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.     

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.     

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.     

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

1. Download : Download high-res image (173KB)
2. Download : Download full-size image

     

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.     

Utility of Transesophageal Echocardiography in Diagnosis of a Left Atrial Myxoma with Regional Pulmonary Venous Obstruction

A case of a 57-year-old patient with regional pulmonary edema secondary to obstruction of the right lower pulmonary vein by a left atrial myxoma is described. Diagnosis was established by transesophageal echocardiography.     

Transesophageal Echocardiography for Prosthetic Valve Evaluation:

Transesophageal echocardiography provides excellent images of mitral and aortic prostheses, due to its higher resolution and less interference from other cardiac structures. Since the introduction of transesophageal echocardiography, it has proved to be valuable for the evaluation of prosthetic heart valves. "Classic" indications include the evaluation of prosthetic valve endocarditis, the search for paravalvular abscesses, and the assessment of regurgitation in mechanical, especially mitral, prostheses. New technical developments such as biplane or multiplane transducers enhance the diagnostic capabilities of the technique. Transesophageal echocardiography can also have advantages in recognizing obstructive lesions such as thrombi or pannus, and help understand the complex morphology of prostheses in grafts. Transesophageal echocardiography should be considered a backup technique whenever transthoracic echocardiography, which always remains the primary approach, is inconclusive or negative in the presence of clinically suspected prosthetic valve malfunction.     

Mediastinal Liposarcoma Causing Left Ventricular Inflow Tract Obstruction: Diagnosis by Transesophageal Echocardiography

A patient with mediastinal liposarcoma causing left ventricular inflow tract obstruction is described. The location of the tumor and its pressure effect were accurately diagnosed by transesophageal echocardiography.     

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.     

Transesophageal Echocardiographic Diagnosis of Left Atrial Wall Dehiscene

Six months following Carbomedics mitral and aortic valve replacement, multiplane transesophageal echocardiography performed (TEE) in a 49-year-old black gentleman showed a prominent 1.0-cm linear echo protruding into the left atrium at the mid-interatrial septal level distal to the sewing ring. Plane angulations at 105 and 111 degrees demonstrated the linear echo to be related to left atrial wall dehiscence indicated by the presence of a cavitary defect at the same level. At the time of surgery, a 1.0 cm-paravalvular defect and dehiscence of the left atrial wall distal to the sewing ring 2.0 centimeters anterior to the posteromedial commisure were found.     

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.     

The Preoperative Evaluation of Infective Endocarditis via 3-Dimensional Transesophageal Echocardiography

Transesophageal echocardiography continues to have a central role in the diagnosis of infective endocarditis and its sequelae. Recent technological advances offer the option of 3-dimensional imaging in the evaluation of patients with infective endocarditis. We present an illustrative case and review the literature regarding the potential advantages and limitations of 3-dimensional transesophageal echocardiography in the diagnosis of complicated infective endocarditis.A 51-year-old man, an intravenous drug user who had undergone bioprosthetic aortic valve replacement 5 months earlier, presented with prosthetic valve endocarditis. Preoperative transesophageal echocardiography with 3D rendition revealed a large abscess involving the mitral aortic intervalvular fibrosa, together with a mycotic aneurysm that had ruptured into the left atrium, resulting in a left ventricle-to-left atrium fistula. Three-dimensional transesophageal echocardiography enabled superior preoperative anatomic delineation and surgical planning. We conclude that 3-dimensional transesophageal echocardiography can be a useful adjunct to traditional 2-dimensional transesophageal echocardiography as a tool in the diagnosis of infective endocarditis.     

Transesophageal Echocardiographic Diagnosis of Intussusception of the Left Atrial Appendage

Intraoperative postbypass transesophageal echocardiography demonstrated a large pedunculated left atrial mass secondary to invagination of the left atrial appendage into the left atrial cavity. The base of the mass was between the entrance of the left upper pulmonary vein and the posterior attachment of the mitral valve at the atrioventricular groove, and the body of it protruded into the left atrium and mitral funnel. Retraction of the appendage to its normal position resulted in disappearance of the mass. This diagnosis should be considered when a pedunculated mass with these morphological features is encountered in this setting. (ECHOCARDIOGRAPHY, Volume 10, November 1993)     

Left Brachiocephalic Vein Mimicking an Aortic Dissection on Transesophageal Echocardiography

Transesophageal echocardiography has gained widespread acceptance for the diagnosis of aortic dissection; however, little attention has been paid to the pitfalls that may be encountered. The left brachiocephalic vein can mimic a localized aortic dissection. The features that distinguished this vein from an aortic dissection are: the lack of the characteristic oscillating motion of an intimal flap; the pattern of flow within the vein; the tubular nature of the vein is seen using the sagittal imaging plane; and an injection of agitated saline into a left arm vein will show contrast enhancement of the left brachiocephalic vein.     

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.     

Left Ventricular to Right Atrial Septal Defect Secondary to Blunt Thoracic Trauma Diagnosed by Transesophageal Echocardiography

A case report is presented of a 58-year-old man who developed a new holosystolic murmur 4 months after a high-speed motor vehicle accident. Cardiac catheterization demonstrated a left-to-right shunt at the right atrial level. Intraoperative transesophageal echocardiography (TEE) identified and localized a discrete atrioventricular septal defect associated with a shunt from the left ventricle to the right atrium without tricuspid regurgitation, findings that were confirmed after surgical exploration. TEE is recommended for patients with a heart murmur and a history of blunt cardiac trauma, may permit early diagnosis, and may allow surgical repair in selected patients without pre-operative catheterization. (ECHOCARDIOGRAPHY, Volume 8, May 1991)