Transnasal transesophageal echocardiography: A new approach for the PFO occlusion in awake patients

Objectives : To reduce risks, discomfort, cost, and operative time for percutaneous patent foramen ovale (PFO) closure, we propose to perform this procedure under transesophageal echo‐guidance using a 10 Fr. catheter introduced through nasal way (TEENW). Background : Transesophageal or intracardiac echocardiography is commonly used to guide percutaneous PFO closure. Sedation needed quite frequently during transesophageal echocardiography, increased patients' discomfort, procedure prolongation, costs, use of both femoral veins, and additional intracardiac manipulations are the main limitations of standard techniques. Methods : We enrolled 20 consecutive patients with a history of cerebral ischemia and PFO with right‐to‐left shunt. In 15 patients Amplatzer® PFO occluder was used, whereas in five patients with longer PFO tunnel (>10 mm) Cardia Intrasept® was selected. Without sedation, a multifrequency monoplane probe, developed for intracardiac echocardiography, was introduced into the nostril and advanced forward the esophagus. Then under echo guidance, the closing device was presented, opened and released. Results : Procedure lasted for an average of 33.3 min, and no complications were seen. At procedure's completion, six patients showed persistence of reduced shunt during Valsalva manoeuvre. At six‐month follow‐up, shunts disappeared in all patients. Conclusion : TEENW is safe and well tolerated, and images' quality is high enough to deserve widespread adoption of this technique for PFO closure. © 2008 Wiley‐Liss, Inc.     

Intraoperative echocardiography in infants and children with congenital cardiac shunt lesions: transesophageal versus epicardial echocardiography

To determine the utility and limitations of intraoperative transesophageal echocardiography in infants and children with congenital intracardiac shunts, intraoperative transesophageal (n = 50) and epicardial (n = 49) echocardiograms were performed before and after cardiopulmonary bypass in children from 4 days to 16 years old and 3 to 45 kg in body weight. A miniaturized transesophageal probe (6.9 mm maximal diameter) was used in 36 patients weighting less than or equal to 20 kg. Epicardial imaging was performed with a 5 MHz precordial probe. The intraoperative transesophageal echocardiographic findings before and after cardiopulmonary bypass were correct and complete in 94% of patients. Transesophageal echocardiography correctly identified atrial septal defects, most types of ventricular septal defects, anomalous pulmonary veins, atrioventricular septal defects, tetralogy of Fallot, truncus arteriosus and double inlet ventricles. It failed to provide a correct diagnosis in only three patients, all of whom had doubly committed subarterial ventricular septal defects. Epicardial echocardiography identified all cases that had a doubly committed subarterial ventricular septal defect. A correct and complete intraoperative diagnosis was obtained with the use of epicardial imaging in 92% before and after cardiopulmonary bypass, but this technique required interruption of surgery and could not be completed in three patients because of induced arrhythmias and hypotension. These results demonstrated that intraoperative transesophageal echocardiography consistently defined important morphologic, color and pulsed Doppler ultrasound features of most congenital shunt lesions. Lesions that involved the right ventricular outflow tract are sometimes difficult to image with uniplane transesophageal echocardiography. There were no complications in any of the 50 subjects.     

Intracardiac echocardiography during catheter-based procedures: ultrasound system,examination technique,and image presentation

A detailed understanding of the anatomic structures of both atria is mandatory for successful catheter-based interventional techniques. Some of the drawbacks of transthoracic and transesophageal echocardiography can be overcome by intracardiac echocardiography (ICE). We present our ICE experience based on 70 out of 186 patients who were included in a multicenter registry of transcatheter interatrial communication closures. The ultrasound catheter was a 9-Fr, 9 MHZ monoplane probe (Ultra ICE catheter) compatible with the motor drive unit and imaging console of the Clear View Ultra. Four slice selections in the axial plane and only one in the sagittal plane were needed in order to obtain a comprehensive guide to ICE interrogation. Their intracardiac ultrasound imaging presentation is an essential and nontrivial step. The anatomic coordinate system was maintained identical to a tomographic imaging plane as follows: Left/right and anterior/posterior in the axial planes and superior/inferior and anterior/posterior in the sagittal plane. In order to identify the imaging coordinates, two specific anatomic landmarks were used. The first one was the crista terminalis (at 10 o'clock) and the second one was the right atrial auricle (at 12 o'clock). Once the ultrasound images were orientated, their interpretation and spatial reconstruction were straightforward. In conclusion, a standardized ICE examination allows for a comprehensive evaluation of the right atrial anatomy and may be helpful in guiding therapeutic catheter-based interventions. The major clinical advantages of ICE include optimal contrast between soft-tissue structures, limited fluoroscopic exposure time, and good patient acceptance, thus avoiding general anesthesia.     

Two-dimensional transesophageal echocardiography (clinical value)]

The introduction of two-dimensional echocardiography (echo 2D) complemented by doppler techniques has allowed to assess the dynamic function of the heart. However in 10-15% patients the standard transthoracic method (TEE) does not provide complete echocardiographic image due to obesity, emphysema and deformations of thorax. These difficulties have been later overcome by transesophageal probe, but it made the examination possible only in one plane-monoplane TEE (m-TEE). Transesophageal echocardiography the biplane probe (bi-TEE), introduced in late 80s has permitted the heart and aorta visualization in two perpendicular planes: transverse (T) and longitudinal (L). The purpose of our study was to establish the diagnostic value of biplane transesophageal echocardiography in comparison with hitherto existing monoplane echocardiography (transverse plane). The study group consists of 60 patients (aged 19-78 years) with various diseases of heart and aorta. We performed biplane transesophageal examinations with the use of Aloka SSD-870 echocardiograph connected with the biplane probe (45 patients) or new, prototypical matrix probe (15 patients). For the heart and aorta assessment the typical projections were used. The advantages of biplane TEE compared with monoplane TEE are as follows: 1) more favorable left ventricular examination, 2) better assessment of the heart apex, 3) the ability to investigate the right heart; tricuspid valve, right ventricular outflow tract, pulmonary valve, pulmonary trunk and right pulmonary artery, 4) precise imaging of both atrial' structures: cavities, intraatrial septum, foramen ovale, left atrial appendage, venae cavae and pulmonary veins, 5) possibility of thoracic aorta diagnostics, especially in ascending aorta.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multiplane transesophageal echocardiography. Imaging planes, echocardiographic anatomy, and clinical experience with a prototype phased array OmniPlane probe

Multiplane transesophageal echocardiography is a new exciting development in echocardiography. We examined the methodology and echo-anatomic correlations of multiplane transesophageal echocardiography and its clinical applications in 100 patients. We used a 5-MHz phased array multiplane (OmniPlane) transesophageal probe. In this instrument, the transducer array can be steered through 180 degrees from any transducer location. This provides a vast assembly of imaging planes, allowing for detailed visualization of all dimensions of cardiac anatomy. This report presents our observations on the echocardiographic anatomy seen in various image planes and the unique clinical potential of multiplane transesophageal echocardiography in the diagnostic assessment of cardiovascular disorders. This technique appears to provide incremental diagnostic information that enhances the interpretative ability. Less esophageal probe manipulation is required with consequent decrease in patient discomfort. We conclude that multiplane transesophageal echocardiography enhances the versatility of transesophageal examination and offers many new avenues for developments such as three-dimensional echocardiography.     

Effect of performing real time three-dimensional transesophageal echocardiography in addition to two-dimensional transesophageal echocardiography on operator diagnostic confidence

Background: This study evaluates the effects of performing real time three‐dimensional transesophageal echocardiography in addition to conventional two‐dimensional transesophageal echocardiography on diagnostic confidence. Methods: Operator diagnostic confidence in addressing clinical questions posed by the referral was scored using a five‐point scale for two‐dimensional transesophageal echocardiography alone and the combination of two‐dimensional and real time three‐dimensional transesophageal echocardiography in 136 consecutive patients undergoing examination in an academic hospital. Results: Mean diagnostic confidence score was higher for the combined studies compared to two‐dimensional transesophageal echocardiography alone (4.5 vs. 4.1, P < 0.001)). The addition of real time three‐dimensional transesophageal echocardiography increased diagnostic confidence score in 45 (33.1%) patients, and the percentage of studies with total diagnostic confidence rose from 40.4% with two‐dimensional transesophageal echocardiography alone to 65.4% after performing real time three‐dimensional transesophageal echocardiography. Type of clinical indication was associated with improved score by the combined exams (P < 0.004). The addition of real time three‐dimensional transesophageal echocardiography was most likely to improve diagnostic confidence score in studies performed to assess valve disease (56.1%) and least likely in examinations performed for intracardiac infection (14.9%). The location (anterior or posterior) of the primary cardiac pathology was not associated with improved score by the combined studies (P = 0.498). Conclusions: The addition of real time three‐dimensional transesophageal echocardiography to two‐dimensional transesophageal echocardiography increases diagnostic confidence in examinations routinely performed in an academic practice. Further studies of the impact of real time three‐dimensional transesophageal echocardiography on patient management, outcomes and displacement of or need for downstream testing are warranted. (Echocardiography 2011;28:235‐242)     

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.     

Transnasal Transesophageal Stress Echocardiography

Exercise echocardiography is a widely used modality for the noninvasive assessment of coronary artery disease. However, limitations exist inherent to the acquisition of transthoracic echocardiographic images. Although transesophageal echocardiography has been used during pacing or pharmacological stress, its use during exercise stress testing has not been clinically feasible due to the large probe size. Recently, a miniaturized transesophageal probe was developed, and we sought to test the feasibility of using this probe during graded treadmill exercise testing. Normal subjects were studied with transnasal echocardiography during upright treadmill exercise testing. The transnasal probe was passed in 13 of the 15 subjects. Excellent-quality monoplane two-dimensional echocardiographic images were obtained in all patients in the upright position. During exercise treadmill testing, high quality clinically useful echocardiographic images of the left ventricular short axis could be maintained. We conclude that transnasal transesophageal stress echocardiography may offer a new modality for the exercise assessment of ischemic heart disease.     

Imaging for percutaneous left atrial appendage closure

Percutaneous left atrial appendage (LAA) closure is increasingly performed worldwide as an alternative to long‐term oral anticoagulation, especially for patients who are considered ineligible for anticoagulation. This is a complex procedure with success that hinges upon good understanding of the LAA and surrounding structures anatomy. Multimodality imaging can provide important three‐dimensional appreciation of the LAA anatomy, which facilitates procedural safety and success. Thus, proceduralists and imagers involved with LAA closure should have good comprehension of such imaging modalities (cardiac CT angiography, transesophageal echocardiography, and/or intracardiac echocardiography) prior to embarking on this procedure. © 2016 Wiley Periodicals, Inc.     

The Value of Live/Real Time Three‐Dimensional Transesophageal Echocardiography in the Assessment of Valvular Vegetations

We studied 13 patients with valvular vegetations who underwent intraoperative live/real time three‐dimensional transesophageal echocardiography (3DTEE) and real time two‐dimensional transesophageal echocardiography (2DTEE). The 3DTEE provided incremental value on top of 2DTEE in its ability to accurately identify and localize vegetations and in identifying complications of infective endocarditis such as abscesses, perforations, and ruptured chordae. By using 3DTEE, we were able to measure vegetation volumes, perforation areas, and estimate the area of the valve that is involved in the infective process. These preliminary results suggest the superiority of 3DTEE over 2DTEE in the evaluation of valvular vegetations and provide incremental knowledge that is useful to the cardiac surgeons. (ECHOCARDIOGRAPHY, Volume 26, November 2009)     

Use of echocardiography as an essential tool for targeted transcatheter biopsy of cardiac masses

Echocardiography has emerged as an essential tool to guide targeted, transcatheter biopsy of cardiac masses. Options for imaging include transthoracic or transesophageal echocardiography and intracardiac echocardiography, with appropriate use being dictated by specific patient characteristics and institutional experience. The authors present a case of three‐dimensional (3‐D) transesophageal echocardiography‐guided transcatheter biopsy of a right ventricular mass and review the current use of echocardiography to guide these procedures.     

Pediatric transesophageal color flow imaging 1990: the long and short of it

Noninvasive cardiac imaging has dramatically altered the practice of cardiology, specifically, the pediatric patient with congenital heart disease over the past decade. Since the introduction of transesophageal echocardiography nearly 15 years ago, addition of high-resolution cross-sectional imaging combined with Doppler color flow mapping has provided a new window to examine the heart. Recently, miniaturization of the transesophageal probe to "pediatric-size" has enabled its use in the smallest of infants to add significantly to the assessment of congenital heart malformations. Most recently, addition of a longitudinal-plane probe to the already-existent, transverse-plane probe has made biplane transesophageal echocardiography a reality with significant additional information being provided by orthogonal images of the cardiac structures. We used these probes in complementary fashion in 30 studies performed in 23 patients ages 1 day to 12 years with a mean of 35 months, weighing 2.6-40 kg (mean 12.4 kg). These studies were performed in the operating room, intensive care unit, cardiac catheterization laboratory, and outpatient department. Limitations of single-plane, transverse transesophageal echocardiography were overcome using the longitudinal-axis pediatric probe: left and right ventricular outflow tracts, distal pulmonary arteries, and all of the interventricular and atrial septa were easily visualized. Its use in the operating room and postoperative cardiac intensive care unit for continuous ventricular monitoring in otherwise-inaccessible patients also provided critical information. Transesophageal echocardiography in infants and small children is a valuable "noninvasive" imaging technique which, with addition of complementary longitudinal-plane views, offers important additional information regarding congenital heart malformations and their repair.     

Spontaneous echo contrast mimicking aortic root thrombus in a patient supported with extracorporeal membrane oxygenation

Aortic root spontaneous echo contrast is a rare but significant finding. We report a 31‐year‐old female who was placed on venoarterial extracorporeal membrane oxygenation emergently for acute mitral regurgitation secondary to papillary muscle rupture. Following stabilization, subsequent transesophageal echocardiography suggested aortic root thrombus and prompted emergent surgery. However, further inspection with intraoperative transesophageal echocardiography revealed a spontaneous echo contrast which aided us in the intraoperative decision making.     

婴幼儿心脏术中心腔内探头经食管超声监测31例

目的探讨10F经心腔内超声导管探头对行经食管超声心动图(transesophageal echocardiography,TEE)先天性心脏病患者的安全性和外科治疗疗效的影响。方法体外循环前、后行TEE,检查心脏和大血管的结构及功能,评价手术效果。结果TEE监测的31例手术中,能提供重要修正意见的有8例(8/31,26%),发现多为残余分流、反流及狭窄,术中未发生明显并发症。结论10F经心腔内超声导管探头行TEE检查,监测婴幼儿先天性心脏病患者进行心血管手术的实用性和安全性,能提供即时的修正意见,值得进一步探索和推广。     

Echocardiographic guidance during placement of the buttoned double-disk device for atrial septal defect closure

The usefulness of two-dimensional and Doppler echocardiography during buttoned double-disk device closure of an atrial septal defect was evaluated in 20 consecutive patients at the time of interventional catheterization. Transesophageal echocardiography was used in 11 patients (ages 5 to 62 years, weights 20 to 91 kg). Because of the size of the available transesophageal echo probe, transthoracic echocardiography was used in the remaining 9 patients (ages 4 to 5.5 years, weights 14 to 21 kg). In the transesophageal echo group, 1 patient was found to have no atrial septal defect despite a previous diagnosis by transthoracic echocardiography, 3 patients had atrial septal defects too large for closure despite attempts in 2, and 7 patients had transesophageal echo guided device placement. All of these 7 patients had small residual shunts by color Doppler, 2 had unusual arm positions, and 2 had surgical removal of the device due to embolization to the pulmonary artery in 1 and failure to obtain close approximation of the occluder and counteroccluder in 1. In the transthoracic echo group, 2 patients had atrial septal defects too large for closure, 1 patient had no femoral venous access, and 6 patients had transthoracic echo guided device placement. All of these 6 patients had small residual shunts by color Doppler and 3 of the 6 had unusual arm positions. For atrial septal defect sizing, transesophageal echo measurements correlated with catheter balloon size more closely than did transthoracic echo measurements (r 2 = 0.97 vs 0.86).(ABSTRACT TRUNCATED AT 250 WORDS)     

Multiplane/3D transesophageal echocardiography monitoring to improve the safety and outcome of complex transvenous lead extractions

Both transesophageal echocardiography (TEE) and intracardiac echocardiography have been used to assist transvenous lead extractions. The clinical utility of continuous echocardiographic monitoring during the procedure is still debated, with different reports supporting opposite findings. In cases where the procedure is expected to be difficult, we propose adding a continuous TEE monitoring using a static 3D/multiplane probe in mid‐esophageal position, with digital remote manipulation of the field of view. This approach may improve the chances of a successful extraction, increase safety, or even guide the entire intervention. We present here a short case series where continuous monitoring by TEE played an important role.     

Is Transesophageal Echocardiography Necessary before D.C. Cardioversion in Patients with a Normal Transthoracic Echocardiogram?

PURPOSE: Transesophageal echocardiography has emerged as an accepted approach before D.C. cardioversion for atrial fibrillation. The frequency of atrial thrombi detected on transesophageal echocardiography has varied from 7% to 23%. Many patients undergoing transesophageal echocardiography have had a previous transthoracic echocardiogram. Though transthoracic echocardiography has a low yield for the detection of intracardiac thrombi, it is highly accurate in diagnosing a structurally abnormal heart. The purpose of this study was to assess the frequency of thrombi detected by transesophageal echocardiography in patients with an entirely normal transthoracic echocardiogram and hence the advocacy of a selective approach in performing transesophageal echocardiography in patients undergoing D.C. cardioversion for atrial fibrillation. METHODS: 112 consecutive patients with atrial fibrillation who had undergone transesophageal echocardiography before D.C. cardioversion were evaluated. They all had a transthoracic echocardiogram within the 2 months preceding their transesophageal echocardiogram. Based on their transthoracic echocardiographic study, they were divided into two groups: Group 1 consisted of patients with a normal transthoracic echocardiogram and Group 2, those with an abnormal study. RESULTS: Thrombi or spontaneous echo contrast were found in 14 of 112 patients (16%). All however were detected in Group 2 patients. There was no patient with a normal transthoracic echocardiogram who had thrombus on his/her transesophageal echocardiogram. CONCLUSIONS: Our results suggest that a selective approach may be exercised in the use of transesophageal echocardiography prior to D.C. cardioversion for atrial fibrillation. Patients with an entirely "normal" transthoracic echocardiogram may proceed directly to cardioversion without a precardioversion transesophageal echocardiogram.     

Accuracy of Intraoperative Epicardial Echocardiography in the Assessment of Surgical Repair of Congenital Heart Defects confirmed

Objective:

To determine the accuracy of epicardial echocardiography in detecting residual lesions after surgical repair of congenital heart defects. To determine the sensitivity, specificity, positive predictive valve, negative predictive valve, and false negative and false positive percentage of the same.

Materials and Methods:

One year hospital-based prospective study of epicardial echocardiography in patients undergoing cardiopulmonary bypass for surgical correction of congenital heart defects in children and adults.

Results:

Epicardial echocardiography was done in 158 patients. Residual lesions were detected in 38 patients by epicardial echocardiography. In 28 of these cases the residual lesions were significant. In 24 of them immediate reoperation was done with good outcome. Epicardial echo has high sensitivity, specificity, positive and negative predictive valve, in detecting residual lesion with congenital heart defects.

Conclusion:

Routine use of intraoperative epicardial echocardiography allows detection of majority of residual defects. It has high accuracy. There were no complications associated with use of epicardial echocardiography. The use of transesophageal echocardiography (TEE) can be avoided in small children and neonates undergoing cardiac surgery.     

Utilization of intraoperative transesophageal echocardiography during repair of congenital cardiac defects: a survey of North American centers

BACKGROUND: Intraoperative transesophageal echocardiography (TEE) has been increasingly utilized during repair of congenital cardiac defects. HYPOTHESIS: The aim of this study was to assess the practice of TEE in this setting. METHODS: A survey was sent to 70 centers in the United States and Canada; replies were obtained from 65 centers (93%). Responses were grouped into four categories: (1) Performance of intraoperative echocardiography, (2) performance practices, (3) equipment and probe issues, (4) billing and reimbursement. Data were available from all responding centers unless specified below. RESULTS: All responding centers employed intraoperative echocardiography, with 98% employing TEE. All responding centers employed intraoperative echocardiography. The majority of centers (72%) utilized intraoperative echocardiography in all cases or all open cases except atrial septal defects, while the remainder employed it selectively. The average duration of TEE experience at responding centers was 6.1 years. Transesophageal echocardiography was primarily the responsibility of cardiologists, with most centers having individuals meeting published TEE training guidelines. The large majority of centers performed both pre- and postbypass TEE studies. Equipment and probes were widely available. All centers disinfected the TEE probe between studies, but for longer times than recommended. CONCLUSION: Utilization of intraoperative TEE during surgery for congenital heart disease is widespread; the results of this survey may be useful to individual institutions as they evaluate their utilization of intraoperative echocardiography.     

常用超声介导房间隔缺损封堵方法的优缺点比较

房间隔缺损是一种常见的先天性心脏病,经皮房间隔缺损封堵术是全世界首选的微创外科修补治疗方法.超声介导是经皮房间隔缺损封堵术中最重要的技术环节.目前,经食道超声心动图是最常用的超声介导方法,另外,经胸超声心动图以及心腔内超声也在运用.现试从经胸超声心动图、经食道超声心动图及心腔内超声的影像学特点、检查安全性,及并发症、检查费用等方面对上述三种方法进行比较.