Pulmonic valve fibroelastoma-A rare incidental finding

Primary cardiac neoplasms are a rare, commonly benign, tumor with an approximate incidence rate of 0.02%. Papillary fibroelastoma (PFE), a common form of primary cardiac neoplasms, typically present as a mass on the aortic and mitral valves, while rarely presenting as a pulmonary valve tumor. The majority of PFEs are asymptomatic, however valvular masses can pose a significant health hazard due to their potential to fragment into the bloodstream, facilitate thrombus formation, and restrict blood flow. Due to these risks, careful resection of the mass is recommended for symptomatic patients and asymptomatic patients if the tumor is large (>1 cm), mobile, or on left-sided valves. Here we present a case of an incidental finding of a pulmonic valve papillary fibroelastoma in a 65-year-old man by transesophageal echocardiography during a coronary artery bypass graft procedure.

Mitral Regurgitation due to Entrapment of Cut Mitral Chordal Apparatus in a Bileaflet Disk Prosthesis

•TEE is essential for the assessment of MVR dysfunction. •TEE can comprehensively assess paravalvular or central MR. •Understanding the pathophysiology of MR after MVR is essential. •Management of MR after MVR depends on the etiology.

Resuscitative transesophageal echocardiography during the acute resuscitation of trauma: A retrospective observational study

BACKGROUND

Resuscitative transesophageal echocardiography (TEE) is an emerging POCUS modality that can be used to guide trauma resuscitation.

METHODS

Trauma patients who underwent TEE within 24 h of admission from 2013 to 2022 were prospectively identified. We retrospectively analyzed resuscitative TEE reports and patient charts in duplicate.

RESULTS

29 providers performed TEE for 54 acute trauma patients. 28 (52%) died in hospital; 33 (61%) required operative intervention (<24 h). Median injury severity score was 29 [IQR 22-43]. The most common indications for TEE were hemodynamic instability (34, 63%), inadequate windows for transthoracic echocardiography (14, 26%) and cardiac arrest (11, 20%). There were no identified complications. A new diagnosis was made in 31 (57%) cases: most commonly right ventricular dysfunction (10, 19%), pericardial effusion (9, 17%), and hypovolemia (6, 11%). TEE ruled out major cardiac injury in 83% of cases. TEE changed resuscitative strategy, in 17 (32%) patients, diagnostic imaging approach in 6 (11%) patients, procedural or operative approach in 5 (9%) patients and disposition from the trauma bay in 4 (7%) patients.

CONCLUSION

Resuscitative TEE during acute trauma care has an additional diagnostic yield to existing diagnostic pathways and may impact definitive management for some patients in the trauma bay.

[The EDEC curriculum-the path to advanced echocardiography in the intensive care unit]

Good knowledge of echocardiography is essential for modern intensive care medicine. A standardized curriculum for acquiring the expertise to perform TTE and TEE is a good way to strengthen one's own diagnostic skills.The EDEC curriculum from ESICM, which has been established for years, offers a good opportunity for structural further training at the advanced level in combination with gaining a high level of professional competence.

Tricuspid Annular Plane Systolic Excursion (TAPSE) for the Assessment of Right Ventricular Function in Adult and Pediatric Cardiac Surgery: Modified Two-dimensional and M-mode TAPSE by Transesophageal Echocardiography Compared to M-mode TAPSE by Transthoracic Echocardiography

OBJECTIVES

To compare transesophageal echocardiography-guided 2-dimensional and M-mode tricuspid annular plane systolic excursion (TAPSE) to transthoracic echocardiography (TTE)-guided M-mode TAPSE in terms of accuracy, interobserver, and intra-observer variability.

DESIGN

A prospective, observational study.

SETTING

Adult and pediatric operating rooms.

PARTICIPANTS

Adult and pediatric patients (42 each) undergoing cardiac surgeries.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Modified midesophageal (Mod-ME), deep transgastric, and transgastric TAPSEs were analyzed for reliability and were compared to TTE TAPSE in both adult and pediatric groups. Modified ME TAPSE showed good method agreement with TTE TAPSE (bias = -0.97, p = 0.08 (adult); bias = 0.17, p = 0.71 [pediatric]), and showed a moderate correlation with right ventricular (RV) fractional area change (FAC) (r = 0.41, p = 0.006, [adult]; r = 0.57, p < 0.001, [pediatric]), with acceptable interobserver variability (percentage error =10.56 [adult]; 4.42 [pediatric]) and intraobserver variability (percentage error = 13.1 [adults]; 12.24 [pediatric]). Transgastric TAPSE poorly agreed with TTE TAPSE and had higher interobserver and intraobserver variability. Deep transgastric TAPSE had good method agreement with TTE TAPSE and had acceptable interobserver and intra-observer variability.

CONCLUSIONS

Modified ME TAPSE is a reliable and reproducible measure of RV function before pericardiotomy in both adult and pediatric cardiac surgery. Right ventricular FAC values reflected the RV systolic function better than TAPSE after pericardiotomy. Deep transgastric TAPSE is reliable and reproducible but is less accurate than Mod-ME TAPSE.

Use of Transesophageal Echocardiography for Enhanced Safety During Bar Removal Procedures After Minimally Invasive Repair of Pectus Excavatum

Background: Minimally invasive repair of pectus excavatum involves placement of retrosternal support (Nuss) bars. Hardware removal has been rarely associated with life-threatening hemorrhage from the heart, aorta, internal mammary arteries, and/or lung. There is no accepted standard intraoperative monitoring technique used during removal. We hypothesized that the use of transesophageal echocardiography (TEE) during Nuss bar removal would enhance safety of the procedure and be cost-effective. Methods: IRB-approved retrospective review of patients who underwent Nuss bar removal with intraoperative TEE monitoring over a 4-year period, from March 2013 to May 2017, was completed. Bar removal procedures were performed supine, under general anesthesia. TEE images were monitored and any distortion of the cardiac silhouette, new pericardial effusion, and/or cardiac arrhythmias would be considered evidence of possible bar adherence, triggering possible conversion to sternotomy or thoracotomy. Results: In total, 87 consecutive patients, mean age of 20 years, were identified. Bars had been in place for a mean of 30 months. Average procedure time was 67 minutes. No patients experienced arrhythmias, cardiac injury, or significant hemorrhage during removal. TEE gave excellent visualization of the cardiac silhouette and pericardium in all cases. No patient required insertion of an arterial line, a postoperative chest X-ray, or overnight hospitalization. Patients were discharged from the recovery room an average of 89 minutes postprocedure. Conclusion: TEE offers a minimally invasive safe way to visualize the pericardium and its contents during Nuss bar removal. Significant cardiac/mediastinal injuries should be immediately visible. The use of TEE is cost-effective and allows safe discharge the day of surgery.

TEE-Graph: efficient privacy and ownership protection for cloud-based graph spectral analysis

Introduction

Big graphs like social network user interactions and customer rating matrices require significant computing resources to maintain. Data owners are now using public cloud resources for storage and computing elasticity. However, existing solutions do not fully address the privacy and ownership protection needs of the key involved parties: data contributors and the data owner who collects data from contributors.

Methods

We propose a Trusted Execution Environment (TEE) based solution: TEE-Graph for graph spectral analysis of outsourced graphs in the cloud. TEEs are new CPU features that can enable much more efficient confidential computing solutions than traditional software-based cryptographic ones. Our approach has several unique contributions compared to existing confidential graph analysis approaches. (1) It utilizes the unique TEE properties to ensure contributors' new privacy needs, e.g., the right of revocation for shared data. (2) It implements efficient access-pattern protection with a differentially private data encoding method. And (3) it implements TEE-based special analysis algorithms: the Lanczos method and the Nystrom method for efficiently handling big graphs and protecting confidentiality from compromised cloud providers.

Results

The TEE-Graph approach is much more efficient than software crypto approaches and also immune to access-pattern-based attacks. Compared with the best-known software crypto approach for graph spectral analysis, PrivateGraph, we have seen that TEE-Graph has 103-105 times lower computation, storage, and communication costs. Furthermore, the proposed access-pattern protection method incurs only about 10%-25% of the overall computation cost.

Discussion

Our experimentation showed that TEE-Graph performs significantly better and has lower costs than typical software approaches. It also addresses the unique ownership and access-pattern issues that other TEE-related graph analytics approaches have not sufficiently studied. The proposed approach can be extended to other graph analytics problems with strong ownership and access-pattern protection.

Prognostic Value of Galectin-3 after Left Atrial Appendage Occlusion for Predicting Peri-Device Leakage

Echocardiographic detection of residual peri-device leakage (PDL) after percutaneous left atrial appendage occlusion (LAAO) is crucial for managing anticoagulation. Galectin-3, a protein involved in tissue-foreign body interactions, may hold significance in understanding PDL and cardiac tissue remodeling after LAAO. This study aimed to analyze galectin-3 serum levels in relation to PDL using a novel echo-morphological classification. LAAO eligible patients were included in the study. Galectin-3 serum levels were measured before LAAO, at 45 days (45D), and at 6 months (6M) after the procedure. Transesophageal echocardiography was used to assess LAAO success. A new echo-morphological classification categorized the degree of LAAO into three different types (A: homogenous echodensity, indicating completely thrombosed device; B: inhomogeneous echolucencies (<50% of device); and C: partially thrombosed device with echolucencies > 50%). Among 47 patients, complete LAAO was achieved in 60% after 45D and in 74% after 6M. We observed a significant increase and distribution of serum levels of galectin-3 [ng/mL] after 45D among the three types (baseline: 13.1 ± 5.8 ng/mL; 45D: 16.3 ± 7.2 ng/mL (Type A) vs. 19.2 ± 8.6 ng/mL (Type B) vs. 25.8 ± 9.4 ng/mL (Type C); p = 0.031), followed by a drop in galectin-3 for Types A and B after 6M toward and below the baseline levels (6M: 8.9 ± 3.1 ng/mL (Type A) vs. 12.4 ± 5.5 ng/mL (Type B)), whereas Type C persisted in showing elevated galectin-3 levels compared to all other types (6M: 17.5 ± 4.5 ng/mL (Type C); p < 0.01). Increased galectin-3 serum levels after LAAO likely reflect the transition from thrombus formation to fibrotic scar development in the LAA lumen. Successful occlusion is associated with a time-restricted decrease in galectin-3 levels after 6 months, while relevant PDL leads to persistently elevated levels, making galectin-3 a potential predictor of occlusion success.

Fleshing Out the Invisible: A Pericardial Paraganglioma

•Pericardial paragangliomas can present with angina and dyspnea. •TTE is often the first-line test for assessing pericardial tumors. •Long sweeps and contrast enhancement may enhance visualization of pericardial masses. •Multimodality imaging may help differentiate malignant from benign tumors.

Overcoming a stubborn patent foramen ovale

Transesophageal echocardiography (TEE) with agitated saline contrast ("bubble study") is the gold standard for detection of patent foramen ovale (PFO). Standard provocative maneuvers help facilitate right-to-left shunting necessary for diagnosing PFO but may be difficult to implement during TEE. Hypovolemia related to preprocedural fasting may challenge detection of PFO in TEE, and additional optimization measures such as fluid replenishment with passive leg raise (PLR) can enhance PFO detection. We present a 57-year-old male with history of cryptogenic stroke and stubborn PFO which during TEE bubble study responded only to ample fluid replenishment with PLR following a period of prolonged preprocedural fasting.

Transesophageal echocardiography-associated gastrointestinal injuries: systematic review and pooled rates of gastrointestinal injuries

Upper gastrointestinal (GI) injuries are associated with transesophageal echocardiography (TEE) complications. We reviewed rates and various types of complications with GI injuries. A comprehensive literature search using five databases was conducted. Pooled rates were calculated for overall injuries, pooled GI complications, lacerations, and perforations with a 95% confidence interval (CI). A total of 26 studies involving 55,319 patients met inclusion criteria. The overall rate of adverse events was 0.51% (95% CI 0.3% to 0.7%). Bleeding was the most commonly reported adverse event, followed by dysphagia and lacerations. The highest rate of adverse events was observed in liver transplant patients (1.35%), followed by critically ill patients in the intensive care unit (1.1%), hospitalized patients (1.1%), patients undergoing intraoperative TEE (0.7%), and those undergoing cardiac procedures (0.67%). The pooled complication rate for bleeding was 0.17% (95% CI 0.1% to 0.3%), while odynophagia/dysphagia had a rate of 0.27% (95% CI -0.1% to 0.5%) and lacerations had a rate of 0.12% (95% CI -0.1% to 0.5%). A subgroup analysis comparing variceal and nonvariceal cohorts from three studies showed no significant difference in bleeding rates. Our study findings showed a low risk of esophageal injury in patients undergoing TEE.

Focused Ultrasonography in Cardiac Arrest

Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.

A rare case of cardiac myxoma with light bulb-like cystic morphology: a case report

Background

Cystic myxomas are quite rare. Moreover, few reports have evaluated the causes that constituted them.

Case summary

A 73-year-old Asian man presented for pre-operative examination of osteoarthritis, and transthoracic echocardiography (TTE) revealed an incidental intracardiac mass. Therefore, he was referred to our department for further evaluation. He had no specific symptoms or family history related to tumours and heart failure. The TTE showed a 32 × 24 mm spherical mass adherent to the left atrial septum. The upper part of the mass was cystic in formation and hypoechoic inside and resembled a light bulb. Transoesophageal echocardiography showed the feeding arteries flowing from the bottom into the cystic part. In addition, two jet strips drained from the cystic part in the direction of the mitral valve. Coronary angiography revealed the feeding arteries, which consisted mainly of the right coronary artery conus branch and the left circumflex branch, and the blood flowed into the saccular area from the feeding arteries and excreted towards the mitral valve. Surgical resection was performed due to the mobility, and the histopathology confirmed a cystic myxoma.

Discussion

We described the unique anatomical formation of a cystic myxoma, which consisted of an exquisite balance between the tumour-feeding arteries and the draining outlet vessels.

Single-operator left atrial appendage occlusion utilizing conscious sedation, transoesophageal echocardiography, lack of outpatient pre-imaging, and same-day expedited discharge: a feasibility case series

BACKGROUND

Contemporary procedural guidelines for percutaneous left atrial appendage occlusions (LAAO) with the WATCHMAN device often require the utilization of pre-screening imaging, general anaesthesia, intubation, a dedicated intra-procedural echocardiographer, and overnight observation. For these reasons, LAAO with the WATCHMAN is not economically feasible for many hospital systems. Thus, we sought to evaluate a newstrategy for implantation that may provide a more minimalistic and less cumbersome approach to LAAO.

CASE SUMMARY

We describe five cases utilizing single-operator left atrial appendage occlusion utilizing conscious sedation, transoesophageal echocardiography, lack of outpatient pre-imaging, and same-day expedited discharge (SOLO-CLOSE)-a novel single-operator procedural strategy for LAAO that safely foregoes the aforementioned procedural requirements and allows for same-day early discharge. All five patients were observed according to our newly devised SOLO-CLOSE protocol and were safely discharged home the same day. Follow-up transoesophageal echocardiography (TEE) at 45 days and 1 year revealed well-seated and well-anchored devices with no leaks (<5 mm) or device-related thrombi.

DISCUSSION

The SOLO-CLOSE series is the first ever documented WATCHMAN strategy that utilizes a single-operator, TEE-guided, nurse-driven conscious sedation protocol that defers pre-screening imaging and allows for same-day discharge. The versatility of this technique allows proceduralists to comfortably achieve successful LAAO despite a wide range of risk profiles. This single-operator technique has potential to become a widely accepted universal approach for non-pharmacological cardioembolic stroke prophylaxis due to its efficacy, safety, simplicity, and presumable cost-effectiveness.

Intraoperative Inversion of the Left Atrial Appendage Following Ligation

•

Intraoperative TEE improves the diagnosis of LAA inversion.

•

Excess negative pressure causes inversion at predictable points in cardiac surgery.

•

Structural characteristics of the LAA may influence inversion susceptibility.

•

Ligation has been used to manage LAA inversion but may actually cause inversion.

•

This may occur from altering the structural characteristics and shortening the LAA.

An Unusual Cause of Aortic Regurgitation in a Patient With Bicuspid Aortic Valve

Aortic fibrous strands are considered residual tissue from aortic valve development. Rupture of these strands is an important albeit uncommon cause of aortic regurgitation (AR). The authors describe a 67-year-old man who was admitted to the authors' hospital with sudden onset shortness of breath and diagnosed with severe AR. The patient was scheduled for Bentall surgery. The transesophageal echocardiogram (TEE) found multiple fibrous strands that were present in multiple locations of the aortic valve, some of which were ruptured. Ruptured fibrous strands are in the differential diagnosis in patients presenting with acute AR without a more conventional explanation, and TEE is instrumental in securing the diagnosis.

Coronary Obstruction during Valve-in-Valve Transcatheter Aortic Valve Replacement: Pre-Procedural Risk Evaluation, Intra-Procedural Monitoring, and Follow-Up

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is emerging as an effective treatment for patients with symptomatically failing bioprosthetic valves and a high prohibitive surgical risk; a longer life expectancy has led to a higher demand for these valve reinterventions due to the increased possibilities of outliving the bioprosthetic valve's durability. Coronary obstruction is the most feared complication of valve-in-valve (ViV) TAVR; it is a rare but life-threatening complication and occurs most frequently at the left coronary artery ostium. Accurate pre-procedural planning, mainly based on cardiac computed tomography, is crucial to determining the feasibility of a ViV TAVR and to assessing the anticipated risk of a coronary obstruction and the eventual need for coronary protection measures. Intraprocedurally, the aortic root and a selective coronary angiography are useful for evaluating the anatomic relationship between the aortic valve and coronary ostia; transesophageal echocardiographic real-time monitoring of the coronary flow with a color Doppler and pulsed-wave Doppler is a valuable tool that allows for a determination of real-time coronary patency and the detection of asymptomatic coronary obstructions. Because of the risk of developing a delayed coronary obstruction, the close postprocedural monitoring of patients at a high risk of developing coronary obstructions is advisable. CT simulations of ViV TAVR, 3D printing models, and fusion imaging represent the future directions that may help provide a personalized lifetime strategy and tailored approach for each patient, potentially minimizing complications and improving outcomes.

Rescue Transesophageal Echocardiography: A Narrative Review of Current Knowledge and Practice

Perioperative transesophageal echocardiography (TEE) has been part of clinical activity for more than 40 years. During this period, TEE has evolved in terms of technology and clinical applications beyond the initial fields of cardiology and cardiac surgery. The benefits of TEE in the diagnosis and management of acute hemodynamic and respiratory collapse have been recognized in noncardiac surgery and by other specialties too. This natural progress led to the development of rescue TEE, a relatively recent clinical application that extends the use of TEE and makes it accessible to a large group of clinicians and patients requiring acute care. In this review, the authors appraise the current clinical applications and evidence base around this topic. The authors provide a thorough review of the various image acquisition protocols, clinical benefits, and compare it with the more frequently used transthoracic echocardiography. Furthermore, the authors have reviewed the current training and credentialing pathways. Overall, rescue TEE is a highly attractive and useful point-of-care examination, but the current evidence base is limited and the technical protocols, training, and credentialing processes are not standardized. There is a need for adequate guidelines and high-quality research to support its application as a bedside rescue tool.

Incidence, Clinical Characteristics, and Impact of Absent Echocardiographic Signs in Patients With Infective Endocarditis After Transcatheter Aortic Valve Implantation

BACKGROUND

Echocardiography is the primary imaging modality for diagnosis of infective endocarditis (IE) in prosthetic valve endocarditis (PVE) including IE after transcatheter aortic valve implantation (TAVI). This study aimed to evaluate the characteristics and clinical outcomes of patients with absent compared with evident echocardiographic signs of TAVI-IE.

METHODS

Patients with definite TAVI-IE derived from the Infectious Endocarditis after TAVI International Registry were investigated comparing those with absent and evident echocardiographic signs of IE defined as vegetation, abscess, pseudo-aneurysm, intracardiac fistula, or valvular perforation or aneurysm.

RESULTS

Among 578 patients, 87 (15.1%) and 491 (84.9%) had absent (IE-neg) and evident (IE-pos) echocardiographic signs of IE, respectively. IE-neg were more often treated via a transfemoral access with a self-expanding device and had higher rates of peri-interventional complications (eg, stroke, major vascular complications) during the TAVI procedure (P < .05 for all). IE-neg had higher rates of IE caused by Staphylococcus aureus (33.7% vs 23.2%; P = .038) and enterococci (37.2% vs 23.8%; P = .009) but lower rates of coagulase-negative staphylococci (4.7% vs 20.0%, P = .001). IE-neg was associated with the same dismal prognosis for in-hospital mortality in a multivariate binary regression analysis (odds ratio: 1.51; 95% confidence interval [CI]: .55-4.12) as well as a for 1-year mortality in Cox regression analysis (hazard ratio: 1.10; 95% CI: .67-1.80).

CONCLUSIONS

Even with negative echocardiographic imaging, patients who have undergone TAVI and presenting with positive blood cultures and symptoms of infection are a high-risk patient group having a reasonable suspicion of IE and the need for an early treatment initiation.

Left ventricular assist device inflow obstruction

Inflow cannula obstruction is a rare complication of left ventricular assist device implantation. In this report, we present a case of inflow obstruction that was successfully treated with left ventricle myectomy and mitral valvectomy. Transesophageal echocardiogram was essential in diagnosing this condition.

The Use of Contrast May Improve Aortic Valve Assessment During Transesophageal Echocardiography

OBJECTIVES

The Doppler profile that quantifies the degree of aortic stenosis is essential, as an inaccurate measurement can alter the surgical plan. The authors aimed to examine the level of agreement between the contrast and noncontrast methods of aortic valve sizing during intraoperative transesophageal echocardiography (TEE).

SETTING

At a tertiary hospital.

PARTICIPANTS

A total of 30 patients undergoing surgical aortic valve replacement for a stenotic valve.

INTERVENTIONS

Perflutren lipid microsphere contrast injection.

MEASUREMENTS AND MAIN RESULTS

The authors reviewed Doppler studies of 30 consecutive patients undergoing aortic valve replacement in whom a contrast agent was given (perflutren lipid microsphere). They measured the peak and/or mean aortic valve gradients and velocity time integral readings through the left ventricular outflow tract (LVOT), and the aortic valve before and after administering the contrast agent. The aortic valve area was then calculated using both methods. Paired t tests and Bland-Altman analyses were used to examine the bias and the level of agreement between the 2 processes. By not using a contrast agent, the aortic valve area was overestimated by 0.26 cm² compared to those measured by transthoracic echocardiography (TTE) (p < 0.001). Using a contrast agent, TEE measurements were comparable to those obtained by TTE. Moreover, the peak and mean aortic valve gradients were underestimated by 19 and 11 mmHg, respectively (p value <0.001). Adding contrast did not affect the pulse-wave Doppler readings of the V1 velocity of the LVOT.

CONCLUSION

This discrepancy is significant and could affect the decision to replace the aortic valve. When evaluating the aortic valve with TEE, the authors recommend using a contrast agent to improve the Doppler profile and to obtain a more accurate measurement of the aortic valve area.

Computed Tomography/Fluoroscopy Fusion and 3D Transesophageal Echocardiography-Guided Percutaneous Paravalvular Leak Closure

Percutaneous paravalvular leak closure seems a safe alternative to surgery in frail patients. However, it is a challenging procedure that should be tailored to each patient with optimal imaging guidance. Transesophageal echocardiography during the procedure and computed tomography scan/fluoroscopy fusion provide guidance for critical steps, such as PVL localization and crossing. (Level of Difficulty: Advanced.).

Complete region of interest reconstruction by fusing multiview deformable three-dimensional transesophageal echocardiography images

BACKGROUND

While three-dimensional transesophageal echocardiography (3D TEE) has been increasingly used for assessing cardiac anatomy and function, it still suffers from a limited field of view (FoV) of the ultrasound transducer. Therefore, it is difficult to examine a complete region of interest without moving the transducer. Existing methods extend the FoV of 3D TEE images by mosaicing multiview static images, which requires synchronization between 3D TEE images and electrocardiogram (ECG) signal to avoid deformations in the images and can only get the widened image at a specific phase.

PURPOSE

This work aims to develop a novel multiview nonrigid registration and fusion method to extend the FoV of 3D TEE images at different cardiac phases, avoiding the bias toward the specifically chosen phase.

METHODS

A multiview nonrigid registration and fusion method is proposed to enlarge the FoV of 3D TEE images by fusing dynamic images captured from different viewpoints sequentially. The deformation field for registering images is defined by a collection of affine transformations organized in a graph structure and is estimated by a direct (intensity-based) method. The accuracy of the proposed method is evaluated by comparing it with two B-spline-based methods, two Demons-based methods, and one learning-based method VoxelMorph. Twenty-nine sequences of in vivo 3D TEE images captured from four patients are used for the comparative experiments. Four performance metrics including checkerboard volumes, signed distance, mean absolute distance (MAD), and Dice similarity coefficient (DSC) are used jointly to evaluate the accuracy of the results. Additionally, paired t-tests are performed to examine the significance of the results.

RESULTS

The qualitative results show that the proposed method can align images more accurately and obtain the fused images with higher quality than the other five methods. Additionally, in the evaluation of the segmented left atrium (LA) walls for the pairwise registration and sequential fusion experiments, the proposed method achieves the MAD of (0.07 ± 0.03) mm for pairwise registration and (0.19 ± 0.02) mm for sequential fusion. Paired t-tests indicate that the results obtained from the proposed method are more accurate than those obtained by the state-of-the-art VoxelMorph and the diffeomorphic Demons methods at the significance level of 0.05. In the evaluation of left ventricle (LV) segmentations for the sequential fusion experiments, the proposed method achieves a DSC of (0.88 ± 0.08), which is also significantly better than diffeomorphic Demons at the 0.05 level. The FoVs of the final fused 3D TEE images obtained by our method are enlarged around two times compared with the original images.

CONCLUSIONS

Without selecting the static (ECG-gated) images from the same cardiac phase, this work addressed the problem of limited FoV of 3D TEE images in the deformable scenario, obtaining the fused images with high accuracy and good quality. The proposed method could provide an alternative to the conventional fusion methods that are biased toward the specifically chosen phase.

TEE guided REBOA deflation following ROSC for non-traumatic cardiac arrest

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is most commonly used to manage non-compressible torso hemorrhage. It is also emerging as a promising treatment for non-traumatic refractory cardiac arrest. Aortic occlusion during chest compressions increases cardio-cerebral perfusion, increasing the potential for sustained return of spontaneous circulation (ROSC) or serving as a bridge to extracorporeal cardiopulmonary resuscitation (ECPR). Optimal patient selection and post-ROSC management in such cases is uncertain and not well reported in the literature. We present a case of non-traumatic out-of-hospital cardiac arrest in which REBOA was placed in the emergency department with subsequent ROSC. Transesophageal echocardiography was used to guide post-ROSC REBOA management and balloon deflation.

Use of a Video Laryngoscope to Reduce Complications of Transesophageal Echocardiography Probe Insertion: A Multicenter Randomized Study

OBJECTIVE

The objective of this multicenter study was to test the hypothesis of whether the use of a video laryngoscope (VL) reduces complications related to transesophageal echocardiography (TEE) probe insertion.

DESIGN

A multicenter randomized control study.

SETTING

At 5 tertiary care level hospitals.

PARTICIPANTS

Three hundred sixty-three adult patients undergoing elective cardiac surgery.

INTERVENTIONS

The patients were randomized into 2 groups-the conventional group (C group; n = 177) and the VL group (n = 186) for TEE probe insertion.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint of the study was the incidence of oropharyngeal injury, which was defined as blood at the tip of the TEE probe at the end of surgery and/or evidence of injury on VL examination at the end of surgery. The secondary endpoints of the study were the number of attempts required for successful TEE probe insertion and the relation between the esophageal inlet and the larynx. There was a higher incidence of injuries in the C group (n = 26; 14.7%) compared to the VL group (n = 14; 7.5%; p = 0.029). The number of attempts for probe insertion was significantly lower in the VL group (p = 0.0023). The most common relation between the esophageal inlet and the larynx was posterolateral (n = 88; 47%), followed by posterior (n = 77; 41%) and lateral (n = 21;12%).

CONCLUSION

The use of VL was associated with a lesser incidence of injury compared to the conventional technique, and its use for this purpose is recommended. The use of VL for probe insertion resulted in fewer attempts compared with the conventional technique. Significant variations do exist in the relation between the esophageal inlet and the larynx, and direct visualization with VL may contribute to better safety.

An Innovative Curriculum For Teaching Transesophageal Echocardiography (TEE) to Emergency Medicine Residents

BACKGROUND

Focused transesophageal echocardiogram (TEE) can be a valuable tool for emergency physicians (EP) during cardiac arrest.

OBJECTIVES

We sought to demonstrate the ability of emergency medicine (EM) residents without prior TEE experience to perform a simulated four-view TEE following a short, flipped conference curriculum.

METHODS

This was a prospective, simulation-based study where EM residents participated in the following four-view TEE curriculum: 1 h of online content reviewed prior to a 20-min in-person lecture and 30-min hands-on practice using a TEE trainer. Each resident attended four testing sessions over an 8-week period and performed a total of 25 TEE scans. Each TEE scan was graded in real time using a 10-point checklist by a TEE-credentialed EP. Interrater reliability of the checklist was calculated using the kappa coefficient (κ). A random sample of 10% of the TEE scans were reviewed by a TEE expert using a standard ultrasound 1-5 scale for image acquisition quality, with a "3" considered to be satisfactory. Residents completed an online pretest and posttest.

RESULTS

Twenty-four residents participated. Mean pre- and posttest scores were 52% (SD 16) and 92% (SD 12), respectively. Mean TEE scores using the 10-point checklist after sessions one and four were 9.4 (SD 0.4) and 9.7 (SD 0.3), respectively. Mean time to complete each TEE scan after sessions one and four were 118.1 (SD 28.3) and 57.1 (SD 17.0) s, respectively. The κ for the checklist was 1. The median score for the image acquisition review was 3 (interquartile range 3-4).

CONCLUSIONS

This simplified flipped conference curriculum can train EM residents to competently perform TEE in a simulated environment.

Patterns of Use in Transesophageal Echocardiography for Liver Transplantation: A Systematic Review

Transesophageal echocardiography is frequently but not always used to guide anesthetic management during liver transplantation. We performed a systematic review of the literature to identify and summarize any studies reporting on the frequency and characteristics of TEE use for liver transplantation. Studies were identified by searching several relevant terms on PubMed and citation searching of relevant reviews. We identified 5 studies reporting the results of surveys performed between 2003 and 2018. Use of TEE for liver transplantation increased from 11.3% of centers in 2003 to greater than 90% of centers by 2014 and 2018. Only 38%-56% of centers use it routinely with the rest using it only in special circumstances. About a third of centers usually perform a comprehensive exam, with the majority performing a more limited exam based on the needs of the case. Use of TEE for liver transplantation is common but not universal. This review summarizes the current knowledge about the frequency and circumstances of use, but there is an opportunity for further systematic study and discussion.

Bacterial endocarditis with AACEK (HACEK) organisms

INTRODUCTION

Gram-negative organisms of the AACEK group, formerly known as HACEK, rarely cause endocarditis.

CASE SERIES

We present three cases of bacterial endocarditis, involving native and prosthetic valves, caused by AACEK organisms. In two patients, Cardiobacterium hominis was the responsible organism, and in a third, Aggregatibacter aphrophilus was implicated. A dental source of infection was identified in two patients, and in all three patients, the presentation of endocarditis was subacute.

DISCUSSION

This case series highlights the indolent nature of infection with the AACEK organisms. It also demonstrates the crucial role of multimodality imaging, especially transesophageal echocardiography, in the diagnosis of AACEk endocarditis of both native and prosthetic valves, and in delineating the extent of abscess in those with prosthetic valve infection.

Mortality Reduction After a Preincision Safety Check Before Cardiac Surgery: Is It the Aorta?

OBJECTIVES

The introduction and use of a preincision safety check were associated with lower mortality after mixed adult cardiac surgery; however, an explanatory mechanism is lacking. Stroke, one of the most severe complications after cardiac surgery, with high mortality, may be reduced by adapting the surgical handling of the ascending aorta. This study assessed the prevalence and predictors of this adaptation after a preincision safety check and the subsequent effect on outcome.

DESIGN

A prospective, single-center, observational study comparing adaptation with no-adaptation. The primary outcome measure was 30-day mortality. Multivariate analyses were performed to determine independent predictors of adaptation. To study the effect of adaptation on outcome, a propensity score-matched cohort was constructed in a 1:3 intervention:control ratio.

SETTING

At Isala Zwolle (NL), a large, nonacademic teaching hospital.

PARTICIPANTS

All consecutive cardiac surgery procedures from 2012 until 2015, including 4,752 surgeries.

INTERVENTIONS

The adaptation of surgical handling of the ascending aorta.

MEASUREMENTS AND MAIN RESULTS

In 283 cardiac surgeries (5.9%), adaptation was indicated. The most important independent predictors for adaptation were extracardiac atherosclerosis, current smoking, and increasing age. In the propensity score-matched cohort consisting of 1,069 procedures, there were no significant differences in outcome. After correction for propensity score, the hazard ratio of adaptation for 30-day mortality was 1.8 (0.85-3.79).

CONCLUSIONS

The adaptation of aortic surgical handling after a preincision safety check was necessary for 5.9% of cardiac surgeries, with extracardiac atherosclerosis as the strongest predictor. Outcome was not significantly different between patients with and without adaptation. Although promising, it remains unclear whether adaptation may fully explain mortality reduction after the use of a preincision safety check.

Ethical and clinical dilemma from an incidental cardiac lipoma in a young and healthy patient

Incidental cardiac tumors are rare and mostly detected on autopsy as patients largely remain asymptomatic. However, diagnosis of an incidental cardiac mass on unrelated workup can pose significant ethical and clinical challenge to the care team. Surgical resection has been the most successful intervention for most primary cardiac tumors; which involves cardiopulmonary bypass-assisted major surgery and is not risk free. Cardiac lipoma is the second most common primary cardiac benign tumor. We report a case of a young otherwise healthy patient who had a cardiac lipoma on computerized tomography scan that was done to rule out kidney stone.

Intraoperative transesophageal echocardiography following mitral valve repair: a systematic review

OBJECTIVE

We aimed to examine the recent evidence and search for novel assessments on intraoperative TEE following mitral valve repair that can impact short and long-term outcomes.

METHODS

The Ovid MEDLINE, PubMed, and EMBASE databases were searched from January 1, 2008, until January 27, 2021, for studies on patients with severe Mitral Valve Regurgitation (MR) undergoing Mitral Valve (MV) repair surgery with intraoperative Transesophageal Echocardiography (TEE) performed after the repair. Additional searches were conducted using Google search engine, Web of Science, and Cochrane Library.

RESULTS

After reviewing 302 records, 8 retrospective and 22 prospective studies were included (n = 30). Due to clinical and methodological diversity, these studies are noncomparable and data were not amenable to quantitative synthesis.

CONCLUSION

Although technological advances allowed the objective assessment of geometric and dynamic alterations of the MV, the impact of the use of these technologies on short- or long-term outcomes was not studied. There is uncertainty and conflicting evidence on the ideal method and metrics to evaluate MV patency post-repair. Few isolated studies validated methods to assess coaptation surface and LV function post-repair.

Intraoperative Transesophageal Echocardiographic Detection of a Gerbode Defect in a Patient Referred for Aortic Valve Endocarditis: A Case Report

This clinical challenge discusses a case in which a patient was referred for aortic valve repair or replacement due to severe aortic regurgitation from infective endocarditis. In addition to discovering a previously unknown tricuspid valve vegetation, the intraoperative echocardiographic evaluation was instrumental in revealing an undiagnosed Gerbode defect. The flow through this Gerbode defect was previously mistaken for tricuspid regurgitation, and the patient was misdiagnosed as exhibiting severe pulmonary hypertension. This case highlights the importance of reviewing preoperative echocardiographic imaging, as well as diligence in completing a thorough intraoperative transesophageal echocardiographic exam prior to cardiopulmonary bypass. In addition, while flow typically occurs in Gerbode defects during systole, this case demonstrates that flow can also occur during diastole, which was most likely due to the severe aortic regurgitation. Fortunately, the patient was able to undergo successful treatment for the unexpected sequalae of the infective endocarditis, including repair of the Gerbode defect, tricuspid valve repair, and aortic valve and root replacement. Importantly, the incorrect diagnosis of severe pulmonary hypertension was removed.

Is NPO (Nil Per Os) order helping or hindering elective cardiac procedures?

The practice of fasting before elective cardiac procedures including cardiac catheterization and transesophageal echocardiography is commonly implemented but evidence for these requirements is lacking. Fasting periods often exceed the intended length of time, increasing the risk of irritability, dehydration, acute kidney injury, hypoglycemia, and length of hospitalization. The practice of perioperative fasting relies on the premise that aspiration during general anesthesia can be mitigated by minimizing the volume of gastric contents, and stomach acidity. But the evidence has shown that fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. Elective cardiac procedures are performed using procedural sedation, where the risk of serious aspiration is small. In most patients, we argue, that strict fasting requirements should be reduced, and a more nuanced fasting protocol based on individual patient characteristics and risk factors should be utilized given the overall low risk of aspiration with elective procedures utilizing procedural sedation. In this review, we examine the historical origins and current evidence relating to the practice of fasting as it relates to cardiac catheterization and transesophageal echocardiography.

Comparison of left atrial appendage parameters using computed tomography vs. transesophageal echocardiography for watchman device implantation: a systematic review & meta-analysis

BACKGROUND

Inaccurate sizing of left atrial appendage (LAA) occlusion devices is associated with increased stroke risk. We compared the LAA size to implant the Watchman device assessed by computed tomography (CT) to transesophageal echocardiography (TEE). We also compared procedural outcomes between the two modalities.

METHODS

Databases were searched to identify studies comparing LAA anatomical measurements and procedural outcomes across imaging modalities for the Watchman device implantation.

RESULTS

Seven studies were included in the analysis (242 patients on TEE, and 232 on CT). The LAA orifice was larger when sized with CT compared to TEE (CT mean vs TEE SMD 0.30mm, 95%CI 0.09-0.51mm, P<0.01; and CT max vs TEE SMD 0.69mm, 95%CI 0.51-0.87mm, P < 0.001). Additionally, CT, including CT-based 3-dimensional models, had higher odds of predicting correct device size compared to TEE (OR 1.64; 95%CI 1.05-2.56; P = 0.03). CT resulted in a lower fluoroscopy time vs TEE (SMD -0.78 min, 95% CI -1.39 to -0.18, P = 0.012). No significant differences were found in device clinical outcomes.

CONCLUSION

Compared to TEE, CT resulted in larger LAA orifice measurements, improved odds of predicting correct device size, and reduced fluoroscopy time in patients undergoing LAA occlusion with the Watchman device. There were no significant differences in other procedural outcomes.

Miniature Erupting Volcano-Shaped Mitral Valve Aneurysm Secondary to Streptococcus agalactiae ST1656 Endocarditis: A Case Report

Mitral valve aneurysm (MVA) is a rare but life-threatening valvular pathologic entity most commonly associated with infective endocarditis (IE) of the aortic valve (AV). We describe a diabetic patient with ruptured anterior MVA secondary to capsular genotype V Streptococcus agalactiae (GBS) harboring novel ST1656 IE without AV involvement. Our patient presented with manifestations of various serious systemic and intracardiac complications, requiring early surgery, but ultimately died from non-cardiogenic causes. This case emphasizes the importance of treating MVA as a dangerous sequela of IE, of performing transesophageal echocardiography to make its accurate diagnosis and institute early surgical intervention, and of considering GBS as a rare but important causative agent of IE in elderly patients with comorbidities.

Normative Transesophageal Echocardiographic Values of Cardiac Structures in the Indian Population-Indian Normative TEE Measurements (INTEEM) Study

OBJECTIVES

Information on normative reference values for cardiac structures is critical for the accurate application of echocardiography for guiding clinical decision-making. Many studies using transthoracic echocardiography (TTE) have shown that Indians have smaller diameters of various cardiac structures. There are no normative studies for transesophageal echocardiography (TEE). The authors observed dimensions of various cardiac structures in healthy Indian patients under general anesthesia using TEE and compared them with existing guidelines from non-Indian data.

DESIGN

The Indian Normative TEE Measurements study was a multicenter, prospective observational study conducted in India.

SETTING

Operating rooms for noncardiac surgeries in tertiary care-level hospitals.

PARTICIPANTS

Adult patients undergoing noncardiac surgery who were free from any cardiac, respiratory, and renal diseases and had no contraindications for TEE.

INTERVENTIONS

After inducing general anesthesia and achieving stable hemodynamic conditions, a comprehensive TEE examination was performed and various measurements were made.

MEASUREMENTS AND MAIN RESULTS

For each of the 83 patients undergoing noncardiac surgery, 39 various measurements for left ventricle, right ventricle, both atria, and all valves were made. This included diameters and functional parameters. They were analyzed in a vendor-neutral software off-line. The absolute values of many of the measurements were higher in men, but when indexed to body surface area (BSA) they were similar in both sexes. The values were lower than most of the Western data but matched previous Indian studies using TTE.

CONCLUSIONS

The authors present normative values of various echocardiographic parameters using TEE. Because of its variations, it is recommended to use India-specific data to make decisions in Indian patients. It may be prudent to use BSA-indexed values during decision-making.

Transcatheter mitral valve-in-valve-in-valve replacement with transseptal puncture in the presence of an atrial septal occluder device

Quite often the iatrogenic atrial septal defect created after percutaneous transcatheter mitral valve replacement procedures is closed with an atrial septal occluder device thus precluding further transseptal interventions if required. In this case report, we describe a patient who previously underwent a valve-in-valve transcatheter mitral valve replacement and iatrogenic atrial septal defect closure with an Amplatzer device, who developed severe prosthetic mitral valve stenosis. This patient required a second percutaneous valve-in-valve in-valve procedure with a transseptal puncture in the presence of an atrial septal occluder device.

Transparency of TEE3D surface rendering helps to assess the scale of hidden disaster

Presented case illustrates additional value of applying a new visualization technique - 3D Surface Rendering during the three-dimensional echocardiography.

TEE-Guided Percutaneous Aspiration of a Large Lead-Associated Vegetation Prior to Transvenous Lead Extraction

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Vacuum-assisted aspiration of large CIED lead vegetations is a promising technology.

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TEE guidance is critical for the safe and complete aspiration of vegetations.

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Real-time TEE identifies important residual findings following lead extraction.

Multivalvular destruction as the primary presentation of aggressive infective endocarditis with subaortic valve membrane

Multivalvular destruction may be a clinical manifestation of infective endocarditis (IE), which is a devastating infection of the heart either alone or superimposed with congenital subaortic membrane as in this case report. Here, we report a case of multivavular destruction with severe vegetation presented as a manifestation of infective endocarditis (IE) in a neglected case of 18-year-old male with previous rheumatic heart disease. Transesophageal echocardiography is an important imaging modality for diagnosis of superimposed aortic and heart lesions. Early necessary investigation and correct diagnosis is mandatory to prevent bad complications.

Application of PBL Mode in a Resident-Focused Perioperative Transesophageal Echocardiography Training Program: A Perspective of MOOC Environment

BACKGROUND

Massive open online courses (MOOCs) is a new teaching technology based on a network platform, which can provide more students with the possibility of systematic and repeated learning. Due to the complexity of transesophageal echocardiography (TEE), the wide range of knowledge involved, and many knowledge points being difficult to understand, it is difficult to meet the teaching needs of this content with the traditional teaching mode. This study aimed to discuss the application of lecture based learning (LBL) and problem based learning (PBL) in the training of perioperative TEE in the context of MOOCs.

METHODS

Sixty residents were randomly divided into two groups to participate in a 5-day perioperative TEE training program. The web-based PBL mode was used in the observation group and the LBL mode was used in the control group, with 30 residents in each group. The teaching effect of the web-based PBL mode was compared with the LBL mode by basic theory test, practice examination, image interpretation and questionnaire.

RESULTS

The image interpretation score and the total test score were higher in the observation group than in the control group with statistically significant differences (P<0.001). The results of the questionnaire show that the residents were more satisfied with the web-based PBL mode than the LBL mode (P<0.001).

CONCLUSION

The web-based PBL method has obvious advantages over the LBL mode in the training of perioperative TEE.

Cardiac hemangioma in a difficult anatomical location presented with ventricular tachycardia. A rare case report

Cardiac hemangioma is a benign and rare primary tumor of the heart. Though it has benign histopathological features, its complications can be life-threatening. We report a young adult male without any prior structural heart disease or medical history who presented with ventricular tachyarrhythmia. Echocardiography revealed an echogenic mass located intramurally in the left lateral ventricle and its distinctive characteristics were revealed with further imaging modalities. Though simple complete removal of the mass is the preferred treatment, its firm texture and thinned encircling myocardium prevented the total excision. In this case report, we discussed cardiac hemangioma, its potential complications and treatment options.

Right atrial mass-multimodality imaging-Massive lipomatous hypertrophy of the atrial septum

Asymptomatic cardiac masses are often diagnosed incidentally. Massive lipomatous hypertrophy can be confused for other cardiac masses and need careful evaluation including multimodality imaging to manage appropriately.

Tricuspid valve Swan-Ganz catheter entrapment before cardiac surgery

A Swan-Ganz catheter during cardiac surgery offers peri-operative haemodynamic monitoring, although insertion of these catheters is not without risk. We report a case of Swan-Ganz catheter entrapment within the tricuspid valve during elective off-pump coronary artery bypass surgery. The diagnosis was made immediately by transoesophageal echocardiography, thus preventing forced withdrawal of the catheter. Intra-operatively, the echocardiographically detected findings of complex entrapment was confirmed. The Swan-Ganz catheter was tightly wrapped around the subvalvular apparatus, requiring on-pump open surgical removal. This case illustrates the anatomical complexity of such a catheter entrapment around the tricuspid valve apparatus and the importance of rapid echocardiographic diagnosis to prevent iatrogenic damage.