Right superior pulmonary vein parameter determined by three-dimensional transesophageal echocardiography is an independent predictor of the outcome after cryoballoon isolation of the pulmonary veins

BACKGROUND

A direct comparison of three-dimensional transesophageal echocardiography (3DTEE) and cardiac computed tomography imaging has demonstrated good inter-technique agreement for the following pulmonary vein (PV) parameters: the ostium area of the right superior PV (RSPV) and its major (a) and minor axis (b) diameters, the left lateral ridge and the minor axis (b) diameter of the left superior PV. Herein, under investigation, was the predictive value of these parameters for arrhythmia recurrence (AR) after PV isolation with the 28 mm second generation cryoballoon (CBG2).

METHODS

One hundred eleven patients (67 men, mean age 58.06 ± 10.58 years) undergoing 3DTEE before PV isolation with the CBG2 for paroxysmal atrial fibrillation were followed. "Point by point" redo intervention was offered in case of AR and reconnected PVs were defined.

RESULTS

During a mean follow-up of 617 ± 258.86 days, 65 (58.9%) patients remained free of AR. Longer RSPV b was found to be the only significant predictor for AR (hazard ratio [HR] 1.059; 95% confidence interval [CI] 1.000-1.121; p = 0.048). RSPV b ≥ 28 mm resulted in a threefold (HR 3.010; 95% CI 1.270-7.134, p = 0.012) increase in the risk of AR. The association of RSPV b with AR was independent of the biophysical parameters of cryoapplications. In 25 "redo" patients, reconnections were found 1.75 times more likely in the RSPV than in the other 3 PVs altogether.

CONCLUSIONS

Right superior PV b measured with 3DTEE might be a significant predictor of AR after PV isolation with the CBG2. In case of RSPV b exceeding 28 mm, alternative PV isolation techniques or use of a larger balloon might be considered.

Three-Dimensional Finger Test: A New Echocardiographic Method to Locate the Best Access Site During NeoChord Procedure

OBJECTIVE

Transventricular beating-heart mitral valve repair (TBMVR) with artificial chordae implantation is a technique to treat mitral valve prolapse. Two-dimensional (2D) echocardiography completed with simultaneous biplane view during surgeon finger pushing on the left ventricular (LV) wall (finger test [FT]) is currently used to localize the desired LV access, on the inferior-lateral wall, between the papillary muscles (PMs). We aimed to compare a new three-dimensional (3D) method with conventional FT in terms of safety and better localization of LV access.

METHODS

During TBMVR, conventional FT was completed using 3D transesophageal echocardiography by placing the sample box in the bicommissural view of the LV, including the PMs and the apex. The 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator's finger pushing on the LV. We asked the first operator, the second operator, and the cardiac surgery fellow, separately, to evaluate the location of their finger pushing, both with the 2D method and the 3D method, to estimate the interoperator concordance.

RESULTS

From 2019 to 2021, 42 TBMVRs were performed without complications related to access using FT completed with the 3D method. Regarding the choice of the right and safe entry site, the operator's agreement was higher using 3D rendering compared with conventional FT (mean agreement 0.59 ± 0.29 for 2D vs 0.83 ± 0.20 for 3D), while full operator agreement was 10 of 42 for 2D and 23 of 42 for 3D (P = 0.004).

CONCLUSIONS

Three-dimensional FT is easy to perform and facilitates surgeons choosing the best access for TBMVR in term of anatomical localization and safety.

Diagnostic accuracy of two-dimensional and three-dimensional transesophageal echocardiography in detecting pannus and thrombus in left mechanical valve obstruction

The aim of this study was to determine the accuracy of two-dimensional and three-dimensional transesophageal echocardiography (TEE) in the detection of pannus and thrombus in left mechanical valve obstruction (LMVO) compared with surgical and histopathology findings.

Materials and methods

Patients with suspected LMVO on transthoracic echocardiography were enrolled consecutively. All patients underwent two-dimensional and three-dimensional TEE, and open-heart surgery to replace obstructed valves. Macroscopic and microscopic analysis of the excised masses was used as the gold standard for the diagnosis of thrombus and/or pannus.

Results

Forty-eight patients [34 women (70.8%), age 49±13 years, New York Heart Association II: 68.8%, New York Heart Association III: 31.2%] were enrolled. In the diagnostic of thrombus, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of three-dimensional TEE were 89.2, 72.7, 85.4, 91.7, and 66.7%, respectively, compared with those of two-dimensional TEE (42.2, 66.7, 43.8, 95, and 7.1%, respectively). In the diagnosis of pannus, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of three-dimensional TEE were 53.3, 100, 85.4, 100, and 82.5%, respectively; compared with those of two-dimensional TEE (7.4, 90.5, 43.8, 50, and 43.2%, respectively). Receiver operating characteristic curves depict that the area under the curves of three-dimensional TEE was higher than the area under the curves of two-dimensional TEE in both diagnoses of thrombus and pannus (0.8560 vs. 0.7330, P=0.0427 and 0.8077 vs. 0.5484, P=0.005, respectively).

Conclusions

This study indicated that three-dimensional TEE had a higher diagnostic value than two-dimensional TEE in the detection of thrombus and pannus in patients with LMVO, and can be a reliable imaging modality to identify the causes of LMVO.

Mitral Annulus Geometry and Dynamic Motion Changes in Patients With Aortic Regurgitation: A Three-Dimensional Transesophageal Echocardiographic Study

OBJECTIVE

The aim of the present study was to investigate the mitral annulus (MA) geometry and dynamic motion changes in patients with aortic regurgitation (AR) before and after aortic valve replacement (AVR). Moreover, the difference in the effect of the type of prosthetic aortic valve on MA was compared.

DESIGN

Prospective observational study.

SETTING

Cardiac operating room at a single hospital.

PARTICIPANTS

Eighty-two patients with isolated moderate-to-severe AR who underwent AVR. Forty patients with normal valves were enrolled as controls.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The MA geometry and dynamic motion throughout the cardiac cycle were evaluated semiautomatically by three-dimensional transesophageal echocardiography. The severity of functional mitral regurgitation was intraoperatively evaluated. All patients were divided into 2 groups depending on the type of prosthetic valve (mechanical valve and bioprosthetic valve groups). Before AVR, compared with the control group without AR, the AR group demonstrated larger MA dimensions and the MA geometry was flatter. The contraction fraction of the MA area, perimeter, and height during the whole cardiac cycle were larger in the AR group (p < 0.05 for all). After AVR, most MA geometric and dynamic parameters decreased and functional mitral regurgitation also improved. In the postoperative subset analyses, the mechanical valve group showed a larger contraction fraction of the MA area and perimeter than the bioprosthetic valve group (p < 0.05 for both).

CONCLUSIONS

The MA geometry and dynamic motion changed markedly in patients with AR. These spatial and dynamic changes were restored to a certain extent after surgical correction of the aortic valve. However, the effects produced by mechanical and bioprosthetic valves on MA were different.

Interventional echocardiography: Opportunities and challenges in an emerging field

The growth of transcatheter structural heart disease interventions has created a subspecialty of interventional imagers who focus on preprocedural planning and the periprocedural guidance of these complex cases. In particular interventional imagers who focus on periprocedural guidance have developed a specific expertise in interventional transesophageal echocardiography (iTEE). This nascent field has challenges in training, reimbursement, and occupational hazards which are unique to this field. This review encompasses the evolution of iTEE, current challenges, and future opportunities.

Head to Head Comparison between Different 3-Dimensional Echocardiographic Rendering Tools in the Imaging of Percutaneous Edge-to-Edge Mitral Valve Repair

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.

Three-Dimensional Transesophageal Echocardiography Simulator: New Learning Tool for Advanced Imaging Techniques

The use of intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) has grown exponentially in recent years. Three-dimensional TEE technology has evolved to allow for real-time display of 3D images and, thus, has become the standard of care for the evaluation of cardiac anatomy and function. Its use has provided a new dimension of clinical insight when managing patients for cardiac surgery or structural heart interventions. While the intraoperative utility of 3D TEE has expanded, there has been a slower advancement in the area of training and, specifically, simulator-based training in 3D TEE. This training is essential, as the skill set involved in acquiring 3D data sets differs from that of two-dimensional (2D) TEE and requires users to be able to appreciate how 3D anatomic display differs from that of tomographic cross-sectional 2D imaging. This added skill set requires mental reconstruction and spatial reorientation to appreciate the added elevational dimension in frustum-based imaging and is best achieved in a simulation environment rather than the busy operating room. In this review article, the authors evaluate the functionality of a 3D TEE simulator and how simulators such as this can establish preclinical proficiency in novices in the expanding area of advanced 3D TEE imaging.

Severe Aortic Regurgitation of Early Degenerated Mitroflow Bioprosthesis: From Echocardiographic Diagnosis to Treatment with Valve-in-Valve Transcatheter Aortic Valve Implantation

Valve-in-Valve transcatheter aortic valve implantation (ViV TAVI) is emerging as an effective therapeutic option for bioprosthetic valve failure. Recently, concern has been raised for early valve deterioration of Mitroflow (Sorin) aortic bioprosthesis, with the development of prevalent stenosis. We report cases of pure severe aortic regurgitation (AR) due to early and mid-term prosthesis degeneration. From June 2018 to October 2019, three patients were treated in our division for the new appearance of severe intraprosthetic regurgitation. Patient 1 (man, 85-year-old) and patient 3 (woman, 83-year-old) had a Mitroflow n. 25 and n. 21 implanted, respectively, in 2012 and 2013 for severe aortic stenosis. Patient 2, a 67-year-old woman with Marfan syndrome underwent a Mitroflow n. 25 implant in 2008 for severe AR and presented chronic type-B aortic dissection. Patient 1 was diagnosed with severe AR in the ambulatory setting, while the other patients presented acute heart failure, requiring inotrope support and high doses intravenous diuretics, and in case 3, temporary extracorporeal ultrafiltration. All patients appeared at high surgical risk and were successfully treated with ViV TAVI, through the right axillary artery in patient 2, and through the femoral artery in patients 1 and 3. Results were good at short- and mid-term follow-up. In conclusion, early and midterm bioprosthesis degeneration with the development of severe AR is a possible complication of the Mitroflow aortic valve. ViV TAVI has been confirmed as a safe and effective therapeutic option in our cases.

Aortic Annular Sizing Using Novel Software in Three-Dimensional Transesophageal Echocardiography for Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

(1) Background: We performed this study to evaluate the agreement between novel automated software of three-dimensional transesophageal echocardiography (3D-TEE) and multidetector computed tomography (MDCT) for aortic annular measurements of preprocedural transcatheter aortic valve replacement (TAVR); (2) Methods: PubMed, EMBASE, Web of Science, and Cochrane Library (Wiley) databases were systematically searched for studies that compared 3D-TEE and MDCT as the reference standard for aortic annular measurement of the following parameters: annular area, annular perimeter, area derived-diameter, perimeter derived-diameter, maximum and minimum diameter. Meta-analytic methods were utilized to determine the pooled correlations and mean differences between 3D-TEE and MDCT. Heterogeneity and publication bias were also assessed. Meta-regression analyses were performed based on the potential factors affecting the correlation of aortic annular area; (3) Results: A total of 889 patients from 10 studies were included in the meta-analysis. Pooled correlation coefficients between 3D-TEE and MDCT of annulus area, perimeter, area derived-diameter, perimeter derived-diameter, maximum and minimum diameter measurements were strong 0.89 (95% CI: 0.84–0.92), 0.88 (95% CI: 0.83–0.92), 0.87 (95% CI: 0.77–0.93), 0.87 (95% CI: 0.77–0.93), 0.79 (95% CI: 0.64–0.87), and 0.75 (95% CI: 0.61–0.84) (Overall p < 0.0001), respectively. Pooled mean differences between 3D-TEE and MDCT of annulus area, perimeter, area derived-diameter, perimeter derived-diameter, maximum and minimum diameter measurements were −20.01 mm² ((95% CI: −35.37 to −0.64), p = 0.011), −2.31 mm ((95% CI: −3.31 to −1.31), p < 0.0001), −0.22 mm ((95% CI: −0.73 to 0.29), p = 0.40), −0.47 mm ((95% CI: −1.06 to 0.12), p = 0.12), −1.36 mm ((95% CI: −2.43 to −0.30), p = 0.012), and 0.31 mm ((95% CI: −0.15 to 0.77), p = 0.18), respectively. There were no statistically significant associations with the baseline patient characteristics of sex, age, left ventricular ejection fraction, mean transaortic gradient, and aortic valve area to the correlation between 3D-TEE and MDCT for aortic annular area sizing; (4) Conclusions: The present study implies that 3D-TEE using novel software tools, automatically analysis, is feasible to MDCT for annulus sizing in clinical practice.

Percutaneous closure of native anterior mitral leaflet perforation under three-dimensional transesophageal echocardiography guidance

We are presenting a unique case of native anterior mitral leaflet (AML) perforation with severe mitral regurgitation leading to progressive dyspnea. Using real time three-dimensional transesophageal echocardiography, this case was accurately diagnosed and percutaneous closure has been done successfully with the device. Review of the literature showed successful transcatheter closure of AML perforation of only four cases, all post-operative status. So, it seems to be the first case of native AML perforation closure till date.

Three-Dimensional Transesophageal Echocardiography as an Alternative to Multidetector Computed Tomography in Aortic Annular Diameter Measurements for Transcatheter Aortic Valve Implantation

Simple Summary

Patients who have multiple associated comorbidities and need to change the aortic valve may have a contraindication to open-heart surgery, the alternative being transcatheter aortic valve implantation, which requires very precise measurements of the aortic annulus to determine the dimensions of the prostheses. Ultrasonographic imaging techniques, such as transesophageal echocardiography, are constantly evolving. The aim of our study was to compare the three-dimensional transesophageal echocardiography and multi-detector computer tomography methods, with the former being an alternative for patients who cannot undergo computer tomography because of a major contraindication. We have demonstrated that there were small differences between aortic annular measurements using multi-detector computer tomography (2.25 ± 0.19 cm) and three-dimensional transesophageal echocardiography (2.25 ± 0.15 cm). Thus, three-dimensional transesophageal echocardiography can be the solution for aortic annular measurements used to select the correct prosthesis for the transcatheter aortic valve implantation procedure in patients who cannot undergo computer tomography.

Abstract

Background and objectives: Transcatheter aortic valve implantation (TAVI) is a therapeutic choice for high surgical risk patients, serving as an alternative to open-heart surgery. Correct measurement of the aortic annulus, which leads to the selection of a suitable prosthesis and accurate outcome prediction, is essential for the success of TAVI. The objective of this study is to evaluate the accuracy of novel imaging te chniques in measuring the aortic annulus by comparing multi-detector computer tomography (MDCT) and three-dimensional transesophageal echocardiography (3D TEE) for the selection of the optimal prosthesis. Materials and Methods: Measurements of the aortic annulus have been performed on 25 patients using MDCT and TEE, and the correlation and agreement levels between the two measuring techniques were analyzed. MDCT measurements were used for the sizing of the prostheses. Results: MDCT and TEE measurements of aortic annular diameters were significantly correlated, with a mean difference of 0.001 cm. Conclusions: 3D TEE measurements have been in good agreement with MDCT and, therefore, 3D TEE can be used as an alternative in cases where MDCT is contraindicated or not available.

Comparison of Four Different Techniques for Estimation of Left Ventricular Volumes Using Intraoperative Real Time Three Dimensional Transesophageal Echocardiography--A Prospective Observational Study

OBJECTIVES

The primary objective of the present study was to compare cardiac output derived with four methods of QLab (Philips, Amsterdam, Netherlands) software using real-time three-dimensional (3D) transesophageal echocardiography, with cardiac output obtained with the 3D left ventricular outflow tract (LVOT) cardiac output method. The secondary objective was to assess left ventricular (LV) volumes, LV ejection fraction, and cardiac output derived with four different methods of real time 3D transesophageal echocardiography processed in QLab software and to determine whether these parameters differed among these four methods.

DESIGN

A prospective observational study.

SETTING

A tertiary referral center and a university level teaching hospital.

PARTICIPANTS

The study comprised 50 patients scheduled for elective coronary artery bypass surgery without any concomitant valvular lesions.

MEASUREMENTS AND MAIN RESULTS

Three-dimensional full-volume datasets were obtained in optimum conditions. The 3D datasets were analyzed using four different methods in QLab, version 9. In method A, LV volumes were derived without endocardial border adjustment. In method B, LV volumes were obtained after endocardial border adjustment in the long-axis view alone. In method C, the iSlice tool (Philips) was used to adjust the endocardial borders in 16 short-axis slices. In method D, endocardial borders were adjusted after dataset processing to obtain LV volumes. The cardiac output derived with the 3D echocardiography LVOT method was 3.93 ± 1.44 L/min, with method A was 3.26 ± 1.42 L/min, with method B was 3.51 ± 1.2 L/min, with method C was 4.01 ± 1.40 L/min, and with method D was 4.18 ± 1.58 L/min. There was a significant positive correlation between the cardiac output derived using the 3D LVOT method and method C (r = 0.71).

CONCLUSIONS

Readjusting the endocardial border contours resulted in higher LV volumes than the volumes estimated using semiautomated border algorithms. The iSlice method produced the highest and the most accurate LV volumes, although it required the longest time to analyze and derive results. The ejection fraction obtained with all four methods of QLab demonstrated no statistical differences and had a strong correlation with the two-dimensional echocardiography-derived left ventricular ejection fraction.

Integration of three-dimensional echocardiography into the modern-day echo laboratory

Three-dimensional echocardiography (3DE) has emerged in recent decades from a conceptual, research tool to an important, useful imaging technique that can informatively impact daily clinical practice. However, its adoption into the modern-day echo laboratory requires the acknowledgment of its value, coupled with proper leadership, education, and resources to implement and integrate its use with conventional echo techniques. 3DE integration involves important updates regarding equipment and patient selection, assimilation of 3D protocols into current clinical routine, laboratory workflow adaptation, storage, and reporting. This review will provide a practical blueprint and key points of how to integrate 3DE into today's echo laboratory, necessary resources to implement 3D workflow, logistical challenges that remain, and future directions to further improve assimilation of this relevant echo technique into the laboratory.

Comparison of Right Ventricular Function Between Three-Dimensional Transesophageal Echocardiography and Pulmonary Artery Catheter

OBJECTIVE

This study aimed to compare measurements of right ventricular function using three-dimensional transesophageal echocardiography (3D TEE), and pulmonary artery catheters (PACs) in patients undergoing cardiac surgery. The authors examined the practicality of using the 3D TEE.

DESIGN

Prospective observational.

SETTING

Cardiac operating room at a single university hospital.

PARTICIPANTS

All adult patients undergoing elective cardiac surgery at a single tertiary care university hospital over two years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), stroke volume (SV), and right ventricular ejection fraction (RVEF) were measured with both 3D TEE and PACs. Assessments were performed using correlation coefficients, paired t tests, and Bland-Altman plots. Thirty-one patients participated in this study. Each measurement showed good agreement. RVEDV and RVESV were slightly lower on 3D TEE than on PAC (205.9 mL v 220.2 mL, p = 0.0018; 143.0 mL v 155.5 mL, p = 0.0143, respectively), whereas no significant differences were observed for SV and RVEF (31.0% v 31.1%, p = 0.0569; 61.6 mL v 66.9 mL, p = 0.92, respectively). Linear regression analysis showed high correlation between 3D TEE and PAC for RVEDV (r = 0.87) and RVESV (r = 0.81), and moderate correlation for SV (r = 0.67) and RVEF (r = 0.67). In the Bland-Altman plot, most patients were within the 95% limits of the agreement throughout all measurements.

CONCLUSION

A high correlation was found between measurements made with a PAC and with 3D TEE in the assessment of right ventricular function. Three-dimensional TEE would be a potential alternative to PAC for assessment of right ventricular function during intraoperative periods.

Reference value of perimeter-derived diameter assessed by three-dimensional transesophageal echocardiography in left atrial appendage occluder size selection

BACKGROUND

The aim of this study was to investigate the utility of perimeter-derived diameter (PDD) measured by three-dimensional (3D) transesophageal echocardiography (TEE) in predicting the size of left atrial appendage (LAA) occluder.

METHODS AND RESULTS

Left atrial appendage landing zone diameter (LZD) was measured by two-dimensional (2D) TEE, 3DTEE, and digital subtraction angiography (DSA) as LZD-2Dmax, LZD-2Dmean, LZD-3Dmax, LZD-3Dmean, LZD-PDD, LZD-DSAmax, respectively, before and during transcatheter LAA closure with Watchman devices in 100 patients. A difference of one or more device size intervals between the predicted size and the size actually implanted was defined as mismatching. Seventy-eight patients were followed up by TEE to obtain occluder compression ratio. The correlation between LZD and the final implanted occluder size was 0.559, 0.641, 0.754, 0.760, 0.782, and 0.848 for LZD-2Dmax, LZD-2Dmean, LZD-3Dmax, LZD-3Dmean, LZD-PDD and LZD-DSAmax, respectively (P < .001). Matching ratio between the size predicted by retrospective measurements of LZD and the device size actually implanted was 65%, 57%, 66%, 63%, 70%, and 83% for LZD-2Dmax, LZD-2Dmean, LZD-3Dmax, LZD-3Dmean, LZD-PDD and LZD-DSAmax, respectively. There was no significant difference in LZD value, matching ratio, and compression ratio between the patients with eccentric and noneccentric LAA landing zone (P > .05). Compression ratio of the mismatching subjects was higher than that in the matching subjects when evaluated by LZD-2Dmean, LZD-3Dmean, and LZD-PDD (P < .05).

CONCLUSIONS

Landing zone diameter derived from LAA perimeter measured by preprocedure 3DTEE showed reference value for LAA occluder size selection, providing superior correlation and matching ratio with the final implanted size and indicating the adjustment of oversizing.

Utility of three-dimensional transesophageal echocardiography to guide transseptal positioning of a single multistage venous cannula to provide both venous drainage and indirect left ventricular venting in veno-arterial extracorporeal membrane oxygenation

A patient with heart failure due to dilated ischemic cardiomyopathy presented in cardiogenic shock for institution of veno-arterial extracorporeal membrane oxygenation as a bridge to cardiac transplantation. To provide adequate venous drainage and simultaneous decompression of the left atrium (indirect left ventricular venting), a single venous cannula was placed across the interatrial septum so that the distal orifice and side ports were located within the left atrium and the proximal set of side ports were positioned at the cavoatrial junction. Three-dimensional transesophageal echocardiography demonstrated utility in guiding cannula placement and appropriate positioning within the left atrium.

A new dimension in patent foramen ovale size estimation

BACKGROUND

Detailed multidimensional assessment of patent foramen ovale (PFO) size with transesophageal echocardiography (TOE) may help to determine PFO pathogenicity in cryptogenic stroke patients. We explored the potential additive value of Live xPlane and three-dimensional (3D) TOE anatomical PFO sizing techniques.

METHODS

Imaging data of 45 patients who underwent a 3D TOE-assisted percutaneous PFO closure were studied. The two-dimensional (2D) PFO separation distance and right-to-left (RL) contrast shunt magnitude were assessed on preprocedural TOE recordings. Peri-procedural measurements of the triangular anatomical PFO opening (base, height, and area) were performed after positioning of a stiff guidewire (SW) through the PFO, using Live xPlane imaging and 3D Zoom mode.

RESULTS

The PFO SW base appeared on average 5 times larger than the preprocedural 2D PFO separation (median difference [IQR] = 13[5] mm; P < .001). For a same PFO separation, the width of the PFO base may vary significantly. The PFO SW base was significantly larger in patients with a large versus a small-to-moderate PFO RL contrast shunt (18 vs 15 mm; P = .007) and in those with a spontaneous versus a provoked shunt (18 vs 14 mm; P = .003).

CONCLUSION

Live xPlane and 3D Zoom TOE allow peri-procedural measurement of the largest dimension of a PFO, which is the PFO base. Patients with a large or spontaneous RL contrast shunt appear to have a larger PFO base. The anatomical PFO base dimension may be taken into account for optimization of device and patient selection strategies.

3D transesophageal echocardiography in TAVR

Recently, there has been an increasingly minimalistic approach to transcatheter aortic valve replacement (TAVR), with most procedures now performed under conscious sedation without real time transesophageal echocardiography (TEE) guidance. Proponents of echo should not feel discouraged by this; it is the initial insights that were gained with procedural TEE during the early years of TAVR that have allowed the procedure's gradual maturation and sophistication. Experienced centers that have promoted extensive TAVR TEE programs continue to maximize the benefits of echocardiography in both procedural planning and execution. Critical to this is the understanding of 3D TEE, allowing the annulus to be sized accurately, relevant neighboring anatomy defined, and complications flagged. This review will outline the current application of 3D TEE in TAVR and discuss challenges and opportunities for 3D echocardiography in this field.

Effect of left ventricular assist device implantation on right ventricular function: Assessment based on right ventricular pressure-volume curves

Right ventricular (RV) failure is significantly associated with morbidity and mortality after left ventricular assist device (LVAD) implantation. However, it remains unclear whether LVAD implantation could worsen RV function. Therefore, we aimed to investigate the effect of LVAD implantation on RV function by comparing RV energetics derived from the RV pressure-volume curve between before and after LVAD implantation. This exploratory observational study was performed between September 2016 and January 2018 at a national center in Japan. Twenty-two patients who underwent LVAD implantation were included in the analysis. We measured RV energetics parameters: RV stroke work index (RVSWI), which was calculated by integrating the area within the RV pressure-volume curve; RV minute work index (RVMWI), which was calculated as RVSWI × heart rate; and right ventriculo-arterial coupling, which was estimated as RV stroke volume/RV end-systolic volume. We compared RV energetics between before and after LVAD implantation. Although RVSWI was similar [424.4 mm Hg · mL/m² (269.5-510.3) vs. 379.9 mm Hg · mL/m² (313.1-608.8), P = 0.485], RVMWI was significantly higher after LVAD implantation [29 834.1 mm Hg · mL/m² /min (18 272.2-36 357.1) vs. 38 544.8 mm Hg · mL/m² /min (29 016.0-57 282.8), P = 0.001], corresponding to a significantly higher cardiac index [2.0 L/min/m² (1.4-2.2) vs. 3.7 L/min/m² (3.3-4.1), P < 0.001] to match LVAD flow. Right ventriculo-arterial coupling was significantly higher after LVAD implantation [0.360 (0.224-0.506) vs. 0.480 (0.343-0.669), P = 0.025], suggesting that the efficiency of RV performance improved. In conclusion, higher RVMWI with higher cardiac index to match LVAD flow and improved efficiency of RV performance indicate that LVAD implantation might not worsen RV function.

Added value of three-dimensional transesophageal echocardiography in management of mitral paravalvular leaks

Prosthetic paravalvular leak (PVL) is a well-known serious complication following surgically as well as percutaneously implanted prosthetic valves. It usually happens due to incomplete sealing of the prosthetic ring to the native cardiac tissue whether immediately postoperative or considerably later as a complication of infective endocarditis, etc Surgery has been always the treatment of choice for clinically significant PVLs. However, percutaneous transcatheter closure therapy has become a successful alternative in carefully selected group of patients. Echocardiography is a cornerstone in the initial diagnosis, assessment of the severity and location of the PVL. Furthermore, it plays a crucial role in the assessment of the feasibility for percutaneous closure and during intra-procedural guidance. Transesophageal echocardiography (TEE) has the advantage over transthoracic echocardiography (TTE) of not being affected by the acoustic shadow of the mitral prosthesis that usually hides the regurgitation jets and makes TTE evaluation difficult. Three-dimensional (3D) TEE has been shown to provide better diagnostic accuracy compared to two-dimensional (2D) TEE as regard to evaluation of PVLs especially in patients with more than one PVL. This is due to better delineation of the location, shape, and size of the PVL and equally important during guiding the transcatheter percutaneous closure.

Detection of LV apical thrombus by three-dimensional transesophageal echocardiography

INTRODUCTION

Patients with apical myocardial infarction are at higher risk of developing left ventricular (LV) thrombi. Standard transesophageal echocardiography (TEE) is commonly used in assessing cardiac source of embolic cerebrovascular accident (CVA). Contrast-enhanced transthoracic echocardiography (TTE) improves sensitivity for thrombus detection compared with noncontrast TTE, and however for LV apical thrombi, contrast-enhanced magnetic resonance imaging (MRI) and/or contrast-enhanced computed tomography (CT) outperform both TTE and TEE in some studies.

CASE

A 67-year-old man with history of prior myocardial infarction (MI), four-vessel coronary artery bypass surgery, congestive heart failure with LV ejection fraction of 30%, and diabetes mellitus presented to our facility with acute right occipital-parietal stroke and recent history of left lower extremity ischemia. Head and neck MRI and MR angiography found multiple posterior circulation infarcts suggestive of cardio-embolic etiology. TTE image quality was suboptimal even after contrast use to evaluate for LV thrombus, and due to renal insufficiency, MRI or CT was precluded and 3DTEE identified large LV apical thrombus with mobile components.

CONCLUSION

3DTEE may increase the detection of LV apical thrombi as well as evaluating its characteristics by live imaging as well as by offline reconstruction. TEE may be a useful diagnostic modality, especially in patients with decreased renal function, where iodinated contrast for cardiac CT or Gadolinium for MRI may be contraindicated. Multimodality imaging studies may further prove the utility of 3D echocardiographic imaging in the detection of LV apical thrombus.

The Additional Value of Three-Dimensional Transesophageal Echocardiography in the Diagnosis of Unusual Complication of Bioprosthetic Mitral Valve

Primary tissue failure of bioprosthetic mitral valves due to cusp perforations or ruptures is an unusual complication on short-term follow-up. An 88-year-old male with a known history of mitral regurgitation (MR) treated with bioprosthetic valve replacement in 2016 was referred to our center for recurrent heart failure. The two-dimensional (2D) transthoracic echocardiography documented an intraprosthetic jet of regurgitation without identifying a clear morphological mechanism, nor quantifying precisely the mitral insufficiency. 3D transesophageal echocardiography (TOE) with the tool FlexiSlice added relevant information by providing insights into the pathophysiological mechanisms of MR. The present case emphasizes the importance of 3D TOE as a fundamental tool for the diagnostic algorithm of bioprosthetic valves failure, even in the more demanding cases.

Three-dimensional transesophageal echocardiography-guided transcatheter closure of multiple mitral paravalvular leaks demonstrating real time avoidance of device-induced valve malfunction

Transcatheter closure of mitral paravalvular leaks has become an accepted alternative to surgical repair, especially in patients at high risk for reoperation. Device placement using three-dimensional (3D) transesophageal echocardiography (TEE) guidance allows en-face views of the valve and provides detailed information for device sizing and placement. We present a case demonstrating hybrid transapical transcatheter 3D TEE-guided closure of two mitral paravalvular leaks. We demonstrate real time 3D TEE guidance for device sizing and placement, and early real time recognition of mechanical mitral valve leaflet impairment during device deployment.

A rare case series of mitral valve clefts diagnosed by 3D echocardiography and mini-review of the literature

Mitral valve cleft is a rare entity. However, it must be recognized as a differential mechanism for mitral valve regurgitation. 3D transesophageal echocardiography plays an essential role in the evaluation of single and multiple mitral valve clefts, improving morphological and functional assessment of the valve, with potential implications on surgical planning. The authors present four rare cases of mitral valve cleft presenting during adulthood, followed by a mini-review about the role of 3D echocardiography, as well as its pitfalls, in the assessment of this complex congenital mitral valve disease.

Three-dimensional transesophageal echocardiography is an attractive alternative to cardiac multi-detector computed tomography for aortic annular sizing: Systematic review and meta-analysis

BACKGROUND

Cardiac imaging is the cornerstone of the pretranscatheter aortic valve replacement (TAVR) assessment. Multi-detector computed tomography (MDCT) is considered the conventional imaging modality. However, there is still no definitive gold standard. Targeted cohort of inoperable high-risk patients with underlying comorbidities, particularly renal impairment, makes apparent the need for MDCT alternative. We aimed to demonstrate the correlation extent between MDCT and three-dimensional transesophageal echocardiography (3DTEE) aortic annular area measures and to answer the question: Is 3DTEE a good alternative to MDCT?

METHODS

A systematic literature search and meta-analysis were conducted to evaluate the degree of correlation and agreement between 3DTEE and MDCT aortic annular sizing. A thorough assessment of EMBASE, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. All studies comparing 3DTEE and MDCT in relation to aortic annular sizing were included.

RESULTS

Thirteen studies were included (N = 1228 patients). A strong linear correlation was found between 3DTEE and MDCT measurements of aortic annulus area (r = 0.84, P < 0.001), mean perimeter (r = 0. 0.85, P < 0.001), and mean diameter (r = 0.80, P < 0.001). Bland-Altman plots revealed smaller mean 3DTEE values in comparison to MDCT for aortic annular area, the mean difference being -2.22 mm² with 95% limits of agreement -12.79 to 8.36.

CONCLUSION

Aortic annulus measurements obtained by 3DTEE demonstrated a high level of correlation with those evaluated by MDCT. This makes 3DTEE a feasible choice for aortic annulus assessment, with advantage of real time assessment, lack of contrast, and no radiation exposure.

Three-dimensional transesophageal echocardiography vs cardiac magnetic resonance in the assessment of planimetric mitral valve area in rheumatic mitral stenosis

AIM

Rheumatic heart disease is a common cause of valvular disease, especially in developing countries. Echocardiography is the gold standard investigation modality for cardiac valves. In rheumatic mitral stenosis (MS), three-dimensional transesophageal echocardiography (3D TEE) provides better alignment of the image plane at the mitral tips and more accurate and reproducible planimetric measurement of mitral valve area (MVA). Cardiac magnetic resonance (CMR) is a new method that provides evaluation of cardiac anatomy and function noninvasively. Previous studies showed strong correlation between planimetric MVA measured by two-dimensional transthoracic echocardiography and CMR. We aimed to compare the planimetric MVAs assessed by 3D TEE and CMR in rheumatic MS patients. To best of our knowledge, this is the first study that compares 3D TEE and CMR for the assessment of the planimetric MVA in rheumatic MS.

METHODS

We retrospectively evaluated 28 rheumatic MS patients who underwent 3D TEE and ECG-gated CMR. 3D TEE planimetric MVAs were measured manually by multiplanar reconstruction (MPR) method and CMR planimetric MVAs were measured manually on short-axis cine images. Then, 3D TEE and CMR measurements were compared.

RESULTS

A total of 28 patients' (mean age 44 ± 12, 82.1% female) planimetric 3D TEE MVAs (1.00 ± 0.20 cm² ) and CMR MVAs (1.04 ± 0.17 cm² ) were found to be highly correlated (P < 0.0001, r: 0.744) with Pearson correlation analysis. Bland-Altman analysis showed strong agreement between two techniques.

CONCLUSION

For the diagnosis and the follow-up of rheumatic MS, planimetric CMR MVA is an alternative noninvasive method which highly correlates with planimetric 3D TEE MVA.

Three-dimensional Transesophageal Echocardiographic Diagnosis of Catheter Endocarditis Hidden in Intracaval Stent

In recent years, with an increasing number of central venous access procedures and cardiac implantable electronic device implantation, the incidence of infective endocarditis (IE) has become more prevalent. Two-dimensional transthoracic echocardiography (2D-TTE) and transesophageal echocardiography (TEE) are a key part of the evaluation of IE, but advances in three-dimensional echocardiography have enabled a better spatial resolution and visualization of cardiac structures, allowing the identification of any valvular vegetations, abscesses, or nodules. Herein, we report the usefulness of 3D-TEE in a difficult diagnosis of hemodialysis catheter endocarditis hidden in intracaval stent.

Usefulness of two- and three-dimensional transesophageal echocardiography in combined mitral valve-in-valve implantation and paraprosthetic leak closure

We demonstrate the usefulness of two- and live/real time three-dimensional transesophageal echocardiography in a procedure, which combined transcatheter mitral valve-in-valve deployment and paraprosthetic leak closure in the same setting using the less invasive transfemoral approach in an adult patient with bioprosthetic mitral valve degeneration. We also highlight the additive value of three-dimensional echocardiography over the two-dimensional technique.

Transesophageal echocardiography measures left atrial appendage volume and function and predicts recurrence of paroxysmal atrial fibrillation after radiofrequency catheter ablation

AIMS

Paroxysmal atrial fibrillation (PAF) commonly recurs after radiofrequency catheter ablation (RFCA). This study aimed to assess left atrial appendage (LAA) volume and function by transesophageal echocardiography (TEE) and to explore its value in predicting PAF recurrence after RFCA.

METHODS

Eighty patients with PAF were recruited. The left atrial (LA) and LAA volume and function were measured by transthoracic echocardiography (TTE) and TEE before ablation. Patients were followed up for 12 months after RFCA, and recurrence was recorded. Odds ratios of candidate risk indicators were determined by logistic regression analysis. Prediction model was constructed using logistic regression with backward selection. Receiver operating characteristic (ROC) curve with area under curve (AUC) was performed to evaluate the prediction efficiency.

RESULTS

Twenty-four (30%) PAF patients had recurrence (R group), and 56 (70%) patients had no recurrence (NR group). Compared to NR group, LA dimension (LAD), LA volume index (LAVI), LAA maximum volume (LAAVmax), and LAA minimum volume (LAAVmin) were significantly higher in R group, while LAA peak emptying flow velocity (LAAeV), LAA peak filling flow velocity (LAAfV), and LAA ejection fraction (LAAEF) significantly declined in R group. According to multivariate analysis and backward selection, LAVI, LAAEF, and LAAeV were significant risk factors for PAF recurrence. The LAVI + LAAEF + LAAeV joint model could effectively predict PAF recurrence with AUC of 0.893 (95% confidence interval = 0.816, 0.970), sensitivity of 0.75, and specificity of 0.929.

CONCLUSIONS

This study demonstrated that LAVI, LAAEF, and LAAeV were significant predictors of PAF recurrence after RFCA.

Utilizing transesophageal echocardiography for placement of pulmonary artery catheters

OBJECTIVE

Pulmonary artery catheters (PACs) have routinely been positioned by wedging into the pulmonary artery before pulling back 1-2 centimeters or advancing the PAC several centimeters after achieving a pulmonary artery waveform. A rare, major complication is pulmonary artery rupture. This study presents transesophageal echocardiography (TEE) for PAC placement by leaving the catheter tip at the one o'clock position, upper window short-axis view of the ascending aorta at the bifurcation of the pulmonary artery (TEE distance).

DESIGN

Prospective observational cohort study.

SETTING

Large urban academic medical center.

PARTICIPANTS

30 males and 30 females undergoing cardiac surgery requiring cardiopulmonary bypass.

INTERVENTION

TEE was utilized to obtain an upper esophageal short-axis view of the aorta with long-axis view of the main and right pulmonary arteries.

MEASUREMENTS AND RESULTS

The distance between TEE position and wedge position was recorded along with patients' gender, height, and weight. A correlation was found between TEE and wedge distances (P < .0001). There were significant gender differences in TEE distance, with a mean of 43.6 cm in females and 46.5 cm in males (P = .0004). The mean wedge distance was 47.5 cm in females and 51.9 cm in males (P < .0001). The differences between distances of wedge and TEE positions (5.39 cm, males; 3.93 cm, females) were also significant (P < .0001).

CONCLUSIONS

By securing the PAC at the one o'clock TEE position, physicians are assured of a safety margin of several centimeters. This direct visualization method for PAC placement may decrease the risk for accidental wedging intraoperatively.

A novel method to measure mitral valve area in patients with rheumatic mitral stenosis using three-dimensional transesophageal echocardiography: Feasibility and validation

AIMS

Neither two- nor three-dimensional (3D) planimetry of the mitral valve (MV) orifice takes the mitral commissures into account. Thus, if the commissures are not completely fused, the MV orifice will not be planar, and MV area (MVA) will be underestimated. The study aimed to validate a novel method for measurement of the MVA using a software that traces the MV orifice including the commissures.

METHODS AND RESULTS

The study included 30 patients undergoing percutaneous balloon mitral valvuloplasty for severe rheumatic mitral stenosis. All performed 3D transesophageal echocardiography (TEE) immediately before the procedure. MVA was measured using the mitral valve navigation (MVN) software of the Philips Q-Lab 10.2 in a diastolic frame with maximum diastolic opening of the MV. Regular 3D planimetry of the MV orifice was also performed. Before balloon dilation, the MVA was calculated invasively using the Gorlin's formula. No significant difference was detected between MVN-derived MVA and Gorlin-derived MVA (0.98 cm² vs. 1.0 cm² , P = .33). A statistically significant difference was detected between Planimetry-derived MVA and Gorlin-derived MVA (0.8 cm² vs. 1.0 cm² , P < .001). There were significant linear correlations between MVN-derived MVA and Gorlin-derived MVA (r = .84, P < .001). Using Bland-Altman analysis, Gorlin-derived MVA showed better and relatively narrower limits of agreement with MVN-derived MVA than planimetry-derived MVA.

CONCLUSION

Measurement of the MVA using the MVN method is feasible and is more correlated to the invasively measured MVA than the 3D planimetry method. This is the most accurate method of measuring the MVA that takes MV commissures into account.

Perforated giant mycotic aneurysm of mitral valve in a drug-addicted young man: Rare complication of infective endocarditis

Infective endocarditis (IE) affects patients at high clinical risk and may present as an acute and rapidly progressive, subacute or chronic infection. Transthoracic and transesophageal echocardiography represent the key diagnostic method in IE diagnosis. In particular, three-dimensional transesophageal echocardiography represents the imaging technique that allows to establish with adequate accuracy dimensions, shape, and localization of endocarditis vegetations. In our case, we show a huge vermiform mycotic aneurysm in an immunodeficient young drug-addicted man with severe mitral valve regurgitation and the additive value of three-dimensional transesophageal echocardiography in this specific clinical setting.

Incremental value of live/real time three-dimensional transesophageal echocardiography in the assessment of ventricular septal rupture following acute myocardial infarction

Ventricular septal rupture is a serious complication following acute myocardial infarctions and is associated with a significant mortality rate. Classically, two-dimensional transthoracic echocardiography has been used to diagnose this complication and visualize its location. Two-dimensional transesophageal echocardiography has supplemented the transthoracic approach by providing more accurate assessment of the defect size and in guiding closure both percutaneously and intraoperatively. This modality, however, is limited to two-dimensional views only, and a greater breadth of information is instead available through the use of three-dimensional transesophageal echocardiography. We present a series of 11 patients in which live/real time three-dimensional transesophageal echocardiography offered incremental benefits over two-dimensional imaging alone.

Morphologic Evaluation of the Mitral Annulus During Displacement of the Heart in Off-Pump Coronary Artery Bypass Surgery

OBJECTIVE

To evaluate the morphologic changes of the mitral annulus using 3-dimensional transesophageal echocardiography during heart displacement to expose the anastomosis site in off-pump coronary artery bypass surgery (OPCAB).

DESIGN

Prospective case series.

SETTING

Single center, university hospital.

PARTICIPANTS

The study comprised 34 consecutive patients who underwent OPCAB of the left circumflex artery (LCX) and the right coronary artery (RCA).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Mitral annulus parameters were measured using the Mitral Valve Quantification program after sternotomy (physiologic position) and during displacement of the heart to expose the LCX (LCX position) and the RCA (RCA position). The height of the mitral annulus was significantly lower in the LCX (5.76 ± 0.90 mm) and RCA (5.92 ± 0.97 mm) positions than in the physiologic position (6.96 ± 0.99 mm; both p < 0.0001). The percent change in the height of the mitral annulus was significantly greater in the mitral regurgitation group than in the mitral regurgitation nondeterioration group when in the LCX (-16.3% ± 6.0% v -11.9% ± 3.3%, p = 0.0203) and RCA (-16.9% ± 6.3% v -12.1% ± 3.8%, p = 0.0207) positions. The anteroposterior and intercommissural diameters, annulus perimeter, and surface area of the mitral annulus did not differ significantly among all heart positions.

CONCLUSIONS

The mitral annulus flattened and lost its saddle shape without expanding while in the LCX and RCA positions. The greater percent change in the height of the mitral annulus may aggravate mitral regurgitation.

Is intra-procedure three-dimensional transesophageal echocardiogram an alternative to preprocedure multidetector computed tomography for the measurement of the aortic annulus in patients undergoing transcatheter aortic valve replacement?

BACKGROUND

The role of three-dimensional transesophageal echocardiography (3DTEE) vs multidetector computed tomography (MDCT) in aortic annular sizing has been poorly defined in patients undergoing transcatheter aortic valve replacements (TAVR). We set to determine the correlation between 3DTEE and MDCT in measuring the aortic annulus prior to TAVR.

METHODS

In an observational, retrospective study, we compared aortic annular areas measured by MDCT and 3DTEE in TAVR patients. The aortic annular area was measured by planimetry of images obtained by MDCT pre-TAVR and by intra-TAVR TEE using 3D rendering of the aortic annulus followed by planimetry. Our primary outcome was degree of correlation between mean aortic annulus area by 3DTEE and MDCT.

RESULTS

Of the 111 consecutive patients undergoing TAVR who had measurements from both modalities available for comparison between February 2012 and April 2015, 87 met inclusion criteria. The mean aortic annular area by MDCT was 4.44±0.88 cm² and by 3DTEE was 4.33±0.78 cm² . There was a strong positive linear correlation between aortic annular area measurements obtained from these two modalities with mild relative underestimation by 3DTEE (ρ=.833). This relationship can be estimated using the predictive formula: [Formula: see text] CONCLUSIONS: Three-dimensional transesophageal echocardiography measurements have a high degree of correlation with MDCT measurements and thus can assist in proper valve prosthesis selection for TAVR. Our study thus supports use of 3DTEE as a reasonable alternative imaging modality in patients undergoing TAVR.

Usefulness of three-dimensional echocardiography in the assessment of valvular involvement in Loeffler endocarditis

Loeffler endocarditis is a complication of hypereosinophilic syndrome resulting from eosinophilic infiltration of heart tissue. We report a case of Loeffler endocarditis in which three-dimensional transthoracic and transesophageal echocardiography provided additional information to what was found by two-dimensional transthoracic echocardiography alone. Our case illustrates the usefulness of combined two- and three-dimensional echocardiography in the assessment of Loeffler endocarditis. In addition, a summary of the features of hypereosinophilic syndrome and Loeffler endocarditis is provided in tabular form.

Incidental tricuspid valve fibroelastoma associated with patent foramen ovale in a young female: Straightforward diagnosis but controversial management

Papillary fibroelastoma is an uncommon primary cardiac tumor, predominantly associated with left-sided valvular endocardium. Affectation of tricuspid valve leaflets is rare, and management in asymptomatic patients remains controversial. We present a 30-year-old female referred for evaluation prior to bariatric surgery. A routine echocardiogram revealed a mobile cardiac mass attached to the tricuspid valve. A patent foramen ovale was also present. Tumor was surgically removed. Histology confirmed the definite diagnosis of a papillary fibroelastoma. In our case, the presence of a patent foramen ovale associated with the right-sided fibroelastoma was decisive in the decision for surgery.

Reduction of left ventricular outflow tract obstruction with transcatheter mitral valve repair

Many patients with severe mitral regurgitation cannot undergo conventional mitral valve surgery due to prohibitive surgical risk and are candidates for transcatheter repair with an edge-to-edge technique. Prior reports suggest efficacy with this approach for mitral regurgitation due to hypertrophic cardiomyopathy with left ventricular outflow obstruction. We present a case report of transcatheter mitral valve repair for posterior leaflet prolapse with concomitant left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve in the absence of hypertrophic cardiomyopathy.

Dyspnea following thoracostomy closure after right pneumonectomy: An uncommon echocardiographic diagnosis and therapeutic approach

Dyspnea and hypoxemia are common postoperative problems after pneumonectomy. One of the rarer causes of respiratory distress after right pneumonectomy is the development of a significant right-to-left shunt across a patent foramen ovale (PFO), which can evolve at a variable interval of time after the operation. We report here our experience with a patient who underwent right pneumonectomy, followed by several complications, and who presented severe dyspnea 7 months later, after the closure of a right thoracostomy. This report outlines the management of this challenging clinical condition; transesophageal echocardiography (TOE) provided a clear diagnosis and guided an effective percutaneous treatment.

Use of three-dimensional transesophageal echocardiography to evaluate mitral valve morphology for risk stratification prior to mitral valvuloplasty

Mitral stenosis is often managed percutaneously with an interventional procedure such as balloon commissurotomy. Although this often results in an increased mitral valve area and improved clinical symptoms, this procedure is not benign and may have serious complications including the development of hemodynamically significant mitral valve regurgitation. Multiple scoring systems have been developed to attempt to risk stratify these patients prior to their procedure.

CASE

A 64-year-old patient underwent an emergent mitral valve replacement after having percutaneous mitral balloon commissurotomy complicated by development of severe mitral regurgitation. Prior to valvuloplasty, her mitral valve was evaluated by traditional methods including calculation of a Wilkins score. Her mitral valve was evaluated after valvuloplasty and preoperatively with three-dimensional transesophageal echocardiography. This examination demonstrated heterogeneous distribution of calcification affecting the mitral valve commissures more than the leaflets, which is consistent with the noncommissural leaflet tearing that occurred during her procedure, causing severe mitral regurgitation. In the future, careful 3D evaluation of mitral valve morphology including leaflets, annular calcification, and subvalvular apparatus may help risk stratify patients prior to intervention.

Aortic root thrombus complicated by left main coronary artery occlusion visualized by 3D echocardiography in a patient with continuous-flow left ventricular assist device

Aortic root thrombus is an uncommon complication of continuous-flow left ventricular assist devices (LVAD). We present the case of a 71-year-old man with ischemic cardiomyopathy who underwent destination therapy HeartMate II LVAD placement. Eighteen months later, he presented with a cerebrovascular accident followed by myocardial infarction. Transesophageal echocardiography revealed an aortic root thrombus spanning the left and noncoronary cusps and obliterating the left main coronary artery. We discuss the incidence, risk factors, and management of aortic root thrombus in LVAD patients. To our knowledge, this is the first report of three-dimensional echocardiography used to characterize an LVAD-associated aortic root thrombus.

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of aortic atherosclerotic thrombi and ulcers

We present two cases in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided incremental value in the assessment of atherosclerotic disease in the aorta. In one patient, it identified additional atherosclerotic ulcers as well as thrombi within them which were missed by two-dimensional (2D) TEE. In both cases, the size of the large mobile atherosclerotic plaque was underestimated by 2DTEE as compared with 3DTEE. Furthermore, 3DTEE provided volume quantification of the thrombi and ulcers which is not possible by 2DTEE. The echocardiographic findings of atherosclerotic plaques were confirmed by computed tomography in one patient and by surgery in the other.

Three-dimensional transesophageal echocardiography incremental value in a rare case of a bileaflet tricuspid valve

Detailed assessment of the tricuspid valve using two-dimensional echocardiography is always challenging, as only two of three leaflets can be seen at a time. Three-dimensional echocardiography can provide the enface view of the tricuspid valve that allows simultaneous visualization of all of the three leaflets. In a 42-year-old male patient scheduled for pulmonary endarterectomy, 3DTEE showed that the tricuspid valve is bileaflet, with one septal and another lateral leaflet. There were two commissures, one of them is anteriorly positioned and the other one is posterior. Our findings were confirmed intra-operatively by direct surgical visualization of the tricuspid valve.