Initial clinical trial of a multi-planar transesophageal echoscope]

The prototype of a multiplanar transesophageal echocardiographic transducer was evaluated clinically. This 5 MHz, phased array, 64-element transducer allows to continuously rotate the imaging plane from the transverse (0 degree) position to a maximal 180 degrees position, thus encompassing transverse, longitudinal, and every intermediate position. The transducer is incorporated in the echoscope tip measuring 16 by 11 by 40 mm. The shaft of the instrument is 110-cm long and has a 9-mm diameter. The instrument has pulsed wave, continuous wave, and color Doppler capabilities. 176 clinical patients were examined with the multiplane transducer. No complications occurred. Advantages of this transducer included: 1) comprehensive scanning of the whole mitral circumference and mitral valve; 2) quick and precise alignment of aortic valve long and short axis views, including long axis views of the ascending aorta, with a mean visualized length of 6 cm; 3) improved imaging and evaluation of transvalvular and paravalvular regurgitant jets in mitral and aortic valve prostheses; 4) complete evaluation of all left ventricular segments using multiple planes from transgastric and transesophageal transducer positions. An important potential application is three-dimensional reconstruction of cardiac structures and color Doppler jets.     

Additional value of biplane transoesophageal imaging in assessment of mitral valve prostheses.

OBJECTIVES--To determine whether biplane transoesophageal imaging offers advantages in the evaluation of mitral prostheses when compared with standard single transverse plane imaging or the precordial approach in suspected prosthetic dysfunction. DESIGN--Prospective mitral valve prosthesis in situ using precordial and biplane transoesophageal ultrasonography. SETTING--Tertiary cardiac referral centre. SUBJECTS--67 consecutive patients with suspected dysfunction of a mitral valve prosthesis (16 had bioprostheses and 51 mechanical prostheses) who underwent precordial, transverse plane, and biplane transoesophageal echocardiography. Correlative invasive confirmation from surgery or angiography, or both, was available in 44 patients. MAIN OUTCOME MEASURES--Number, type, and site of leak according to the three means of scanning. RESULTS--Transverse plane transoesophageal imaging alone identified all 31 medial/lateral paravalvar leaks but only 24/30 of the anterior/posterior leaks. Combining the information from both imaging planes confirmed that biplane scanning identified all paravalvar leaks. Five of the six patients with prosthetic valve endocarditis, all three with valvar thrombus or obstruction, and all three with mitral annulus rupture were diagnosed from transverse plane imaging alone. Longitudinal plane imaging alone enabled diagnosis of the remaining case of prosthetic endocarditis and a further case of subvalvar pannus formation. CONCLUSIONS--Transverse plane transoesophageal imaging was superior to the longitudinal imaging in identifying medial and lateral lesions around the sewing ring of a mitral valve prosthesis. Longitudinal plane imaging was superior in identifying anterior and posterior lesions. Biplane imaging is therefore an important development in the study of mitral prosthesis function.     

Role of transoesophageal echocardiography in evaluation of cardiogenic embolism.

OBJECTIVE--To determine the value of transoesophageal echocardiography in the assessment of selected patients at risk of cardiogenic embolism or after it. DESIGN--Prospective comparison of the results of transoesophageal and transthoracic echocardiography. Transoesophageal echocardiography was performed with a 5 MHz single plane phased array transducer. SETTING--University teaching hospital. PATIENTS--100 patients referred for transoesophageal echocardiography after a cerebral ischaemic event or peripheral arterial embolism (n = 63), before percutaneous balloon dilatation of the mitral valve (n = 23), or before electrical cardioversion of atrial fibrillation (n = 14). RESULTS--Transthoracic echocardiography showed potential sources of embolism in four patients including left ventricular thrombus in two patients (with one false positive), left atrial appendage thrombus (n = 1), and patent foramen ovale (n = 1). Transoesophageal echocardiography showed 59 potential embolic sources in 45 patients including left atrial spontaneous echo contrast (n = 33), left atrial appendage thrombus (n = 13), left ventricular thrombus (n = 5), patent foramen ovale (n = 3), left ventricular spontaneous echo contrast (n = 2), mitral valve prosthesis thrombus (n = 1), mitral valve prolapse (n = 1), and pronounced aortic atheroma (n = 1). Transoesophagal echocardiography showed potential embolic sources in 36/53 (68%) patients with atrial fibrillation compared with 9/47 (19%) patients in sinus rhythm. Percutaneous balloon dilatation of the mitral valve was performed without embolic complications in 18 patients without left atrial thrombi and in three patients with small fixed thrombi in the left atrial appendage. It was cancelled in two patients with large thrombi in the left atrial appendage. Cardioversion was performed without embolic complications in 14 patients without left atrial thrombi. CONCLUSIONS--Transoesophageal echocardiography detects potential sources of embolism better than transthoracic echocardiography in selected patients at risk of cardiogenic embolism or after it.     

经食管超声心动图评价人工心脏瓣膜的功能

本文利用经胸及经食管超声技术观察了51例人工瓣膜置换术后的瓣膜功能及反流程度,并比较了两种技术在评价人工瓣膜中的优缺点。结果表明:(1)经食管超声心动图(TEE)在观察左房及左心耳血栓,判定二尖瓣位人工机械瓣反流程度及鉴别反流与瓣周漏方面均优于经胸超声心动图(TTE)技术,(2)TEE在检出人工二尖瓣反流方面明显优于TTE,且TEE及TTE对人工二尖瓣反流的检出率分别为87.76%和14.29%,(3)TEE在检出主动瓣反流方面与TTE比较,无显著性差异(P>0.05),但可低估瓣膜反流程度。经食管超声技术是判定二尖瓣位人工瓣功能异常的敏感、可靠方法。     

Role of transoesophageal echocardiography in evaluation of cardiogenic embolism.

OBJECTIVE--To determine the value of transoesophageal echocardiography in the assessment of selected patients at risk of cardiogenic embolism or after it. DESIGN--Prospective comparison of the results of transoesophageal and transthoracic echocardiography. Transoesophageal echocardiography was performed with a 5 MHz single plane phased array transducer. SETTING--University teaching hospital. PATIENTS--100 patients referred for transoesophageal echocardiography after a cerebral ischaemic event or peripheral arterial embolism (n = 63), before percutaneous balloon dilatation of the mitral valve (n = 23), or before electrical cardioversion of atrial fibrillation (n = 14). RESULTS--Transthoracic echocardiography showed potential sources of embolism in four patients including left ventricular thrombus in two patients (with one false positive), left atrial appendage thrombus (n = 1), and patent foramen ovale (n = 1). Transoesophageal echocardiography showed 59 potential embolic sources in 45 patients including left atrial spontaneous echo contrast (n = 33), left atrial appendage thrombus (n = 13), left ventricular thrombus (n = 5), patent foramen ovale (n = 3), left ventricular spontaneous echo contrast (n = 2), mitral valve prosthesis thrombus (n = 1), mitral valve prolapse (n = 1), and pronounced aortic atheroma (n = 1). Transoesophagal echocardiography showed potential embolic sources in 36/53 (68%) patients with atrial fibrillation compared with 9/47 (19%) patients in sinus rhythm. Percutaneous balloon dilatation of the mitral valve was performed without embolic complications in 18 patients without left atrial thrombi and in three patients with small fixed thrombi in the left atrial appendage. It was cancelled in two patients with large thrombi in the left atrial appendage. Cardioversion was performed without embolic complications in 14 patients without left atrial thrombi. CONCLUSIONS--Transoesophageal echocardiography detects potential sources of embolism better than transthoracic echocardiography in selected patients at risk of cardiogenic embolism or after it.     

The importance of secondary mitral valve involvement in primary aortic valve endocarditis; the mitral kissing vegetation.

AIMS: Secondary involvement of the mitral valve is well documented in primary aortic valve endocarditis. A poorly considered, but probably important causative mechanism, involving both left-sided valves, is 'mitral kissing vegetation'. This results from large aortic vegetations prolapsing into the left ventricular outflow tract and making contact with the ventricular aspect of the anterior mitral leaflet thus causing secondary infection. METHODS AND RESULTS: In 192 consecutive patients with aortic valve endocarditis, two to 18 (7.6+/-2.6) serial transoesophageal echocardiographic examinations were analysed per patient to demonstrate the development of mitral kissing vegetation on initially competent, morphologically normal mitral leaflets. In 19 patients (9.9%) with aortic valve endocarditis, mitral kissing vegetation was diagnosed within 11.6+/-9.0 (range 1-31) days following primary transoesophageal echocardiography. In all patients with mitral kissing vegetation, vegetations attached to aortic cusps were >6 mm. On hospital admission, patients with aortic valve endocarditis plus mitral kissing vegetation presented more often with a positive sepsis score, embolic events, renal failure and had larger aortic valve vegetations (9.9+/-3.3 vs 5.7+/-2.3 mm). Prognosis of aortic valve endocarditis plus mitral kissing vegetation was unfavourable (P<0.005) when compared to patients with aortic valve endocarditis alone. CONCLUSION: In aortic valve endocarditis early echocardiographic detection of mitral kissing vegetation and timely surgery may preserve the mitral valve apparatus, and favourably influence the long-term prognosis.     

Comparative value of transthoracic and transoesophageal echocardiography before balloon dilatation of the mitral valve.

OBJECTIVE--To assess the relative merits of transthoracic and transoesophageal echocardiography before balloon dilatation of the mitral valve. DESIGN--Transthoracic and transoesophageal echocardiograms were prospectively performed in 35 patients being considered for balloon dilatation of the mitral valve. Echocardiograms were analysed for image quality, the assessment of valve morphology, the detection of left atrial thrombus, and the assessment of mitral regurgitation and other valvar pathology. PATIENTS--35 consecutive patients with symptomatic dominant mitral stenosis. INTERVENTIONS--30 eventually underwent balloon dilatation of the mitral valve by the Inoue technique. Five patients had mitral valve replacement. MAIN OUTCOME MEASURES--Echocardiographic and surgical detection of left atrial thrombus and successful, uncomplicated balloon dilatation of the mitral valve. RESULTS--Left atrial thrombus was detected in 1/35 patients by transthoracic studies compared with 6/35 from transoesophageal studies. Otherwise both techniques gave comparable results. Thrombus was confirmed at mitral valve replacement in five patients. Successful dilatation of the mitral valve was performed in 30 patients. CONCLUSIONS--Transthoracic echocardiography is a useful screening procedure but transoesophageal echocardiography is mandatory before balloon dilatation of the mitral valve for the detection of left atrial thrombus.     

Intraoperative transoesophageal echocardiography in aortic valve surgery

From January 1994 to May 1998, 272 patients underwent homograft aortic valve replacement (n = 139), Ross procedure (n = 100) and aortic valve repair (n = 33). Transoesophageal echocardiography was performed intraoperatively before and after cardiopulmonary bypass. Aortic valve morphology, aortic root diameter, pulmonary valve morphology, pulmonary annulus diameter and mitral valve morphology were assessed by two-dimensional imaging. Colour flow mapping was used for assessing severity of aortic regurgitation before and after the procedure. There were no complications related to the procedure. The accuracy of aortic annular diameter measured in the long axis view was confirmed at surgery. The aortic valve morphology was thought suitable for repair and a satisfactory repair was performed in 33 patients as assessed by transoesophageal echocardiography. Post-operative transoesophageal echocardiography showed a competent aortic valve in all but four of the remaining 239 patients. Intraoperative transoesophageal echocardiography is easy to learn and provides the surgeon additional information necessary to decide a particular procedure. In addition, intraoperative transoesophageal echocardiography provides accurate assessment of the results of surgery on the table.     

Use of transoesophageal echocardiography to detect left atrial thrombi before percutaneous balloon dilatation of the mitral valve: a prospective study.

OBJECTIVE--Systemic emboli related to atrial thrombi are a well known complication of percutaneous balloon dilatation of the mitral valve. The presence of left atrial thrombi therefore, is believed to be a contraindication to balloon dilatation. The purpose of this study was to determine the frequency of left atrial thrombi in patients referred for balloon dilatation of the mitral valve, the added benefit of pre-procedural transoesophageal echocardiography, and to identify factors that predicted left atrial thrombi. DESIGN--Prospective study over a 14 month period of 20 consecutive patients by cross sectional transthoracic echocardiography 24-48 hours before balloon dilatation of the mitral valve and by transoesophageal echocardiography immediately before the procedure. RESULTS--One patient had a left atrial thrombus detected by transthoracic study. Two patients (10%) had left atrial thrombi identified by transoesophageal echocardiography. In both valve dilatation was not attempted and the thrombi were confirmed at surgery. The remaining 18 patients all underwent successful balloon dilatation of the mitral valve without clinical evidence of an embolic event. No association was found between patient age, mitral valve area, transmitral gradient, left atrial size, presence of atrial fibrillation, severity of mitral regurgitation, cardiac output, or the presence of left atrial swirling and an increased prevalence of atrial thrombi. CONCLUSION--Left atrial thrombi are often seen despite long term systemic anticoagulation in patients referred for balloon dilatation of the mitral valve. The frequency of unsuspected left atrial thrombi detected by transoesophageal echocardiography was similar to the reported frequency of embolic events after balloon dilatation of the mitral valve. Transoesophageal echocardiography for the identification of left atrial thrombi is strongly recommended in all patients before balloon dilatation of the mitral valve including those treated with systemic anticoagulation and those who have had a normal transthoracic echocardiographic study.     

Use of transoesophageal echocardiography to detect left atrial thrombi before percutaneous balloon dilatation of the mitral valve: a prospective study.

OBJECTIVE--Systemic emboli related to atrial thrombi are a well known complication of percutaneous balloon dilatation of the mitral valve. The presence of left atrial thrombi therefore, is believed to be a contraindication to balloon dilatation. The purpose of this study was to determine the frequency of left atrial thrombi in patients referred for balloon dilatation of the mitral valve, the added benefit of pre-procedural transoesophageal echocardiography, and to identify factors that predicted left atrial thrombi. DESIGN--Prospective study over a 14 month period of 20 consecutive patients by cross sectional transthoracic echocardiography 24-48 hours before balloon dilatation of the mitral valve and by transoesophageal echocardiography immediately before the procedure. RESULTS--One patient had a left atrial thrombus detected by transthoracic study. Two patients (10%) had left atrial thrombi identified by transoesophageal echocardiography. In both valve dilatation was not attempted and the thrombi were confirmed at surgery. The remaining 18 patients all underwent successful balloon dilatation of the mitral valve without clinical evidence of an embolic event. No association was found between patient age, mitral valve area, transmitral gradient, left atrial size, presence of atrial fibrillation, severity of mitral regurgitation, cardiac output, or the presence of left atrial swirling and an increased prevalence of atrial thrombi. CONCLUSION--Left atrial thrombi are often seen despite long term systemic anticoagulation in patients referred for balloon dilatation of the mitral valve. The frequency of unsuspected left atrial thrombi detected by transoesophageal echocardiography was similar to the reported frequency of embolic events after balloon dilatation of the mitral valve. Transoesophageal echocardiography for the identification of left atrial thrombi is strongly recommended in all patients before balloon dilatation of the mitral valve including those treated with systemic anticoagulation and those who have had a normal transthoracic echocardiographic study.     

Echocardiographic features of left atrial dissection.

AIMS: To study left atrial dissection, a rare complication of mitral valve replacement. METHODS AND RESULTS: From our hospital database of 5497 transoesophageal echocardiograms, we analysed 524 echocardiograms performed on 478 patients with mitral valve prosthesis. We found four patients (0.84%) with left atrial dissection diagnosed by transoesophageal echocardiography that visualized the left atrial dissection: in three patients the diagnosis was confirmed intraoperatively. Three patients had previously had replacements of the mitral valve. Left atrial dissection was a severe complication: one patient died and the two patients successfully operated on had paraprosthetic regurgitation. CONCLUSION: Transoesophageal echocardiography is the first choice for diagnosis of left atrial dissection, a rare complication of mitral valve replacement with an acute/subacute clinical course. Previous mitral valve replacement seems to be the main risk factor to develop left atrial dissection.     

A hammock in the left atrium

Shone's anomaly describes a complex involving multiple left sided cardiac obstructions, namely, parachute deformity of the mitral valve, supravalvular ring of the left atrium, subaortic stenosis and aortic coarctation. We are reporting a case of Shone's anomaly characterised by aortic recoarctation, mitral supravalvular membrane, bicuspid aortic valve, complicated complete atrioventricular block and bradycardia-induced nonsustained polymorphic ventricular tachycardia. We revealed mitral supravalvular membrane by 3D transoesophageal echocardiography.     

Location, size and morphological characteristics of left atrial thrombi as assessed by echocardiography in patients with rheumatic mitral valve disease.

AIMS: This study aimed to assess the use of transthoracic and transoesophageal echocardiography in diagnosing the thrombi located in the left atrium and/or left atrial appendage in patients with rheumatic mitral valve disease, and to investigate the characteristics of thrombi in comparison to intraoperative findings. METHODS AND RESULTS: The study group was comprised of 474 patients who underwent transthoracic and transoesophageal echocardiography prior to mitral valve surgery. Location, thickness and morphological characteristics of thrombi were determined by transoesophageal echocardiography. Intraoperative assessment disclosed left atrial thrombi in 105 patients. Thickness of thrombi < or = 1cm, and thrombi confined to left atrial appendage were associated with false-negative results by transthoracic echocardiography. However, diameter and morphological characteristics of thrombi, left atrial and left atrial appendage size, and the presence of the spontaneous echo contrast were not associated with the diagnosis of thrombi by transthoracic echocardiography. For overall left atrial thrombi, sensitivity and specificity of transthoracic echocardiography were 32%, and 94%, respectively. Sensitivity and specificity of transoesophageal echocardiography for thrombi in the left atrial appendage were 98%, and 98%, for thrombi in the main left atrial cavity were 81%, and 99%, and for thrombi located in both left atrium and appendage cavities were 100%, and 100%, respectively. CONCLUSION: In patients with rheumatic mitral valve disease, detection of left atrial thrombi by transthoracic echocardiography seems to be determined by thickness and location of thrombi. The multilobed structure of the left atrial appendage and artifacts over posterior wall of the left atrium may still prevent precise diagnosis even with transoesophageal echocardiography.     

Incidence and predictive factors of mitral insufficiency in surgically treated aortic stenosis. Transthoracic and transesophageal ultrasonographic evaluation

Mitral regurgitation is common in adults with aortic stenosis. When severe, it may aggravate the clinical condition and pose an additional therapeutic problem. The authors studied 40 consecutive patients with severe surgical aortic stenosis prospectively by transthoracic echocardiography and pre-operative transoesophageal echocardiography to determine the incidence, mechanism and degree of mitral regurgitation and its eventual relationship to the aortic stenosis. Mitral regurgitation was detected in all cases when both investigations were taken into consideration. It was usually mild, evaluated grade 2 by measuring the surface of the colour Doppler regurgitant jet, or mild to minimal of transoesophageal echocardiography in 35/40 patients (87.5% of cases). Rarely, a case of significant, autonomous mitral regurgitation (2 cases of valvular dystrophy, 1 pure severe mitral stenosis). On the other hand, calcification of the mitral annulus is common (14/40 patients, 35% of cases). The severity of the regurgitation in univariate analysis was significantly correlated mainly to the age of the patients (p = 0.027). The severity of the aortic stenosis (p = 0.0082) and the parameters related to the effects of stenosis, such as ventricular wall thickness and left atrial size. In multivariate analysis, the severity of the aortic stenosis and of its consequences were confirmed to play a role in the genesis of mitral regurgitation, the severity of which was correlated on transthoracic echocardiography to the aortic valve surface area and the left ventricular ejection fraction and, on transoesophageal echocardiography, to the transvalvular pressure gradient.     

Role of transoesophageal echocardiography in the diagnosis and management of aortic root abscess.

OBJECTIVE--To assess and compare the roles of transthoracic and transoesophageal echocardiography in the diagnosis and management of an aortic root abscess. DESIGN--To select patients with echocardiographic diagnosis of aortic valve endocarditis with and without an aortic root abscess and correlate this with a retrospective review of surgical and necropsy data. SETTING--Tertiary referral centre at a university teaching hospital. PATIENTS AND METHODS--34 patients with confirmed aortic valve endocarditis were treated over a four and a half year period. All patients underwent both transthoracic and transoesophageal echocardiography with 17 patients having biplane or multiplane imaging. RESULT--11 patients (32%) had an aortic root abscess. Transthoracic echocardiography identified four cases of aortic root abscess whereas transoesophageal echocardiography correctly detected all 11 cases and also detected complications including mitral aortic intervalvar fibrosa fistula in two patients and right atrial involvement in another two patients. Only biplane imaging was able to show an anterior aortic root abscess in one patient and the circumferential involvement of the aortic annulus in another two patients. All patients with an aortic root abscess were treated surgically after transoesophageal echocardiographic diagnosis. After operation, prosthetic aortic regurgitation was present in seven patients and a repeat operation was performed in three patients. Only transoesophageal echocardiography detected a postoperative aorto-right atrial fistula in two patients and recurrence of the root abscess in another. There were five deaths in hospital (45%). CONCLUSIONS--Compared with transthoracic echocardiography, transoesophageal echocardiography was more sensitive and more specific for the early diagnosis of aortic root abscess and its complications and facilitated both the preoperative and postoperative management of these patients. Biplane and multiplane imaging provide additional diagnostic information. All patients with suspected aortic valve endocarditis should have an early transoesophageal echocardiographic study.     

Comparative value of transthoracic and transoesophageal echocardiography before balloon dilatation of the mitral valve

Objective—To assess the relative merits of transthoracic and transoesophageal echocardiography before balloon dilatation of the mitral valve.

Design—Transthoracic and transoesophageal echocardiograms were prospectively performed in 35 patients being considered for balloon dilatation of the mitral valve. Echocardiograms were analysed for image quality, the assessment of valve morphology, the detection of left atrial thrombus, and the assessment of mitral regurgitation and other valvar pathology.

Patients—35 consecutive patients with symptomatic dominant mitral stenosis.

Interventions—30 eventually underwent balloon dilatation of the mitral valve by the Inoue technique. Five patients had mitral valve replacement.

Main outcome measures—Echocardiographic and surgical detection of left atrial thrombus and successful, uncomplicated balloon dilatation of the mitral valve.

Results—Left atrial thrombus was detected in 1/35 patients by transthoracic studies compared with 6/35 from transoesophageal studies. Otherwise both techniques gave comparable results. Thrombus was confirmed at mitral valve replacement in five patients. Successful dilatation of the mitral valve was performed in 30 patients.

Conclusions—Transthoracic echocardiography is a useful screening procedure but transoesophageal echocardiography is mandatory before balloon dilatation of the mitral valve for the detection of left atrial thrombus.

     

Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma.

OBJECTIVE: To assess the diagnostic potential of transthoracic and transoesophageal echocardiography for the detection of traumatic cardiovascular injuries in patients suffering from severe blunt chest trauma. DESIGN: Prospective study over a three year period. SETTING: A regional cardiothoracic centre. PATIENTS: 134 consecutive patients (94 M/40 F; mean age 38 (SD 14) years) suffering from severe blunt chest trauma (injury severity score 33.5 (18.2)). Most patients (89%) were victims of motor vehicle accidents. EVALUATION: All patients underwent transthoracic and transoesophageal echocardiography within 8 h of admission. Aortography was performed in the first 20 patients and in a further five equivocal cases. RESULTS: Transthoracic echocardiography provided suboptimal images in 83 patients, detecting three aortic ruptures, 28 pericardial effusions (one cardiac tamponade), 35 left pleural effusions, and 15 myocardial contusions. Transoesophageal echocardiography was feasible in 131 patients and detected 14 aortic ruptures (13 at the isthmus), 40 pericardial effusions, 51 left pleural effusions, 34 periaortic haematomas, 45 myocardial contusions, right atrial laceration in one patient with cardiac tamponade, one tricuspid valve rupture, and one severe mitral regurgitation caused by annular disruption. For the detection of aortic rupture transoesophageal echocardiography showed 93% sensitivity, 98% specificity, and 98% accuracy. Time to surgery was significantly shorter (30 (12) v 71 (21) min; P < 0.05) for patients operated on only on the basis of transoesophageal echocardiographic findings. CONCLUSIONS: Transthoracic echocardiography has low diagnostic yield in severe blunt chest trauma, while transoesophageal echocardiography provides accurate diagnosis in a short time at the bedside, is inexpensive, minimally invasive, and does not interfere with other diagnostic or therapeutic procedures.     

Advantages of biplane transesophageal echocardiography

Biplane transesophageal echocardiography (BTEE) was intraoperatively performed on 27 patients; ten patients with coronary artery bypass graft surgery, ten with aortic valve replacement, five with mitral valve replacement, one with reconstruction of complete AV-canal, and one with surgical repair of dissecting aortic aneurysm. Compared with the transverse views of the monoplane TEE, BTEE permits the following additional images of the heart: 1) Longitudinal "two-chamber-view" for assessment of left ventricular (LV) anterior, apical, and posterior wall motion, and for assessment of mitral valve anatomy and function (e.g., grading of color flow regurgitation). 2) Imaging of the right-ventricular outflow tract (RVOT) for evaluation of RVOT obstruction, including a crosswise imaging of aortic valve. 3) Proximal two-thirds of the aorta ascendens for the diagnosis of dissecting aortic aneurysm (de Bakey Types I and II). 4) Imaging of the superior vena cava, helpful for detecting transposition of pulmonary veins. 5) Apex of left ventricle, advantageous for detecting thrombus. 6) Longitudinal view of the descending aorta: from the origin of the left subclavian artery down to the origin of the coeliac artery (origins of both vessels, inclusively). We prepared post mortem sections of the heart corresponding to the longitudinal echocardiographic views and documented them by photography. In conclusion, the second plane provides an important improvement in semi-invasive imaging of the heart.     

Thrombosis of mechanical heart valve prosthesis. Value of transesophageal echocardiography in the study of mitral valve prosthesis

Forty-three consecutive patients with mechanical valve prostheses underwent transthoracic and transoesophageal echocardiography for suspected thrombolic prosthetic valve dysfunction. The results of these investigations were compared with those of cineradiography and the clinical outcome. The diagnosis of thrombosis was retained in 11 of the 43 patients (10 mitral and 1 aortic valve prostheses). The transthoracic Doppler echo was clearly abnormal in 6 of the 11 cases. Transoesophageal echo was of essential value in all cases but one, showing abnormal movement of the mobile element and/or a paraprosthetic thrombus. The cineradiography gave false negative results in 6 cases. In conclusion, these cases underline the undeniable value of transoesophageal echocardiography in occlusive or non-occlusive thrombosis of a mitral valve prosthesis. This investigation should be undertaken whenever there is the least suspicion of thrombosis of the prosthesis.     

Systolic closure of aortic valve in patients with prosthetic mitral valves.

Systolic closure of the aortic valve was found in 10 of 36 patients who underwent mitral valve replacement. Eight patients had early systolic closure, and two had mid-systolic closure. The left ventricular outflow tract dimension on M-mode and two dimensional echocardiograms, left ventricular posterior wall and septal thickness, left ventricular dimensions in systole and diastole, aortic valve opening, and mitral to aortic valve distance were not significantly different between patients with and without systolic closure of the aortic valve. Two of the 10 patients with systolic aortic valve closure were catheterised and in neither was there a gradient between the left ventricle and the aorta. The two patients with mid-systolic closure, however, were the patients who had the narrowest left ventricular outflow tract which could cause significant distortion of blood flow. Systolic closure of the aortic valve in patients with mitral valve replacement is probably not caused by left ventricular outflow tract obstruction, though abnormalities in laminar flow from the left ventricular outflow tract may be involved.