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.     

Echocardiography in Percutaneous Balloon Mitral Valvuloplasty

Percutaneous balloon valvuloplasty (BV) has been used successfully in recent years for the relief of mitral stenosis, and in many instances, as an alternative to cardiac surgery. This procedure requires precise evaluation of both valve morphology and function for preprocedure decision making and follow-up of patients. Two-dimensional (2-D) echocardiography is a unique, noninvasive tool for evaluating morphologic characteristics of valve, subvalvular apparatus, and valve annular size. Doppler echocardiogarphy provides functional information on transvalvular flow velocity, which can be used to derive pressure gradient across valve and regurgitant flow. Mitral valve area can be either obtained from 2-D echocardiography or derived from Doppler pressure half time. Echocardiography is currently the most widely used technique for assessing results of percutaneous BV. More recently, transesophageal echocardiography (TEE) has been used for the evaluation of patients undergoing percutaneous mitral BV in whom left atrial thrombus is suspected and for the intraoperative monitoring of the valvuloplasty procedure. In this article we discuss the advantages and limitations of both transthoracic echocardiography and TEE, its recent developments in monitoring the procedure, evaluation of immediate results and long term follow-up after the valvuloplasty procedure, and its clinical utility in the selection of patients for percutaneous BV.     

Live/Real Time Three-Dimensional Transesophageal Echocardiography

Since the advent of matrix array transducer, three-dimensional transesophageal echocardiography has come to frequent clinical use. It has significantly enhanced the communication between the operators and cardiac imagers in the operating room as well as in the cardiac interventional labs. This article reviews the history, technological aspects, and the protocol for acquisition and processing of the data sets. It also discusses its advantages in various clinical scenarios, both in diagnostic and therapeutic situations. It highlights its limitations in the current form and prospects of future development. (Echocardiography 2012;29:103-111)     

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.     

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.     

Transesophageal Echocardiography During Interventional Catheterization in Congenital Heart Disease

The rapidly expanding role of transesophageal echocardiography (TEE) in the management and treatment of congenital heart disease includes guidance of interventional cardiac catheterization procedures and monitoring of results. TEE is particularly helpful for assessing device position during device closure of atrial septal defects (ASD), ventricular septal defects, and perivalvar defects, especially when multiple or complex defects are present. It is also useful during balloon dilation of certain congenital and postoperative obstructions. Stent placement for treatment of intracardiac obstructions is facilitated by TEE guidance. The risks associated with Brockenbrough transseptal puncture and ASD enlargement, particularly in the setting of unusual atrial anatomy, may be reduced by TEE guidance of the procedure. TEE monitoring of video assisted thoracoscopic closure of patent ductus arteriousus has contributed to the high success rate of this innovative procedure. TEE imaging assists in positioning of devices and catheters, reduces radiation exposure and contrast load, and provides immediate and continous assessment not only of results, but of potential complications of interventional procedures. As the applications of interventional catheterization in the field of pediatric cardiology increase so will the role of TEE.     

经食管实时三维超声心动图在二尖瓣疾病中的应用

经食管实时三维超声心动图是心脏彩超发展的重大飞跃,克服了经胸超声的很多缺点,在疾病诊断与治疗都发挥着巨大作用。现就其在二尖瓣疾病的应用做一综述。     

经皮二尖瓣球囊成形术和血栓前状态

目的：探讨经皮二尖瓣球囊成形术（ＰＢＭＶ）前后血栓前状态与血液动力学的变化。　　方法：对２０ 例有症状的风湿性心脏病二尖瓣狭窄患者根据其心律情况分为窦性心律组（ｎ＝ ８）,和心房颤动心律组（ｎ＝ １２）,并施行ＰＢＭＶ,观察ＰＢＭＶ前后血液流变学和血液动力学参数。同时选择２０名正常人作为正常对照（正常对照组）。　　结果：在ＰＢＭＶ后血液动力学参数发生变化的同时纤维蛋白原（Ｆｂｇ）显著下降（Ｐ＜ ０．０１）。左心房血液成份在心房颤动心律组与窦性心律组之间有明显差异（Ｐ＜ ０．０５～０．０１）,其中Ｄ－二聚体和全血粘度的低切变差异最显著（Ｐ＜０．０１）。　　结论：风湿性心脏病二尖瓣狭窄患者存在血栓前状态基础和血液动力学异常,尤其是心房颤动者,应常规使用抗凝药     

经皮球囊二尖瓣成形术对心率变异的影响

为了解经皮球囊二尖瓣成形术（ＰＢＭＶ）对风湿性心脏病二尖瓣狭窄病人心率变异（ＨＲＶ）的影响，自同期行ＰＢＭＶ的７１例病人中选择窦性心律者作为观察对象。于术前二日和术后第三日记录５ｍｉｎ的心搏数，经短时ＨＲＶ软件分析。结果表明术后ＲＲ间期均值标准差（３３．１８±１０．４２ｍｓｖｓ４２．８０±１５．８４ｍｓ，Ｐ＜０．０５）、相邻ＲＲ间期差值的均方根（２９．６１±１３．３８ｍｓｖｓ３７．５２±２６．０８ｍｓ，Ｐ＜０．０５）、相邻ＲＲ间期差值大于５０ｍｓ的百分比（６．７６±７．４９％ｖｓ９．０３±１０．２３％，Ｐ＜０．０１）、高频能谱（６１５．５８±４８５．６２ｂｐｍ２ｖｓ７０１．９７±６４９．９６ｂｐｍ２，Ｐ＜０．０５）均明显增大或升高。而平均心率（７４．３２±１１．３７ｂｐｍｖｓ６５．８８±７．７３ｂｐｍ，Ｐ＜０．０１）、最大心率（９５．６８±２８．６８ｂｐｍｖｓ７６．１４±８．５３ｂｐｍ，Ｐ＜０．０１）、低频能谱（４３８．２２±４０９．３１ｂｐｍ２ｖｓ２４０．１８±１９８．６８ｂｐｍ２，Ｐ＜０．０１）、极低频能谱（９７１．７４±５２９．５３ｂｐｍ２ｖｓ７２１．４３±５６４．０９ｂｐｍ２，Ｐ＜０．０１）均明显降?     

Intracardiac Echocardiography in Structural Heart Disease Interventions

Intracardiac echocardiography has historically been used to guide a limited number of transcatheter cardiac interventions. However, the tremendous advances in structural heart disease interventions in the last decade led to a growing interest in intracardiac echocardiography as a potential alternative to transesophageal echocardiography that mitigates the need for endotracheal intubation. Nonetheless, the scarcity of data, the imperfection of the current probes, and the limited experience among operators prevented a wider adoption of this technology. This review summarizes the contemporary relevant evidence and provides the structural interventionalist with an illustrative guide on the use of intracardiac echocardiography to guide various structural heart interventions.     

经皮球囊二尖瓣扩张术的并发症及其处理

采用Inoue球囊法进行经皮球囊二尖瓣成形术治疗风湿性二尖瓣狭窄病人共300例，术后左房平均压由3．26±1．14kPa（1kPa＝7．5mmHg）降至1．33±0．89kPa，跨瓣压差由2．41±0．93kPa降至0．44±0．39kPa，二尖瓣口面积由1．03±0．23cm2增至2．09±0．38cm2；无一例死亡，53例出现不同的并发症，包括急性心包填塞5例（1．7％），二尖瓣反流（≥2级）9例（3％），肢体动脉栓塞1例（0．3％），房间隔水平分流14例（4．7％），并发症中仅6例因病情严重而需外科手术处理。本文对各种并发症的发生，预防和应急处理措施进行了讨论。     

Three-Dimensional Echocardiography in Valvular Heart Disease

Two-dimensional echocardiography (2DE) with color Doppler has been the standard tool for assessing valvular heart disease. However, this requires conceptualizing three-dimensional (3D) valvular anatomy from individual 2D slices, which is inadequate for complex valvular abnormalities. Similarly, Doppler-based methods are inherently limited by several assumptions and are influenced by hemodynamics and concomitant valvular disease. 3DE has improved both morphological and functional assessment of valvular heart disease. It provides additional morphological information, which leads to better understanding of the mechanism of valvular dysfunction and surgical planning. 3D planimetry has proven to be accurate in the evaluation of valvular stenosis. This direct assessment eliminates measurement errors and could potentially serve as new gold standard. The continuity equation for aortic stenosis can be simplified by directly measuring left ventricular outflow tract area and stroke volume. In patients with valvular regurgitation, vena contracta area can be directly measured by using 3D color Doppler which is more accurate than the standard 2D methods. By applying hemi-elliptical formula or directly measuring isovelocity surface area, 3DE has significantly improved the accuracy in regurgitant severity assessment. This is particularly useful in patients with eccentric jets. 3DE has an advantage over 2DE in assessment of tricuspid valve due to its complex geometry. Direct planimetry of orifice area in tricuspid stenosis, or vena contracta area in tricuspid regurgitation are promising although validation studies are needed before they can be applied for clinical decision making. 3DE has not been widely studied in pulmonic valve disease but preliminary data indicate that it is feasible. (Echocardiography 2012;29:88-97)     

Very Long Term Follow-Up After Percutaneous Balloon Mitral Valvuloplasty

Objectives

The aim of this study was to assess very long term outcomes after successful percutaneous balloon mitral valvuloplasty (PBMV).

巨大左心房患者的经皮二尖瓣球囊成形术

本文介绍了13例巨大左心房患者的经皮二尖瓣球囊成形术(PBMV).认为手术成功的关键是房间隔穿刺,但已不能采用常规的方法.作者探索了正中法、右侧法和左侧法,并认为右侧法最好.巨大左心房者常为风湿性心脏病二尖瓣严重狭窄的晚期表现,病情重,合并症多,全身情况差,无法耐受开胸手术,而一般内科治疗效果不好.虽然PBMV也有一定风险,但可能是目前唯一较好的治疗方法.本组病例效果令人满意.     

Clinical Determinations of Volumes of Normal and Aneurysmatic Left Ventricles by Three-Dimensional Transesophageal Echocardiography

Biplane methods of determining left ventricular volumes are inaccurate in the presence of aneurysmal distortions. Multiplane transesophageal echocardiography, which provides multiple, unobstructed cross-sectional views of the heart from a single, stable position, has the potential for more accurate determinations of volumes of irregular cavity forms than the biplane methods. The aim of the study was to determine the feasibility of three-dimensional measurements of ventricular volumes in patients with normal and aneurysmatic left ventricles by using multiplane transesophageal echocardiography. With the echotransducer in the mid-esophageal (transesophageal) position, nine echo cross-sectional images of the left ventricle in approximately 20 degrees angular increments were obtained from each of 29 patients with coronary artery disease who had undergone biplane ventriculography during diagnostic cardiac catheterization. In 17 of these 29 patients, echo cross-sectional images of the left ventricle with the echotransducer in transgastric position were also obtained. End-diastolic volume, end-systolic volume, and ejection fraction were determined from multiplane transesophageal echocardiographic images and biplane ventriculographic images by the disc-summation method and compared with each other. In another ten patients with indwelling pulmonary artery catheters, stroke volumes calculated from multiplane transesophageal echocardiographic images were compared with those derived from thermodilution cardiac output measurements. Correlations between biplane ventriculographic and multiplane transesophageal echocardiographic measurements were higher in the ten patients with normal ventricular shape [for end-diastolic volumes, r = 0.91, SEE = 19 ml; for end-systolic volumes, r = 0.98, SEE = 9.3 ml; for ejection fractions (EFs), r = 0.91, SEE = 5.4%] than in the 19 patients with ventricular aneurysms (for end-diastolic volumes, r = 0.61, SEE = 31.5 ml; for end-systolic volumes, r = 0.66, SEE = 32.5 ml; for EFs, r = 0.79, SEE = 8%). Correlations between echocardiographic volumes from the transesophageal and transgastric transducer positions were high independent of left ventricular geometry (for end-diastolic volumes, r = 0.84, SEE = 13.1 ml; for end-systolic volumes, r = 0.98, SEE = 9.6 ml; for EFs, r = 0.97, SEE = 3.4%). In 12 observations (4 normal and 8 aneurysmal) from the ten patients with indwelling pulmonary artery catheters, correlation between stroke volumes determined from thermodilution cardiac output measurements and those derived from multiplane transesophageal echocardiographic images was high (r = 0.91, SEE = 6 ml). The results indicate that three-dimensional measurements of volumes of irregular and distorted left ventricles are feasible with multiplane transesophageal echocardiography. This method may be more accurate than biplane methods, especially in the presence of left ventricular aneurysms.     

经皮穿刺二尖瓣球囊扩张成形术后心房颤动复律的体会

对二尖瓣球囊扩张成形术后心房颤动（Ａｆ）同步直流电复律２０例患者的复律过程进行观察和随访，探讨复律的影响因素及窦性心律的维持。结果表明：复律时出现心律失常组的年龄（４３．４±３．１岁）、Ａｆ持续时间（５０．７±１６．８月）、心瓣膜病程（１６０．７±３０．２月）、左房内径（４８．２±７．３ｍｍ）等均高于未出现心律失常组（依次为：３４．７±４．５岁、２１．６±１０．２月、１０１．５±２３．５月、４２．１±４．５ｍｍ），Ｐ＜０．０５。经逐步回归分析发现复律放电能量与病人年龄、Ａｆ持续时间、转复时心率、左房内径等因素有关。复律时除应注意上述影响因素外，还应适当调整放电能量以使复律易于成功。对窦性心律的维持认为以口服胺碘酮效果较好