Transoesophageal echocardiography in cardiac anaesthesia

Echocardiography is the most widely used minimally invasive investigation to diagnose heart disease. Transoesophageal echocardiography (TOE) was first introduced perioperatively in the 1980s and is now an important monitoring tool for patients undergoing cardiac surgery. Because of the close proximity of the oesophagus to the heart, TOE facilitates the acquisition of high-resolution images. The TOE probe is a multiplane transducer. This means that the image planes can be rotated from 0° to 180°, enabling three-dimensional (3D) assessment of the structure of interest. Intraoperative TOE has been shown to improve outcome in a variety of cardiac surgeries. The introduction of real-time 3D TOE has provided better diagnosis of the mechanism of certain valve pathologies. TOE has become an important investigation in the assessment of haemodynamic instability in the perioperative period because it allows rapid and accurate diagnosis.     

Novel use of transesophageal echocardiographic probe for intraoperative epicardial imaging

We studied 3 patients in whom standard transesophageal echocardiography was either not feasible nor offered suboptimal images. A standard multi-plane transesophageal echocardiography probe was covered in a sterile sheath containing ultrasonic gel, and the tip of the probe was placed on the beating heart by the surgeon. Echocardiographic imaging planes were selected by combining multi-plane imaging with "flexion" and "extension" of the probe by the echocardiographer, with minimal surgical manipulation. Good-quality "epicardial-transesophageal echocardiography" images were obtained in all cases, allowing effective decision-making by the surgeon. The small size of the probe and availability of multi-plane imaging allowed comprehensive and detailed imaging of the heart with minimal manipulation of the probe. There were no side effects attributable to the epicardial-transesophageal echocardiography. The new technique of epicardial echocardiography with a multi-plane transesophageal echocardiography probe overcomes the limitations of conventional transesophageal echocardiography and of epicardial echocardiography in selected patients and allows excellent visualization of cardiac structure and function with minimal interference with the surgical field, and with no extra expenditure.     

Cardiac axis-oriented full-volume data acquisition in real-time three-dimensional transesophageal echocardiography to facilitate on-cart analysis

We propose a useful method to acquire a full-volume dataset that allows for efficient assessment of cardiac structures by real-time 3-dimensional transesophageal echocardiography (3DTEE). In our method, bicommissural full-volume acquisition, the dataset is acquired with the X-Y-Z axes aligned along the lines connecting the mitral commissures, the mitral annular center to the left ventricular apex, and the mitral anterior-posterior ends, respectively. The image dataset obtained using this method not only allows for visualization of en face images of the cardiac structures, but box cropping of the dataset also provides useful sectional images that are the analogues of the standard 2DTEE views. Our method can potentially standardize 3D image orientation of the cardiac structures and facilitate intraoperative on-cart analysis in real-time 3DTEE.     

Transoesophageal echocardiography in cardiac anaesthesia

Echocardiography is the most widely used minimally invasive investigation to diagnose heart disease. Transoesophageal echocardiography (TOE) was first introduced perioperatively in the 1980s and is now an important monitoring tool for patients undergoing cardiac surgery. Because of the close proximity of the oesophagus to the heart, TOE facilitates the acquisition of high-resolution images. The TOE probe is a multiplane transducer. This means that the image planes can be rotated from 0° to 180°, enabling three-dimensional (3D) assessment of the structure of interest. Intraoperative TOE has been shown to improve outcome in a variety of cardiac surgeries. The introduction of real-time 3D TOE has provided better diagnosis of the mechanism of certain valve pathologies. TOE has become an important investigation in the assessment of haemodynamic instability in the perioperative period because it allows rapid and accurate diagnosis.     

Pulmonary thromboembolism with floating thrombus trapped in patent foramen ovale

A 39-year-old man was hospitalized with symptoms of acute deep vein thrombosis, and computed tomography showed that he had pulmonary thromboembolism. Transthoracic echocardiography showed a large, right atrial thrombus and transesophageal echocardiography showed migrating thrombus trapped in a patent foramen ovale and extending all the way up to the ascending aorta. He underwent surgical embolectomy under cardiopulmonary bypass. At the conclusion of the operation, repeat transesophageal echocardiography examination revealed fresh but small thrombus in the right atrium. This continued entry of thrombi into the heart was further managed with fluoroscopy-guided insertion of a retrievable inferior vena cava filter through the internal jugular vein in the operating room itself.     

Three-dimensional reconstructions of normal and aneurysmatic left ventricles in vivo using transesophageal echocardiography

OBJECTIVE: To perform three-dimensional surface reconstructions to provide spatial delineations of a normal and an aneurysmatic left ventricle, using transesophageal echocardiography. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Eight patients in cardiogenic shock admitted to the intensive care unit and two patients undergoing surgery with general anesthesia. INTERVENTIONS: Using a multiplane transesophageal echocardiography probe, nine echocardiographic cross-sectional images of the heart at approximately 20 degrees angular increments were obtained from midesophageal level in each patient for three-dimensional surface reconstructions. Multiple determinations of cardiac output using the thermodilution principle were also made in each patient to verify the accuracy of three-dimensional data sets. MEASUREMENTS AND MAIN RESULTS: End-diastolic and end-systolic volumes were determined from three-dimensional data sets using the disc-summation method. Stroke volume was derived as the difference between end-diastolic and end-systolic volumes. Stroke volume was also calculated from thermodilution cardiac output measurements and heart rate. Correlation and limits of agreement between stroke volumes derived by the two methods were determined. Three-dimensional wire-frame models of a normal and an aneurysmatic left ventricle at end-systole were constructed from the nine echocardiographic cross-sectional images. Correlation coefficient between stroke volume derived from three-dimensional data sets using the disc-summation method and that measured by the thermodilution method was 0.91 (p < 0.001). Wire-frame models reveal a normal symmetric cavity and an aneurysmal cavity in sharp relief. CONCLUSIONS: Three-dimensional surface reconstruction can be performed from multiple cross-sectional images obtained using an unmodified commercially available multiplane transesophageal echocardiography probe, to reveal the left ventricular cavity in sharp relief. High correlation between stroke volume calculated from three-dimensional data sets and that measured by the thermodilution method attests to the accuracy of the three-dimensional data sets.     

Diagnosis of patent foramen ovale with multiplane transesophageal echocardiography in adult cardiac surgical patients

OBJECTIVE: To evaluate multiplane transesophageal echocardiography (TEE) for detection of patent foramen ovale (PFO) and to compare multiplane TEE with visual inspection (VI) for PFO detection. DESIGN: A prospective observational study. SETTING: University hospital (single institution). PARTICIPANTS: Patients presenting for cardiac surgery requiring TEE. INTERVENTIONS: Multiplane TEE including 2 atrial views with color-flow Doppler (CFD) and contrast echocardiography (CE) with a provocative respiratory maneuver (PRM) and comparison of multiplane TEE and VI with respect to PFO detection. MEASUREMENTS AND MAIN RESULTS: The cohort size was 187. PFO prevalence was 27.3%. CFD with serial decrease of the Nyquist limit detected 51% of all PFO: 41.2% in the bicaval view alone, 27.5% in the 4-chamber view alone, and 9.8% in both views. CE detected 78.4% of all PFO: 72.5% with PRM, 45.1% with no PRM, and 27.4% with/without PRM. PFO detection by multiplane TEE and visual inspection were correlated in 41 subjects. TEE diagnosed 11 PFO (26.8% prevalence, 3 missed by VI). VI diagnosed 12 PFO (29.3% prevalence, 4 missed by TEE). CONCLUSIONS: Multiplane TEE is a gold standard for detection of PFO. Despite advances in TEE technology, 2-dimensional imaging does not detect all PFO. To maximize PFO detection, multiple TEE modalities are required in multiple views, despite a low Nyquist limit for CFD or a PRM for CE. Even though multiplane TEE is equivalent to VI for PFO detection, the discrepancy rate may be an important consideration in the individual case.     

Transesophageal echocardiography in renal cell carcinoma: an accurate diagnostic technique for intracaval neoplastic extension

Between 4 and 10% of patients with renal cell carcinoma have tumor involving the inferior vena cava and many of these patients have suprahepatic extension. In patients with intracaval neoplastic extension precise definition of the superior aspect of the tumor thrombus is critical. Transabdominal ultrasonography, computerized tomography (CT), magnetic resonance imaging (MRI) and inferior venacavography are all currently used to evaluate the inferior vena cava in these patients. Intraoperative transesophageal echocardiography was used to image the inferior vena cava in 5 patients with renal cell carcinoma and intracaval neoplastic extension. In each patient transesophageal echocardiography correctly revealed the superior extent of tumor thrombus. In 3 patients tumor thrombus was found at a higher level by transesophageal echocardiography than by CT, MRI and inferior venacavography. In all patients tumor imaging by transesophageal echocardiography correlated well with the gross appearance and extent of tumor found at operation. Echocardiography also documented the absence of residual gross tumor after resection. Transesophageal echocardiography was also useful to assess left ventricular function. Although each of these patients had a pulmonary artery catheter as well transesophageal echocardiography can be useful in situations when right atrial tumor thrombus prevents right heart catheterization. This small series demonstrates that intraoperative transesophageal echocardiography can accurately evaluate the extent of tumor thrombus and provides a means to assess myocardial function complementary to the pulmonary artery catheter.     

Application of transesophageal echocardiography in removal of right atrial tumor thrombus of adrenal cortical carcinoma--a case report

Surgical removal of adrenal cortical carcinoma complicated by intra-atrial tumor thrombus is very difficult and risky if the removal of thrombus is incomplete, leading possibly to pulmonary embolism. Application of multiplane transesophageal echocardiography during surgical operation may help notifying the size and location of tumor thrombus and also help determining the completeness of the thrombus removal. We present a case of successful removal of adrenal cortical carcinoma with tumor thrombus extension to the right atrium under comprehensive anesthetic care including continuous intraoperative transesophageal echocardiography monitoring.     

Preoperative morphological analysis by transesophageal echocardiography and predictive value of plasma landiolol concentration during systolic anterior motion mitral valve repair : a report of three cases

We report three cases with systolic anterior motion (SAM) after mitral valve plasty. Preoperative mitral valve morphology is a risk factor for SAM. The morphological characteristics of SAM have been revealed in several studies. We found a small distance between coaptation and the interventricular septum in all cases, and cases 2, and 3 had a low AL/PL ratio, whereas case 3 had a large PML, which was revealed by transesophageal echocardiography. With the use of 3D transesophageal echocardiography, when mitral valve prolapse was investigated, in all three cases, it was easy to specify lesions. The issue for the future is 3D analysis when SAM is occurring.     

Transesophageal echocardiography in the diagnosis of acute aortic syndrome

In recent years, technological advances in echocardiography have led to improvements in the diagnosis of acute aortic disease. With transesophageal echocardiography (TEE) and, particularly, bi- and multiplane probes, the physiopathologic understanding of these diseases has widened. Thus, new entities such as penetrating ulcer and intramural hematoma have been described and differentiated from classical aortic dissection.     

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.     

Three-dimensional echocardiography: a new paradigm shift

Significant advances in three-dimensional echocardiography (3DE) have made this modality a powerful diagnostic tool in the cardiology clinic. It can provide accurate and reliable measurements of chamber size and function. In addition, 3DE offers novel views and comprehensive anatomic definition of valvular and congenital abnormalities by rendering 3D contoured images of the structures. It is also useful in monitoring the effectiveness of surgical or percutaneous transcatheter interventions. With demonstrations of efficacy in various clinical settings, 3DE has become a complementary part of the routine diagnostic armamentarium. However, 3DE is regarded as simply a tool for 3D volume or image rendering. If we confine the role of 3DE to this, it will remain a complementary tool to two-dimensional echocardiography (2DE) in the future. Three-dimensional echocardiography has roles beyond 3D volume or image rendering. Three-dimensional echocardiography can acquire a full volume dataset in a single shot, and with combined use of the multiplanar reconstructive mode, it can provide anatomically well-defined 2D planes from the full volume dataset. Hence, by omitting routine 2DE work, 3DE may save time for image acquisition and allow more precise and reproducible review or measurement. Taking this perspective into account, 3DE can be a suitable modality for use as a substitute for 2DE in daily practice. With further advances of 3DE and development of a unified review system capable of display and geometrical assessment of 2D as well as 3D images, 3DE will represent a new paradigm shift in echocardiographic examination in the future.     

Tornado-like appearance of spontaneous echo contrast assessed by real-time 3D transesophageal echocardiography

We report a case showing that real-time 3D transesophageal echocardiography provides unique information about the dynamic nature of spontaneous echo contrast (SEC) in 3D space and has the potential to provide better understanding of SEC. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Usefulness of Intraoperative Real‐Time 3D Transesophageal Echocardiography in Cardiac Surgery

Abstract Background: Recent advances in three‐dimensional (3D) echocardiography allow to obtain real‐time 3D transesophageal (RT3DTEE) images intraoperatively. Methods: Preoperative transthoral echocardiography (TTE) revealed: hypertrophic ventricular septum (TTE:19.3 mm), systolic anterior motion (SAM) not causing obstruction and malcoaptation of the anterior mitral valve leaflet (AMVL), and posterior mitral valve leaflet (PMVL) with severe mitral regurgitation. Results: Intraoperative TEE with a x7‐2t MATRIX‐array transducer (Philips, Andover, MA, USA) with a transducer frequency of x7–2 t mHz, connected to a iE33 (Philips), shows us that the main mechanism and site of regurgitation was an AMVL cleft. We also measured a 24.3‐mm thickness of the ventricular septum and analyzing the 3D full volume acquisition revealed that there was no SAM. Conclusion: Intraoperative RT3DTEE permitted comprehensive 3D viewing of the mitral valve revealing the mechanism of mitral valve regurgitation, SAM, and the exact width of the hypertrophic ventricular septum.     

Transoesophageal echocardiography in cardiac anaesthesia

The use of transoesophageal echocardiography (TOE) has increased in the last 20 years and TOE is now a standard perioperative monitoring tool used for patients undergoing cardiac surgery. Because of the close proximity of the oesophagus to the heart, TOE facilitates the acquisition of high-resolution images. The TOE probe is a multiplane transducer. This means that the image planes can be rotated from 0 to 180 degrees, enabling three-dimensional assessment of the structure of interest. Intraoperative TOE has been shown to improve outcome in a variety of cardiac surgeries. TOE findings assist in the planning, execution and evaluation of surgery. TOE has a substantial impact on surgical decision-making. Intraoperative TOE modifies the planned surgical operation in 15% of cardiac surgical procedures.     

Transoesophageal echocardiography in cardiac anaesthesia

Echocardiography is the most widely used minimally invasive investigation to diagnose heart disease. Transoesophageal echocardiography (TOE) was first introduced perioperatively in the 1980s and is now an important monitoring tool for patients undergoing cardiac surgery. Because of the close proximity of the oesophagus to the heart, TOE facilitates the acquisition of high-resolution images. The TOE probe is a multiplane transducer. This means that the image planes can be rotated from 0° to 180°, enabling three-dimensional assessment of the structure of interest. Intraoperative TOE has been shown to improve outcome in mitral valve surgery and is frequently used by the surgeon as an aid in deciding whether to repair or replace the valve. TOE has become an important investigation in the assessment of haemodynamic instability in the perioperative period because it allows rapid and accurate diagnosis.     

Perioperative Echokardiographie

Over the past decades, echocardiography has undergone a continuous evolution in technology that has promoted its clinical application and acceptance throughout perioperative medicine. These technological advances include improvements in transducer development that permit superior imaging quality and a wider selection of probes for epicardial, epiaortic, and surface echocardiography which can also be used in conjunction with multiplane transesophageal echocardiography. Moreover, the addition of Doppler technology and digital acquisition has secured the role of echocardiography as a valuable and relatively noninvasive diagnostic tool for the assessment of cardiovascular disease and hemodynamic monitoring throughout the perioperative period. Therefore, it has become increasingly important for perioperative physicians to understand the basic principles and underlying fundamental concepts pertaining to the technology and physics of echocardiography, as well as its inherent limitations. The current review outlines the modes and applications of different echocardiographic techniques used in perioperative echocardiography including M-mode, two-dimensional echocardiography, and Doppler assessment of blood flow. In addition, the limitations of these techniques and typical artifacts associated with the perioperative use of echocardiography are described.     

Positron emission tomography/computed tomography for the diagnosis of endocarditis in patients with pulmonic stented valve/pulmonic stent

Percutaneous pulmonic valve and pulmonic stent implantation have become a well-established treatment for recurrent pulmonic stenosis or insufficiency in patients with repaired congenital heart disease. Late endocarditis is seldom reported, but its diagnosis might be challenging due to the limited visualization of the stented valve or stent by transesophageal echocardiography. We present 2 young patients who were hospitalized for suspected endocarditis and in whom the diagnosis was made with the aid of positron emission tomography/computed tomography scan.     

Intracoronary air embolism detected during intraoperative transesophageal echocardiography

A 39-year-old hypertensive man with severe aortic stenosis underwent aortic valve replacement monitored by intraoperative transesophageal echocardiography. Upon weaning the patient off extracorporeal circulation, hemodynamics became severely compromised, with hypotension, tachycardia, and elevated precordial electrocardiographic tracings. The echocardiographic images were instrumental during the episode to demonstrate that the anterior wall presented hypokinesis consistent with ischemia in the region but that there were also images of hyperrefringence highly suggestive of intracoronary air embolism. Intraoperative transesophageal echocardiography allowed us to diagnose the real cause of the ischemic event and rule out an atheromatous plaque as the source. Perfusion pressure was increased to treat the air embolism. The echocardiographic image demonstrated success, specifically restoration of left ventricular regional contractility. This experience revealed the usefulness of transesophageal echocardiography in intraoperative monitoring to diagnose ischemia, assess the cause, and guide treatment.