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.     

Improved Assessment of Pathological Regurgitation in Patients with Prosthetic Heart Valves by Multiplane Transesophageal Echocardiography

The aim of this study was to evaluate the diagnostic increment of individually optimized axes in the assessment of pathological prosthetic valve regurgitation. Forty-two patients with pathologically regurgitant prostheses in the aortic (n = 21), mitral (n = 15), and tricuspid (n = 6) positions were examined by multiplane transesophageal echocardiography. The investigation was performed utilizing the transverse axis first, the longitudinal axis second, and the intermediate axes afterwards. The presence of regurgitation, the differentiation between trans- and perivalvular origin, and the localization of perivalvular leakages at the sewing ring were evaluated. Findings in the biplane and intermediate axes were compared to surgery or autopsy in all patients. There was slightly higher detection rate for aortic prosthetic regurgitation using the intermediate axes than the biplane axes. The intermediate axes revealed significantly fewer differences to the morphological control than the biplane axes with regard to the differentiation of peri- and transprosthetic aortic regurgitation and to the localization of a periprosthetic aortic regurgitant origin. The intermediate axes provided significantly better agreement to surgery/autopsy than the biplane axes regarding the localization of the origin of mitral periprosthetic regurgitation. Morphological visualization of the perivalvular gap adds important information on the precise localization of the regurgitant origin. The pathological gap was visualized significantly more often using the intermediate than the biplane axes in all types of prostheses. The data in this study therefore suggest that multiplane transesophageal echocardiography is superior to biplane transesophageal echocardiography in the assessment of pathologic prosthetic regurgitation.     

Visualization of Mitral Valve Tunnel Aneurysm by Transesophageal Echocardiography

We report the echocardiographic findings in a patient with a mitral valve aneurysm, probably occurring as a complication of aortic valve endocarditis. Transesophageal echocardiography showed a tunnel-shaped aneurysm of the atrial side of the anterior mitral leaflet, expanding in systole and collapsing in diastole. Transesophageal echocardiography is a useful diagnostic tool for the evaluation of mitral valve pathology.     

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.     

Transesophageal color Doppler flow imaging in the evaluation of prosthetic cardiac valves

To determine the value of transesophageal echocardiography in the assessment of prosthetic cardiac valves, 11 patients with clinically suspected cardiac prosthetic valve dysfunction were studied by transesophageal two-dimensional imaging, as well as by color Doppler flow mapping. Among these 11 patients, there were 10 with biological tissue valves and 3 with metallic valves (1 Bjork-Shiley, 2 St. Jude). Nine patients had replacement of mitral valves alone. The remaining two had received both mitral and aortic prostheses. The degree of mitral regurgitation was graded by transesophageal color Doppler according to the area of the regurgitant jet visualized. The degree of aortic regurgitation was graded by the jet height/left ventricular outflow height ratio method. All transesophageal studies were performed without complication and all were well tolerated. The pathological morphology of the cardiac prosthesis was clearly visualized by transesophageal two-dimensional imaging and subsequently proven at surgery. Of those tested, one patient was found to have a torn leaflet, one had a dislodged leaflet, one patient had paravalvular leakage, four had cusp vegetations, and five patients had prosthetic degeneration for other reasons. Mitral regurgitation was graded as absent in one patient, mild in two patients, moderate in two patients, and severe in six patients. Aortic regurgitation was graded as severe in both patients with aortic prostheses. We conclude that in patients with clinically suspected cardiac prosthetic dysfunction, transesophageal two-dimensional imaging combined with color Doppler can provide reliable information that corresponds to surgical findings.     

The Potential Impact of Contemporary Transthoracic Echocardiography on the Management of Patients with Native Valve Endocarditis: A Comparison with Transesophageal Echocardiography

Background: Between 1987 and 1994, several studies demostrated transthoracic echocardiography (TTE) to be less sensitive than transesophageal echocardiography (TEE) in detecting native valve endocarditis. Recent technologic advances, especially the introduction of harmonic imaging and digital processing and storage, have improved TTE image quality. The aim of this study was to determine the diagnostic accuracy of contemporary TTE. Methods: Between 2003 and 2007, 75 patients underwent both TTE and TEE for clinically suspected infective endocarditis. The diagnostic accuracy of TTE was assessed using transesophageal echocardiography as the gold standard for diagnosis of endocarditis. Results: Of the 75 patients in this study, 33 were found to be positive by TEE. The sensitivity for detection of infective endocarditis by TTE was 81.8%. It provided good image quality in 81.5% of cases; in these patients sensitivity was even greater (89.3%). Conclusion: Contemporary TTE has improved the diagnostic accuracy of infective endocarditis by ameliorating image quality; it provides an accurate assessment of endocarditis and may reduce the need for TEE.     

Meta-Analysis of Positive Blood Cultures During Transesophageal Echocardiography

We have reviewed ten prospective studies of bacteremia with transesophageal echocardiography (TEE) in 720 patients. The incidence of TEE related positive culture is low, and general recommendation for antibiotic prophylaxis during TEE is not warranted.     

Diagnosis and Management of Complicated Left Atrial Mural Endocarditis: The Role of Transesophageal Echocardiography

Mural endocarditis that involves the left atrial wall is rare. We report on the transesophageal findings in a patient with left atrial mural endocarditis and discuss its recognition, complications, and treatment.     

Aspergillus Mural Vegetation Identified by Transesophageal Echocardiography

We report a case of Aspergillus sp. mural or nonvalvular endocarditis, which was diagnosed by transesophageal echocardiography (TEE) as a vegetation attached to the anterolateral papillary muscle of the left ventricle. Mural endocarditis is often missed by transthoracic echocardiography (TTE) as was the case with this patient. TEE easily identified the vegetation.     

Diagnosis of Contained Aortic Rupture by Transesophageal Echocardiography

Hematogenous seeding is the most common mechanism for the development of peripheral arterial infections. Echocardiography, and especially transesophageal echocardiography, has played an increasingly important role in the diagnosis of aortic pathology. Rupture of an aortic aneurysm is difficult to diagnose antemortem, and requires a high index of suspicion and a rapid diagnosis if surgery is to be beneficial. We present a case of a ruptured aortic aneurysm secondary to seeding from B. fragilis bacteremia suspected by transesophageal echocardiography and confirmed by surgical exploration. The two-dimensional echocardiographic and color flow Doppler findings are described and differentiated from those seen in an aortic dissection.     

Prosthetic Aortic Valve Thrombosis Detected by Doppler Echocardiography

Thrombosis of the prosthetic valve is a highly lethal medical emergency that requires immediate diagnosis and prompt therapy. Establishing the diagnosis may be difficult, despite numerous physical, echocardiographic, fluoroscopic, and angiographic signs, which have been described. We report a case of prosthetic aortic valve thrombosis diagnosed by Doppler echocardiography.     

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.     

Mobilization of a Bacterial Vegetation Visualized During Transesophageal Echocardiography

In this report, we describe visualization during transesophageal echocardiography of an embolus leaving the heart from the mitral valve of a patient with infective endocarditis.     

Antibiotic Prophylaxis for Endocarditis Prevention During Transesophageal Echocardiography: Controversy, Consideration, and What Really Happens

A survey was conducted in order to gain a better understanding of actual practice policies followed by academically affiliated institutions regarding the use of prophylactic antibiotics during transesophageal echocardiography. Results revealed that 10 of the 20 centers routinely used intravenous antibiotic prophylaxis for high risk transesophageal echocardiography. However, 5 of the 20 centers did not use any prophylactic antibiotics routinely, and the remaining 5 centers used primarily oral prophylactic regimens. In addition, the type of patient that was considered high risk for which antibiotic prophylaxis was used differed among institutions. Practice guidelines in 4 of the 20 institutions have changed in the last 5 years. These findings demonstrate a wide variation in the actual practice policies of different institutions, probably reflecting, in part, the lack of convincing evidence that prophylactic antibiotics benefit this subgroup of patients.     

Long-Term Follow-Up and Dobutamine Stress Echocardiography of 19-mm Prosthetic Heart Valves

BACKGROUND: In patients with a small aortic root, the use of 19-mm valve prostheses for valve replacement is controversial because of the small orifice area of these valves. METHODS: To assess stress hemodynamics in patients with 19-mm valve prostheses, to find predictors of unfavorable hemodynamics, and to document the long-term follow-up, we examined 30 patients (age, 64 +/- 19 years; 27 women and 3 men; follow-up, 38 +/- 50 months) clinically and with the use of dobutamine stress echocardiography. A history was taken, and a physical examination was performed. At rest and during dobutamine stress, Doppler echocardiography was performed. RESULTS: At rest, transprosthetic gradients were moderately elevated with mean and peak gradients of 15 +/- 7 and 32 +/- 14 mmHg, and effective orifice areas were small (0.91 +/- 0.31 cm(2)). Gradients rose markedly during stress (mean, 37 +/- 14 mmHg; peak, 83 +/- 41 mmHg). Predictors of high transprosthetic gradients were larger body surface area, younger age, and valve type. Mean and peak gradients were lower with St. Jude Medical Hemodynamic Plus valves than with standard St. Jude Medical (P < 0.05) and other valves, and the effective orifice area was highest (1.07 +/- 0.29 cm(2); P < 0.05 versus standard St. Jude Medical) in this valve model. Sixty percent of patients developed significant dynamic subvalvular or intraventricular gradients (84 +/- 41 mmHg) during dobutamine stress. CONCLUSIONS: After aortic valve replacement with 19-mm prostheses in patients with a small aortic root, dobutamine stress leads to high transvalvular gradients, which are dependent on valve model, age, and body surface area. In addition, 60% of patients develop significant dynamic outflow obstructions. These findings and the persistence of some degree of exercise-induced symptoms in 70% of patients suggest that alternative surgical techniques should be considered if the size of the aortic annulus demands a 19-mm valve, especially if the patient seeks physical activity, is young, or is of larger body size.     

Spleen Size and Appearance by Transesophageal Echocardiography in Patients With Suspected Infective Endocarditis

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Transesophageal Echocardiography in the Evaluation of Aortic Trauma

Transesophageal echocardiography (TEE) is superior to other imaging techniques for the diagnosis of aortic trauma. It can accurately, rapidly, and safely diagnose life-threatening conditions such as aortic rupture, pseudoaneurysm, traumatic aortic dissection, and intramural hematoma. TEE is useful for the diagnosis and prevention of iatrogenic aortic trauma induced by cardiovascular surgery, intraaortic procedures, and cardiopulmonary resuscitation.