The Echocardiography Society of Saudi Heart Association Recommendation on Quality and Laboratory Accreditation Guideline and Standards.

OBJECTIVE: To create the Saudi Arabian Society of Echocardiography Accreditation Commission Guidelines and Standards. METHOD: A review of available the North American and European accreditation guidelines was conducted and a model, locally appropriate for Saudi echocardiography laboratories and applicable in the current settings, was developed. RESULTS: The document specifies the organizational setting as well as the following categories of personnel: medical director, technical director, medical staff, and technical staff. The guideline team also examined aspects related to the facility and the facility safety policies and protocols. Examination and procedural issues for Adult transthoracic echocardiography including instrumentation, archiving media, examination interpretation and reports are also included as well as the required components for the Adult transthoracic echocardiography report. The last section of the guidelines focuses on Key Performance Indicators. A similar approach was taken regarding the Adult Stress Echocardiography, Transesophageal Echo, and monitoring of the patients during the procedures. CONCLUSION: The development of the Saudi Echocardiography Guidelines and Standards is a basic requirement for accreditation and also mandatory to improve the quality and utilization of such an important investigation.

Role of intraoperative transesophageal echocardiography in pediatric cardiac surgery.

BACKGROUND: Intraoperative transesophageal echocardiography (TEE) has a major role in detecting residual lesions during and/or after pediatric cardiac surgery. METHODS: All pediatric patients who underwent cardiac surgery between July 2001 and December 2008 were reviewed. The records of surgical procedure, intraoperative TEE, and predischarge transthoracic echocardiograms were reviewed to determine minor and major residual cardiac lesions after surgical repair. RESULTS: During the study period, a total of 2268 pediatric cardiac patients were operated in our center. Mean age was 21 months (from 1 day to 14 years). Of these patients, 1016 (48%) had preoperative TEE and 1036 (46%) were evaluated by intraoperative echocardiography (TEE or epicardial study). We identified variations between TEE and preoperative transthoracic echocardiography in 14 patients (1.3%). Only one surgical procedure was cancelled after atrial septal defect exclusion. The other 13 patients had minor variation from their surgical plan. Major residual lesions requiring surgical revision were detected in 41 patients (3.9%), with the following primary diagnoses: tetralogy of Fallot in 12 patients (29%), atrioventricular septal defect in seven patients (17%), ventricular septal defect in seven patients (17%), double outlet right ventricle in two patients (5%), Shone complex in two patients (5%), subaortic stenosis in two patients (5%), mitral regurgitation in two patients (5%), pulmonary atresia in two patients (5%), and five patients (12%) with other diagnoses. CONCLUSION: Intraoperative TEE has a major impact in pediatric cardiac surgery to detect significant residual lesions. Preoperative TEE has a limited role in case of a high quality preoperative transthoracic echocardiography. We recommend routine use of intraoperative TEE during and/or after intracardiac repair in children.

Acute pulmonary thromboembolism during mitral valve repair.

Perioperative pulmonary thromboembolism during cardiac surgery is extremely rare. We report a 55-year-old male, who developed acute pulmonary thromboembolism during mitral valve repair. Intra-operative trans oesophageal echocardiography failed to demonstrate thromboembolus in the pulmonary arteries but it showed the secondary signs of acute pulmonary artery obstruction. Thromboembolectomy was done after high index of suspicion on clinical grounds was found and the patient recovered. The diagnostic accuracy and sensitivity of transoesophageal echocardiography in circumstances with altered haemodynamics is questionable and has not been investigated. Therefore, indirect evidence of pulmonary artery obstruction on echocardiography may have a predictive value and failure to demonstrate pulmonary thromboembolism by this tool should not exclude the possibility of it especially when it is highly suspected.

Mitral annular disjunction in advanced myxomatous mitral valve disease: echocardiographic detection and surgical correction.

Mitral annular disjunction is a structural abnormality of the mitral annulus fibrosus described by pathologists in association with mitral leaflet prolapse and defined as a separation between the atrial wall-mitral valve (MV) junction and the left ventricular attachment allowing for hypermobility of the MV apparatus. The transesophageal echocardiographic characteristics of this abnormality have not been previously described. In patients undergoing MV repair for myxomatous MV degeneration and evaluated using a standardized transesophageal echocardiographic protocol, annular disjunction (mean value 10 +/- 3 mm) was seen at the base of the posterior leaflet in 98% of patients with advanced, and in 9% of patients with mild/moderate MV degeneration. There was a significant correlation between the magnitude of disjunction and the number of segments with prolapse/flail (r = 0.397, P = .001). We found annular disjunction to be a common component of MV apparatus in advanced MV degeneration. Its recognition on transesophageal echocardiography is important to facilitate optimal MV repair. The modification of the repair technique allows surgical correction of the annular disjunction, which seems to optimize long-term results in these challenging cases.

Intraoperative transesophageal echocardiography accurately predicts mitral valve anatomy and suitability for repair.

Mitral valve (MV) repair is the procedure of choice for MV prolapse or flail. However, valve repair is more technically demanding and requires a precise definition of MV morphology to determine the timing, complexity, and feasibility of repair. We prospectively examined 170 consecutive patients with MV prolapse or flail referred for MV repair. The MV valve was systematically assessed by intraoperative transesophageal echocardiography. MV anatomy was independently assessed at the time of operation. Accuracy of transesophageal echocardiography in identifying MV segments ranged from 90% to 97%, and was best for the middle segment/scallop of either anterior or posterior leaflet. MV repair was successful in 91% of patients. Success rate was the lowest (78%) in the presence of extensive bileaflet disease involving at least 2 segments of each leaflet. Independent predictors of unsuccessful repair were central jet of mitral regurgitation, calcification or severe dilatation of the mitral annulus, and extensive leaflet disease with involvement of at least 3 segments.