Endoleak in covered CP stent causes procedural failure during transcatheter closure of sinus venosus defects.

Transcatheter sinus venosus defect closure uses a long covered stent of appropriate length and diameter across the cavoatrial junction after balloon interrogation. The fabric in the covered stent creates a roof for the right upper pulmonary vein that closes the interatrial communication and redirects the vein into the left atrium behind the stent. A fabric tear in the covered stent may cause endoleak that will result in residual flows across the struts of the covered stent, causing procedural failure. This report highlights the identification of fabric leak by angiography and transesophageal echocardiography and steps to overcome this complication by the placement of another overlapping covered stent.

Purely Endoscopic Supracerebellar Infratentorial Approach to the Pineal Region in Pediatric Population.

Pineal lesions represent less than 1% of all brain tumors (Villani et al., Clin Neurol Neurosurg 109:1-6, 2007). The abysmal location and critical neurovascular structures remain a surgical challenge, despite the advent of microneurosurgery. The classical wide surgical suboccipital craniotomy with the supracerebellar infratentorial approach, described by Sir Victor Horsley (Victor, Proc R Soc Med 3:77-78, 1910), is infamous for its considerable surgical morbidity and mortality. This was later upgraded microneurosurgically by Stein to improve surgical outcomes (Stein, J Neurosurg 35:197-202, 1971).Ruge et al. reported the first purely endoscopic fenestration of quadrigeminal arachnoid cysts via this corridor (Ruge et al., Neurosurgery 38:830-7, 1996). A cadaver-based anatomical study by Cardia et al. demonstrated the viability for endoscope-assisted techniques (Cardia et al., J Neurosurg 2006;104(6 Suppl):409-14). However, the first purely endoscopic supracerebellar infratentorial (eSCIT) approach to a pineal cyst was performed in 2008 by Gore et al. (Gore PA et al., Neurosurgery 62:108-9, 2008).Unlike transventricular endoscopy, eSCIT approach poses no mechanical risk to the fornices and can be utilized irrespective of ventricular size. More vascular control and resultant reduction in uncontrolled hemorrhage improve the feasibility of attaining complete resection, especially around corners (Zaidi et al,, World Neurosurg 84, 2015). Gravity-dependent positioning and cerebrospinal fluid (CSF) diversion aid cerebellar relaxation, creating the ideal anatomical pathway. Also, angle of the straight sinus, tentorium, and tectal adherence can often influence the choice of approach; thus direct endoscopic visualization not only counteracts access to the engorged Galenic complex but also encourages sharp dissection of the arachnoid (Cardia et al., J Neurosurg 104:409-14, 2006). These tactics help provide excellent illumination with magnification, making it less fatiguing for the surgeon (Broggi et al., Neurosurgery 67:159-65, 2010).The purely endoscopic approach thwarts the dreaded risk of air embolisms, via simple copious irrigation from a small burr hole (Shahinian and Ra, J Neurol Surg B Skull Base 74:114-7, 2013). The tiny opening and closure are rapid to create, and the smaller wound decreases postoperative pain and morbidity. Recent literature supports its numerous advantages and favorable outcomes, making it a tough contender to traditional open methods.

Novel Three-Dimensional Printed Human Heart Models and Ultrasound Omniplane Simulator for Transesophageal Echocardiography Training.

Simulation-based training plays an essential role in transesophageal echocardiography (TEE) education. Using 3-dimensional printing technology, the authors invented a novel TEE teaching system consisting of a series of heart models that can be segmented according to actual TEE views, and an ultrasound omniplane simulator to demonstrate how ultrasound beams intersect the heart at different angles and generate images. This novel teaching system is able to provide a more direct way to visualize the mechanics of obtaining TEE images than traditional online or mannequin-based simulators. It can also provide tangible feedback of both an ultrasound scan plane and a TEE view of the heart, which has been proven to improve trainees' spatial awareness and can significantly help in understanding and memorizing complex anatomic structures. This teaching system itself is also portable and inexpensive, making it conducive to teaching TEE in regions of diverse economic status. This teaching system also can be expected to be used for just-in-time training in a variety of clinical scenarios, including operating rooms, intensive care units, etc.

Low left atrial appendage emptying velocity is a predictor of atrial fibrillation recurrence after catheter ablation.

BACKGROUND: Recurrence of atrial fibrillation (AF) after catheter ablation (CA) remains common and studies have shown about 5%-9% annual recurrence rate after CA. We sought to assess the echocardiogram derived left atrial appendage (LAA) emptying velocity as a predictor of AF recurrence after CA. OBJECTIVE: To determine if LAA emptying is a marker of recurrence of AF post-CA METHODS: A total of 303 consecutive patients who underwent CA for AF between 2014 and 2020 were included. Baseline clinical characteristics and echocardiographic data of the patients were obtained by chart review. LAA emptying velocities were obtained from transesophageal echocardiogram (TEE). LA voltage was obtained during the mapping for CA. Chi-square test and nominal logistic regression were used for statistical analysis. An receiver operator characteristic curve was used to determine LAA velocity cut-off. RESULTS: Mean patient age was 61.7 ± 10.5; 32% were female. Mean LAA emptying velocity was 47.5 ± 20.2. A total of 103 (40%) patients had recurrence after CA. In the multivariable model, after adjusting for potential confounders, LAA emptying velocity of ≥52.3 was associated with decreased AF recurrence postablation (odds ratio [OR]: 0.55; 95% confidence interval  [CI]: 0.31-0.97; p = .03*). There were 190 (73%) patients in normal sinus rhythm during TEE and CA, and sensitivity analysis of these patients showed that LAA velocity ≥52.3 remained associated with decreased AF recurrence (OR: 0.35; 95% CI: 0.15-0.82; p = .01*). CONCLUSION: LAA emptying velocity measured during preprocedural TEE can serve as a predictor of AF recurrence in patients undergoing CA.

Evaluation of inter-observer variability regarding aortic and mitral valve findings on transesophageal echocardiograms ordered for suspected endocarditis.

BACKGROUND: Transesophageal echocardiography (TEE) is the gold standard for the detection of valvular vegetations (VV). Differentiating small VV from degenerative changes is challenging and prone to inter-observer variability. We evaluated inter-observer agreement regarding aortic (AV) and mitral valve (MV) findings on TEEs ordered for suspected infective endocarditis (IE). METHODS: A total of 349 consecutive TEEs were evaluated. Studies were classified as "definite, possible, or no" IE with valve masses classified further by morphology. Nine faculty echocardiographers scored randomly selected TEEs of the AV (N = 38) and MV (N = 35). Inter-reader variability was calculated using the Fleiss/Scott Kappa (Kf). RESULTS: Positive blood cultures were present in 81% and 45% had definite IE by the modified Duke criteria. There was moderate reader agreement regarding the presence of a valvular mass for both the AV (Kf = .41, 95% CI [.30-.53]) and MV (Kf = .49, 95% CI [.34-.65]). For diagnosis of IE, there was fair agreement for the AV (Kf = .29, 95% CI [.18-.42]) and moderate agreement for the MV (Kf = .53, 95% CI [.36-.70]). Masses described as large, multi-lobulated, or pedunculated were more frequently categorized as clinical IE, (p < .006, both valves), however those with filamentous lesions were not (p < .001, both valves). CONCLUSIONS: In a large academic center, the inter-observer agreement for the presence of a left sided valvular mass was moderate and agreement regarding the final diagnosis of IE was fair to moderate, with better agreement among readers evaluating the MV. Lesion morphology is associated with the clinical diagnosis of IE.

Severe aortic regurgitation from aortic valve perforation in Libman-Sacks endocarditis: Incremental value of 3D TEE.

A 43-year-old woman with stroke and systemic lupus erythematosus was found to have severe eccentric aortic regurgitation. Three-dimensional transesophageal echocardiogram further defined the origin of the regurgitant jet through a perforation in the left coronary cusp next to a mass with a tiny stalk attached to the left coronary cusp.

Utility of transesophageal echocardiogram surveillance after watchman device placement.

BACKGROUND: In atrial fibrillation patients undergoing left atrial appendage occlusion with a Watchman device, surveillance imaging with a transesophageal echocardiogram (TEE) is typically performed at 45 days and 1 year to evaluate for device-related thrombus (DRT) and peri-device leak (PDL) before the cessation of oral anticoagulation. The incidence of these complications is relatively low, and the ideal timing and duration of surveillance is unknown. We sought to evaluate the incidence of DRT and PDL after Watchman placement at 45 days and 1 year to determine the necessity of surveillance TEEs. METHODS: We retrospectively analyzed 361 patients who received a Watchman device between January 2016 and January 2020. Baseline clinical and echocardiographic data, post-procedure antithrombotic therapy, and surveillance echocardiographic data were collected from the NCDR LAAO Registry. Nested backward variable elimination regression was performed to derive independent predictors of the composite outcome of DRT and PDL. RESULTS: A total of 286 patients who had post-procedure TEEs were included in the analysis. At 45 days, 9 patients had DRT (3.2%) and 44 patients had PDL (15.0%). At 1 year, 5 patients had DRT (5.6%) and 8 patients had PDL (8.9%). All DRT at 45 days was treated with continued anticoagulation while no change in protocol occurred with PDL. All DRT at 1 year occurred in new patients without prior thrombus. A history of prior transient ischemic attack (TIA) and thromboembolism was significantly associated with DRT or PDL at 1 year. CONCLUSIONS: We identified several patients with device-related complications at 45 days and 1 year despite appropriate device sizing and adequate use of antithrombotic therapy. The incidence of DRT increased from 45 days to 1 year and occurred in patients without prior thrombus. These findings highlight the importance of surveillance imaging and suggest the potential need for extended surveillance in select patients.

Two Consecutive Cases of Quadricuspid Aortic Valve and a Review of 149 Cases.

The quadricuspid aortic valve (QAV) is a rare congenital anomaly that typically is unrelated to other cardiac anomalies. It usually is discovered incidentally through imaging modalities such as echocardiogram or computed tomography angiogram, during surgery, or autopsy. Some patients with QAV develop aortic regurgitation and, rarely, other cardiovascular complications like aortic aneurysm. Due to its rarity, it is difficult to characterize these patients or standardize management. However, review of case reports can be very useful in rare medical conditions such as QAV. In this manuscript, in addition to presenting two cases of QAV, the authors reviewed 149 cases of QAV from 2010 to 2020 from published case studies and series in order to gain a better insight into the characteristics of the patient population with QAV and its management.

A Narrative Review of the 2020 Guidelines for Use of Transesophageal Echocardiography to Assist with Surgical Decision- Making by the Cardiac Anesthesiologist in the Operating Room.

Transesophageal echocardiography (TEE) has become an integral part in helping to diagnose, manage, and assess interventions in the cardiac operating room. Multiple guidelines have been created by the American Society of Echocardiography for performing a TEE examination for different cardiac pathologies. The operating room can provide unique challenges when performing a TEE examination, which include hemodynamic instability, time constraints, and use of general anesthesia. The Guideline for the use of TEE to assist in surgical decision- making in the operating room recently was published to provide a starting protocol for conducting a TEE examination for different cardiac surgeries and for using the information obtained to interpret and to communicate findings to the surgical team. This present narrative review focuses and expands upon the relevant portions for the cardiac anesthesiologist.

Autoimmune Pericarditis: Multimodality Imaging.

PURPOSE OF THE REVIEW: The purpose of this review is to understand the underlying mechanism that leads to pericarditis in systemic autoimmune and autoinflammatory diseases. The underlying mechanism plays a vital role in the appropriate management of patients. In addition, we will review the current landscape of available cardiac imaging modalities with emphasis on pericardial conditions as well as proposed treatment and management tailored toward pericardial autoimmune and autoinflammatory processes. RECENT FINDINGS: Approximately 22% of all cases of pericarditis with a known etiology are caused by systemic autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and vasculitis. In recent years, there have been advancements of imaging modalities including cardiac MRI, cardiac CT scan, and PET scan and their respective nuances in regard to contrast use, technique, and views which clinicians may utilize to better understand the extent of a patient's pericardial pathology and the trajectory of his or her disease process. In this review, we will discuss systemic autoimmune and autoinflammatory diseases that involve the pericardium. We will also review different imaging modalities that are currently used to further characterize such conditions. Having a deeper understanding of such techniques will improve patient outcomes by helping clinicians tailor treatment plans according to the unique underlying condition.

Intraoperative pump thrombosis (PT) in HeartMate (HM) III.

Pump thrombosis (PT) is a rare and infrequent complication of HeartMate III left ventricular assist device (LVAD). While there are reports of PT in the postoperative period, to our knowledge, there have been no prior reports on PT in the intraoperative period. Here we present a case of a 24-year-old female who required HeartMate III LVAD implantation for progressive heart failure and the intraoperative period was complicated with PT. Managing PT in the intraoperative period is challenging and time-sensitive because of its rare occurrence and paucity of recommendations in diagnosing the PT.

Using aortic arch short axis views during transesophageal echocardiographic examination facilitates right ventricular assist device imaging.

Given the increased need for mechanical circulatory support and subsequent development of right ventricular assist devices (RVAD), appropriate imaging needs to be described to facilitate care in patients with cardiogenic shock and heart failure. We present three cases in which the upper esophageal aortic arch short axis (UE AA SAX) view on transesophageal echocardiography (TEE) was utilized to effectively image RVADs: to confirm normal positioning, to detect and guide repositioning, and to visualize malfunction. These cases support the importance of the UE AA SAX TEE view in RVAD outflow imaging and, when obtainable, should be included in routine RVAD assessment.

Forgoing transesophageal echocardiogram in selected patients with complicated Staphylococcus aureus bacteremia.

Infective endocarditis (IE) has been increasingly recognized as an important complication of Staphylococcus aureus bacteremia (SAB), leading to a low threshold for echocardiography and extended treatment with anti-staphylococcal agents. However, outside of IE, many indications for prolonged anti-staphylococcal therapy courses are present. We sought to determine the frequency in which findings from a transesophageal echocardiogram (TEE) changed clinical SAB management in a large Canadian health region. Residents (> 18 years) with SAB from 2012 to 2014 who underwent transthoracic echocardiogram (TTE) and TEE were assessed. Patients potentially benefiting from an extended course of anti-staphylococcal agents were defined a priori. Patient demographics, treatment (including surgical), and clinical outcomes were extracted and evaluated. Of the 705 episodes of SAB that underwent a screening echocardiogram, 203 episodes underwent both a TTE and TEE, of which 92.1% (187/203) contained an a priori indication for extended anti-staphylococcal therapy. Regardless of TEE results, actual duration of therapy did not differ in SAB episodes that had ≥ 1 extended anti-staphylococcal therapy criteria (36.7 days, IQR 23.4-48.6 vs. 43.8 days, IQR 33.3-49.5, p = 0.17). Additionally, there were no cases in which TEE was utilized as the sole reason to shorten duration of therapy or proceed to surgery for those with SAB. Routine performance of TEE may be unnecessary in all SAB as many patients have pre-existing indications for extended anti-staphylococcal therapy independent of TEE findings. An algorithm to selectively identify cases of SAB that would benefit from TEE can reduce resource and equipment expenditure and patient risks associated with TEE.

Direct Current Cardioversion in Atrial Fibrillation Patients on Edoxaban Therapy Versus Vitamin K Antagonists: a Real-world Propensity Score-Matched Study.

PURPOSE: The purpose of the present study was to compare the long-term effectiveness and safety of newly initiated anticoagulation with edoxaban (EDO) versus uninterrupted vitamin K antagonist (VKA) therapy in patients with atrial fibrillation (AF) scheduled for transesophageal echocardiogram (TEE)-guided direct electrical current cardioversion (DCC). METHODS: A propensity score-matched cohort observational study was performed comparing the safety and effectiveness of edoxaban versus well-controlled VKA therapy among a cohort of consecutive non-valvular AF patients scheduled for DCC. The primary safety outcome was major bleeding. The primary efficacy outcome was the composite of stroke, transient ischemic attack (TIA), and systemic embolism (SE). FINDINGS: A total of 130 AF patients receiving edoxaban 60-mg (EDO) treatment were compared with the same number of VKA recipients. The cumulative incidence of major bleedings was 1.54% in the EDO group and 3.08% in the VKA group (P = 0.4). The cumulative incidence of thromboembolic events was 1.54% in the EDO group and 2.31% in the VKA group (P = 0.9). A non-significant trend in improved adherence was observed between the EDO and VKA groups with a total anticoagulant therapy discontinuation rate of 4.62% (6/130) vs 6.15% (8/130), respectively (P = 0.06). IMPLICATIONS: Our study provides the evidence of a safe and effective use of edoxaban in this clinical setting, justified by no significant difference in major bleedings and thromboembolic events between edoxaban and well-controlled VKA treatments.

Complications after transesophageal echocardiogram in pediatric patients with gastrostomy tube and/or Nissen fundoplication.

INTRODUCTION: Transesophageal echocardiography (TEE) is frequently used in children with and without congenital heart disease when transthoracic echocardiography is inadequate for visualizing cardiac structures. Recent guidelines state relative contraindications of TEE include post-gastrostomy tube (GT) or Nissen fundoplication surgery. No data exist documenting the incidence of complications in this population after a TEE. Aim of this study was to document the incidence of abdominal complications after TEE in pediatric patients who previously had a GT or Nissen fundoplication. METHODS: Single institution retrospective study was performed evaluating patients from 2013 through 2020. Patients were included if they had previously undergone a GT or Nissen procedure and subsequently underwent a TEE procedure. Baseline demographics were obtained. Major (esophageal/gastric perforation, oropharyngeal dysphagia, GT displacement, and Nissen breakdown) and minor (abdominal pain, feeding intolerance, and GT leakage) complications were recorded. RESULTS: Total of 34 patients underwent 48 TEE procedures. Age was 6.2 ± 6.6 years (median 3.0 years, .4 - 23.0 years) and weight was 18.5 ± 14.8 kgs (median 12.4 kgs, 4.2 - 57.5 kg) at time of TEE. Twenty-nine patients had congenital heart disease. Five patients had a Nissen fundoplication, 14 patients had a GT, and 15 patients had both procedures prior to the TEE. No patient had a major abdominal complication after the TEE. One patient had abdominal pain (2.1%), one patient had feeding intolerance and leakage around the GT site (2.1%), and two patients had leakage around the GT site (4.2%) after the TEE. Patients that experienced complications were significantly younger (1.7 ± 1.1 years vs. 6.6 ± 6.7 years, P < .01) and weighed less (8.7 ± 3.5 kg vs. 20.1 ± 15.5 kg, P < .01) than those that had no complications. All minor complications resolved with minimal interventions required. CONCLUSION: In this study, major abdominal complications did not occur after a TEE procedure in pediatric patients that had previous abdominal surgeries. The incidence of minor complications was relatively low and was easily remedied in this patient population. Though a relative contraindication by guidelines, TEE imaging, including transgastric views, can be performed relatively safely in pediatric patients with prior abdominal surgeries if needed.

Abnormal P-wave terminal force in lead V1 is associated with low left atrial appendage ejection velocity.

BACKGROUND: Sinus P-wave abnormalities have been associated stroke in people with atrial fibrillation (AF). The majority of AF-related strokes occur from left atrial appendage (LAA) thromboembolism. Dysfunction of the left atrium (LA) and left atrial appendage (LAA) can increase rates of thromboembolic stroke. We studied whether abnormal P wave terminal force in V1 (aPTFV1) is associated with decreased LAA ejection velocity (LAAV) on transesophageal echocardiography (TEE). METHODS: We conducted a retrospective cross-sectional study reviewing patients at a tertiary care medical center who underwent TEE in sinus rhythm and had an interpretable sinus ECG within 12 months of TEE. Participants were excluded for complex congenital heart disease, age <18, cardiac transplantation, and chronic atrial pacing. Logistic regression analysis was used to estimate the odds ratios of LAAV<40 cm/s for aPTFV1. RESULTS: In our final cohort of 169 patients (28% of which had LAAV <40), the multivariate odds ratio of aPTFV1 for LAAV<40 cm/s after adjustment for CHA2DS2VASc variables, heart rate during TEE, history of atrial arrhythmias, and left atrial volume index was 2.24 (95% CI of 1.13-6.00). CONCLUSION: Abnromal P-wave terminal force in lead V1 is associated with low LAAV after adjustment for potential confounders. Future research is needed for validation of our findings and determination of clinical utility.

Out-of-Hospital Transesophageal Echocardiogram for Cardiac Arrest Resuscitation: The Initial Case.

Objective: The use of transesophageal echocardiogram (TEE) during cardiac arrest in the emergency department (ED) is a newer concept. TEE provides dynamic evaluation of chest compressions and rhythm analysis. Hand placement using external landmarks can result in maximal compression over the aorta, rather than the ventricles of the heart. Methods: We present the initial case of TEE performed in the out of hospital setting in an ambulance to facilitate cardiac arrest resuscitation using a disposable TEE probe. Results: This case is a proof of concept that TEE can be successfully performed and contribute to clinical care of cardiac arrest in the out of hospital setting. Conclusion: Further research needs to be performed to determine the clinical benefit, indications, and curriculum for emergency providers to successfully deliver this potentially valuable resource prior to widespread adoption.

Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the Emergency Department.

Placement of a transvenous pacer is an important procedure mainly used to treat hemodynamically unstable brady-arrhythmias. In the Emergency Department (ED), wire placement into the right ventricle is typically performed blindly, or in some cases, under transthoracic ultrasound guidance. This case report describes a patient with extensive cardiac history who presented after a witnessed arrest, and after return of spontaneous circulation, sustained an unstable bradycardia requiring emergent transvenous pacer placement while in the ED. A temporary pacer wire was placed transvenously without successful capture. Transesophageal echocardiography was then utilized to guide and adjust the pacer wire placement helping to successfully achieve capture. To our knowledge, this is the first report to describe transesophageal echocardiogram-assisted placement of a transvenous pacer wire while in the ED.

Use of Transesophageal Echocardiogram and Interdisciplinary Approach to Intraoperative Management of Renal Cell Carcinoma With Inferior Vena Cava Invasion.

OBJECTIVE: Report experience of patients undergoing surgery for resection of renal cell carcinoma with inferior vena cava invasion and use of transesophageal echocardiogram (TEE). DESIGN: Retrospective and observational study. SETTING: Single large university hospital. PARTICIPANTS: The study comprised 55 consecutive who underwent resection of renal cell carcinoma. INTERVENTIONS: A transesophageal echocardiogram was performed by cardiac anesthesiologists in high grade tumors. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients had tumor thrombi classified as level III, and 6 patients were classified as level IV. There was increased use of TEE for higher level of tumor thrombi. CONCLUSIONS: The surgical management of renal cell carcinoma with inferior vena cava tumor extension is complex. High-grade tumors require individualized treatment. Successful outcomes require collaboration between surgeons and anesthesiologists. Patients with level IIIb to IV tumor invasion benefit from TEE assessment and monitoring, which may be life-saving, and cardiac anesthesia should be involved in those types of cases.

A Rare Cause of a Left Atrial Mass.

Intramyocardial hematomas are a rare complication of myocardial infarctions. Normally restricted to the left ventricle, in certain scenarios, such as after a percutaneous coronary intervention, intramyocardial hematomas also can occur in the left atrium. Herein, the case of a 74-year-old man who presented to the authors' institution with a large inferior wall myocardial infarction refractory to multiple pressor therapy and thus necessitated venoarterial extracorporeal membrane oxygenation support is described. Through the course of his hospital stay, the patient developed a large left atrial intramyocardial hematoma obstructing mitral inflow as seen on intraoperative transesophageal echocardiography. Ultimately, because of the patient's complex comorbid status, his case was managed conservatively. In this E-challenge, the reason for the conservative approach and the alternative approach of surgically draining the intramyocardial hematoma are discussed.