Double trouble: A case of periprocedural detection of intracardiac thrombus and aortic root dissection during emergent transfemoral TAVR

We report a case of emergency transcatheter aortic valve replacement (TAVR) in a 65‐year‐old patient presenting with decompensated severe aortic stenosis. Transesophageal echocardiography (TEE) was used effectively to obtain measurements of the aortic annulus and for intra‐procedural guidance. At baseline, we detected a left atrial appendage thrombus and a localized aortic root dissection after balloon valvuloplasty. The case highlights the important role that TEE may play during TAVR procedures.     

Implementation of Real Time Three-Dimensional Transesophageal Echocardiography in Percutaneous Mitral Balloon Valvuloplasty and Structural Heart Disease Interventions

Percutaneous interventions for structural heart disease are performed in a dynamic and complex environment that necessitates multiple imaging modalities to achieve procedural success. Structural interventions are routinely guided by two-dimensional (2D) modalities such as x-ray fluoroscopy, transesophageal echocardiography (TEE), and intracardiac echocardiography. Real time imaging with three-dimensional (3D) echocardiography is a novel method of guidance to facilitate complex structural interventions with the promise of greater safety and efficacy. Real time 3D TEE (RT3D-TEE) affords the capability of imaging catheters and devices, the interventional objective, and adjacent structures simultaneously. We present an overview of RT3D-TEE and explore its functionality in structural heart interventions by using percutaneous mitral balloon valvuloplasty as a model.     

Live/Real Time Three-Dimensional Transesophageal Echocardiographic Evaluation of Mitral and Aortic Valve Prosthetic Paravalvular Regurgitation

Thirteen patients already scheduled for surgery for repair of prosthetic paravalvular regurgitation underwent intraoperative real time two-dimensional transesophageal echocardiography (2D TEE) and live/real time three-dimensional transesophageal echocardiography (3D TEE). In all patients, 3D TEE was able to provide more information regarding the location and size of the paravalvular defect as compared to 2D TEE. 3D TEE resulted in a more accurate localization of the defect and an estimation of the size of the defect that correlated much more closely with surgical findings when compared with 2D TEE. Our preliminary results demonstrate the superiority of 3D TEE over 2D TEE in the evaluation of paravalvular prosthetic regurgitation. 3D TEE not only provides an accurate assessment of the exact site of the leakage, but also gives a more accurate estimate of its size. This information could be valuable to surgeons who may encounter difficulty when localizing and estimating the size of paraprosthetic leaks while the heart is devoid of blood during surgery.     

Use of real-time three-dimensional transesophageal echocardiography in type A aortic dissections: Advantages of 3D TEE illustrated in three cases

Stanford type A aortic dissections often present to the hospital requiring emergent surgical intervention. Initial diagnosis is usually made by computed tomography; however transesophageal echocardiography (TEE) can further characterize aortic dissections with specific advantages: It may be performed on an unstable patient, it can be used intra-operatively, and it has the ability to provide continuous real-time information. Three-dimensional (3D) TEE has become more accessible over recent years allowing it to serve as an additional tool in the operating room. We present a case series of three patients presenting with type A aortic dissections and the advantages of intra-operative 3D TEE to diagnose the extent of dissection in each case. Prior case reports have demonstrated the use of 3D TEE in type A aortic dissections to characterize the extent of dissection and involvement of neighboring structures. In our three cases described, 3D TEE provided additional understanding of spatial relationships between the dissection flap and neighboring structures such as the aortic valve and coronary orifices that were not fully appreciated with two-dimensional TEE, which affected surgical decisions in the operating room. This case series demonstrates the utility and benefit of real-time 3D TEE during intra-operative management of a type A aortic dissection.     

Assessment of left atrial appendage by live three-dimensional echocardiography: early experience and comparison with transesophageal echocardiography

BACKGROUND: Live Three-Dimensional Echocardiography (L3D, Sonos 7500, Philips) has the potential to visualize all cardiac structures including left atrial appendage (LAA). We tested the feasibility of evaluating LAA by L3D and compared the findings to transthoracic echocardiography (2D) and in a subset of patients with transesophageal echocardiography (TEE). METHODS: L3D images were obtained in 204 consecutive patients referred for routine 2D or TEE. We performed wide-angled acquisitions from parasternal and apical views. TomTec system (4D Cardio-view, RT 1.2) was used to visualize LAA from multiple vantage points. RESULTS: LAA was adequately visualized by L3D in 139 of 204 (68.1%) patients. L3D visualization was dependent on image quality, suboptimal in 100 and diagnostic in 104 patients. Overall, LAA was visualized in 93 (45.5%) patients by 2D compared to 139 (68.1%) by L3D (P < 0.0001). In 100 patients with suboptimal image quality by L3D, LAA visualization was 16% by 2D and 35% by L3D, whereas in 104 patients with diagnostic images, LAA was visualized in 77 (74%) by 2D and in all 104 (100%) patients by L3D (P < 0.0001). In 37 patients referred for transesophageal echocardiography (TEE), live three-dimensional echocardiography (L3D) visualized left atrial appendage (LAA) in 34 patients with diagnostic image quality. Eight patients with LAA thrombi on TEE had thrombi detected by L3D as well. All patients with LAA thrombus had enlarged LA by both 2D and TEE. CONCLUSIONS: L3D is a promising technique in evaluation of LAA with and without thrombi. In patients with good quality transthoracic images L3D may be used as a screening tool in assessment of LAA.     

Initial experience with live/real time three-dimensional transesophageal echocardiography

A new tool has been recently introduced to the echocardiography armamentarium, live/real time three-dimensional (3D) transesophageal echocardiography (TEE). In these cases, we describe our initial experience in 13 patients studied intraoperatively and in the echocardiography suite. This important technology promises improved anatomic definition, diagnostic confidence, and novel views of the complicated cardiovascular pathology encountered in common clinical practice.     

Echocardiography in transcatheter aortic (Core)Valve implantation: Part 2—Transesophageal echocardiography

Transesophageal echocardiography (TEE) plays a significant role during transcatheter aortic valve implantation (TAVR). 2DTEE allows assessment of anatomy of the aortic valve, aortic root, left ventricular (LV) outflow tract, severity of the aortic valve stenosis (AS), and the presence and severity of other valve stenosis and regurgitation. Left and right ventricular size and global function as well as cardiac hemodynamics pre and post TAVR and LV regional wall motion can be assessed. Three‐dimensional (3D) imaging adds significantly via accurate measurement of aortic annulus that helps select the appropriate valve size. Biplane imaging allows simultaneous assessment of target cardiac structure in two orthogonal views and provides a rapid assessment during and immediately post valve deployment by evaluating stent height, leaflet motion, and the presence and severity of paravalvular leak (PVL). 2DTEE and 3DTEE allow evaluation of mechanism of PVL that helps guide the decision regarding need for balloon post dilation of the implanted valve or valve in valve implantation.     

Value of transesophageal 3D echocardiography as an adjunct to conventional 2D imaging in preoperative evaluation of cardiac masses

Background: This study sought to compare three-dimensional (3D) and two-dimensional (2D) transesophageal echocardiography (TEE) to assess intracardiac masses. It was hypothesized that 3D TEE would reveal incremental information for surgical and nonsurgical management. Methods: In 41 patients presenting with intracardiac masses (17 thrombi, 15 myxomas, 2 lymphomas, 2 caseous calcifications of the mitral valve and one each of hypernephroma, hepatocellular carcinoma, rhabdomyosarcoma, lipoma, and fibroelastoma), 2D and 3D TEE were performed, aiming to assess the surface characteristics of the lesions, their relationship to surrounding structures, and attachments. Diagnoses were made by histopathology (n = 28), by computed tomography (n = 8), or by magnetic resonance imaging (n = 5). Benefit was categorized as follows: (A) New information obtained through 3D TEE; (B) helpful unique views but no additional findings compared to 2D TEE; (C) results equivalent to 2D TEE; (D) 3D TEE missed 2D findings. Results: In 15 subjects (37%), 3D TEE revealed one or more items of additional information (category A) regarding type and site of attachment (n = 9, 22%), surface features (n = 6, 15%), and spatial relationship to surrounding structures (n = 8, 20%). In at least 18% of all intracardiac masses, 3D TEE can be expected to deliver supplementary information. In six patients, additional findings led to decisions deviating from those made on the basis of 2D TEE. In 11 subjects (27%), 3D echocardiographic findings were categorized as "B." Conclusions: Information revealed by 3D imaging facilitates therapeutic decision making and especially the choice of an optimal surgical access prior to removal of intracardiac masses.     

Real-time three-dimensional echocardiography during percutaneous edge-to-edge mitral valve repair

Objectives

Catheter-based mitral valve clip repair is an effective procedure in selected patients with mitral regurgitation. Two-dimensional (2D TEE) is the primary imaging mode for guidance of mitral-clip procedures. Recently, real-time three-dimensional transesophageal echocardiography (RT 3D TEE) has been used as an additional imaging mode. This review describes the use of 2D TEE and RT 3D TEE imaging during percutaneous edge-to-edge mitral valve repair (mitral-clip).

Results

Compared to 2D TEE, RT 3D TEE provides additional information in several steps of the procedure including alignment of catheter trajectory, clip positioning and orientation of clip arms.

Conclusions

RT 3D TEE is a powerful new imaging tool that may become the technique of choice for guidance of mitral-clip procedures.     

Is It Time to Move on from Two-Dimensional Transesophageal to Three-Dimensional Transthoracic Echocardiography for Assessment of Left Atrial Appendage? Review of Existing Literature

Left atrial appendage (LAA) has unique anatomical and physiological properties, which make it a common site for thrombus formation in many cardiovascular and systemic diseases. Assessment of LAA for thrombus thus becomes important in many clinical situations and two-dimensional transesophageal echocardiography (2D TEE), which allows excellent quality images of LAA because of its close proximity to esophagus is routinely used for this purpose. However, it is a semiinvasive procedure, requires more time and involves some degree of patient discomfort. With some training and experience, two-dimensional transthoracic echocardiography (2D TTE) can visualize LAA in most patients with good acoustic windows. A disadvantage of both 2D TTE and 2D TEE is that they provide only a thin slice or section of cardiac structures at any given time limiting their utility in comprehensively assessing the LAA for thrombus. On the other hand, live/real time three-dimensional (3D) TTE overcomes this limitation of both 2D TTE and 2D TEE because of its ability to encompass whole of the LAA in three-dimensions in the acquired data set, which can then be cropped and sectioned systematically at any desired angulation to more definitively look for clot. 3D TTE is also useful in differentiating a clot from pectinate muscles in the LAA, which can mimic a thrombus resulting in patient mismanagement. In addition, 3D TTE is helpful in sectioning a clot for lysis, which has implications in clot resolution. We reviewed the existing literature comparing the relative advantages and disadvantages of 3D TTE versus 2D TEE and found that in patients with good acoustic windows 3D TTE had similar efficacy for detecting LAA thrombus. (Echocardiography 2012;29:112-116)     

Usefulness of transesophageal three-dimensional echocardiography in the identification of individual segment/scallop prolapse of the mitral valve

We evaluated the potential usefulness of three-dimensional (3D) transesophageal echocardiography (TEE) in assessing individual scallop/segment prolapse in 36 adult patients with mitral valve prolapse (MVP) undergoing surgical correction. Intraoperative 3D TEE correctly identified the location of scallop/segment prolapse in 34 of 36 patients (94%). However, in 6 of these patients 3D TEE images revealed more scallops or segments with prolapse than the surgeon noted intraoperatively. Prolapse of these areas was less prominent and this could possibly explain the lack of correlation with the surgical findings in these patients. In another 2 patients areas of prolapse seen by the surgeon were missed by 3D TEE because some of those scallops/segments could not be well imaged due to image "drop out" and artifacts. Thus, perfect correlation between 3D TEE and surgery was noted in 28 of 36 (78%) patients. Noncoaptation of the MV was also identified in 2 patients. The prolapsed area of posterior (n = 28 observations) and anterior (n = 9 observations) MV leaflets ranged from 1 cm2 to 9 cm2 (mean 3.50 cm2+/- 2.14) and 1.20 cm2 to 5.99 cm2 (mean 3.21 cm2+/- 1.33), respectively. Interobserver and intraobserver agreement for location and area of MVP was excellent (r = 0.97 and r = 0.99, respectively; all P values are <0.0001). In conclusion, 3D TEE is useful in identifying the location of MVP. It may also be potentially useful in assessing the extent of individual scallop/segment prolapse and identifying sites of MV noncoaptation. This information could aid the surgeon in deciding the extent of MV resection.     

Real-Time Monitoring of von Willebrand Factor in the Catheterization Laboratory: The Seatbelt of Mini-Invasive Transcatheter Aortic Valve Replacement?

Significant paravalvular regurgitation (PVR) remains a relatively frequent (4% to 9%) and deleterious complication of transcatheter aortic valve replacement (TAVR), even with the latest generation of bioprosthesis. Although mini-invasive TAVR without general anesthesia or transesophageal echocardiography (TEE) is progressively becoming the predominant approach, identification and grading of PVR in the catheterization laboratory remain an important and challenging clinical issue. The authors discuss how a recently reported blood biomarker reflecting the von Willebrand factor activity, that is, the closure time with adenosine diphosphate, can be successfully applied during the TAVR procedure to detect and monitor PVR in real time, with an excellent negative predictive value. This point-of-care testing performed directly in the catheterization laboratory may improve the diagnosis of PVR and rationalize the decision of whether or not to perform corrective measures. They further discuss how such a test could be a substitute for the multimodal approach combining TEE, hemodynamics, and cine-angiography, and help to secure the transition to the mini-invasive approach and facilitate the expanding indications of less invasive procedures to lower-risk patients without jeopardizing procedural and clinical outcomes.     

Diagnosis of Supravalvular Aortic Stenosis by Transesophageal Echocardiography

The role of transesophageal echocardiography (TEE) in diagnosis of disorders of the thoracic aorta is well established. In this report the TEE findings in an adult patient with supravalvular aortic stenosis are presented. This showed narrowing of the ascending aorta just above the sinuses, due to fibromuscular thickening, causing an hour-glass shaped deformity. The excellent image quality obtained by TEE is far superior to transthoracic echocardiography. Coronary artery ostial obstruction a known association of supravalvular aortic stenosis can be caused by different mechanisms including adherence of the aortic valve leaflet to the ridge of obstructive muscle or premature atherosclerosis. TEE can define the mechanism of coronary artery ostial obstruction associated with supravalvular aortic stenosis.     

Transesophageal Three-Dimensional Color Doppler Echocardiographic Reconstruction of the Left Vertebral Artery

We present a patient in whom we successfully reconstructed a long segment of the proximal left vertebral artery in three dimensions using color Doppler transesophageal echocardiography (TEE). Three-dimensional (3-D) color Doppler TEE may complement two-dimensional (2-D) TEE by its ability to view cross sections of the left vertebral artery at any desired level from the 3-D data stored in the computer.     

Preoperative assessment of mitral valve prolapse and chordae rupture using real time three-dimensional transesophageal echocardiography

Background: Mitral valve (MV) repair provides a better outcome in patients with significant mitral regurgitation than MV replacement. Valve repair requires a thorough understanding of MV morphology. Recently developed real time three‐dimensional transesophageal echocardiography (RT3D TEE) can provide online acquisition and accurate information of cardiac structures. The study aim was to evaluate the feasibility and accuracy of using RT3D TEE to assess mitral valve prolapse (MVP) and chordae rupture for surgical planning purposes. Methods: Fifty‐six consecutive patients with moderate to severe mitral regurgitation due to MVP received two‐dimensional (2D) TEE and RT3D TEE the day before operation. The accuracy of the assessment of MVP and chordae rupture by RT3D TEE was determined and compared with assessment by 2D TEE using surgical inspection as the gold standard. Results: The overall sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 2D TEE in detection of MVP were 87%, 96%, 93%, 88%, and 95%, respectively, whereas those of RT3D TEE were 100%, 99%, 99%, 98%, and 100%, respectively (P < 0.05 for all comparisons). The receiver operating characteristic (ROC) curve areas for assessment of anterior leaflet and posterior leaflet segment involvement using RT3D TEE (ROC areas 0.96 and 0.99) were higher than for those using 2D TEE (ROC areas 0.86 and 0.94). Interobserver agreement for RT3D TEE (κ= 0.97, 95% confidence interval [CI] 0.92–1.00) was significantly greater than for 2D TEE (κ= 0.89, 95% CI 0.81–0.93) (P < 0.05). Conclusion: RT3D TEE is a feasible, accurate and reproducible method for evaluating MVP and chordae rupture in the clinical setting. (Echocardiography 2011;28:1003‐1010)     

Evaluation of a Posterior Mitral Valve Leaflet Aneurysm by Real Time Three-Dimensional Transesophageal Echocardiography

Posterior mitral valve (MV) leaflet aneurysms are extremely rare complications of infective endocarditis (IE). When MV aneurysms occur, they usually involve the anterior leaflet. Real time three-dimensional transesophageal echocardiography (RT3D TEE) has been recently developed and provides views of unparalleled quality by optimizing visualization of spatial relationships. We present a rare case of a posterior MV leaflet aneurysm due to IE in a 64-year-old woman, best visualized by RT3D TEE.     

Rupture of Aortic Dissection During Attempted Transesophageal Echocardiography

Transesophageal echocardiography (TEE) provides a rapid and accurate diagnosis in patients with dissection of the thoracic aorta. The procedure is considered to be safe. We report a case where rupture of a dissecting thoracic aneurysm occurred during attempted TEE in a patient, who had been clinically stable for 1 week. TEE was performed because aortic valve endocarditis was suspected, and the procedure did not include close surveillance of the blood pressure. Careful manipulation of the probe, adequate sedation, monitoring, and treatment of acute rises in blood pressure was recommended in patients with even a slight suspicion of dissection undergoing TEE.     

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.     

Aortic Stenosis

Noninvasive assessment of aortic valve area by echocardiography has become the standard of practice over the past few years. The advent of transesophageal echocardiography (TEE) has provided a new method for the assessment of aortic valve area (AVA) using planimetry by two-dimensional imaging. Clear visualization of the anatomy of the valve, as well as accuracy of AVA assessment, makes TEE an invaluable tool for the evaluation of aortic valve stenosis. TEE is especially helpful in clinical settings when there is a discrepancy between the AVA obtained by transthoracic echocardiography and cardiac catheterization. TEE is particularly helpful in the assessment of the aortic valve during intraoperative echocardiography. This review discusses the techniques, imaging planes, and details for assessing AVA by TEE. The role of TEE in AVA assessment is described, with specific clinical case examples cited.     

Comparison of accuracy of aortic valve area assessment in aortic stenosis by real time three-dimensional echocardiography in biplane mode versus two-dimensional transthoracic and transesophageal echocardiography

Our aim was to validate the clinical feasibility of assessment of the area of the aortic valve orifice (AVA) by real time three-dimensional echocardiography (RT3DE) in biplane mode by planimetry and to compare it with the echo-Doppler methods more commonly used to evaluate valvular aortic stenosis (AS).RT3DE in biplane mode is a novel technique that allows operators to visualize the aortic valve orifice anatomy in any desired plane orientation. Its usefulness and accuracy have not previously been established.Using this technique, we studied a series of patients with AS and compared the results with those obtained by two-dimensional transesophageal echocardiography (TEE) planimetry and two-dimensional transthoracic echocardiography using the continuity equation (TTE-CE). RT3DE planimetries in biplane mode were measured by two independent observers. Bland-Altman analysis was used to compare these two methods.Forty-one patients with AS were enrolled in the study (15 women, 26 men, mean age 73.5 +/- 8.2 years). RT3DE planimetry was feasible in 92.7%. Average AVA determined by TTE-CE was 0.76 +/- 0.20 cm, by TEE planimetry 0.73 +/- 0.1 cm, and by RT3DE planimetry 0.76 +/- 0.20 cm(2). The average differences in AVA were-0.001 +/- 0.254 cm(2) and 0.03 +/- 0.155 cm(2) (RT3DE/TEE). The correlation coefficient for AVA (RT3DE/TTE-CE) was 0.82 and for AVA (RT3DE/TEE) it was 0.94, P < 0.0001. No significant intra- and interobserver variability was observed. In conclusion, RT3DE in biplane mode provides a feasible and reproducible method for measuring the area of the aortic valve orifice in aortic stenosis.