Analysis of the interatrial septum by transesophageal echocardiography in adult cardiac surgical patients: anatomic variants and correlation with patent foramen ovale

OBJECTIVES: The purpose of this study was to document the perioperative prevalence of anatomic variants of the interatrial septum (IAS), to classify atrial septal aneurysm based on mobility pattern, and to correlate anatomic variants of IAS with patent foramen ovale (PFO). DESIGN: A prospective observational study. SETTING: University hospital (single institution). PARTICIPANTS: Patients presenting for cardiac surgery requiring transesophageal echocardiography. INTERVENTIONS: Multiplane TEE in 2 atrial views with color-flow Doppler and contrast echocardiography with a provocative respiratory maneuver. MEASUREMENTS AND MAIN RESULTS: The cohort size was 206. PFO prevalence was 30.1%. The prevalence of IAS lipomatous hypertrophy was 43.2%, atrial septal flap (ASF) 43.2%, and atrial septal aneurysm (ASA) 28.6%. ASF and ASA were significantly ( p < 0.05) associated with PFO. Selected ASA subtypes are significantly associated with PFO ( p < 0.05). CONCLUSIONS: IAS anatomic variants are common in adult cardiac surgical patients undergoing multiplane TEE. The presence of ASF and ASA predicts enhanced PFO detection. ASA mobility patterns significantly correlate ( p < 0.05) with the presence of PFO.     

Intraoperative Determination of Cardiac Output Using Multiplane Transesophageal Echocardiography: A Comparison to Thermodilution

Background: Limitations in the imaging views that can be obtained with transesophageal echocardiography (TEE) have hindered development of a widely adopted Doppler method for cardiac output (CO) monitoring. The authors evaluated a CO technique that combines steerable continuous-wave Doppler with the imaging capabilities of two-dimensional multiplane TEE.

Methods: From the transverse plane transgastric, short-axis view of the left ventricle, the imaging array was rotated to view the left ventricular outflow tract (LVOT) and ascending aorta. Steerable continuous-wave Doppler was subsequently used to measure aortic blood flow velocities. Aortic valve area was determined using a triangular orifice model. Matched thermodilution and Doppler CO measurements were obtained serially during surgery.

Results: The left ventricular outflow tract was imaged in 32 of 33 patients (97%). Data analysis reveal a mean difference between techniques of - 0.01 l/min, and a standard deviation of the differences of 0.56 l/min. Multiple regression showed a correlation of r = 0.98 between intrasubject changes in CO. Multiplane TEE correctly tracked the direction of 37 of 38 serial changes in thermodilution CO but with a modest 14% underestimation of the magnitude of these changes.     

Anaesthetic management of a patient with Williams syndrome undergoing aortoplasty for supravalvular aortic stenosis

PURPOSE: A case of a patient associated with Williams syndrome undergoing aortoplasty for supravalvular aortic stenosis is presented. CLINICAL FEATURES: Williams syndrome is a rare disease associated with a characteristic facies, supravalvular aortic stenosis, and mental retardation. A 15-yr-old girl with Williams syndrome underwent aortoplasty for supravalvular aortic stenosis. Anaesthesia was induced with fentanyl and thiamylal, and maintained with nitrous oxide, oxygen, sevoflurane, and continuous intravenous infusion of fentanyl. Supravalvular aortic stenosis was evaluated using a multiplane transesophageal echocardiography (TEE) probe before and after repair. CONCLUSION: Multiplane TEE was found to be very useful for anaesthetic management in a patient with Williams syndrome undergoing aortoplasty for supravalvular aortic stenosis.     

Is transesophageal echocardiography still necessary to exclude patent foramen ovale?

Objectives. Current guidelines still recommend transesophageal echocardiography (TEE) as reference method to diagnose interatrial shunts. The aim was to test the accuracy of high-end transthoracal echocardiography (TTE) to exclude inter-atrial shunts. Methods. Prospective TTE and TEE study with second harmonic imaging to determine left-to-right shunt (L/R) by both colour Doppler or R/L by contrast echocardiography in patients with unexplained cerebrovascular incidents or newly detected valvular or myocardial disease. Results. An inter-atrial shunt was diagnosed in 200 of 438 analyzed patients (117 males). Colour Doppler echocardiography visualized a shunt in 67 patients (34%) on TTE vs. 84 (42%) patients on TEE (p <0.0001). However injection of agitated blood with a valsalva maneuver detected 190 (95%) interatrial shunts by both TTE and TEE, but 10 shunts (5%) only by TTE. Conclusions. Our study shows that patent foramen ovale can safely be demonstrated with high-end transthoracic contrast- echocardiography. If additional studies confirm our results, TTE has the potential to become the method of choice in the diagnosis of PFO.     

National survey regarding the management of an intraoperatively diagnosed patent foramen ovale during coronary artery bypass graft surgery

OBJECTIVE: With the increased use of intraoperative transesophageal echocardiography (TEE), patent foramen ovale (PFO) has become a common finding during routine coronary artery bypass graft (CABG) surgery. This survey was designed to study potential differences in the management of intraoperatively diagnosed PFO. DESIGN: A written survey. SETTING: US university and community hospitals. PARTICIPANTS: The authors randomly selected 50% of US cardiac surgeons listed in the Cardiothoracic Surgery Network Database (n = 734). INTERVENTIONS: A written survey was mailed to the participants. The survey questions included respondents' use of TEE during CABG surgery, examination for a PFO with TEE, and management of intraoperatively diagnosed PFO in the CABG surgery. MEASUREMENTS AND MAIN RESULTS: Overall, 64% of individuals (468/734) responded to the survey request. TEE is available in the primary institution of 98.6% of respondents and used to search for a PFO in approximately one third of all CABG surgeries. During planned on-pump CABG surgery, 27.9% of respondents always close an intraoperatively diagnosed PFO, whereas 10.2% of respondents never close an intraoperatively diagnosed PFO. During planned off-pump CABG surgery, 27.6% of surgeons never change their plan, and 11% of respondents always convert the procedure to on-pump CABG to close the PFO. The majority of respondents decide whether to close a PFO based on the size of the PFO, the right atrial pressure, and a history of possible paradoxical embolism. CONCLUSIONS: In the United States, TEE is used extensively during CABG surgery. There is significant variability in how intraoperatively diagnosed PFO is managed during CABG surgery.     

Präoperative Diagnostik eines offenen Foramen ovale Rationaler Einsatz der transthorakalen und transösophagealen Kontrastechokardiographie

Background: The detection or ruling out of a patent foramen ovale (PFO) can be determined noninvasively by contrast echocardiography (CE). The transesophageal technique is superior to the transthoracic technique regarding sensitivity, whereas the specificity of both methods is equally high. This prospective study shows the rational use of transesophageal CE for the detection of a PFO, in patients without cardiovascular disorders. Methods: 165 patients (92 female, 73 male, age 48±18 years) with planned neuro-surgery in a sitting position, underwent CE to rule out a PFO. If the CE was positive, an alternative position was selected in order to avoid a paradoxical air embolism. Results: Initially, a transthoracic CE was performed in all patients resulting in 21 patients (13%) being positive and 39 patients (24%) being negative by sufficient image quality. A transesophageal CE was performed in 96 of the remaining 105 patients (63%). Here, further 25 patients showed a positive CE in the sense of a PFO. The combined use of transthoracic and transesophagel CE revealed a PFO in 46 of 165 patients (28%). Conclusion: The use of both, transthoracic and transesophageal CE is an efficient approach to the preoperative detection of a PFO in the sense of quality and economics. Depending upon the image quality, the use of a transesophageal examination could be avoided in one third of the cases.     

Role of transesophageal echocardiography in the management of pediatric patients with congenital heart disease

Transesophageal echocardiography (TEE) has become a critical diagnostic and perioperative management tool for patients with congenital heart disease (CHD) undergoing cardiac and noncardiac surgical procedures. This review highlights the role of TEE in routine management of pediatric cardiac patient population with focus on indications, views, applications and technological advances.     

Intraoperative transesophageal echocardiography is beneficial for hemodynamic stabilization during left ventricular assist device implantation in children

Background:  Mechanical circulatory support, with a left ventricular assist device (LVAD) is used in an increasing number of children for treatment of advanced heart failure as bridge-to-transplant. To date no data are available and no studies have defined the role of intraoperative transesophageal echocardiography (TEE) for hemodynamic stabilization during Centrimag Levitronix centrifugal pump implantation in children.
Methods:  Children with therapy resistant heart failure, undergoing LVAD implantation using Berlin Heart Excor pediatric cannula connected to a Levitronix Centrifumag pump, are intraoperatively monitored using an Oldelft micromultiplane TEE. Intraoperative TEE is specially used to monitor right ventricular (RV) and left ventricular (LV) function, correct position of the cannulas and response to pharmacological treatment.
Results:  In five consecutive patients RV function was assessed by TEE after starting LVAD Levitronix centrifugal pump. Initial RV failure presents with RV dilation and LV collapse. After titration of vasopressor and inotropic agents, RV contractility improved and thereby the filling of the LV. In one child, despite those measures the RV showed no improvement by TEE and a Levitronix right ventricular assist device to support the RV function was implanted as well. All patients could hemodynamically be stabilized before transport to the intensive care unit.
Conclusion:  The complex interaction of the RV and LV function and correct positioning of the cannula, during LVAD implantation in children with end-stage cardiac failure is improved by simultaneous visualization of cardiac performance of both ventricles and cannula positioning by means of intraoperative multiplane TEE.     

Is transesophageal echocardiography still necessary to exclude patent foramen ovale?

OBJECTIVES: Current guidelines still recommend transesophageal echocardiography (TEE) as reference method to diagnose interatrial shunts. The aim was to test the accuracy of high-end transthoracal echocardiography (TTE) to exclude inter-atrial shunts. METHODS: Prospective TTE and TEE study with second harmonic imaging to determine left-to-right shunt (L/R) by both colour Doppler or R/L by contrast echocardiography in patients with unexplained cerebrovascular incidents or newly detected valvular or myocardial disease. RESULTS: An inter-atrial shunt was diagnosed in 200 of 438 analyzed patients (117 males). Colour Doppler echocardiography visualized a shunt in 67 patients (34%) on TTE vs. 84 (42%) patients on TEE (p <0.0001). However injection of agitated blood with a valsalva maneuver detected 190 (95%) interatrial shunts by both TTE and TEE, but 10 shunts (5%) only by TTE. CONCLUSIONS: Our study shows that patent foramen ovale can safely be demonstrated with high-end transthoracic contrast- echocardiography. If additional studies confirm our results, TTE has the potential to become the method of choice in the diagnosis of PFO.     

Blunt chest trauma victims: role of intravascular ultrasound and transesophageal echocardiography in cases of abnormal thoracic aortogram

PURPOSE: The objective of our study was to use transesophageal echocardiography (TEE) and intravascular ultrasonography (IVUS) to evaluate their role in interrogating abnormal or equivocal findings seen on thoracic aortography performed on blunt chest trauma patients. METHODS: A prospective, nonblinded, observational, institutional review board-approved study of IVUS and TEE was conducted in acute blunt chest trauma victims with abnormal findings on thoracic aortograms. IVUS was performed with a 20-MHz catheter and TEE was performed with an omniplane probe. RESULTS: Abnormal aortographic findings were present in 10 men and 4 women (mean age, 40.5 years). All 14 patients were evaluated with IVUS and 13 with TEE. TEE was not performed on one patient because of time constraints. By IVUS, there were 11 true-positives, 2 true-negatives, and 1 equivocal (considered as false-negative), resulting in 91.7% sensitivity and 100% specificity. In the equivocal case, an intimal flap was missed by IVUS and by TEE, but was present at surgery. By TEE, there were six true-positives, two true-negatives, one false-positive, and four false-negatives, resulting in 60% sensitivity and 66.7% specificity. In the false-positive case, an avulsed intercostal artery without an intimal flap was found at surgery. The remaining three false-negative cases were a missed intimal flap, a missed intramural hematoma, and a missed intimal flap obscured by a mural hematoma. In our study, both IVUS and TEE were found to be diagnostic in the four equivocal aortograms. Three of the equivocal results were cases read as a prominent ductus diverticulum versus a pseudoaneurysm. Two were confirmed to be false lumen/pseudoaneurysm by both IVUS and TEE, whereas the other was confirmed to be a prominent ductus diverticulum by both of these modalities. In the fourth equivocal case, thoracic aortography showed an abnormal contour but no intimal flap located along the lesser curvature of the aorta at the junction of the arch and isthmus. No abnormalities were found by IVUS or TEE. This patient was followed clinically. A follow-up thoracic aortogram obtained 1 year later showed no aortic injury. CONCLUSION: When thoracic aortography yields an abnormal and especially equivocal findings, both IVUS and TEE are helpful in further sorting this out rather than subjecting the patient to a potentially unnecessary thoracotomy. In cases of aortic injury suspected at the lesser curvature of the arch-isthmic junction, TEE allowed better delineation because of multiplane imaging capability.     

The use of multiplane transesophageal echocardiography to evaluate residual patent ductus arteriosus during video-assisted thoracoscopy in adults

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for interruption of patent ductus arteriosus (PDA), while intraoperative transesophageal echocardiography (TEE) has proven to be an effective monitor in the evaluation of residual patency. Previous reports on the adequacy of surgical interruption of PDA under VATS and TEE are available for pediatric patients, but only limited information is available for adults with PDA. MATEIALS AND METHODS: Between August 1995 and October 1997, we monitored 35 adult patients undergoing PDA interruption via VATS with Hewlett-Packard color Doppler multiplane TEE throughout the procedure. The average PDA diameter was 10.2 +/- 1.8 mm. All the PDA were completely ligated. RESULTS: Thirty-two patients showed no ductal flow after double ligation. In the other three patients, residual flow was detected intraoperatively after double ligation, but it was quickly abolished by the third ligation. One patient showed faint ductal flow by transthoracic echocardiography at postoperative follow-up, but no reintervention was needed. CONCLUSIONS: Our study showed that, with the refinement of adult PDA interruption via VATS, intraoperative multiplane TEE provides higher resolution for direct evaluation of the entire course of PDA ligation without interrupting the surgical procedure and minimizes the incidence of complications.     

Real-time intraoperative transesophageal echocardiography-how useful? experience of 5,016 cases

To evaluate transesophageal echocardiography (TEE) as an intraoperative monitoring modality and to assess its safety, reliability, and overall utility in real-time use during cardiac surgery. Prospective, observational cohort study performed from January 1993 to June 1997. Operating room of a tertiary care hospital for cardiology and cardiovascular surgery. Five thousand and sixteen adult patients with acquired heart disease, who underwent 1,356 valve procedures and 3,660 coronary artery bypass graftings (CABGs). All patients were monitored with radial artery and pulmonary artery catheters, along with continuous TEE monitoring with a multiplane transducer.

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Prebypass imaging yielded unsuspected findings that either helped or modified the surgical plan in 158 of 1,356 valve procedures (11.65%) and in 993 of 3,660 CABGs (27.13%). There were 3,217 TEE-guided hemodynamic interventions in 944 patients (25.79%) in the CABG group and 629 in 142 patients (10.47%) in the valve group. TEE was the sole guiding factor in initiating therapy in 23.53% of events, whereas it was supportive to other monitoring modalities in 76.46% of events. Postbypass TEE identified the need for graft revision in 29 patients (0.8%), intra-aortic balloon pump (IABP) requirement in 29 patients (0.8%), and inadequate valve repair in 28 patients (2.08%). For the entire series, 38.78% of patients benefited from prebypass and 39.16% from postbypass use of TEE. There were no complications attributable to the use of TEE in the entire series. There was 87% concordance between online interpretation by a trained anesthesiologist and offline analysis by a cardiologist. Intraoperative TEE is useful in formulating the surgical plan, guiding various hemodynamic interventions, and assessing the immediate results of surgery. It is safe and the results are reliable in the hands of trained anesthesiologists.     

Intraoperative transoesophageal echocardiography as an adjuvant to fluoroscopy during endovascular thoracic aortic repair.

OBJECTIVES: To define the utility of intraoperative transeophageal echocardiography (TEE) during endovascular thoracic aortic repair. DESIGN: Retrospective study. MATERIALS: Five patients underwent six transluminal endovascular stent-graft procedures for repair of thoracic aortic disease. METHODS: After induction of anaesthesia, a multiplane or biplane TEE probe was placed to obtain views of the diseased aorta. Both transverse and longitudinal planes of the aortic arch and descending thoracic aortic segments were imaged. The aortic pathology was confirmed by TEE and the proximal and distal extents of the intrathoracic lesion were defined. Doppler and colour-flow imaging was used to identify flow patterns through the aorta before and after stent-graft deployment. RESULTS: Visualisation and confirmation of the aortic pathology by ultrasonography was accomplished in all patients. TEE was able to confirm proper placement of the endograft relative to the aortic lesion after deployment and was able to confirm exclusion of blood flow into the aneurysm sacs. CONCLUSIONS: TEE may facilitate repair by confirming aortic pathology, identifying endograft placement, assessment of the adequacy of aneurysm sack isolation, as well as dynamic intraoperative cardiac assessment.     

Preoperative and intraoperative echocardiography to detect right-to-left shunt in patients undergoing neurosurgical procedures in the sitting position

In patients undergoing neurosurgical procedures at high risk for venous air embolism (VAE), the presence of a right-to-left shunt adds an additional risk for paradoxical air embolism (PAE). Although this is a rare complication, it can have devastating results. The most common form of right-to-left shunt is a patient foramen ovale (PFO), which can be detected by contrast echocardiography. This study evaluates the efficacy of preoperative precordial and intraoperative transesophageal echocardiography (TEE) to detect right-to-left shunting in patients undergoing neurosurgical procedures while in the sitting position. In 101 patients precordial contrast echocardiography was performed prior to surgery. The Valsalva maneuver was utilized as a provocative maneuver to facilitate demonstration of right-to-left shunting. Fifty-one of these patients also had intraoperative TEE monitoring. Right-to-left shunting was demonstrated in only six of the 101 patients examined. Of these, four were detected by TEE. This is less than the expected incidence based on the known incidence of PFO in the general population. The usefulness of preoperative ECHO as a screening test for PFO in patients undergoing neurosurgical procedures is limited, but when a PFO is found, valuable information is acquired to help manage these patients.     

Meta-analysis of the diagnostic accuracy of transesophageal echocardiography for assessment of atherosclerosis in the ascending aorta in patients undergoing cardiac surgery

Background: Stroke after cardiac surgery may be caused by emboli emerging from an atherosclerotic ascending aorta (AA). Epiaortic ultrasound scanning (EUS), the current ‘gold’ standard for detecting AA atherosclerosis, has not gained widespread use because there is a lack of optimized ultrasound devices, it lengthens the procedure, it endangers sterility, and there is a false belief by many surgeons that palpation is as sensitive as EUS. Furthermore there is no clear evidence proving that the use of epiaortic scanning changes outcome in cardiac surgery. Various researchers investigated the ability of transesophageal echocardiography (TEE) to discriminate between the presence and absence of AA atherosclerosis. It is acknowledged that TEE has limited value in this, but it has never been supported by a meta‐analysis estimating the true diagnostic accuracy of TEE based on all quantitative evidence. We aimed to do this using state‐of‐the‐art methodology of diagnostic meta‐analyses. Methods: We searched multiple databases for studies comparing TEE vs. EUS for detection of atherosclerosis. A random‐effects bivariate meta‐regression model was used to obtain summary estimates of sensitivity and specificity, incorporating the correlation between sensitivity and specificity as well as covariates to explore heterogeneity across studies. Results: We extracted six studies with a total of 346 patients, of whom 419 aortic segments were analyzed, including 100 segments with atherosclerosis [median prevalence 25% (range 17–62%)]. Summary estimates of sensitivity and specificity were 21% (95% CI 13–32%) and 99% (96–99%), respectively. Conclusions: Because of the low sensitivity of TEE for the detection of AA atherosclerosis, a negative test result requires verification by additional testing using epiaortic scanning. In case of a positive test result, AA atherosclerosis can be considered as present, and less manipulative strategies might be indicated.     

TEE bei intracavaler Ausdehnung von Nierenzellkarzinomen Intraoperatives Management mit transösophagealer Echokardiographie

OBJECTIVE: To evaluate the role of intraoperative real-time transesophageal echocardiography (TEE) for the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension. METHODS: Retrospective analysis of the intraoperative application of TEE in a series of 4 patients. RESULTS: Real-time TEE with a multiplane probe allowed visualization of inferior vena cava tumor extensions, accurate assessment of the distal extent of vena cava invasion into hepatic veins and right atrium, monitoring of embolism and evaluation of cardiac preload and function in all patients. CONCLUSION: Intraoperative TEE is a useful adjunct to the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension.     

An intraoperative assessment of the ascending aorta: a comparison of digital palpation, transesophageal echocardiography, and epiaortic ultrasonography

OBJECTIVES: There are a number of techniques available to assess the aorta for atheromatous disease in the intraoperative period. This study compared the relationship among the findings of digital palpation (DP), transesophageal echocardiography (TEE), and epiaortic ultrasound (EAU) in the detection of atheroma in the ascending aorta. DESIGN: A prospective, observational study. SETTING: A single-institution, cardiothoracic specialty hospital. Participants: One hundred fifty-four patients undergoing elective cardiac surgery. INTERVENTIONS: The ascending aorta of patients undergoing elective coronary artery bypass surgery was assessed for atheroma by means of the 3 techniques. Atheroma was scored as present or absent. The sensitivity and specificity of the techniques were compared. MEASUREMENTS AND MAIN RESULTS: Assuming EAU provides the "gold standard," the sensitivity of both TEE and DP were low. Digital palpation identified only 20 patients (12%); TEE 31 patients (20%); and, in contrast, EAU detected atheroma in 81 patients (53%). There were 3 and 6 false-positives by DP and TEE, respectively. CONCLUSION: Assuming EAU as the "gold standard" to detect atheroma, this study has shown that when assessing the ascending aorta neither DP nor TEE appear sensitive. This study supports the proposal that detection of atheroma should be performed by EAU.     

Transesophageal Echocardiography for Ascending Aortic Dissection: Is It Enough for Surgical Intervention?

BACKGROUND: Acute ascending aortic dissection is a surgical emergency that requires expeditious diagnosis and prompt surgical intervention. In many centers, transesophageal echocardiography (TEE) is the test of choice on which surgical decisions are based. Echocardiographic false-positive diagnoses are rare but can occur with potentially severe consequences. CASE REPORT: Two clinical cases where ascending aortic dissections were falsely diagnosed by TEE are presented. DISCUSSION: Recent literature comparing the diagnostic accuracy of TEE and other imaging techniques are reviewed. Anatomical limitations of TEE and potential causes of false-positive results are discussed. Multiplane probe reduces, but does not eliminate, the occurrence of false-positive findings. To improve diagnostic specificity without undue delays in the course of clinical decision making, we recommend dividing positive TEE findings into "definite" and "probable" categories. Such subclassification is helpful in identifying cases where additional confirmatory tests are desirable in situations of uncertain diagnosis.     

The impact of newly diagnosed patent foramen ovale in patients undergoing off-pump coronary artery bypass grafting: case series of eleven patients

The increased use of transesophageal echocardiography (TEE) by anesthesiologists may lead to an increase in the intraoperative detection of previously undiagnosed patent foramen ovale (PFO). The impact of heart manipulation on interatrial shunting through a PFO during off-pump coronary artery bypass graft (CABG) has not been studied. We retrospectively studied 11 patients with PFOs who underwent off-pump CABG. TEE contrast studies and blood gas analyses were performed at baseline, during heart elevation for distal coronary arteries anastomoses, and at the end of the surgery. At baseline, 5 of 11 patients had left-to-right shunting and 2 of 11 had right-to-left shunting. Heart elevation did not result in oxygen desaturation in any patient; however, it caused the disappearance of a right-to-left shunt (n = 1), persistence of this shunt (n = 1), and the development of a new right-to-left shunt (n = 2). Return of the heart to its original position resulted in a return of TEE findings to the baseline state in all patients. This series suggests that off-pump CABG can be performed safely in the majority of patients with PFOs; however, additional investigation is needed to assure that adverse effects do not occur in a subset of patients undergoing off-pump CABG in the presence of a PFO. IMPLICATIONS: This case series suggests that coronary artery bypass graft surgery can be safely performed in most patients with patent foramen ovale without the use of a cardiopulmonary bypass.     

Real-time three-dimensional transesophageal echocardiography is useful for the localization of a small mitral paravalvular leak

The use of multiplane transesophageal echocardiography (TEE) to reconstruct 3-dimensional (3D) images is limited by time-consuming, multiplane image acquisition and the need for offline processing. To overcome these limitations, a 3D fully sampled matrix array transducer was recently developed to allow real-time acquisition and online display of 3D images. In this case, real-time 3D transesophageal echocardiography produced clear image of a small paraprosthetic leak point. Although the surgical view from the left atrium was poor due to severe adhesions, we were able to perform optimal repair of the small leak after intraoperative confirmation of the location of the leak that was identified by preoperative real-time 3D transesophageal echocardiography.