Misidentification of the True Aortic Annulus With 2-dimensional Echocardiography: A Critical Appraisal Using 3-Dimensional Imaging.

OBJECTIVES: This study aimed to evaluate the accuracy of identifying the true aortic valve (AV) annulus using 2-dimensional (2D) echocardiography, with the goal of highlighting potential misidentification issues in clinical practice. DESIGN: An observational study employing 3-dimensional (3D) datasets to generate 2D images of the AV annulus for analysis. SETTING: The study was conducted in an academic medical center. PARTICIPANTS: Three-dimensional transesophageal echocardiography datasets were obtained from 11 patients with normal AV and aortic root anatomies undergoing coronary artery bypass surgery. Attending anesthesiologists certified by the National Board of Echocardiography (NBE) were approached subsequently to participate in this study. INTERVENTIONS: Two images per patient were generated from 3D datasets, reflecting the mid-esophageal long-axis view of the AV, a true AV annulus image, and an off-axis image. A survey was distributed to NBE-certified perioperative echocardiographers across 12 academic institutions to identify the true AV annulus from these images. MEASUREMENTS AND MAIN RESULTS: The survey, completed by 45 qualified respondents, revealed a significant misidentification rate of the true AV annulus, with only 36.8% of responses correctly identifying it. The rate of correct identification varied across image sets, with 44.4% of participants unable to correctly identify any true AV annulus image. CONCLUSIONS: The study highlighted the limitations of 2D echocardiography in accurately identifying the true AV annulus in complex 3D structures like the aortic root. The findings suggest a need for greater reliance on advanced imaging modalities, such as 3D echocardiography, to improve accuracy in clinical practice.

Treatment-Relevant Findings in Transesophageal Echocardiography After Stroke: A Prospective Multicenter Cohort Study.

BACKGROUND AND PURPOSE: Cardiac ultrasound to identify sources of cardioembolism is part of the diagnostic workup of acute ischemic stroke. Recommendations on whether transesophageal echocardiography (TEE) should be performed in addition to transthoracic echocardiography (TTE) are controversial. We aimed to determine the incremental diagnostic yield of TEE in addition to TTE in patients with acute ischemic stroke with undetermined cause. METHODS: In a prospective, observational, pragmatic multicenter cohort study, patients with acute ischemic stroke or transient ischemic attack with undetermined cause before cardiac ultrasound were studied by TTE and TEE. The primary outcome was the rate of treatment-relevant findings in TTE and TEE as defined by a panel of experts based on current evidence. Further outcomes included the rate of changes in the assessment of stroke cause after TEE. RESULTS: Between July 1, 2017, and June 30, 2019, we enrolled 494 patients, of whom 492 (99.6%) received TTE and 454 (91.9%) received TEE. Mean age was 64.7 years, and 204 (41.3%) were women. TEE showed a higher rate of treatment-relevant findings than TTE (86 [18.9%] versus 64 [14.1%], P<0.001). TEE in addition to TTE resulted in 29 (6.4%) additional patients with treatment-relevant findings. Among 191 patients ≤60 years additional treatment-relevant findings by TEE were observed in 27 (14.1%) patients. Classification of stroke cause changed after TEE in 52 of 453 patients (11.5%), resulting in a significant difference in the distribution of stroke cause before and after TEE (P<0.001). CONCLUSIONS: In patients with undetermined cause of stroke, TEE yielded a higher number of treatment-relevant findings than TTE. TEE appears especially useful in younger patients with stroke, with treatment-relevant findings in one out of seven patients ≤60 years. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03411642.

Optimizing transesophageal atrial pacing in mice to detect atrial fibrillation.

Mice are routinely used to investigate molecular mechanisms underlying the atrial fibrillation (AF) substrate. We sought to optimize transesophageal rapid atrial pacing (RAP) protocols for the detection of AF susceptibility in mouse models. Hypertensive and control C57Bl/6J mice were subjected to burst RAP at a fixed stimulus amplitude. The role of parasympathetic involvement in pacing-related atrioventricular (AV) block and AF was examined using an intraperitoneal injection of atropine. In a crossover study, burst and decremental RAP at twice diastolic threshold were compared for induction of AV block during pacing. The efficacy of burst and decremental RAP to elicit an AF phenotype was subsequently investigated in mice deficient in the lymphocyte adaptor protein (Lnk-/-) resulting in systemic inflammation, or the paired-like homeodomain-2 transcription factor (Pitx2+/-) as a positive control. When pacing at a fixed stimulus intensity, pacing-induced AV block with AF induction occurred frequently, so that there was no difference in AF burden between hypertensive and control mice. These effects were prevented by atropine administration, implicating parasympathetic activation due to ganglionic stimulation as the etiology. When mice with AV block during pacing were eliminated from the analysis, male Lnk-/- mice displayed an AF phenotype only during burst RAP compared with controls, whereas male Pitx2+/- mice showed AF susceptibility during burst and decremental RAP. Notably, Lnk-/- and Pitx2+/- females exhibited no AF phenotype. Our data support the conclusion that multiple parameters should be used to ascertain AF inducibility and facilitate reproducibility across models and studies.NEW & NOTEWORTHY Methods were developed to optimize transesophageal rapid atrial pacing (RAP) to detect AF susceptibility in new and established mouse models. High stimulus intensity and pacing rates caused parasympathetic stimulation, with pacing-induced AV block and excessive AF induction in normal mice. For a given model, pacing at twice TH enabled improved phenotype discrimination in a pacing mode and sex-specific manner. Transesophageal RAP should be individually optimized when developing a mouse model of AF.

An appraisal of clinical practice guidelines for the appropriate use of echocardiography for adult infective endocarditis-the timing and mode of assessment (TTE or TEE).

BACKGROUND: Echocardiography (echo) is the primary imaging modality for infective endocarditis (IE). However, the recommendations on timing and mode selection for transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) vary across guidelines, which can be confusing for clinical decision makers. In this case, we aim to appraise the quality of recommendations by appraising the quality of various guidelines. METHODS: A search of guidelines containing recommendations for the appropriate use of echo in adult IE patients published in English between 2007 and 2019 was conducted. The APPRAISAL OF GUIDELINES FOR RESEARCH & EVALUATION II (AGREE II) instrument was applied independently by two reviewers to assess the integrated quality of the identified guidelines. The recommendations of concern are extracted from related chapters. RESULTS: A total of 9 guidelines met the criteria, with AGREE II scores ranging from 36 to 79%, and the domain of "stakeholder involvement" received the lowest score. The most contentious issue is whether a follow-up TEE is mandatory in uncomplicated native valve IE with an initial positive TTE. Conflicting recommendations are presented with a low evidence level based on little evidence. CONCLUSIONS: In general, the recommendations proposed in the 9 identified guidelines on the appropriate use of echo are satisfying. The guideline quality score can be taken into account by the clinicians when evaluating the recommendations for clinical decisions. Additional studies with high evidence level should be conducted on the most controversial issues of whether a subsequent TEE is mandatory in uncomplicated native valve IE with an initial positive TTE.

Normal reference values for mechanical mitral prosthetic valve inner diameters and areas assessed by two-dimensional and real-time three-dimensional transesophageal echocardiography.

It was previously observed that two dimensional (2D) Doppler derived and real-time three-dimensional (RT-3D) directly measured valve areas were smaller than reported manufacturer sizes. It may be helpful to obtain the ranges of inner diameters (IDs) and the geometric orifice area (GOA) during evaluation of prosthetic mitral valves. In this study, we aimed to provide reference dimensional parameters of bileflet mitral mechanical prosthetic valves. Patients with recent mitral valve replacement were examined by 2D and RT-3D transesophageal echocardiography (TEE) in the early postoperative period when the presence of pannus overgrowth was unlikely. Measurements of 2D IDs, 3D hinge to hinge (HHD) and edge to edge diameters (EED) and 3D GOA were obtained and compared with reported manufacturer sizes and areas. This study enrolled 126 patients with mitral prosthetic valves (38 ATS, 42 Carbomedics, 46 St. Jude Medical, all bileaflet). The measured 2D and 3D IDs and GOA were significantly smaller than reported manufacturer sizes in the majority of the valve sizes. This RT-3D TEE-guided study provides ranges of reference values for directly measured IDs and GOA of the three most commonly used mechanical mitral prosthetic valve types for the first time in a relatively large series.

Focused Transesophageal Echocardiography During Cardiac Arrest Resuscitation: JACC Review Topic of the Week.

Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis-those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes.

Incidence, Natural History, and Factors Associated With Paravalvular Leak Following Surgical Aortic Valve Replacement.

Objective: Our study investigates the incidence, cumulative incidence, natural history, and factors associated with intraoperative paravalvular leak (PVL) and the development of a postoperative PVL in a contemporary consecutive cohort of patients following surgical aortic valve replacement. Methods: A total of 636 patients underwent surgical aortic valve replacement from 2006 to 2016; 410 (64.5%) underwent minimally invasive aortic valve replacement and 226 (35.5%) underwent conventional aortic valve replacement. Primary outcomes were the incidence of intraoperative PVL and cumulative incidence of postoperative PVL. Secondary outcomes were the incidence of in-hospital and long-term death and need for reoperation. Results: The overall incidence of intraoperative PVL was 1.4% (95% confidence interval [CI]: 1% to 3%). All intraoperative PVLs developed in the hand-tied group. The overall incidence of postoperative PVL was 5.3% (95% CI: 4% to 7%). In the univariable and multivariable analyses, postoperative renal failure was the only factor significantly associated with the development of a postoperative PVL. Conclusions: The incidence of intraoperative PVL is low. Cumulative incidence of postoperative PVL was 3.1% (95% CI: 1.0% to 13.6%), 4.3% (95% CI: 1.3% to 16.5%), and 5.0% (95% CI: 1.4% to 17.9%) at 1, 3, and 5 years, respectively. All intraoperative PVLs occurred with hand-tied knots. A larger cohort may identify additional risk factors.

Three-Dimensional Printing and Transesophageal Echocardiographic Imaging of Patient-Specific Mitral Valve Models in a Pulsatile Phantom Model.

Three-dimensional printing is increasingly used in the health care industry. Making patient-specific anatomic task trainers has been one of the more commonly described uses of this technique specifically, allowing surgeons to perform complex procedures on patient-specific models in a nonoperative setting. With regard to transesophageal echocardiography (TEE) training, commercially available simulators have been increasingly used. Even though these simulators are haptic in nature and anatomically near realistic, they lack patient specificity and the training of the dynamic workflow and imaging protocol used in the operative setting. Herein a customized pulsatile left-sided heart model that uses patient-specific 3-dimensional printed valves under physiological intracardiac pressures as a TEE task trainer is described. With this model, dynamic patient-specific valvular anatomy can be visualized with actual TEE machines by trainees to familiarize themselves with the surgery equipment and the imaging protocol.

Grading Aortic Valve Stenosis With Dimensionless Index During Pre-cardiopulmonary Bypass Transesophageal Echocardiography: A Comparison With Transthoracic Echocardiography.

OBJECTIVE: The authors hypothesized that grading valvular aortic stenosis (AS) with dimensionless index (DI) during intraoperative pre-cardiopulmonary bypass (pre-CPB) transesophageal echocardiography (TEE) would match the grade of AS during preoperative transthoracic echocardiography (TTE) for the same patients more often than when using peak velocity (Vp), mean pressure gradient (PGm), or aortic valve area (AVA). DESIGN: Retrospective, observational. SETTING: Single university hospital. PARTICIPANTS: The participants in this study included 123 cardiac surgical patients with any degree of AS, who underwent open cardiac surgery between 2010 and 2016 at the Medical University of South Carolina and had Vp, PGm, AVA, and DI values available from reporting databases or archived imaging. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: When using DI, pre-CPB TEE grading of AS severity was 1 grade higher 21.1% of the time and 1 grade lower 13.0% of the time compared with TTE, for an overall disagreement rate of 34.1%. The overall disagreement rates between pre-CPB TEE and TTE for Vp, PGm, and AVA were 39.8%, 33.3%, and 33.3%, respectively. CONCLUSIONS: The authors could not demonstrate that DI was better than Vp, PGm, or AVA at matching AS grades between intraoperative pre-CPB TEE and preoperative TTE. When DI was used, pre-CPB TEE was more likely to overestimate than underestimate the severity of AS compared with TTE. However, when Vp or PGm was used, pre-CPB TEE was more likely to underestimate the severity of AS compared with TTE. A comprehensive approach without overemphasis on 1 parameter should be used for AS assessment by intraoperative TEE.

Risk assessment for infected endocarditis in Staphylococcus aureus bacteremia patients: When is transesophageal echocardiography needed?

AIMS: Echocardiography is the main technique for the diagnosis of endocarditis in patients with Staphylococcus aureus bacteremia (SAB), but a consensus about performing transthoracic echocardiography or transesophageal echocardiography (TEE) as first-line tests is currently lacking. Recently, a new scoring system has been proposed by Palraj et al. to guide the use of TEE in this population. Our aim was to validate this scoring system or modify it, if necessary. METHODS AND RESULTS: Data from SAB patients admitted from 2012 to 2014 were collected. We tested the Palraj scores to stratify patients' risk for endocarditis. Moreover, we analyzed our population to identify any other possible clinical predictors of endocarditis not included in the score. Endocarditis was diagnosed in 38 of 205 patients (18.5%). Palraj's score was effective in the detection of patients at high risk of endocarditis. In addition, we identified the presence of cardiac devices, prolonged bacteremia and intravenous drug abuse (IVDA) as elements strongly correlated with endocarditis. Two scoring systems (Day-1 and Day-5) were derived including IVDA as a variable. Using a Day-1 cut-off value ≥5 and a Day-5 cut-off value ≥2, the 'modified Palraj's score' showed sensitivities of 42.1% and 97.0% and specificities of 88.6% and 32.0% for Day-1 and Day-5 scores, respectively. CONCLUSION: We modify and expand upon an effective scoring system to identify SAB patients at high risk for endocarditis in order to guide use of TEE. The inclusion of IVDA in the criteria for the calculation of the scores improves its effectiveness.

Transesophageal Echocardiographic Evaluation of a Double Orifice Mitral Valve.

Intraoperative transesophageal echocardiography currently is used routinely for many cardiothoracic surgical procedures. Although it is often used for intraoperative cardiac monitoring and to confirm preoperative echocardiographic findings, it may sometimes result in the discovery of unexpected pathology. In this e-challenge, a patient was found to have a mitral valve abnormality that was not previously detected on the preoperative transthoracic echocardiogram. The mitral valve anomaly subsequently was evaluated to characterize the anatomy, interrogate the valve, and provide a diagnosis.

Patent foramen ovale with complex anatomy: Comparison of two different devices (Amplatzer Septal Occluder device and Amplatzer PFO Occluder device 30/35).

BACKGROUND: Patent foramen ovale (PFO) closure after a cryptogenic cerebral ischemic event is a routinely procedure. The most used device is Amplatzer™ PFO Occluder 25 mm, but PFOs with complex anatomy require larger device for closure. We compared Amplatzer™ Septal Occluder (ASO) device versus Amplatzer™ PFO Occluder 30 or 35 mm (A-PFO 30/35) about the safety of procedure and the presence of residual shunt during the follow-up. METHODS: From June 2002 to July 2016, 355 patients (pts) with PFO undergone closure at our institution. Among these ones, 70 pts (19.7%) had a PFO with complex anatomy and a single device with greater diameter was implanted. In these cases, the following devices were used: Gore® Septal Occluder (GSO) in 4 pts; ASO device in 33 pts (group I) and A-PFO 30/35 in 33 pts (group II). Patients treated with GSO device were excluded by our analysis. RESULTS: Comparing group I and group II, there weren't complications during the procedures. Two patients of group II were lost at follow-up. At last follow-up, 1 pt of group I (3%) and 10 pts of group II (32.3%) had a residual shunt (p < 0.01). 7 of 10 pts of group II and the only 1 of group I with residual shunt underwent a complete closure by Amplatzer™ Vascular Plug (AVP) devices. CONCLUSIONS: ASO devices and A-PFO 30/35 devices are both safe to close complex PFO; but A-PFO 30/35 is associated with a more incidence of residual shunt.

Validation of Quantitative 3-Dimensional Transesophageal Echocardiography Mitral Valve Analysis Using Stereoscopic Display.

OBJECTIVE: The use of 3-dimensional (3D) transesophageal echocardiography (TEE) in perioperative evaluation of the mitral valve (MV) is increasing progressively, including the use of 3D MV models for quantitative analysis. However, the use of 3D MV models in clinical practice still is limited by the need for specific training and the long time required for analysis. A new stereoscopic visualization tool (EchoPixel True 3D) allows virtual examination of anatomic structures in the clinical setting, but its accuracy and feasibility for intraoperative use is unknown. The aim of this study was to assess the feasibility of 3D holographic display and evaluate 3D quantitative measurements on a volumetric MV image using the EchoPixel system compared with the 3D MV model generated by QLAB Mitral Valve Navigation (MVN) software. DESIGN: This was a retrospective comparative study. SETTING: The study took place in a tertiary care center. PARTICIPANTS: A total of 40 patients, 20 with severe mitral regurgitation who underwent mitral valve repair and 20 controls with normal MV, were enrolled retrospectively. INTERVENTIONS: The 3D-TEE datasets of the MV were analyzed using a 3D MV model and stereoscopic display. The agreement of measurements, intraobserver and interobserver variability, and time for analysis were assessed. MEASUREMENTS AND MAIN RESULTS: Fair agreement between the 2 software systems was found for annular circumference and area in pathologic valves, but good agreement was reported for prolapse height and linear annular diameters. A higher agreement for all annular parameters and prolapse height was seen in normal valves. Excellent intraobserver and interobserver reliability was proved for the same parameters; time for analysis between the 2 methods in pathologic valves was substantially equivalent, although longer in pathologic valves when compared with normal MV using both tools. CONCLUSION: EchoPixel proved to be reliable to display 3D TEE datasets and accurate for direct linear measurement of both MV annular sizes and prolapse height compared to QLAB MVN software; it also carries a low interobserver and intraobserver variability for most measurements.

Mitral Annular Plane Systolic Excursion: A Simple, Reliable Echocardiographic Parameter to Detect Left Ventricular Systolic Dysfunction in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting with Transesophageal Echocardiography.

OBJECTIVES: This study's objective was to test the hypothesis that transesophageal echocardiography (TEE)-based mitral annular plane systolic excursion (MAPSE) measurement is useful in perioperative settings to detect left ventricular (LV) systolic dysfunction in patients undergoing off-pump coronary artery bypass grafting (OPCAB). DESIGN: Retrospective observational study. SETTING: Tertiary-care level hospitals. PARTICIPANTS: The study comprised 116 patients undergoing OPCAB to obtain cutoffs of MAPSE to detect LV dysfunction. These cutoffs were validated in another 105 patients from 2 other institutions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In 116 patients who had undergone OPCAB during the study period with TEE monitoring, MAPSE was measured post hoc at the lateral and septal mitral (and average) annulus using the software tool M.mode.ify (http://www.ultrasoundoftheweek.com/M.mode.ify). Receiver operating curves were constructed to obtain cutoff values of MAPSE at the lateral and septal (and average) annulus of the mitral valve to predict LV systolic dysfunction, which was defined by an ejection fraction <52% for men and <54% for women as measured using the biplane method of disks. These cutoff values then were validated in another 105 patients. LV systolic dysfunction was present in 43% patients. Youden's index values of 9mm for lateral MPASE (area under the receiver operating curve [AUC] 0.93 [confidence interval {CI} 0.87-0.97]; p < 0.0001); 7mm for septal MAPSE (AUC 0.87 [CI 0.79-0.92]; p < 0.0001); and 9mm for average MAPSE (AUC 0.92 [CI 0.86-0.96]; p < 0.0001) were obtained. These cutoffs were statistically significant in the validation cohort (p < 0.0001) with an AUC of 0.84 (CI 0.75-0.90), sensitivity of 86.2%, specificity of 80.8%, positive predictive value of 84.8%, and negative predictive value of 82.6%. CONCLUSIONS: MAPSE is a simple, rapid, and reliable method to detect LV dysfunction using TEE in patients undergoing OPCAB. Its use as screening tool for LV dysfunction is recommended.