Transesophageal echocardiography is superior to transthoracic echocardiography in the diagnosis of sinus venosus atrial septal defect

The purpose of this study was to compare transthoracic and transesophageal echocardiography in the diagnosis of various types of atrial septal defects. Forty-one adult patients with the clinical diagnosis of atrial septal defect were studied by transthoracic and transesophageal echocardiography (30 women, 11 men; 18 to 81 years of age). Transthoracic echocardiography demonstrated the atrial septal defect in 33 patients (secundum type in 28, primum type in 3 and sinus venosus type in 2). Transesophageal echocardiography demonstrated the defect in all 41 patients. Thus, in 8 (20%) of 41 patients the atrial septal defect was demonstrated by transesophageal and not by transthoracic echocardiography. Six of the eight had a sinus venosus type atrial septal defect; the other two patients had a secundum atrial septal defect (one of these two had a technically poor transthoracic echocardiogram and the other had a small atrial septal defect). Transthoracic echocardiography, therefore, failed to demonstrate the sinus venosus defect in six (75%) of eight patients. An anomalous venous connection associated with the sinus venosus defect was visualized by transesophageal echocardiography in seven of the eight patients but was not seen on transthoracic echocardiography in any patient. Sinus venosus type atrial septal defects are frequently not visualized in adults by conventional transthoracic echocardiography. Transesophageal echocardiography is recommended when an atrial septal defect is clinically suspected but cannot be visualized by transthoracic echocardiography.     

Primary cardiac angiosarcoma detected by magnetic resonance imaging but not by computed tomography

A 51-year-old man with a primary angiosarcoma of the right atrium is reported. The angiosarcoma was not detected by transthoracic echocardiography or computed tomography, but magnetic resonance imaging and transesophageal echocardiography did show the tumor of the right atrial free wall. We performed a transvenous endomyocardial biopsy of the tumor under the guidance of transesophageal echocardiography and made the pathological diagnosis. This case demonstrates the advantage of magnetic resonance imaging and transesophageal echocardiography for tumor detection over transthoracic echocardiography and computed tomography and the usefulness of transesophageal echocardiography for guiding the right atrial endomyocardial biopsy procedure.     

Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis

To compare the diagnostic value of transesophageal and transthoracic echocardiography in infective endocarditis, paired transesophageal and transthoracic echocardiograms were obtained prospectively for 66 episodes of suspected endocarditis in 62 patients. Echocardiographic results were compared with the presence or absence of endocarditis determined by pathologic or nonechocardiographic data from the subsequent clinical course. All echocardiograms were interpreted by an observer told only that the studies were from patients in whom the diagnosis of endocarditis was suspected. The diagnosis of endocarditis was eventually made in 16 of the 66 episodes of suspected endocarditis (14 by pathologic and 2 by clinical criteria). In 7 of 16 transthoracic and 15 of 16 transesophageal echocardiograms, endocarditis was diagnosed at a probability level of "almost certain," giving a sensitivity of 44% and 94%, respectively (p less than 0.01). For the remaining episodes, 49 of 50 transthoracic and all transesophageal studies yielded normal results, giving a specificity of 98% and 100%, respectively. This study suggests that transesophageal echocardiography is highly sensitive and specific for the diagnosis of infective endocarditis and significantly more sensitive than transthoracic echocardiography. Although echocardiography cannot rule out endocarditis, the high diagnostic sensitivity of transesophageal echocardiography results in a low probability of the disease when the study yields negative results in a patient with an intermediate likelihood of the disease.     

Diagnosis of Partial Anomalous Pulmonary Venous Connection with Intact Interatrial Septum by Echocardiography

This case illustrates the complementary use of transthoracic echocardiography and transesophageal echocardiography in the diagnosis of partial anomalous pulmonary venous connection. The transthoracic echocardiogram suggested the presence of anomalous pulmonary venous return by demonstrating right heart volume overload and evidence of an intact atrial septum. Transesophageal echocardiography was required to confirm these findings and provide a firm anatomic diagnosis before surgery. This case also emphasizes that a high degree of clinical suspicion for this condition should occur in situations in which apparent right heart volume overload is otherwise unexplained.     

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

We report a case of left atrial myxoma simulating a thrombus on transthoracic echocardiography, but correctly diagnosed using transesophageal echocardiography. As this tumor is usually fatal unless surgically resected, a correct diagnosis is essential. Myxomas which do not prolapse between the mitral valve leaflets and coexist with mitral stenosis may be difficult to diagnose accurately using transthoracic echocardiography. The advantages of transesophageal compared with transthoracic echocardiography in the diagnosis of nonclassical left atrial myxoma are discussed.     

Comparative value of transthoracic and transesophageal echocardiography in the assessment of congenital abnormalities of the atrioventricular junction

Information obtained from transthoracic and transesophageal echocardiography (two-dimensional echocardiography with spectral Doppler and color flow imaging) was compared in 17 patients with major congenital abnormalities of the atrioventricular (AV) junction (10 discordant AV connections, 1 criss-cross connection, 5 absent right connections and 1 absent left connection). The findings by either technique were correlated with findings at cardiac catheterization (12 patients) and at surgery (5 patients). In two of six patients with an absent AV connection as defined by transthoracic echocardiography, transesophageal imaging demonstrated an imperforate AV valve. In 11 of 11 patients with a discordant or criss-cross connection, assessment of AV valve and ventricular morphology (by defining the chordal attachments of both AV valves) was possible with transesophageal echocardiography (3 of 11 patients by transthoracic echocardiography); chordal straddling was detected in 1 patient and excluded in 3 others with an associated inlet ventricular septal defect. Anomalous pulmonary venous connection (one patient), atrial septal defect (three patients) and subpulmonary stenosis (five patients) were better assessed by transesophageal imaging, and atrial appendage morphology could be demonstrated in all. The transesophageal technique was less useful in demonstrating the anterior subaortic infundibulum or aortopulmonary shunt (two patients). Although systemic ventricular function could be assessed by either method with use of short-axis M-mode scans, transesophageal pulsed Doppler interrogation of AV valve and pulmonary venous flow patterns provided clues to diastolic dysfunction of the systemic ventricle.     

Transesophageal echocardiography in the diagnosis of cor triatriatum in the adult]

Cor triatriatum (CT) is a rare congenital defect, surgically correctable, and sometimes difficult to diagnose by cardiac catheterization. This report describes three young patients with this particular defect, one of whom was sent to us because of signs of right ventricular failure. The diagnosis of CT was made by transesophageal echocardiography and confirmed by cardiac catheterization and surgical data. The other two cases underwent cardiac catheterization and cardiac surgery during infancy for other congenital defects. The diagnosis of CT was made only during post-operative controls by transthoracic echocardiography. In these two cases transesophageal echocardiography provided the most valuable information about the morphological features of the membrane and the mitral valve, and about the flow between the two left atrial chambers.     

Echocardiographic diagnosis of pulmonary vein varix.

Pulmonary vein varix is a rare abnormality, often resembling a pulmonary or mediastinal mass on chest radiographs, and pulmonary angiography has been the mainstay of diagnosis. An unusual case of pulmonary vein varix was clearly defined by echocardiography performed in a 47-year-old woman with chest discomfort who had been found to have an abnormal structure behind the cardiac silhouette on a chest radiograph. The diagnosis of left lower pulmonary vein varix was noninvasively confirmed by transthoracic echocardiography and transesophageal echocardiography.     

Hepatic venous flow assessed by transesophageal echocardiography

Systemic venous flow patterns are easily assessed by transthoracic echocardiography for evaluation of right heart dynamics. However, the transthoracic approach cannot be used in patients undergoing thoracic surgery. The present study describes a method for obtaining hepatic venous flow velocity with transesophageal Doppler echocardiography. Twenty-nine patients were studied with transthoracic echocardiography just before cardiac surgery and with transesophageal echocardiography during surgery. Hepatic venous flow velocity recordings were obtained in 14 of 29 patients with the transthoracic and in all 29 with the transesophageal approach. Timing of flow pattern was similar with the two methods, but recordings obtained with transesophageal echocardiography were inverted compared with those obtained with transthoracic echocardiography as a result of the difference in probe location in relation to flow direction. The time-velocity integrals obtained with the two techniques did not differ significantly; for the transthoracic and transesophageal approaches, they were, respectively, 7.3 +/- 3.4 versus 5.7 +/- 4.4 for systolic flow; 1.0 +/- 1.0 versus 0.5 +/- 0.6 for end-systolic flow reversal; 4.7 +/- 2.3 versus 3.7 +/- 1.7 for diastolic flow; 2.0 +/- 1.8 versus 1.5 +/- 1.5 for atrial flow reversal and 1.9 +/- 1.0 versus 1.7 +/- 1.1 for systolic/diastolic ratio. In conclusion, hepatic venous flow values are obtained more frequently and with better quality by transesophageal than by transthoracic echocardiography. The flow patterns and velocity integrals are similar with both methods and previous experience with transthoracic echocardiography should be applicable to the transesophageal technique. Transesophageal Doppler echocardiography therefore has potential for studying right heart dynamics during anesthesia and surgery.     

Diagnosis of papillary muscle rupture after acute myocardial infarction by transthoracic and transesophageal echocardiography

The sensitivity of transthoracic echocardiography to visualize the structural abnormality of papillary muscle rupture (PMR) after acute myocardial infarction can be anticipated to average about 50%; therefore, we evaluated five patients exhibiting the condition with both transthoracic and transesophageal echocardiography. The use of the two imaging techniques resulted in the fact that no instance of PMR was missed. Using transthoracic echocardiography in two patients and transesophageal echocardiography in four, the ruptured papillary muscle was visualized directly. Mitral insufficiency as an indirect sign was observed in all patients. In one patient the papillary muscle rupture developed in a mitral valve previously affected by endocarditis. All patients underwent mitral valve replacement and coronary artery bypass grafting. The diagnosis was confirmed at surgery in all patients. Four patients died in hospital, the fifth 5 months later. We recommend that transesophageal echocardiography be performed in patients with suspected PMR if transthoracic echocardiography does not provide an unequivocal diagnosis.     

Transesophageal Echocardiographic Visualization of Leaflet Destruction in Two Patients with Suspected Endocarditis

We report two cases of nonvegetant endocarditis, one with a perforated mitral valve aneurysm, the other with a perforated aortic leaflet. In both cases, the diagnosis of perforation was not made by transthoracic Doppler echocardiography but by transesophageal Doppler echocardiography. Transesophageal echocardiography is particularly useful in the context of nonvegetant endocarditis for a rapid diagnosis because an urgent surgical treatment may possibly be needed. (ECHOCARDIOGRAPHY, Volume 8, May 1991)     

A coronary artery fistula with saccular aneurysm mimicking a right atrial cystic mass

A 16 year-old Korean girl with cardiomegaly was found to have a "right atrial cystic mass" on transthoracic echocardiography. An unusual cystic structure made the diagnosis difficult. However, transesophageal echocardiography and multidetector computed tomography revealed a coronary artery fistula with a distal saccular aneurysm involving the interatrial septum and draining into the right atrium. Multidetector computed tomography provided clear anatomic visualization that fully delineated the abnormal structures. Multidetector computed tomography may be considered as a good alternative for transesophageal echocardiography in assessing a tortuous coronary artery fistula and aneurysm with complex anatomy.     

Fenestrated Aneurysm of the Mitral Valve

Aneurysms of the cardiac valves remain rare. In this report, we describe the first case of a left ventricular to mitral valve aneurysm to left atrial shunt through a fenestrated aneurysm of the mitral valve diagnosed and successfully repaired under the guidance of transesophageal echocardiography. The transesophageal echocardiography provided substantial additional data to the transthoracic echocardiography, and was valuable in planning the surgical approach. Transesophageal echocardiography should be considered when clear-cut transthoracic echocardiographic interpretation cannot be made in patients with mitral regurgitation. (ECHOCARDIOGRAPHY, Volume 8, September 1991)     

Direct visualization of ruptured chordae tendineae by transesophageal two-dimensional echocardiography

To determine the value of transesophageal echocardiography in the detection of ruptured chordae tendineae, 28 patients who had surgical therapy for pure mitral regurgitation were evaluated prospectively by conventional transthoracic and transesophageal two-dimensional echocardiography. Seventeen patients (Group I) had ruptured chordae tendineae and 11 (Group II) had intact chordae tendineae. Transthoracic echocardiography detected ruptured chordae tendineae in 6 patients from Group I (sensitivity 35%) and flail leaflets in 11 patients from Group I (sensitivity 65%). Transesophageal echocardiography disclosed ruptured chordae tendineae in all 17 Group I patients (sensitivity 100%); the sensitivity was significantly higher than that of transthoracic echocardiography. No abnormal chordal echoes were visualized in any patient from Group II by either transthoracic or transesophageal echocardiography (specificity 100%). Transesophageal echocardiography is a highly sensitive method for detecting ruptured chordae tendineae and is superior to transthoracic echocardiography in establishing its diagnosis.     

Transthoracic echocardiography versus transesophageal echocardiography in detecting cardiac sources of embolism

Although the yield of potential cardiac sources of embolism by echocardiography in patients with stroke and arterial embolism has been low, with the advent of transesophageal echocardiography, a renewed enthusiasm for echocardiography in these patients has developed. This article reviews the six major studies comparing transthoracic to transesophageal echocardiography in the search for potential cardiac sources of embolism. The overall yield of transesophageal echocardiography in these studies for potential cardiac sources of embolism is 43% compared to 14% by transthoracic echocardiography in a total of 367 patients. In patients without clinical cardiac disease, the yield is lower but still substantially higher by transesophageal echocardiography (24% compared to 7% by transthoracic echocardiography). For left atrial thrombus, left atrial spontaneous contrast, patent foreman ovale, and atrial septal aneurysm (ASA), transesophageal echocardiography is clearly superior than transthoracic echocardiography. Data on the detection of mitral valve prolapse and left ventricular thrombus are conflicting and neither method is clearly superior. In addition, transesophageal echocardiography identifies certain abnormalities including debris in the aorta and prosthetic strands that transthoracic echocardiography is incapable of identifying. Although transthoracic echocardiography should continue to be the initial screening modality for stroke patients, transesophageal echocardiography should be performed when surface findings are negative or equivocal in patients with likely cardioembolic stroke.     

Quadricuspid Aortic Valve: A Case Report and Review of the Literature

The quadricuspid aortic valve (QAV) is a rare malformation; often isolated, sometimes associated with other heart diseases. Before the era of echocardiography, the diagnosis was made incidentally at autopsy or during surgery of valve replacement. The extensive use of echocardiography has allowed an early and accurate diagnosis of this malformation. In many cases, the transthoracic approach is suitable for the diagnosis but, transesophageal echocardiography is a tool for the accurate definition of the valve anatomy. This review analyzes, after the presentation of a clinical case, the current knowledge on embryogenesis, classification, diagnosis and clinical course of QAV.     

Echokardiographische Diagnostik angeborener Herzfehler im Erwachsenenalter

Echo and Doppler echocardiographic procedures have gained special importance in the diagnostics of congenital diseases in adults. These procedures permit detailed visualization of the pathomorphology of the heart as well as reliable evaluation of the hemodynamic changes. There are differentiated indications for the various procedures, such as transthoracic and transesophageal echocardiography, Doppler and color-Doppler echocardiography, contrast echocardiography and 3-dimensional echocardiography. This article discusses the opposition of the various echo and Doppler echocardiographic procedures with respect to the diagnostics of the most frequent non-operated congenital diseases in adults. The pathomorphology of the various congenital diseases will be summarized and then the important echocardiographic criteria presented which are decisive for the diagnostic procedure. In simple congenital malformation of cardiac valves, such as bicuspid aortic valve (Figure 1: aortic ring abscess), pulmonary valve stenosis (Figure 2), Ebstein's anomaly (Figure 3) or malformations of the mitral valve (Figure 4: cleft in the anterior mitral cusp), the diagnosis can often be made using transthoracic echo and Doppler echocardiography, and the severity of the defect determined. However, the sonographic conditions, especially in adults, are frequently too limited to permit recognition of detailed smaller changes, so that transesophageal examination is required to finally confirm the diagnosis in these patients. In the diagnostics of diseases of the left ventricular outflow tract and the thoracic aorta, such as subvalvular aortic valve stenosis (Figure 5), the sinus of Valsalva aneurysm or the coarctation of the aorta (Figure 6), the left ventricular outflow tract can be evaluated morphologically from a transthoracic procedure and the accelerations of flow can be recorded by continuous wave Doppler. If there is no sclerosis of the fibrous membrane, these can often not be depicted by transthoracic procedures, so that a supplementary transesophageal examination is meaningful. This is required in any case for diseases of the descending thoracic aorta. In the case of congenital lesions, such as atrial septal defects (Figure 7: anomalous pulmonary venous return, Figure 8: 3-dimensional visualization of an atrial septal defect, Figure 9: sinus venosus defect), ventricular septal defect or a patent ductus arteriosus Botalli (Figure 10), color-Doppler and contrast echocardiography have become especially important. Transesophageal examination is also indicated for these congenital diseases for direct depiction of the defect as well as for precise evaluation of the shunt. Moreover, in atrial septal defects, it has been shown that a 3-dimensional echocardiography provides additional advantage with respect to spatial relationship of the defect to the other cardiac structures, as well as presenting dynamic changes during a heart cycle. Extensive knowledge of complex congenital heart disease, such as tetralogy of Fallot (Figure 11), complete transposition of the great arteries, congenitally corrected transposition of the great arteries (Figure 12), the double-outlet right ventricle, truncus arteriosus communis, the cor triatriatum, tricuspid atresia (Figure 13) or the univentricular heart (Figure 14) usually requires performance of a transthoracic echo- and Doppler echocardiographic examination to assess the pathomorphological changes and to examine hemodynamics. In the majority of patients, supplementary transesophageal echocardiography and an echo contrast examination are important. Initial examinations using 3-dimensional echocardiography are very promising in this connection and with respect to the exact spatial presentation of pathoanatomical structures.     

Acquired aortopulmonary fistula

An acquired aortopulmonary artery fistula is rare. We describe a case with an aortic arch aneurysm communicating with the main pulmonary artery. The diagnosis was made on the basis of transthoracic echocardiography and confirmed by transesophageal echocardiography. A post-mortem examination revealed the complete anatomy of the aneurysm and the aortopulmonary communication.     

Transesophageal echocardiography in critically ill patients

The feasibility, safety and clinical impact of transesophageal echocardiography were evaluated in 51 critically ill intensive care unit patients (28 men and 23 women; mean age 63 years) in whom transthoracic echocardiography was inadequate. At the time of transesophageal echocardiography, 30 patients (59%) were being mechanically ventilated. Transesophageal echocardiography was performed without significant complications in 49 patients (96%), and 2 patients with heart failure had worsening of hemodynamic and respiratory difficulties after insertion of the transesophageal probe. The most frequent indication, in 25 patients (49%), was unexplained hemodynamic instability. Other indications included evaluation of mitral regurgitation severity, prosthetic valvular dysfunction, endocarditis, aortic dissection and potential donor heart. In 30 patients (59%), transesophageal echocardiography identified cardiovascular problems that could not be clearly diagnosed by transthoracic echocardiography. In the remaining patients, transesophageal echocardiography permitted confident exclusion of suspected abnormalities because of its superior imaging qualities. Cardiac surgery was prompted by transesophageal echocardiographic findings in 12 patients (24%) and these findings were confirmed at operation in all. Therefore, transesophageal echocardiography can be safely performed and has a definite role in the diagnosis and expeditious management of critically ill cardiovascular patients.     

经胸与经食管超声心动图对心脏人工瓣膜的对比研究

４７例心脏人工机械瓣膜置换术后的病人，经胸超声心动图（ＴＴＥ）和经食管超声心动图（ＴＥＥ）对比研究显示，低估二尖瓣置换后人工瓣膜返流程度的分级和返流的发生率；主动脉瓣和二尖瓣置换的病人，ＴＴＥ探查人工二尖瓣返流的效果硬差。ＴＥＥ能较容易地探查人工二尖瓣瓣周漏。揭示对人工二尖瓣的评价，ＴＥＥ比ＴＴＥ能提供更多更可靠的信息，毫无疑问这是由于ＴＴＥ检查时人工瓣膜材料的声衰减和血流掩盖的影响，但我们的经验揭示，在评价主动脉瓣置换人工瓣膜时，ＴＥＥ并不优于ＴＴＥ。