Should Transesophageal Echocardiography Become a Routine Test in Patients with Suspected Pulmonary Thromboembolism?

Pulmonary thromboembolism presents in two clinical subsets: acute pulmonary embolism (PE) with or without right heart thrombi or paradoxical embolism and chronic thromboembolic pulmonary hypertension (CTEPH). Both PE and CTEPH have been underdiagnosed and carry high mortality rates. Acute massive PE is a hemodynamic entity leading to right ventricular overload readily identified with the use of transthoracic echocardiography. Transesophageal echocardiography (TEE) is a noninvasive bedside technique that has high diagnostic accuracy for the detection of central pulmonary thromboembolism. Due to the high prevalence of central pulmonary thromboembolism in acute PE, TEE is a useful method to provide the necessary proof for the institution of thrombolytic therapy. In the subset of patients with acute PE combined with right heart thrombi or paradoxical embolism, TEE is the technique of choice to guide surgery. CTEPH presents as primary pulmonary hypertension, but it has become a surgically curable disease. TEE is a fast, fairly sensitive, and highly specific diagnostic bedside modality to select surgical candidates with CTEPH. TEE should become a routine test in patients with suspected massive acute PE, suspected right heart thrombi, or paradoxical embolism associated with acute pulmonary embolism and in patients with primary pulmonary hypertension to select those having CTEPH who are suitable for surgery.     

Transesophageal Echocardiography in Candidates for Percutaneous Balloon Mitral Valvuloplasty

Prior to percutaneous balloon mitral valvuloplasty (PBMV), mitral valve morphology and the presence of left atrial thrombi are usually evaluated by transthoracic two-dimensional and Doppler echocardiography (TTE). This study analyzes the impact of transesophageal echocardiography (TEE) in addition to TTE on the selection of candidates considered for PBMV for mitral stenosis. Seventy-five patients with severe mitral stenosis who were considered as appropriate candidates for PBMV based on TTE findings were studied. In 19 (25%) patients, TEE revealed findings that were essential for PBMV but were missed by TTE: left atrial thrombi (n = 14; including 13 in left atrial appendage), right atrial thrombus (n = 1), incomplete cor triatriatum (n = 1) and mitral valve vegetation (n = 1). In two other patients, a left atrial thrombus had been suspected by TTE but could be excluded by TEE. TEE and TTE revealed similar scores of thickening, calcification, and mobility of the mitral valve. Compared to TTE, thickening of the subvalvular apparatus was graded lower using horizontal plane TEE due to shadowing by the mitral valve (echo score 1.8 ± 0.8 vs 1.4 ± 0.7; P < 0.05) whereas results from longitudinal plane TEE were similar to TTE findings. The data show that due to the high prevalence of left atrial thrombi, TEE should be performed in addition to TTE in all patients prior to PBMV.     

Transesophageal versus transthoracic echocardiography in the evaluation of right atrial tumors

The purpose of this study was to define the contribution of transesophageal echocardiography to the diagnosis of right atrial tumors in a large series of patients with this rare finding. Transesophageal echocardiography (TEE) has been found to be valuable in evaluating patients with intracardiac masses and has been shown ton be superior to transthoracic echocardiography (TTE) in evaluating left heart masses. Between 1989 and 1993, 23 patients with either known tumors elsewhere or right atrial masses that were detected on TTE were evaluated with TEE. TEE studies were performed in the noninvasive cardiology laboratory. All patients were studied with 5 MHz biplane or omniplane transducers. The right atrium was evaluated for the presence, characteristics, extent, and attachment of any masses and for extension of these masses into the great vessels or other cardiac chambers. No complications occurred. Six patients had primary right atrium tumors. In 10 patients the tumors reached the right atrium via the inferior vena cava. Seven patients had malignant secondary tumors. TEE demonstrated three tumors not detected by TTE. Furthermore TEE provided 16 additional findings not seen on TTE. In conclusion, TEE is superior to TTE in the evaluation of right atrial tumors. TEE should be considered in patients with right atrial tumors even when these tumors have been demonstrated with TTE.     

Right Atrial and Ventricular Infarction

In order to compare the results of transesophageal echocardiography (TEE) in diagnosis of right atrial (RA) and right ventricular (RV) infarction with those of transthoracic echocardiography (TTE), 11 patients admitted to the coronary care unit with the diagnosis of posteroinferior left ventricular (LV) acute myocardial infarction (MI) and electrocardiographic suspicion of extension to RV were studied. In two of the 11 patients, RA infarction was identified on the basis of akinesis of the RA free wall, dilatation of the atrial cavity, spontaneous echo contrast, mural thrombosis, and poor atrial contribution to RV filling. In all 11 patients, RV infarction was determined by akinesis of one or more segmental regions, dilatation of the cavity in four patients, and tricuspid regurgitation in seven. Only six cases of RV infarction were diagnosed with TTE. The findings indicate that TEE provides additional information to TTE for determining RA and RV infarction during the early stages of MI.     

Comparative assessment of left atrial appendage by transesophageal and combined two- and three-dimensional transthoracic echocardiography

Objective: Our objective was to compare the utility of combined two‐dimensional (2D) transthoracic echocardiography (TTE) and three‐dimensional (3D) TTE versus 2D transesophageal echocardiography (TEE) in evaluation of the left atrium (LA) and LA appendage (LAA) for clot. Background: 2DTEE, usually performed to visualize the LAA, is semi‐invasive and not without risks. With improved technology the LAA has been increasingly visualized by 2DTTE and 3DTTE in many patients. Methods: We compared combined 2DTTE and 3DTTE with 2DTEE in evaluating the LA/LAA for a thrombus. Ninety‐two patients underwent 2DTTE, 3DTTE, and 2DTEE. An additional 20 patients, in whom TEE could not be performed, underwent 2DTTE and 3DTTE. Results: LA and LAA could be visualized in all patients. Of 92 patients studied, 74 had no thrombus and 7 had thrombus in the LAA by all modalities. Eleven patients, 9 with atrial fibrillation (AF), had a suspected thrombus by 2DTEE, but 3DTTE cropping clearly showed these to be prominent pectinate muscles which were seen in short axis on 2DTEE as rounded echo dense masses and therefore mimicked thrombi. These 9 patients with AF underwent successful cardioversion without any complications. Of the 20 patients in whom TEE could not be performed, 19 had no thrombus in the LA/LAA and 1 had a clot in the LAA. These 19 patients underwent successful cardioversion without complications. Conclusions: Our preliminary study suggests that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LA and LAA for thrombus. In some patients TEE, but not 3DTTE, may misdiagnose pectinate musculature as thrombus.     

Transthoracic echocardiography for precardioversion screening during atrial flutter/fibrillation in young patients

BACKGROUND: Transthoracic echocardiography (TTE) is reliable for detection of thrombi in the left ventricle and right atrium, but not in the left atrial appendage. Therefore, transesophageal echocardiography (TEE) is routinely performed in adults prior to electric cardioversion for atrial flutter/fibrillation (AFF). Whether young survivors of congenital heart disease repair with AFF need routine TEE prior to electric cardioversion is unknown. HYPOTHESIS: Electric cardioversion for AFF is safe in survivors of congenital heart disease repair/palliation if an intracardiac thrombus is not suspected on TTE imaging. METHODS: This study reports the outcome of patients in a pediatric tertiary care cardiac unit where electric cardioversion was performed if no intracardiac thrombus was suspected on TTE. We performed a retrospective chart review of all patients treated with electric cardioversion for AFF at Children's Hospital of Michigan during 1997-2002. RESULTS: Of 35 patients who presented with 110 episodes of AFF requiring electric cardioversion during the study duration, 32 (age 3 months-49 years, median age 20.5 years, 104 AFF episodes) had previously undergone palliative surgery or repair of their congenital heart disease. Of these 32 patients, 18 were survivors of a Fontan palliation (for a single-ventricle variant) and the remaining 14 were survivors of other defects and repairs (septal defects, valve replacements, and tetralogy of Fallot). During 81% of the episodes, patients were receiving aspirin, warfarin, or heparin for anticoagulation at presentation. Transthoracic echocardiography was performed in 74 AFF episodes; of these, 10 TTE studies were suspicious for atrial thrombi. Transesophageal echocardiography confirmed the presence of a thrombus in 3 of these 10 patients. These patients received warfarin for 2 weeks and then underwent electric cardioversion. No thromboembolic events occurred immediately after or on follow-up in any patient. CONCLUSIONS: These findings suggest that TTE may be an effective imaging tool for precardioversion screening in young patients with AFF.     

Aetiological distribution of pulmonary hypertension and the value of transthoracic echocardiography screening in the respiratory department: A retrospective analysis from China

Methods

The aetiological composition and clinical characteristics of patients with pulmonary hypertension (PH) hospitalised in the respiratory department were retrospectively analysed, as well as the correlation between transthoracic echocardiography (TTE) and right heart catheterization (RHC) for evaluating pulmonary artery systolic pressure (PASP) and mean pulmonary artery pressure (mPAP).

Results

Of 731 patients, 544 (74.42%) were diagnosed with PH by RHC. Pulmonary arterial hypertension (PAH) was the most common type of PH, accounting for 30.10%; PH due to lung disease and/or hypoxia accounted for 20.79%, and PH due to pulmonary artery obstructions accounted for 19.29%. TTE has the highest specificity for diagnosing PH due to pulmonary artery obstructions. The specificity was 0.9375, the sensitivity was 0.7361 and the area under the ROC curve (AUC) was 0.836. PASP, and mPAP estimated by TTE were different for various types of PH. In terms of PASP, TTE overestimated PASP in PH due to lung disease and/or hypoxia, but there was no significant difference compared with RHC (P > 0.05). TTE underestimates PAH patients' PASP compared with RHC. In terms of mPAP, TTE underestimated the mPAP of all types of PH, as there was a significant difference in the TTE-estimated mPAP of patients with PAH compared with RHC but not on other types of PH. Pearson correlation analysis of TTE and RHC showed a moderate overall correlation (rPASP 0.598, P < 0.001; rmPAP 0.588, P < 0.001).

Conclusions

Among the patients with PH in the respiratory department, patients with PAH accounted for the majority. TTE has high sensitivity and specificity for the diagnosis of PH due to pulmonary artery obstructions in the respiratory department.     

Aortic valve papillary fibroelastoma

Cardiac papillary fibroelastoma (CPF) is a rare primary benign cardiac tumor. Before the use of echocardiography, the lesion was identified at autopsy or incidentally during cardiac surgery. CPF is the third most common primary cardiac tumor after atrial myxoma and lipoma, and is the most common tumor of the valvular endothelium. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) permit diagnosis of the tumor in living patients. CPF may be the cause of cerebrovascular or cardiac ischemia due to embolization or occlusion of the vascular ostia. Embolic material may arise from fragments of the tumor itself, or from surrounding thrombus. The case is reported of a patient with CPF of the aortic valve in whom TEE diagnosis was conducted and the tumor removed surgically.     

Transthoracic echocardiographic predictors of left atrial appendage thrombus

Transesophageal echocardiography (TEE) is commonly performed to detect the presence of a left atrial appendage (LAA) thrombus in the setting of an embolic event or before an anticipated electrical cardioversion for atrial fibrillation. The predictive value of transthoracic echocardiographic (TTE) findings in these patients has not been well defined. This study evaluated whether TTE findings can predict LAA thrombi using TEE as the gold standard for the identification of LAA thrombi. From November 1995 to March 2003, 10,753 patients underwent TEE to exclude LAA thrombi after embolic events or before cardioversion. Of these, 3,768 patients had complete TTE examinations performed <2 weeks before undergoing TEE. Demographics, TTE, and cardiac rhythm variables were analyzed using univariate and multivariate logistic regression to identify predictors of LAA thrombi diagnosed on subsequent TEE. LAA thrombi were identified by TEE in 199 patients (5.3%). Several TTE variables predicted LAA thrombi by TEE, including mitral stenosis, atrial fibrillation, tricuspid regurgitation, valvular prosthesis, left ventricular dysfunction, and right ventricular dysfunction. Mitral regurgitation was associated with a reduced risk for LAA thrombi (odds ratio 0.61, p = 0.003). A structurally normal heart in sinus rhythm (n = 247, 6.9%) had a 100% negative predictive value for LAA thrombi. In conclusion, several TTE variables were found to be predictive of LAA thrombi. The likelihood of LAA thrombi being found on TEE was infinitely small in the absence of these variables and the presence of sinus rhythm.     

Utility of transesophageal echocardiography in identification of thrombogenic milieu in patients with atrial fibrillation (an ACUTE ancillary study)

The ACUTE trial randomly assigned patients who had atrial fibrillation (AF) of >2 days' duration to a transesophageal echocardiographically guided or a conventional strategy before cardioversion. In the 571 patients who underwent transesophageal echocardiography (TEE) in the ACUTE trial, we assessed the relative predictive value of baseline data derived by history, transthoracic echocardiography, and TEE for prediction of thrombus and adjudicated embolism (thromboembolism) as a composite end point. TEE was performed at 70 centers in 571 patients, 549 in the transesophageal echocardiographically guided group and 22 crossovers in the conventional group. Six patients (1.1%) who had embolism and 79 (13.8%) who had thrombi were identified in this group. Thrombus was completely resolved in 76.5% of patients who had repeat transesophageal echocardiographic procedures after 31.7 +/- 7.5 days of anticoagulation. For patients who had embolic events, none had a transesophageal echocardiographically identified thrombus; 5 of 6 (83.3%) had >/=1 transesophageal echocardiographic risk factors (including spontaneous echocardiographic contrast, aortic atheroma, patent foramen ovale, atrial septal aneurysm, mitral valve strands), and 4 of 6 (66.66%) had subtherapeutic anticoagulation or no anticoagulation. Clinical, transthoracic echocardiographic, and transesophageal echocardiographic risk factors contributed significantly to the prediction of composite thrombus/embolism. However, transesophageal echocardiographic thromboembolic risk factors were the strongest predictors of thromboembolism and provided statistically significant incremental value (chi-square 38.0, p <0.001) for identification of risk. Thus, in addition to thrombus identification, TEE has significant incremental value in the identification of patients who had high thromboembolic risk. In conclusion, this study supports the role of TEE and anticoagulation monitoring in patients who have atrial fibrillation and is useful for identifying thromboembolic risk factors.     

Contribution of transesophageal echocardiography in the investigation of the atrium in systemic embolism]

Transesophageal echocardiography (TEE) is a semi-invasive examination that provides better images of the atrium than classical transthoracic echocardiography (TTE) due to the anatomical positioning of the captor and the high frequency Doppler apparatus used. We used TEE and TTE to evaluate the incidence of the cardiac origin of emboli in 46 patients with unexplained stroke or transient ischemic attack (TIA): 23 had documented heart disease (mean age 60 years) and 23 had no cardiac disease (mean age 43 years). Among those with existing heart disease, 4% of the anomalies certainly or probably responsible for the emboli in addition to the underlying cardiopathy were detected by TTE versus 37% by TEE (as compared to values reported in the literature: 25% by TTE and 51% by TEE). In particular, 4 abnormalities were better visualized by TEE: left atrial thrombus, especially those located in the auricle (5 TEE versus 1 TTE); spontaneous contrast showing the swirl of blood stagnating in the dilated left atria of patients with mitral valve disease seen in 7-39% of the TIA by TEE as compared to less than 1% by TTE (3 TEE versus 0 TTE); aneurysm of the interauricular septum (AIAS) observed in 5-16% of the TIA by TEE as opposed to 0-1% by TTE (4 TEE versus 1 TTE); patent foramen ovale (PFO) was noted more frequently following injection of a contrast medium when visualized by TEE (19-22%) than by TTE (6-8%) and can explain the passage of a paradoxical embolus (1 TEE versus 0 TTE). The incidences of left atrial thrombus, AIAS and PFO are well correlated with systemic emboli, especially in young adults having experienced an unexplained TIA without underlying cardiopathy. TEE is an easy-to-use and well tolerated technique for detecting the cardiac origin of emboli in unexplained stroke. Whether to opt for a medical or surgical treatment to avoid recurrences is discussed.     

The transesophageal echocardiographic diagnosis of left atrial myxoma simulating a left atrial thrombus in the setting of mitral stenosis

We report the case of a 56-year-old woman with a history of rheumatic heart disease. The clinical, electrocardiographic, and radiologic findings suggested mitral stenosis. Left atrial obstructive myxoma simulating a thrombus was found by transthoracic echocardiography (TTE). The diagnosis was established by use of transesophageal echocardiography (TEE), confirmed after surgery and by anatomical investigation. Cardiac myxoma associated with mitral stenosis may be difficult to diagnose accurately using TTE. The advantage of TEE in this case and in patients with mitral stenosis is emphasized.     

经食管超声评估风湿性房颤栓塞危险性的价值

目的　探讨经食管超声心动图 (TEE)评估风湿性房颤患者栓塞危险性的价值。方法　 10 6例心房颤动患者分为风湿性房颤组 (n =5 1)和特发性房颤组 (n =5 5 ) ,所有患者同时进行TTE和TEE检查 ,对两组间左房自发性超声对比现象 (leftatrialspontaneousechocontrast,LASEC)的严重程度、LA、LVd、LVs、FS、二尖瓣瓣口面积等进行比较。结果　 10 6例中经TEE检查发现 14个血栓 ,而TTE检查仅发现 4个血栓 ,两组间左房血栓发生率、LASEC的严重程度、LA、FS及二尖瓣瓣口面积均有显著差异 (P <0 0 5 ) ,相关分析显示LASEC与LA呈显著正相关 ,与二尖瓣瓣口面积显著负相关。结论　风湿性房颤患者左房血栓发生率高 ,发生栓塞危险性较大 ,应积极抗凝治疗。TEE对于房颤患者血栓的检测及栓塞危险性的评估较TTE更有优势 ,LASEC、LA、二尖瓣瓣口面积可作为房颤患者左房血栓形成的预示因子。     

Pulmonary artery thrombi detected by echocardiography in patients with pulmonary hypertension secondary to atrial septal defect.

This report presents three patients with severe pulmonary hypertension secondary to atrial septal defect associated with thrombus and spontaneous echo contrast within the pulmonary artery diagnosed by transthoracic and transoesophageal echocardiography. Clinical and echocardiographic features seem to suggest local thrombus formation within the pulmonary arteries as a direct consequence of pulmonary hypertension rather than venous thromboembolism.     

Transesophageal echocardiography in the selection of patients prior to percutaneous mitral valvuloplasty. Study of 71 consecutive patients]

We studied 71 consecutive patients with mitral stenosis candidates for mitral valvuloplasty by means of transthoracic (TTE) and transesophageal echocardiography (TEE). We compared the information obtained by the two methods with respect to: mitral valve morphology (echocardiographic score), severity of mitral regurgitation, prevalence of atrial thrombus and incidence of spontaneous contrast in the left atrium. The assessment of valvular thickening, mobility and calcification was similar by the two methods. The assessment of the subvalvular disease was significantly lower by TEE than the assessed by TTE (1.66 +/- 0.6 vs 2.12 +/- 0.5; p less than 0.001). The total "score" obtained by TEE was significantly lower than the "score" obtained by TTE (7.32 +/- 1.9 vs 7.88 +/- 1.8; p +/- 0.001), but when we classified the patients in groups according to the "score", there were no significant differences between the groups obtained by the two methods. We detected mitral regurgitation in 27 patients (38%) by TTE and in 36 (50%) by TEE. The difference in the quantification of the mitral regurgitation was no more than one grade in any case. Atrial thrombus were detected in 16 patients (22%) by TEE and in 2 patients by TTE. Spontaneous contrast was seen in 53 patients (75%) by TEE and in only 1 by TTE. We conclude that TEE is essential in detecting atrial thrombus, but does not provide any new information about mitral valve morphology and mitral regurgitation in the selection of patients for percutaneous mitral valvuloplasty.     

Right atrial thrombus migration during echocardiography: a case for urgent intervention.

A 65-year-old woman presented with increasing shortness of breath, chest pain and ST-T wave abnormalities on the electrocardiogram suggestive of unstable angina. Cross-sectional echocardiography performed to assess wall-motion abnormality and left ventricular function revealed a pedunculated right atrial thrombus prolapsing into the right ventricle which suddenly dislodged and migrated into the pulmonary circulation during the examination. A diagnosis of recurrent pulmonary thromboembolism was made, necessitating urgent pulmonary angiography with infusion of streptokinase. The patient made an uneventful recovery.     

Mitral Stenosis, Sinus Venosus Atrial Septal Defect, and Partial Anomalous Pulmonary Venous Return

We describe a 42-year-old man with rheumatic mitral stenosis, sinus venosus atrial septal defect, and anomalous drainage of the right upper pulmonary vein to the superior vena cava. Transthoracic echocardiography (TTE) failed to identify the atrial septal defect and the partial anomalous pulmonary venous return. Transesophageal echocardiography (TEE), using a multiplane probe, was useful in delineating the abnormalities. To our knowledge, this is the first reported patient with rheumatic mitral stenosis and sinus venosus defect.     

Pulmonary thromboendarterectomy for chronic pulmonary thromboembolism in three patients with systemic lupus erythematosus and antiphospholipid syndrome]

Pulmonary hypertension (PH) is a serious and often fatal complication of systemic lupus erythematosus (SLE). Several potential mechanisms have been postulated for narrowing of vessels as a result of pulmonary vasculitis and pulmonary thromboembolism caused by antiphospholipid antibodies. Pulmonary thromboendarterectomy for chronic pulmonary thromboembolism is performed to alleviate pulmonary hypertension. We report three rare cases of SLE with antiphospholipid syndrome in patients who presented with PH secondary to chronic pulmonary thromboembolism. Pulmonary thromboendarterectomy was performed, and all patients remained well without deterioration of PH after surgery. Pulmonary thromboendarterectomy should be considered as an effective method of treatment for this disease.     

房颤时左心耳结构和功能改变与肺静脉血流的关系研究

目的评价房颤时左心耳结构和功能改变与肺静脉血流变化的关系。方法74例房颤患者和16例正常人接受经胸超声心动图(TTE)和经食道超声心动图(TEE)检查,检测左心耳血栓形成、结构、功能和肺静脉血流频谱指标。结果18例房颤患者存在左心耳血栓,血栓组、非血栓组和正常组间左心耳结构、功能和肺静脉血流频谱有显著差异,其中血栓组左心耳扩大,血流速度下降最严重,左心耳结构、功能和肺静脉血流密切相关。结论房颤时左心耳结构改变,功能减退,肺静脉血流和左心耳结构、功能关系密切,能准确反应左心耳功能,在血栓评价中具有重要意义。     

Ratio of peak early to late diastolic filling velocity of the left ventricular inflow is associated with left atrial appendage thrombus formation in elderly patients with acute ischemic stroke and sinus rhythm

OBJECTIVES: To investigate the useful parameters of transthoracic echocardiography (TTE) for the diagnosis of stroke subtypes in patients with acute cerebral infarction. METHODS: One hundred and one acute ischemic stroke patients met all of the following criteria; > or = 50 years of age, normal sinus rhythm on admission, and transesophageal echocardiography (TEE) within 7 days from the onset. The clinical significance of the TTE parameters on admission was examined for identifying intracardiac thrombus formation as follows: left atrial dimension, left ventricular end-diastolic dimension, percentage fractional shortening, left ventricular mass index, ratio of the transmitral inflow velocities (E/A), and deceleration time of the E wave. RESULTS: There were 28 patients with E/A > or = 1.0(70 +/- 12 years old) and 73 with E/A < 1.0 (73 +/- 10 years old). No patient showed pulmonary congestion on chest radiography. There were no significant differences in age, TTE parameters, and plasma levels of brain natriuretic peptide between the two groups. Patients with E/A > or = 1.0 had higher incidence of left atrial appendage thrombus formation and/or spontaneous echographic contrast than those with < 1.0 (25% vs 5%, p = 0.0058). There was a significant relationship between E/A and emptying flow velocity of the left atrial appendage (r = -0.569, p < 0.0001). Multivariate logistic regression analysis showed E/A was an independent predictor for left atrial appendage thrombus (risk ratio 1.531 per 0.1 increase, 95% confidence interval 1.129-2.076, p = 0.0002). CONCLUSIONS: Increased level of E/A on admission was associated with the occurrence of left atrial appendage thrombus formation in patients with acute ischemic stroke.