of biplane transesophageal echocardiography in neonates, infants and children with congenital heart disease

A study was performed to assess the feasibility, additional diagnostic value and potential applications of biplane transesophageal echocardiography in neonates, infants and children. One hundred thirty-two consecutive studies were attempted in 111 anesthetized children with congenital heart disease. Longitudinal and transverse planes were compared using 3 methods: (1) separate 7 mm longitudinal and transverse pediatric transducers used sequentially; (2) an experimental 9 x 8 mm biplane pediatric transducer; and (3) a standard adult biplane transducer (12 x 9 or 13 x 9 mm). In all but 1 patient, a probe could be inserted. The longitudinal plane provided superior visualization of both the right and left ventricular outflow tracts, the interatrial septum, the main pulmonary artery, the ascending aorta and the right coronary artery. In 18 patients (16%), the longitudinal plane provided completely new diagnostic information that was not obtained with combined transthoracic and transverse plane transesophageal echocardiography. However, the transverse plane was mandatory for demonstration of the 4-chamber view, short-axis cross sections through the great arteries, the distal right pulmonary artery and bifurcation of the left coronary artery. The longitudinal plane is complementary to the transverse plane, but cannot substitute for it.

Transesophageal echocardiography with a single-plane probe. Long-axis views of the heart from the apical (transgastric) approach

The literature suggests that during transesophageal echocardiography (TEE), a short-axis view can be obtained in the gastric position using a single-plane probe. Recently, we have found that a long-axis apical display of the heart can be achieved by placing the tip of the probe in the fundus of the stomach. In a 3-month period, we attempted to obtain this view in 54 consecutive patients. Twelve of the patients had TEE done under general anesthesia, while the other 42 patients had the procedure performed under sedation with midazolam at hospital bedside or as an outpatient. The long-axis transgastric view was obtained in 51 of the 54 patients (94%). The image quality was graded subjectively as good in 39 (72%) and fair in the other 12 patients (22%). This view helped to establish the diagnosis in eight patients (15%) and to increase the level of confidence about the accuracy of the diagnosis in 23 (43%) other patients. Four patients' findings are described. We conclude that the new long-axis transgastric view is easy to obtain, does not add much time to the usual TEE study, does not add to the low complication rate of TEE, and may help to interrogate the distal structures of the heart.

Transesophageal echocardiographic diagnosis of right-sided cardiac masses in patients with central lines

Transesophageal echocardiography provides excellent images of intracardiac masses; however, its use among a series of patients with central venous lines has not been fully described. Nineteen patients (aged 52 +/- 16 years; 10 women) had masses detected by transesophageal echocardiography in the presence of a permanent (0.2 to 16 years) pacing wire (n = 8), and a current (n = 9) or recent (n = 2) (1 to 281 days) indwelling catheter. Transthoracic echocardiography suggested the presence of a mass in 5 patients (26%), although in only 2 cases were its findings consistent with transesophageal findings. Transesophageal echocardiography indicated the presence of a mass in or near the superior vena cava in 13 patients, in the right atrium in 6, and adjacent to the tricuspid valve in 3. Discrete masses measured 1.6 +/- 2.1 cm2 in area during transesophageal echocardiography. Eleven patients had positive blood cultures, 7 with staphylococcal species. Mass size was not significantly altered by the type of line or sepsis, but showed a weak correlation with line age (r = 0.56). Transesophageal echocardiography altered the management of 9 patients, prompting surgery (n = 3) and line removal (n = 3), and antibiotic (n = 2) or anticoagulation (n = 3) therapy.

Evaluation of biplane color Doppler transesophageal echocardiography in 200 consecutive patients

BACKGROUND

We developed the first biplane transesophageal echocardiography (TEE) probe with two orthogonal transducers, allowing synchronous side-by-side displays of the heart on a monitor TV, and compared its diagnostic value with that of conventional single-plane TEE using commercially available Doppler equipment in 200 consecutive patients intraoperatively, perioperatively, or on an outpatient basis.

METHODS AND RESULTS

Insertion was easy, except in one patient with a mediastinal tumor, and no complications were encountered. Both transverse and longitudinal scans allowed correct identification of true and false lumina in all 30 aortic dissection examinations, but longitudinal scanning was slightly superior in detecting types I and III entry sites. Three entries that were not detected by transverse scanning (two of DeBakey type I and one of type III) were visualized by longitudinal scanning. Among 37 cases of mitral regurgitation (MR), longitudinal scans were significantly superior (p less than 0.05) in revealing multiple jets (nine compared with two with transverse scanning). Although both planes yielded almost identical mean values for the maximum jet areas, a difference of over 50% in jet area size on the two planes was observed in 19 cases. The measured jet areas showed significant correlation with the angiographic MR grading, especially for the larger of the biplane measurements (p less than 0.01), and different grades showed little overlap. Longitudinal images increased the acoustic window of the heart and aorta from the esophagus. Moreover, longitudinal scanning provided good visualization of both ventricular outflow tracts, the ascending aorta, main pulmonary artery, and superior vena cava.

CONCLUSIONS

This modality greatly facilitates a three-dimensional comprehension of cardiovascular lesions and flow dynamics, especially in aortic dissection and MR, and its safety was demonstrated. Our data demonstrate the usefulness of this new technique in comparison with conventional single-plane TEE.

Impact of transesophageal echocardiography on the treatment of patients with aortic dissection

To determine the impact of transesophageal echocardiography (TE) on the treatment of patients with aortic dissection, the clinical course and outcome of 18 patients with TE diagnosis of dissection were analyzed. Ascending aortic dissection was present in nine patients, of whom six had surgery with confirmation of TE findings. Angiography was performed in only two of these patients and was falsely negative in one patient. Angiography was not performed in the three patients who were not surgical candidates. In the nine patients who had descending aortic dissection, angiography was performed in seven patients, of whom two underwent surgery. Information provided by angiography did not change the treatment of these patients. Thus, TE provides a prompt and accurate diagnosis in aortic dissection obviating the need for angiography in most patients.