Usefulness of transesophageal echocardiography for guiding pulmonary artery catheter placement in the operating room

Summary The usefulness of transesophageal echocardiography (TEE) for guiding the placement of a pulmonary artery (PA) catheter was evaluated in 31 patients (TEE group); 31 patients who were treated before TEE guidance was used (control group). In the control group, use of the PA catheter was abandoned in two patients; because of an unstable condition and marked arrhythmias, respectively. The key findings for TEE guidance were: (1) pulsatile to-and-fro movement of the balloon, i.e., shuttle movement and (2) loss of shuttle movement at wedging of the balloon, i.e., anchoring sign. When the PA catheter did not enter the right vertricle (RV), the balloon was found to be in the inferior vena cava or the right atrium (RA) without shuttle movement. Coiling of the catheter was suggested in the latter situation. Coiling also occurred in the RV, often associated with frequent arrhythmias. These findings indicate that the catheter should be withdrawn once. TEE allowed for readjustment of the catheter tip position by enabling the balloon to be wedged twice. An excessively deep placement of the catheter tip was seen in 5 of the controls, but in none of the TEE group. Biplane TEE was found to be advantageous for guiding PA catheter placement and for visualizing the RV inflow and outflow tract in a single view, with the shuttle movement of the balloon in its long axis. TEE acts as an eye in the operating room, as does fluoroscopy, enabling smooth placement of the PA catheter.     

Diagnosis of mitral valve myxoma by transesophageal echocardiography

Mitral valve myxomas are rare. We report a patient with a mitralmyxoma arising from the posterior mitral leaflet in whom transthoracicechocardiography revealed equivocal findings. However, transoesophagealechocardiography provided accurate relevant anatomical informationincluding the size, morphological characteristics, and tumourattachment point.     

Atherosclerotic aortic plaques detected by transesophageal echocardiography

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Role of perioperative transesophageal echocardiography in the management of adolescent truncus arteriosus: Rare case report

Truncus arteriosus (TA) is a rare congenital heart disease defined as a single arterial vessel arising from the heart that gives origin to the systemic, pulmonary and coronary circulations. The truncal valve in majority of the cases is tricuspid though quadricuspid and bicuspid valves have been reported. Patients with TA typically have a large nonrestrictive sub truncal ventricular septal defect. Survival of these infants beyond 1-year is uncommon. Here, we report a unique case of 12-year-old female patient with persistent TA who underwent surgical repair by using transesophageal echocardiography as a monitoring device during the perioperative management.     

Diagnosis of right atrial mass by perioperative transesophageal echocardiography

A 67-year-old lady presented with shortness of breath, and wasfound to have severe triple vessel disease by coronary angiography.Transthoracic echocardiography (TTE) was reported as normal.However a large cystic mass was unexpectedly found in the rightatrium by intra-operative transesophageal echocardiography (TOE).This mass was attached to the anterior wall, just by the inter-atrialseptum. Flow was demonstrated within the mass by colour flowdoppler. The right atrium was opened and the mass excised duringcardio-pulmonary bypass. A right coronary artery aneurysm wasdiagnosed, which was confirmed on histopathological examination.The importance of intra-operative TEE in demonstrating new findingsand changing management is highlighted. Coronary artery aneurysmmay predispose to embolism or thrombosis if untreated, and maynot be seen on angiography or TTE, as in this case.     

Clinical usefulness of biplane transesophageal echocardiography

The clinical usefulness of biplane color Doppler transesophageal echocardiography is illustrated by the results obtained in 300 successive examinations. The additional contribution of the newer longitudinal plane was judged significant or major in 64% of the cases. The method was useful mainly for intraoperative examinations, assessment of native valvular disease, prosthetic valve evaluation, search for tumors, and assessment of endocarditis, congenital heart disease, and aortic disease. In contrast, the longitudinal plane option was not contributory in 68% of the cases of thromboembolism. Typically, the technique aided in the evaluation of mitral valve insufficiency and the detection of paraprosthetic leaks. Lesions located at the level of the ascending aorta, the left and right ventricular outflow tracts, and the interatrial septum were also visualized best. The limitations of the method were negligible and the duration of the examination was not significantly increased in comparison to the monoplane method. When available, biplane transesophageal echocardiography seems to be preferred in most clinical settings.     

Fatal ventricular arrhythmia as a complication of transesophageal echocardiography.

AIM: To report a case of serious ventricular arrhythmia during transesophageal echocardiography. METHODS AND RESULTS: A 58-year-old woman with previous mitral and tricuspid valve replacement and permanent pacemaker implantation suffered from recurrent fever and Staphylococcus aureus bacteremia. Transesophageal echocardiography was performed as part of the assessment for infective endocarditis. During this procedure the patient developed sustained ventricular tachycardia and subsequently ventricular flutter. She was successfully resuscitated. Subsequently the procedure was undertaken under general anesthesia with no complications. CONCLUSION: The increasing use of TEE in a wider spectrum of patients, many of whom are seriously ill, may result in serious side-effects.     

Definition of flow parameters in proximal nonstenotic coronary arteries using transesophageal Doppler echocardiography

Transesophageal echocardiography (TEE) enables the visualization of proximal coronary arteries. We investigated the feasibility of coronary flow evaluation using TEE, as well as to define flow parameters found in normal proximal coronary arteries. The subgroups of patients with normal proximal segments of coronary arteries were selected from the cohort of 210 patients undergoing routine coronary angiography. The left main coronary artery (LMCA), proximal segment of left anterior descending coronary artery (LAD), left circumflex artery (LCx), and right coronary artery (RCA) were analyzed separately in 147, 64, 53, and 70 patients, respectively. Proximal coronary arteries were evaluated in the transverse plane using a 5-MHz TEE probe, and the flow in normal arteries was registered using pulsed-wave Doppler. The registration of flow with pulsed-wave Doppler was feasible in 88% of studies for the LMCA, 85% for the LAD, 58% for the LCx, and 65% for the RCA. Normal flow was laminar with distinct phasic character (diastolic predominance). Mean +/- SD values of peak coronary flow velocity were (systole/diastole) for the LMCA, 36 +/- 11/71 +/- 19 cm/sec; the LAD, 31 +/- 9/67 +/- 19 cm/sec; the LCx, 36 +/- 13/75 +/- 24 cm/sec; and the RCA, 25 +/- 8/39 +/- 12 cm/sec. Peak diastolic coronary flow velocity was most significantly correlated with heart rate. Doppler evaluation of proximal coronary flow is feasible using TEE in the majority of patients. The knowledge of normal flow values, which is different for the left and the right coronary artery, provides the background for proper interpretation of flow in diseased coronary arteries.     

Visualization of mitral valve aneurysm by transesophageal echocardiography

This article describes the transesophageal echocardiographic findings in a patient with pathologically proven mitral valve aneurysm. This aneurysm probably occurred as a complication of aortic valve endocarditis. Transesophageal echocardiography showed a saccular structure attached to the left atrial side of the anterior mitral leaflet with systolic expansion and diastolic collapse, and its orifice was visualized with excellent resolution. Transesophageal echocardiography is a useful diagnostic tool for evaluation of mitral valve aneurysm.     

Assessment of congenital coronary artery fistulas by transesophageal color Doppler echocardiography

PURPOSE: Coronary angiography is the gold standard for imaging the coronary tree, but the relation of coronary artery fistulas to other structures, and their origin and course, may not be apparent. We evaluated the ability of multiplane color Doppler transesophageal echocardiography to identify coronary fistulas. PATIENTS AND METHODS: Twenty-one patients with angiographically confirmed coronary artery fistulas were investigated by transesophageal echocardiography in four Italian hospitals between January 1997 and May 2001. RESULTS: Transesophageal echocardiography correctly diagnosed fistulous connection in all 21 patients. This included 6 patients with connections from the left circumflex artery (into the right chambers of the heart in 5 patients, and into the left ventricle in 1 patient), 10 patients with a fistula arising from the left anterior descending artery or left main coronary artery (with drainage into the right ventricle or main pulmonary artery), and 5 patients with a fistula from the right coronary artery (with drainage sites in the lateral aspect of the right ventricle, the low posterior right atrium, or the superior vena cava). In 4 of the 21 patients, angiography did not identify the precise site of a fistula into the coronary sinus or right ventricle. CONCLUSION: Color Doppler transesophageal echocardiography is useful in the diagnosis and in the precise localization of coronary artery fistulas.     

Future technical prospects in biplane transesophageal echocardiography: use of adult and pediatric biplane matrix probes

This study evaluates the feasibility of the combined use of an adult matrix probe with a real-time biplane imaging system, and also describes the performance of a newly developed pediatric matrix probe.     

Methemoglobinemia revisited: an important complication after transesophageal echocardiography.

Methemoglobinemia induced by the use of benzocaine-containing topical anesthetics is a rare, but potentially lethal complication after transesophageal echocardiography (TEE). We report a patient who developed methemoglobinemia after TEE. A review of the literature was performed and the majority of cases of benzocaine-induced methemoglobinemia reported thus far have occurred in patients undergoing TEE, endotracheal intubation, esophagogastroduodenoscopy, and bronchoscopy. All of these procedures have become more frequent than before, and there is a need to reemphasize the potential problem and to reconsider the need for further use of topical anesthetics.     

Application and perspectives of transesophageal stress echocardiography using monoplane and biplane instruments

Transesophageal stress echocardiography has been reported to have a high sensitivity and specificity for noninvasive identification and assessment of coronary artery disease. Its advantage is the virtually never obstructed acoustic window on the heart yielding superior image quality in almost all patients. Pharmacological stress as well as simultaneous atrial pacing--attaching electrodes to the echoscope--have been applied as stress modalities. Both transesophageal stress echocardiography modalities have been shown to be well tolerated, safe, and feasible in most patients. These promising initial experiences led to clinical application of this method for preoperative risk evaluation, for detection of restenosis after PTCA, and for evaluation of hibernating myocardium. This technique was also successful for evaluation of stress induced changes of transmitral and pulmonary venous flow in patients with left ventricular hypertrophy and coronary artery disease. Although all studies published so far were performed with monoplane technique, the sensitivity for detection of one-vessel and, even more so, multivessel disease was high. However, apical and basal wall-motion abnormalities may go undetected using monoplane equipment. The advent of biplane transesophageal imaging enables the visualization of more ventricular segments. Future studies will show to which degree biplane transesophageal stress echocardiography improves the diagnostic accuracy.     

Simultaneous transesophageal cardioversion and echocardiography: Feasibility and safety

BACKGROUND: Transesophageal echocardiography (TEE) is routinely used to exclude atrial thrombus prior to cardioversion of atrial fibrillation (AF). Because the TEE probe lies adjacent to the atria, cardioversion using an electrode attached to the TEE probe should allow for immediate low-energy transesophageal cardioversion. OBJECTIVE: The purpose of this study was to evaluate a cardioversion electrode sheath that can be affixed to conventional TEE probes for simultaneous thrombus exclusion and cardioversion of AF. METHODS: A thin electrode was integrated into a latex or polyurethane sheath covering a conventional TEE probe. TEE thrombus exclusion and biphasic transesophageal cardioversion using a step-up protocol were performed during deep sedation. Esophagoscopy was performed immediately after cardioversion and after 1 week. RESULTS: TEE was performed in 27 patients. One patient showed left atrial thrombi. Transesophageal cardioversion was successful in 25 of the remaining 26 patients. Mean atrial cardioversion threshold was 63 +/- 48 J. Transesophageal cardioversion restored sinus rhythm in two patients with unsuccessful transthoracic cardioversion. Transesophageal cardioversion in deep sedation was well tolerated. Esophagoscopy revealed slight mucosal damage in three patients at the site of shock application; two of these patients showed signs of gastroesophageal reflux disease. Mucosal damage unrelated to the site of shock delivery was noted in three patients. CONCLUSION: Atrial thrombus exclusion and transesophageal cardioversion of AF via a disposable cardioversion sheath offers the opportunity to perform transesophageal cardioversion and TEE thrombus exclusion during one sedation. It may not be suitable for use in patients with gastroesophageal reflux disease. Transesophageal cardioversion may establish sinus rhythm in selected patients refractory to transthoracic cardioversion.     

New direction of biplane transesophageal echocardiography with special emphasis on real-time biplane imaging and matrix phased-array biplane transducer

This article reports on the technical aspects of an online real-time biplane transesophageal echocardiographic imaging system and of a single-matrix, phased-array transducer capable of transverse and longitudinal scanning.     

Where does the pulmonary artery catheter float: Transesophageal echocardiography evaluation

Background:

Pulmonary artery (PA) catheter provides a variety of cardiac and hemodynamic parameters. In majority of the patients, the catheter tends to float in the right pulmonary artery (RPA) than the left pulmonary artery (LPA). We evaluated the location of PA catheter with the help of transesophageal echocardiography (TEE) to know the incidence of its localization. Three views were utilized for this purpose; midesophageal ascending aorta (AA) short-axis view, modified mid esophageal aortic valve long-axis view, and modified bicaval view.

Methods:

We enrolled 135 patients undergoing elective cardiac surgery where both the PA catheter and TEE were to be used; for this prospective observational study. PA catheter was visualized by TEE in the above mentioned views and the degree of clarity of visualization by three views was also noted. Position of the PA catheter was further confirmed by a postoperative chest radiograph.

Results:

One patient was excluded from the data analysis. PA catheter was visualized in RPA in 129 patients (96%) and in LPA in 4 patients (3%). In 1 patient, the catheter was visualized in main PA in the chest radiograph. The midesophageal AA short-axis, modified aortic valve long-axis, and modified bicaval view provided good visualization in 51.45%, 57.4%, and 62.3% patients respectively. Taken together, PA catheter visualization was good in 128 (95.5%) patients.

Conclusion:

We conclude that the PA catheter has a high probability of entering the RPA as compared to LPA (96% vs. 3%) and TEE provides good visualization of the catheter in RPA.     

Color Doppler and transesophageal echocardiography of vascular sling

Summary Three patients with vascular sling were studied by two-dimensional and color Doppler echocardiography and angiocardiography. One case was associated with atrial septal defect and another with tetralogy of Fallot and patent ductus arteriosus. The third case had no associated intracardiac anomalies. Color Doppler flow mapping was performed in all three patients, and transesophageal echocardiography was studied in two patients.Color Doppler echocardiography showed the characteristic features of this congenital anomaly in all three patients, especially in detecting the site of anomalous origin of the left pulmonary artery. A small patent ductus arteriosus was misinterpreted as the normal left pulmonary artery in one patient. Small pulmonary arteries in the patient with tetralogy of Fallot made the diagnosis difficult. Using transesophageal echocardiography, we clearly identified the trachea, esophagus, and abnormal left pulmonary artery.     

扩张型心肌病冠状动脉血流储备功能的超声研究

目的 应用多平面经食管多普勒超声心动图(TEE)潘生丁负荷试验,探讨扩张型心肌病患者的冠状动脉循环特点及血流储备(CFR)功能。方法 正常对照组15例,扩张型心肌病组12例。应用TEE测定冠状动脉前降支血流频谱,以基础状态下(R)和潘生丁负荷后(D)冠状动脉舒张期最大流速比值(D/R PDV)为CFR的指标。结果 与对照组比较,扩张型心肌病D/R PDV明显减低(3.43±0.62 vs 2.15±O.75,P<0.01)。扩张型心肌病组D/R PDV与心率负相关(r=-O.73,P相似文献   

The role of transesophageal echocardiography in the intraoperative period

The goal of hemodynamic monitoring and management during major surgery is to guarantee adequate organ perfusion, a major prerequisite for adequate tissue oxygenation and thus, end-organ function. Further, hemodynamic monitoring should serve to prevent, detect, and to effectively guide treatment of potentially life-threatening hemodynamic events, such as severe hypovolemia due to hemorrhage, or cardiac failure. The ideal monitoring device does not exist, but some conditions must be met: it should be easy and operator-independently to use; it should provide adequate, reproducible information in real time. In this review we discuss in particular the role of intraoperative use of transesophageal echocardiography (TOE). Although TOE has gained special relevance in cardiac surgery, its role in major non cardiac surgery is still to be determined. We particularly focus on its ability to provide measurements of cardiac output (CO), and its role to guide fluid therapy. Within the last decade, concepts oriented on optimizing stroke volume and cardiac output mainly by fluid administration and guided by continuous monitoring of cardiac output or so called functional parameters of cardiac preload gained particular attention. Although they are potentially linked to an increased amount of fluid infusion, recent data give evidence that such pre-emptive concepts of hemodynamic optimization result in a decrease in morbidity and mortality. As TOE allows a real time direct visualization of cardiac structures, other potentially important advantages of its use also outside the cardiac surgery operation room can be postulated, namely the ability to evaluate the anatomical and functional integrity of the left and the right heart chambers. Finally, a practical approach to TOE monitoring is presented, based on a local experience.     

Negative predictive value of multiplane transesophageal echocardiography in the diagnosis of infective endocarditis.

BACKGROUND: The clinical implications of a negative multiplane transesophageal echocardiography (TEE) have not yet been reported. We aim to determine the negative predictive value (NPV) of a negative multiplane TEE in patients with suspected infective endocarditis (IE). METHODS AND RESULTS: We identified 83 consecutive patients with suspected IE and negative multiplane TEE from our echocardiographic database. Of 74 patients with a minimum of 1-month follow-up, only 1 patient developed "definite IE". Eight patients had "possible IE". The calculated NPV of multiplane TEE in IE was 98.6% if we only considered the case of "definite IE". If we assumed that all patients with "possible IE" had the disease, then the NPV of multiplane TEE was 87.8%. CONCLUSIONS: Multiplane TEE is a highly accurate diagnostic tool with excellent NPV in IE. However, in a highly suspicious clinical setting for IE, a repeat TEE is still recommended to assess evolving echocardiographic features.