Intraoperative diagnosis of aortic pseudoaneurysm with transesophageal echocardiography

A pseudoaneurysm of the ascending aorta is a rare complication of aortic valve endocarditis that requires prompt diagnosis. Several imaging strategies can be used; however, transesophageal echocardiography (TEE) has been utilized more frequently due to its superior resolution in detection of aortic valve complications. This case presents a patient with prosthetic valve dysfunction in which intraoperative TEE was used to diagnose a previously undetected aortic pseudoaneurysm, thus leading to a change in surgical management.     

Transesophageal echocardiography: expanding indications for ICU use. How TEE can complement--or surpass--transthoracic techniques

Transesophageal echocardiography (TEE) is a Doppler technique that uses the esophagus as an acoustic window. In critically ill patients (particularly ventilated patients), TEE may be used to assess left ventricular function, valvular disease, endocarditis, and prosthetic valve dysfunction. It is also helpful in elucidating the cause of hypotension after cardiac surgery, and can detect chronic aortic dissection and transection, valve rupture, and myocardial contusion in trauma victims. TEE is superior to transthoracic echocardiography in evaluating a cardiac source of embolism. Contraindications to TEE include esophageal disorders and an uncorrected bleeding diathesis; a large hiatal hernia may cause suboptimal transgastric images.     

主动脉瓣置换术后二尖瓣穿孔超声表现1例

患者因“反复心累、气促1+年,加重3+月”入院。术前TTE诊断为：主动脉瓣重度返流,二尖瓣轻度返流,感染性心内膜炎可能性。患者拟行主动脉瓣置换术。麻醉后TEE再次明确术前超声诊断,外科医师遂即体外循环下行主动脉瓣置换术。体外循环脱机后TEE监测发现二尖瓣前叶瓣体出现新增反流束,缩流颈为2mm,考虑以下原因：1. 术前超声及术中TEE漏诊的可能性;2.可疑医源性二尖瓣损伤;3.因术中未对二尖瓣进行探查,不排除血流动力学不稳定加重瓣体损伤。外科医师遂即行二尖瓣瓣叶修复术,术后TEE显示二尖瓣前叶瓣体反流消失,主动脉瓣未见瓣周漏。患者于术后12天顺利出院。     

Fluoroscopic balloon-guided transesophageal echocardiography in a patient with Zenker's diverticulum.

During the past 20 years, transesophageal echocardiography (TEE) became an important diagnostic technique. Indications for TEE include: defining the cause and severity of native valve disease, particularly mitral regurgitation; detecting vegetations and other sequelae of endocarditis; assessing prosthetic valve function; and identifying a potential cardiac source for emboli.(1) TEE is usually well tolerated and is associated with few adverse events. However, structural abnormalities of the esophagus such as diverticula, stenoses, tumors, and advanced varices are relative contraindications to TEE because of the technical difficulties associated with probe advancement and the risk of esophageal perforation.(2) This report describes the successful performance of TEE in a patient with a Zenker's diverticulum. The patient was severely symptomatic of atrial fibrillation and was a poor candidate for long-term anticoagulation. Therefore, it was necessary to rule out a thrombus before cardioversion. Because the Zenker's diverticulum was large, a novel approach was taken using a balloon to occlude the orifice allowing safe passage of the TEE probe.     

Clinical and echocardiographic evaluation of mitral valve aneurysms: a retrospective,single center study

Mitral valve aneurysms (MVAs) are rarely encountered in echocardiography laboratories. Although they are commonly associated with endocarditis of the aortic valve, various mechanisms have been suggested for the etiopathogenesis of MVAs associated with non-infectious conditions. 5,887 patients who underwent transesophageal echocardiography (TEE) between 2007 and 2012 were evaluated retrospectively for MVA. Mitral valve aneurysm is defined as a localized saccular bulging of the mitral leaflet towards the left atrium with systolic expansion and diastolic collapse. The color flow Doppler image of a perforation was described as a high-velocity turbulent jet traversing a valve leaflet in systole. We found that 12 of 5,887 patients (0.204 %) had MVA in TEE examinations. The mean age of patients with MVA was 53 years (range 21–80 years), including four females and eight males. Nine patients presented with symptoms of endocarditis. On TEE, aneurysms were located in the anterior mitral leaflet in 11 patients, and in the posterior mitral leaflet in one patient. Eight patients had severe, three had moderate, and one had trace mitral regurgitation. Of the nine patients with perforated leaflets, eight patients had severe and one patient had moderate mitral regurgitation. Aortic regurgitation was present in nine patients, being severe in three, moderate in two, mild in two, and trace in two patients. Two patients without severe mitral regurgitation were followed-up conservatively, while nine patients underwent surgery. Two patients died from septic shock, one in the postoperative period and the other one prior to surgery. Although MVAs occur during the course of aortic valve endocarditis and, in particular, due to aortic regurgitation jet, it should be borne in mind that they may develop as an isolated valvular pathology and may be misdiagnosed as chordal rupture, other cardiac masses, or vegetation. Thus, MVAs may not be so infrequent as they are thought; they may justify to be considered in the differential diagnosis of masses seen on the mitral valve on echocardiographic examination.     

Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era.

BACKGROUND: Thirteen years ago, transthoracic echocardiography (TTE) was found to be less sensitive than transesophageal echocardiography (TEE) for native valve vegetations. Since then, harmonic imaging and other advances have improved TTE. How this affects the sensitivity of TTE is unknown. METHODS: Fifty patients with echocardiography-diagnosed endocarditis had TTE and TEE examinations on high-end machines. These were matched for date of study with 50 patients who had TTE and TEE examinations that were negative for vegetations. RESULTS: A total of 51 vegetations were seen on TEE. The sensitivity of TTE for vegetations was only 55% (aortic 50% [12/24]; mitral 62% [16/26]; tricuspid 0% [0/1]). Anatomic valvular abnormalities did not alter the sensitivity of TTE (P =.42 for mitral; P =.97 for aortic valves). However, larger vegetations were more likely to be found by TTE. CONCLUSION: Despite advances in imaging during 12 years, TTE is still insensitive compared with TEE for the detection of native valve vegetations, and fails to demonstrate nearly half of them.     

Appropriate use of echocardiography in managing Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is increasing, both in the community and in healthcare settings. Accurate and timely diagnosis of underlying infective endocarditis (IE) is critical for optimal management of SAB cases as it has significant management and prognostic implications. Reported prevalence of IE in patients with SAB varies depending on the study population, and ranges from 10 to 30%. As clinical presentation of IE can be nonspecific, echocardiography is usually recommended in SAB cases to 'rule out' IE. Due to its poor sensitivity (<50%), especially for diagnosing prosthetic valve IE, transthoracic echocardiography is considered inadequate in this setting and clinicians have to rely on transesophageal echocardiography (TEE) to confirm or exclude endocarditis in SAB cases. Although some experts recommend TEE in all patients presenting with SAB, it is believed that the use of TEE could be guided by individual patient risk factors, mode of acquisition of SAB and clinical presentation. In this article, published data regarding the use of TEE in the SAB population are reviewed and a simplified algorithm to guide use of TEE in SAB cases is proposed.     

Infective endocarditis of the pulmonary valve following pulmonary artery catheterisation

The risk of infective endocarditis following pulmonary artery catheterisation in patients with sepsis remains unquantified. Although catheter-induced endocardial and valvular injury are well recognised, valve infection is rare. A case of mixed pulmonary valve endocarditis associated with the use of a pulmonary artery catheter (PAC) in a patient with multisystem failure following liver trauma is described. This illustrates that diagnosis of infective endocarditis in critically ill patients can be difficult because concurrent illness and therapy may mimic or mask the usual presenting signs. The value of transoesophageal echocardiography in this context is emphasised.     

Cardiac computed tomography angiography results in diagnostic and therapeutic change in prosthetic heart valve endocarditis

Echocardiography may miss prosthetic heart valve (PHV) endocarditis which advocates for novel imaging techniques to improve diagnostic accuracy and patient outcome. The purpose of this study was to determine the complementary diagnostic value of cardiac computed tomography angiography (CTA) to the clinical routine workup including transthoracic and transesophageal echocardiography (TTE/TEE) in patients with suspected PHV endocarditis and its impact on patient treatment. A diagnostic prospective cross-sectional study was chosen as design. Besides clinical routine workup (including TTE/TEE), CTA was performed to assess its diagnostic accuracy and complementary diagnostic/therapeutic value. For the diagnostic accuracy, the reference standard was surgical findings or clinical follow-up. To determine the complementary diagnostic/therapeutic value an expert-panel was used as reference standard. Twenty-eight patients were included. CTA resulted in a major diagnostic change in six patients (21 %) mainly driven by novel detection of mycotic aneurysms by CTA. Furthermore, treatment changes occurred in seven patients (25 %) compared to clinical routine workup. Diagnostic accuracy of routine clinical workup plus CTA was superior to clinical routine workup alone for the detection of PHV endocarditis in general, vegetations and peri-annular extension. This study demonstrates that CTA and clinical workup including TTE and TEE are complementary in patients with PHV endocarditis. Therefore, CTA imaging has to be considered after clinical routine workup in patients with a high suspicion on PHV endocarditis.     

三维超声评估感染性心内膜炎栓塞事件及住院死亡的危险特征

目的 采用三维经食管超声心动图评估感染性心内膜炎栓塞及住院死亡的超声特征。方法 回顾性收集124例自体瓣膜感染性心内膜炎患者,分析其经胸二维超声、多平面和三维经食管超声特征。将手术前或后1个月内栓塞和死亡作为主要终点事件。将大赘生物、脓肿或瘘、腱索断裂、中重度瓣膜反流和瓣膜穿孔或严重瓣膜破坏各计1分,进行简单积分,对心脏受损累计简单积分、赘生物大小、瓣膜受损严重并失去正常形态结构采用Hosmer和ROC曲线下面积评估栓塞和不良事件。结果 124例患者中,27例（27/124,21.77%）患者发生栓塞。与二维经胸超声心动图比较,多平面和三维经食管超声心动图可识别赘生物的确切位置及其长度,而二维经胸超声心动图漏诊左心房和乳头肌赘生物。栓塞及不良事件患者血红蛋白显著低于非栓塞及不良事件患者（P<0.05）。栓塞及不良事件患者多部位赘生物形成、赘生物活动度和瓣膜严重受损并失去正常形态构成比均高于非栓塞及不良事件患者（P均<0.05）。感染性心内膜炎心脏受损累计简单积分、赘生物大小、瓣膜严重受损并失去正常形态结构曲线下面积分别为0.65（P=0.06）、0.60（P=0.19）、0.70（P=0.03）。结论 多平面及三维经食管超声对感染性心内膜炎,尤其位于不常见位置的赘生物诊断起重要作用。瓣膜严重受损并失去正常形态者与栓塞及不良事件有关。     

Prise en charge précoce des insuffisances aortique et mitrale aigu?s en réanimation

Acute pulmonary edema is the most frequent presentation of aortic (AR) and mitral (MR) regurgitation in the intensive care unit (ICU). The etiologic diagnosis is performed using transthoracic echocardiography and mainly transesophageal echocardiography (TEE). The aim of the medical management in ICU is to stabilize the hemodynamic status of the patient before the surgical treatment, in the absence of major comorbidities. Timing of surgery depends on the response to the optimal medical treatment. It consists in a valve replacement with a bioprosthesis or a mechanical prosthesis or in a mitral valve repair. Acute type A aortic dissection is one of the etiologies of acute AR. Rupture of the ascending aorta is at the first line and severely impairs the final outcome. In the situation of an ischemic MR, management also includes myocardial revascularization. Infective endocarditis (IE) is responsible of the majority of the AR and MR in the ICU. TEE for the diagnosis is mandatory. Antibiotics represent the first line of the optimal medical treatment. Urgent valve surgery is indicated when regurgitation leads to acute heart failure. Early surgical treatment decreases the risk of embolic events, local extension and improves survival rate. Only hemorrhagic brain stroke could postpone surgery due to the risk of intra-cerebral bleeding induced by extracorporeal circulation. Prognosis of AR and MR is worse when caused by IE, and even more severe in case of IE on a prosthetic valve. A multidisciplinary team approach should improve the survival rate in ICU patients admitted with AR and MR-related morbidities.     

Appropriate use of echocardiography in managing Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is increasing, both in the community and in healthcare settings. Accurate and timely diagnosis of underlying infective endocarditis (IE) is critical for optimal management of SAB cases as it has significant management and prognostic implications. Reported prevalence of IE in patients with SAB varies depending on the study population, and ranges from 10 to 30%. As clinical presentation of IE can be nonspecific, echocardiography is usually recommended in SAB cases to ‘rule out’ IE. Due to its poor sensitivity (<50%), especially for diagnosing prosthetic valve IE, transthoracic echocardiography is considered inadequate in this setting and clinicians have to rely on transesophageal echocardiography (TEE) to confirm or exclude endocarditis in SAB cases. Although some experts recommend TEE in all patients presenting with SAB, it is believed that the use of TEE could be guided by individual patient risk factors, mode of acquisition of SAB and clinical presentation. In this article, published data regarding the use of TEE in the SAB population are reviewed and a simplified algorithm to guide use of TEE in SAB cases is proposed.     

Echocardiography in infective endocarditis.

BACKGROUND: Echocardiographic demonstration of valvular infection now ranks with positive blood cultures as one of the two major clinical criteria for diagnosis of infective endocarditis (IE), according to new, more accurate guidelines for diagnosis. Because early detection of IE and its complications is essential for determining whether to pursue medical therapy or to intervene surgically, transthoracic echocardiography (TTE) is an essential part of the initial examination of patients with suspected IE. METHODS: Using MEDLINE, we searched and reviewed all articles with the key words infective endocarditis and transesophageal echocardiography. RESULTS: With its superior imaging, transesophageal echocardiography (TEE) has proven to be more sensitive than TTE for the diagnosis of IE as well as in the detection of IE-associated complications. CONCLUSIONS: While superior in predicting which patients with IE have perivalvular abscess or prosthetic valve dysfunction and which are most susceptible to systemic embolism, TEE is more invasive and must be used selectively.     

The role of transesophageal echocardiography in critical care: UCSF experience.

The applications of transesophageal echocardiography (TEE) now encompass the arena of critical care. We reviewed the indications, findings, and outcome of TEE in the critical care setting in a tertiary care hospital and report our experience. Eighty-three transesophageal echocardiograms were performed in 69 critically ill patients for the following indications: endocarditis (43%), embolic source (13%), hypotension (10%), mitral regurgitation (10%), left ventricular function (6%), aortic dissection (4%), prosthetic valve dissection (4%), and other (10%). Findings were unexpected in 21 of 83 studies and led to a change in management in 17%. On the basis of the results of TEE, 22% of patients had further evaluation by a more invasive technique, and 19% of patients had surgical intervention without further study. No significant complications attributable to TEE were noted. We conclude that TEE is a safe and useful diagnostic technique with fairly broad applications in the critical care setting.     

Catastrophic mitral prosthesis dehiscence diagnosed by three‐dimensional transesophageal echocardiography

In emergency situations, real‐time three‐dimensional transesophageal echocardiography (RT 3‐dimensional TEE) may provide unique anatomic insights on prosthetic valves when two‐dimensional imaging is inconclusive. We report the case of a 76‐year‐old woman, in cardiogenic shock, who had undergone mitral valve replacement 3 months ago. RT 3‐dimensional TEE revealed almost total, catastrophic prosthesis dehiscence following infective endocarditis, the prosthesis being perpendicular to the normal mitral plane. Corrective surgery was not feasible, and the patient died shortly after admission. Although the outcome was unfortunate, RT 3‐dimensional TEE helped rapidly reach a definitive diagnosis, essential for decision‐making. Three‐dimensional TEE should be used as a complementary technique in difficult cases. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42:249–251, 2014     

先天性二叶主动脉瓣畸形的超声诊断价值

目的分析先天性二叶主动脉瓣畸形(BAVD)的多普勒超声表现,以提高对该病的认识.方法采用Acuson 128xp10及Sequoia256彩超仪,通过经胸超声(TTE)及经食道超声(TEE)检测44例(BAVD)患者的主动脉瓣表现、并发症.结果BAVD在大动脉短轴切面上为两个瓣膜及两个瓣膜联合点,舒张期呈单一关闭线,75%患者有不同程度瓣膜受损.主动脉瓣狭窄(AS)占34%,主动脉瓣关闭不全(AR)占68%,升主动脉扩张占30%;合并主动脉瓣赘生物5例,伴二尖瓣病变5例,房间隔缺及膜周部室缺各1例.结论BAVD可出现不同程度的AS及AR和由此所致的各种血流动力学异常,可伴多种先天及后天性心血管异常.多谱勒超声是诊断BAVD及其并发症的最佳方法.     

The technique of transesophageal echocardiography. How to procure detailed views of an array of cardiac structures

Use of transesophageal echocardiography (TEE) is growing in ambulatory, intensive care, and intraoperative settings. Forward flexion or retroflexion of the TEE probe tip at different levels in the esophagus reveals a variety of intracardiac structures; in the basal short-axis view, for example, the aortic valve can be seen, as can the left atrial appendage lateral to the aorta and pulmonary artery. In the four-chamber view, the mitral and tricuspid valves and interatrial septum can be viewed, and the morphology of the mitral valve leaflets and mitral annulus can be assessed. Cross-sectional views of both ventricles can be obtained in the transgastric short-axis view. In addition, the entire thoracic aorta, as well as the proximal ascending and transverse arch, can be visualized with TEE.     

Pacemaker endocarditis: clinical features and management of 60 consecutive cases

BACKGROUND: The incidence of endocarditis related to pacemakers is increasing, while the diagnosis and management remain difficult. The objective of this study was to evaluate the clinical features and management of endocarditis after implantation of pacemakers (PM) or cardioverter defibrillators (ICD). METHODS: We analyzed the hospital course of 60 consecutive patients (48 men, mean age 68 +/- 12 years) admitted to our center for PM (n = 59) or ICD (n = 1) endocarditis between 1998 and 2004. RESULTS: Fever (78%), asthenia (65%), and local symptoms (35%) were common. Positive cultures were obtained in 53 cases (Staphylococcus 89%). Sixteen patients (27%) had pulmonary embolism. Vegetations (mean size 15.2 +/- 8 mm, range 5 to 35 mm) were found in 54 cases (90%), with transthoracic echocardiography in 26 cases (43%), and transesophageal echocardiography (TEE) in 50 cases (89% of the 56 patients who had TEE). Devices were removed surgically (n = 20) or percutaneously (n = 37). In the surgical group, vegetations were larger (17.9 +/- 7 mm vs 13.2 +/- 7 mm, P = 0.01). After removal, 42 patients (70%) had a new PM. Mortality factors (6 deaths - follow up 3.4 +/- 2 years) were the number of vegetations and absence of extraction of the device (P < 0.02). Clinical features and management of the 37 patients with early onset endocarditis (within 1 year after implantation) did not differ from those with late onset. CONCLUSIONS: PM endocarditis was essentially staphylococcal. TEE was required for the diagnosis of vegetations. Complete removal of the device is required and associated with a favorable outcome.     

Bacillus cereus endocarditis in native aortic valve

Bacillus cereus endocarditis is rare. It has been implicated in immunocompromised individuals, especially in intravenous drug users as well as in those with a cardiac prosthesis. The patient was a 31-year-old ex-intravenous drug addict with a past history of staphylococcal pulmonary valve endocarditis, who presented with symptoms of decompensated cardiac failure. Echocardiography showed severe aortic regurgitation with an oscillating vegetation seen on the right coronary cusp of the aortic valve. The blood cultures grew Bacillus cereus. We report this as a rare case of Bacillus cereus endocarditis affecting a native aortic valve.     

Volume quantification of intracardiac mass lesions by transesophageal three-dimensional echocardiography

As compared with two-dimensional (2-D) transesophageal echocardiography (TEE), 3-D echocardiography now permits more realistic visualization of cardiac anatomy and of intracardiac lesions. The aim of this study was to apply newer 3-D echocardiographic techniques to quantify volumes of intracardiac masses undergoing surgical resection seen during an intraoperative TEE. The calculated volumes were compared with actual in vitro measurements of surgically resected masses. A total of 14 patients (9 men; 5 women; age range between 21 and 77 years) with intracardiac mass lesions (4 tumors: 3 left atrial myxomas and 1 mitral valve fibroelastoma, and 10 vegetations: 5 aortic valve, 3 mitral valve, 1 tricuspid and 1 pulmonary valve) were studied. Using commercially available 3-D reconstruction software (TomTec v. 4.1), the volumes of intracardiac masses were estimated using both the average rotation (rotation around the long axis, AR) and disk summation (parallel short axis cuts, DS) methods. Volumes of these lesions were also measured in vitro by water submersion. They ranged from 0.20 mL to 24 mL (mean +/- SD = 8.07 +/- 9.21 mL). Both 3-D TEE AR and 3-D TEE DS calculated volumes correlated excellently with in vitro measured volumes (r = 1.00 and r = 0.98, respectively, p = < 0.0001). The correlation between 3-D TEE AR and 3-D TEE DS calculated volumes was also excellent (r = 0.98, p = < 0.0001). In conclusion, the volume assessments by 3-D TEE of intracardiac mass lesions correlated well with in vitro measured volumes of surgical specimens. This technique may prove to be valuable in further defining intracardiac pathology and is a further advancement toward the application of clinically useful 3-D echocardiography.