Hyperosmolar Therapy in Elderly Neurosurgical Patients: Comparison of the Effect of Mannitol (20%) and Hypertonic Saline (3%) on Advanced Cardiovascular Parameters using Transesophageal Echocardiography - A Preliminary Randomized Controlled Trial.

OBJECTIVE: Osmotherapeutic agents increase the intravascular volume by withdrawing water from the brain followed by relative hypovolemia due to diuresis leading to significant changes in systemic hemodynamics which might have adverse consequences in the elderly. We studied the effect of mannitol (20%) and hypertonic saline (3%) on left ventricle outflow tract velocity-time integral (LVOT-VTI) and cardiac output in elderly patients undergoing supratentorial neurosurgical procedures using transesophageal echocardiography. METHODS: We recruited twenty-eight patients aged above 65 years undergoing supratentorial craniotomy who received equiosmolar solutions of 5.35 ml/kg of 3% hypertonic saline (Group HS, n=14) or 5 ml/kg of 20% mannitol (Group M, n=14). LVOT-VTI was recorded at baseline, 15, 30, 45, 60 and 90 minutes post-infusion and cardiac output (CO) was derived. We also recorded heart rate, blood pressure, fluid balance, brain relaxation, vasopressor use, complications and neurological outcome. RESULTS: We found a significant decrease in LVOT-VTI at 45, and 60 mins in Group M as compared to Group HS [mean(SD), 16.76(1.81) v/s 20.78(1.87), P <0.001, 17.4(2.38) v/s 19.16(2), P = 0.044, respectively]. We also found a corresponding significant fall in CO [3863.16(845.87) v/s 4745.59 (1209.33) ml/min, P = 0.034] and systolic blood pressure (P = 0.039), at 45 mins in Group M. Urine output was higher in Group M (P <0.001). All other parameters were comparable. CONCLUSION: Hypertonic saline appears to be associated with better systemic hemodynamics (LVOT-VTI, CO) while providing equivalent brain relaxation as mannitol in elderly patients. A future larger study is required to confirm our preliminary findings.

Pseudomonas aeruginosa: An Unusual Culprit of Left-Sided Native Valve Infective Endocarditis.

Endocarditis refers to infection or inflammation of the endocardium, and various pathogens can be involved in infective endocarditis (IE). Endocarditis is usually caused by bacteremia in patients with risk factors, including IV drug abuse, indwelling central venous or urinary catheters, recent dental infections, and implantable cardiac devices. Pseudomonas aeruginosa (P. aeruginosa) is an extremely rare causative organism in IE, predominantly among IV drug users and involving right-sided valves. Left-sided native valve P. aeruginosa IE without established risk factors is uncommon. We present a case of a 68-year-old male with no traditional IE risk factors who presented with intermittent fevers. Blood cultures grew P. aeruginosa, and transesophageal echocardiography revealed posterior mitral valve vegetation. The patient received broad-spectrum IV antibiotics, which were eventually narrowed down to IV cefepime, guided by culture antimicrobial sensitivities. Although the literature describes various risks for P. aeruginosa IE, it can still occur in the absence of traditional predisposing factors. Due to this organism's rapid resistance acquisition and the complication of septic emboli, an expeditious diagnosis and treatment with antibiotics and/or valve surgery are vital to reducing mortality associated with this entity.

The Case of the "Disappearing Ventricle": A Report.

Embolization of entrapped intracardiac air represents a significant risk to the patient undergoing open-heart surgery. Entrapment of as little as 0.5 mL of gas in the heart can cause temporary myocardial dysfunction, cardiac arrhythmias, and systemic emboli. In contrast, larger emboli can disrupt the evaluation of heart function by limiting visualization during echocardiography. We present the case of a 67-year-old male who presented with dizziness, nausea, and chest pain. A left heart catheterization revealed multi-vessel disease. Undergoing general anesthesia, the patient received three-vessel coronary artery bypass grafting, mitral valve repair, ring annuloplasty, and left atrial appendage closure. Upon aortic unclamping, transgastric echocardiography showed significant gas almost wholly obscuring the left heart chambers despite de-airing maneuvers. Successful resolution relied upon higher mean blood pressure and time, demonstrating the importance of intraoperative imaging and interdisciplinary collaboration.

Intraoperative and Intraprocedural Use of 3-Dimensional Transesophageal Echocardiography: An International European Association of Cardiothoracic Anesthesia and Intensive Care Survey of Cardiac Surgical Centers.

OBJECTIVE: To assess the intraoperative use of 3-dimensional transesophageal echocardiography (3D TEE) in cardiac surgical centers, the authors created a survey aimed at evaluating the availability of equipment and the use of 3D TEE for specific surgical and interventional procedures and single-image modalities. The respondents were asked to identify the perceived impact on patient management and current limitations to its routine use. DESIGN: A multiple choice 25-question online survey submitted to the members of the European Association of Cardiothoracic Anesthesia and Intensive Care (EACTAIC) on December 6, 2021, and closed on January 31, 2022. SETTING: An online survey. PARTICIPANTS: Registered EACTAIC members in 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 239 respondents from 44 different countries took part in the survey (27% of the total 903 EACTAIC members). Most respondents (59%) were TEE-certified by the National Board of Echocardiography, European Association of Cardiovascular Imaging (EACVI/EACTAIC), or had a national certificate. Of the respondents, 68% had no formal 3D TEE training. Eight percent of respondents had no 3D machines, whereas 40% had one for each operating room, and 33% had only one for the entire operating room block. 3D TEE was performed most frequently in more than 67% of cases for mitral valve surgery, and in more than 54% of cases for mitral and tricuspid clips, aortic valve, tricuspid valve, and aortic surgery. CONCLUSION: Current guidelines suggest integrating 3D TEE into all comprehensive examinations. The authors' survey reported that intraoperative 3D TEE was used in the majority of mitral valve surgery and only one-half of the other valve surgeries and transcatheter procedures. Its use may be explained by the availability of 3D machines, trained personnel, and limited time to perform TEE in the operating room. Educational initiatives for training in 3D TEE may further increase its routine use.

Mural infective endocarditis with a mass on the fossa ovalis in the right atrium.

Infective endocarditis (IE) is a life-threatening disease that affects the endocardial surface of the heart. Although heart valves are commonly involved in IE, in rare cases, vegetation is attached to the cardiac walls without valvular endocardial involvement, which is referred to as mural IE. In this case, a 60-year-old female presented with a seven-day history of fever associated with worsening pain in the right shoulder and left hip. Streptococcus dysgalactiae subsp. Equisimilis was detected in both blood and joint fluid cultures. Although transthoracic echocardiography revealed no mass, transesophageal echocardiography revealed a mobile mass in the fossa ovalis of the right atrium. She was subsequently diagnosed with mural IE and successfully treated with antibiotics without cardiac surgery. To our knowledge, only a few reports have described mural IE with vegetation in or around the fossa ovalis of the right atrium. This case highlights the importance of transesophageal echocardiography in diagnosing mural IE. The treatment strategy for mural IE should be discussed individually and in a multidisciplinary manner because current IE guidelines may not be applicable to mural IE cases due to differences in disease characteristics and clinical course between mural and valvular IE.

Intraoperative Echocardiography: Guide to Decision-Making.

PURPOSE OF REVIEW: This review aims to provide a concise overview of key recommendations, with a specific focus on common challenges faced by intraoperative echocardiographers when dealing with frequently encountered valvular pathologies and mechanical circulatory support. It offers valuable insights for medical practitioners in this field. RECENT FINDINGS: The American Society of Echocardiography (ASE) and the American College of Cardiology/American Heart Association (ACC/AHA) have released updated comprehensive guidelines for the use of transesophageal echocardiography (TEE) for the assessment of cardiac structures and implanted devices to help guide intraoperative decision-making. Transesophageal echocardiography (TEE) is a regularly employed intraoperative diagnostic and monitoring tool, offering various modalities for the rapid evaluation of valvular and aortic pathology, hemodynamic disturbances, and cardiac function. It is particularly valuable in assessing and placing mechanical circulatory support (MCS) devices, providing views often challenging to obtain through transthoracic echocardiography. Additionally, intraoperative TEE can be used for decision-making in patients with valvular disease allowing incorporation of patient-specific and situational factors. Echocardiographers can employ this information in real-time to help guide surgical treatment selection such as repair, replacement, or deferral of intervention.

Impact of transesophageal echocardiography dynamic monitoring of left ventricular preload on postoperative gastrointestinal function in colorectal cancer patients undergoing radical surgery.

Background: Patients undergoing intestinal tumour surgery are fasted preoperatively for a series of bowel preparations, which makes it difficult to assess the patients' volume, posing a challenge to intraoperative fluid replacement. Besides, inappropriate fluid therapy can cause organ damage and affect the prognosis of patients, and it increases the burden of patients and has a certain impact on patients and families. Material and methods: The authors designed a single-centre, prospective, single-blinded, randomized, parallel-controlled trial. Fifty-four patients undergoing elective radical resection of colorectal cancer were selected and divided into two groups according to whether transesophageal echocardiography (TEE) was used or not during the operation, that is the goal-directed fluid therapy (GDFT) group (group T) guided by TEE and the restrictive fluid therapy group (group C). Fluid replacement was guided according to left ventricular end-diastolic volume index (LVEDVI) in group T and according to restrictive fluid replacement regimen in group C. Results: The first postoperative exhaust time and defecation time in group T [(45±21), (53±24) h] were significantly shorter (P<0.05) than those in group C [(63±26), (77±30) h]. There were no significant differences (P>0.05) in liquid intake time and postoperative nausea and vomiting incidences between the two groups. The total intraoperative fluid volume in group T was significantly higher (P<0.05) than that in group C. There was no significant difference (P>0.05) in urine volume between the two groups. There were no significant differences (P>0.05) in lactate content, mean arterial pressure, and heart rate at various time points between the two groups. The length of hospital stay in group C [(18±4) days] was significantly longer (P<0.05) than that in group T [(15±4) days]. Conclusions: For patients undergoing colorectal cancer surgery, fluid therapy by monitoring LVEDVI resulted in faster recovery of gastrointestinal function and shorter hospital stay.

Anterolateral papillary muscle suction causing low flow in a COVID-19 patient without medical history: a case report of central extracorporeal life support with left ventricular apex decompression.

BACKGROUND: Left ventricular (LV) decompression is an essential strategy for improving early survival in patients with refractory cardiogenic shock. Low pump flow in patients on extracorporeal life support (ECLS) with LV apex decompression is a life-threatening issue. However, identifying the underlying causes of low flow can be challenging. CASE PRESENTATION: A 38-year-old woman with COVID-19-related fulminant myocarditis was treated with central ECLS with LV apex decompression. The pump flow in the intensive care unit (ICU) was intermittently low, and low flow alerts were frequent. The initial evaluation based on pressure monitor waveforms and transthoracic echocardiography failed to identify the underlying cause. Prompt bedside transesophageal echocardiography (TEE) revealed that the anterolateral papillary muscle was suctioned into the vent cannula of the LV apex during systole. The patient underwent a repeat sternal midline incision in the operating room, and the cannula at the LV apex was repositioned. There were no further suction events after the repositioning, and the patient was weaned from ECLS 12 days after admission to the ICU. The patient was discharged in a stable condition and without neurological deficits. CONCLUSIONS: TEE is an important diagnostic tool to identify the underlying cause of low flow flow in patients undergoing ECLS with LV apex decompression.

A comparison of conventional and advanced 3D imaging techniques for percutaneous left atrial appendage closure.

Background: Understanding complex cardiac anatomy is essential for percutaneous left atrial appendage (LAA) closure. Conventional multi-slice computed tomography (MSCT) and transesophageal echocardiography (TEE) are now supported by advanced 3D printing and virtual reality (VR) techniques for three-dimensional visualization of volumetric data sets. This study aimed to investigate their added value for LAA closure procedures. Methods: Ten patients scheduled for interventional LAA closure were evaluated with MSCT and TEE. Patient-specific 3D printings and VR models were fabricated based on MSCT data. Ten cardiologists then comparatively assessed LAA anatomy and its procedure relevant surrounding structures with all four imaging modalities and rated their procedural utility on a 5-point Likert scale questionnaire (from 1 = strongly agree to 5 = strongly disagree). Results: Device sizing was rated highest in MSCT (MSCT: 1.9 ± 0.8; TEE: 2.6 ± 0.9; 3D printing: 2.5 ± 1.0; VR: 2.5 ± 1.1; p < 0.01); TEE, VR, and 3D printing were superior in the visualization of the Fossa ovalis compared to MSCT (MSCT: 3.3 ± 1.4; TEE: 2.2 ± 1.3; 3D printing: 2.2 ± 1.4; VR: 1.9 ± 1.3; all p < 0.01). The major strength of VR and 3D printing techniques was a superior depth perception (VR: 1.6 ± 0.5; 3D printing: 1.8 ± 0.4; TEE: 2.9 ± 0.7; MSCT: 2.6 ± 0.8; p < 0.01). The visualization of extracardiac structures was rated less accurate in TEE than MSCT (TEE: 2.6 ± 0.9; MSCT: 1.9 ± 0.8, p < 0.01). However, 3D printing and VR insufficiently visualized extracardiac structures in the present study. Conclusion: A true 3D visualization in VR or 3D printing provides an additional value in the evaluation of the LAA for the planning of percutaneous closure. In particular, the superior perception of depth was seen as a strength of a 3D visualization. This may contribute to a better overall understanding of the anatomy. Clinical studies are needed to evaluate whether a more comprehensive understanding through advanced multimodal imaging of patient-specific anatomy using VR may translate into improved procedural outcomes.

Clinical Protocol for Selecting Intracardiac or Transesophageal Echocardiography-Guided Left Atrial Appendage Occlusion.

Intracardiac echocardiography (ICE) has emerged as an alternative to transesophageal echo (TEE) to guide left atrial appendage occlusion (LAAO). We established a protocol to select patients appropriate for ICE guidance. Patients undergoing LAAO with the Watchman or Watchman FLX device (Boston Scientific, Marlborough, MA) from January 2018-March 2022 at a large United States center were included. The novel protocol prospectively selected TEE or ICE guidance beginning in January 2020; previous LAAO procedures were retrospectively included. ICE was selected for patients with uninterrupted anticoagulation and appropriate LAA anatomy, renal function, and moderate sedation tolerance. In-hospital outcomes with successful implantation without conversion to TEE-guidance, no peridevice leak (PDL), and no procedural complications were compared. Composite 1-year outcome included freedom from PDL, device related thrombus, stroke, and all-cause mortality. A total of 234 patients were included; the mean age was 76.1 ± 8.3 years old, and 42.3% were female. ICE guidance was used for 63 procedures; TEE guidance was used for 171 procedures. For the composite outcome, ICE-guided LAAO was superior to TEE-guided LAAO (risk difference 0.102, 96.8% vs. 86.5%, 95% CI 0.003-0.203; p=0.029). In comparison to the TEE-guided group, ICE-guided procedures were shorter (89.1 ± 26.3 vs. 99.8 ± 30.0 minutes, p=0.0087) with less general anesthesia (26.6% vs. 98.8%, p<0.0001). One-year composite adverse outcomes did not differ significantly (80.7% vs. 88.9%, P=0.17). In conclusion, the protocol to select appropriate patients for ICE vs. TEE guidance for LAAO is safe and effective. Larger studies are indicated to validate this approach to improve outcomes, shorten procedures, and avoid general anesthesia.

Imaging of the Mitral Valve.

Echocardiographic imaging is the foundation for the evaluation of mitral valve dysfunction. Both transthoracic and transesophageal echocardiography provide insight into the anatomy, pathology, and classification mitral valve dysfunction. Echocardiography also provides a multi-parametric approach with semi-quantitative and quantitative parameters to assess the severity of mitral regurgitation and mitral stenosis. Transesophageal imaging is essential in the assessment of patients considered for surgical or transcatheter interventional strategies to treat mitral valve dysfunction. Cardiac computed tomography (CT) and cardiac MRI are useful adjunctive imaging techniques in mitral valve disease with CT providing detailed procedural specificity and MRI providing detailed ventricular and regurgitant flow analysis.

Renal cell carcinoma with an "uncoiling" tumor thrombus: intraoperative shift from level III to level IV.

BACKGROUND: The gold standard treatment for renal cell carcinoma (RCC) with tumor thrombus (TT) is complete surgical excision. The surgery is complex and challenging to the surgeon, especially with large tumor thrombus extending into the inferior vena cava (IVC) and right atrium. Traditionally, these difficult cases required the use of cardiopulmonary bypass (CPB) with or without deep hypothermic cardiac arrest, but in recent years, different surgical techniques derived from the field of liver transplantation have been used in efforts to avoid CPB. CASE PRESENTATION: We present a case of RCC with TT level IIIc (extending above major hepatic veins) that "uncoiled" intraoperatively into the right atrium after division of the IVC ligament, transforming into a level IV TT. Despite the new TT extension, the surgery was successfully completed exclusively through an abdominal approach without CPB and while using intraoperative transesophageal echocardiography (TEE) monitoring and a cardiothoracic team standby. CONCLUSIONS: This case highlights the need for a multidisciplinary approach and the utility of intraoperative continous TEE monitoring which helped to visualize the change of the TT venous extension, allowing the surgical teamto modify their surgical approach as needed avoiding a catastrophic event.

Application of echocardiography in transcatheter aortic valve replacement in patients with severe aortic regurgitation and correlation analysis of postprocedural complications.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is gradually becoming an alternative therapy for patients who cannot adapt to surgical treatment or have contraindications. OBJECTIVES: The purpose of this study was to investigate the value of echocardiography in the evaluation of severe AR patients treated with TAVR and to analyze the correlations with postprocedural complications to improve the evaluation and screening of patients. METHODS: We retrospectively analyzed clinical and echocardiographic data of 70 patients with severe AR. Periaortic valve structures were carefully measured by esophageal echocardiography (TEE) and compared with the multilayer slice computed tomography (MSCT) findings. Real-time three-dimensional esophageal echocardiography (RT-3D TEE) was monitored during the operation, and a 30-day postprocedural follow-up was performed. The relationship between postprocedural complications and patients' clinical data or periaortic valve structures was analyzed by multifactorial analysis to identify relevant predictors of complications. RESULTS: The TEE measurements of periaortic valve structures were in good agreement with the MSCT measurements. Among the patients who underwent successful operations, both left atrial (LA) and left ventricular (LV) diameters were reduced, and the left ventricular ejection fraction (LVEF) was improved 30 days after TAVR compared with the preprocedural period (P < .05). Permanent pacemakers were implanted in 15 patients. The presence of preprocedural right bundle branch block (RBBB) (OR: 2.93; 95% CI: 1.18-12.70; P = .01) was an independent factor for permanent pacemaker implantation after TAVR. CONCLUSIONS: Echocardiography plays an extremely important role in TAVR procedures. The presence of preprocedural RBBB can be an independent predictor of postprocedural pacemaker implantation.

Nomogram to predict recurrence risk factors in patients with non-valvular paroxysmal atrial fibrillation after catheter radiofrequency ablation.

BACKGROUND: Radiofrequency catheter ablation (RFCA) is an effective method for controlling the heart rate of paroxysmal atrial fibrillation (PAF). However, recurrence is trouble under the RFCA. To gain a deeper understanding of the risk factors for recurrence in patients, we created a nomogram model to provide clinicians with treatment recommendations. METHODS: A total of two hundred thirty-three patients with PAF treated with RFCA at Guizhou Medical University Hospital between January 2021 and December 2022 were consecutively included in this study, and after 1 year of follow-up coverage, 166 patients met the nadir inclusion criteria. Patients with AF were divided into an AF recurrence group and a non-recurrence group. The nomogram was constructed using univariate and multivariate logistic regression analyses. By calculating the area under the curve, we analyzed the predictive ability of the risk scores (AUC). In addition, the performance of the nomogram in terms of calibration, discrimination, and clinical utility was evaluated. RESULTS: At the 12-month follow-up, 48 patients (28.92%) experienced a recurrence of AF after RFCA, while 118 patients (71.08%) maintained a sinus rhythm. In addition to age, sex, and TRV, LAD, and TTPG were independent predictors of recurrence of RFCA. The c-index of the nomogram predicted AF recurrence with an accuracy of .723, showing good decision curves and a calibrated nomogram, as determined by internal validation using a bootstrap sample size of 1000. CONCLUSION: We created a nomogram based on multifactorial logistic regression analysis to estimate the probability of recurrence in patients with atrial fibrillation 1 year after catheter ablation. This plot can be utilized by clinicians to predict the likelihood of recurrence.

The Role of Transesophageal Echocardiogram in the Diagnosis and Treatment of Intracardiac Tumors: A Case of Atrial Myxoma.

Cardiac myxoma is the most common primary heart tumor in adults. Although biologically benign, they can be life-threatening by obstructing heart function. They typically develop in the left atrium and can be polypoid (causing more obstruction) or papillary (more likely to cause embolizations). Symptoms are nonspecific, and diagnosis is relatively rare. Echocardiography is essential for quick diagnosis, and surgical removal is the primary treatment with low mortality rates, excellent postoperative survival, and low recurrence rates. We report a 73-year-old woman presented to the emergency room with extreme fatigue and weight loss. Further investigations revealed a mass in the left atrium suggestive of an intracardiac tumor on a thoracic computer tomography scan. A subsequent transesophageal echocardiogram was performed, which showed a large, mobile, and friable hyperechogenic intra-auricular mass adhered to the atrial septum with moderate mitral regurgitation and moderate aortic stenosis. This case highlights the crucial role that the transesophageal echocardiogram plays in these patients by accelerating diagnosis, assisting with myxoma resolution, and confirming the complete removal of the myxoma.

Decision making of iatrogenic coronary embolism after SAVR: a case report.

BACKGROUND: Acute coronary artery obstruction is a rare but lethal complication of surgical aortic valve replacement (SAVR), which may be caused by embolization of resected native tissue such as calcium plaque, thrombus, or perivalvular aortic tissue like fat embolus. Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are the main treatment modalities. PCI is less invasive, but it is difficult to determine its feasibility intraoperatively. CASE PRESENTATION: We report an 86-year-old woman who had asymptomatic severe aortic stenosis. She had scleroderma with an intractable left leg ulcer and bilateral leg varices. Considering the possibility of the spread of infection from the leg wound, SAVR was performed via right anterior thoracotomy to avoid complications such as mediastinitis. Coronary artery occlusion was suspected after weaning of cardiopulmonary bypass in the operation room due to asynergy with ST elevation and new severe mitral regurgitation. Transoesophageal echocardiography (TEE) helped diagnose coronary obstruction by embolus based on the degree of stenosis and the movement of the stenosis site. Percutaneous catheter intervention was performed successfully to restore coronary perfusion. CONCLUSION: TEE facilitated the diagnosis of coronary artery stenosis caused by an embolus and helped in determining the feasibility of percutaneous catheter intervention, thus allowing us to choose PCI over CABG as a less invasive surgery. This is especially invaluable in cases where obtaining a saphenous graft for CABG is difficult or where CABG would have required conversion from minimally invasive surgery (anterolateral approach) to median sternotomy.

Coexistence Case of Papillary Fibroelastoma and Lambl's Excrescence of the Left Heart, Which Is Occasionally Associated with Significant Stroke.

Papillary fibroelastoma (PFE) is a benign tumor that arises mostly from left-sided valves. PFE can cause stroke, and surgical resection may be needed. Lambl's excrescence (LE) is a filiform valvular lesion and is considered a possible cause of stroke. A 79-year-old man with light-headedness and left-sided hemiparesis was diagnosed with stroke. Transesophageal echocardiography (TEE) revealed a round-shaped mobile mass in the left ventricular outflow tract (LVOT), which was considered the cause of the stroke. Surgical resection was performed transaortically, and during surgery, a mass was incidentally detected on the noncoronary cusp (NCC), which was also resected followed by aortic valve replacement. Pathology confirmed that the mass in the LVOT was a PFE and that the filiform mass on the NCC was LE. We herein report a rare case of PFE in the LVOT and coexisting LE on the NCC. A careful examination via TEE helps to identify other possible causes of stroke hidden behind the obvious cause.

Quantification of Mitral Regurgitation in Mitral Valve Prolapse by Three-Dimensional Vena Contracta Area: Derived Cutoff Values and Comparison With Two-Dimensional Multiparametric Approach.

BACKGROUND: Echocardiographic grading of mitral regurgitation (MR) in mitral valve prolapse (MVP) is challenging. Three-dimensional (3D) vena contracta area (VCA) has been proposed as a valuable method. However, data defining the cutoff values of severity and validation in the subset of patients with MVP are scarce. The aim of this study was to validate the 3D VCA by 3D color-Doppler transesophageal echocardiography (TEE) in patients with MVP and to define the cutoff values of severity grading. The secondary aim was to compare 3D VCA to the effective regurgitant orifice area estimation by proximal isovelocity surface area (EROA-PISA) method. METHODS: A total of 1,138 patients with at least moderate MR who underwent TEE were included. Three-dimensional VCA was measured, and the cutoff value and area under the curve (AUC) for the prediction of severe MR were estimated by receiver operating characteristic curve using a guideline-suggested multiparametric approach as the reference standard. In a subgroup of patients, 3D regurgitant volume (RV) and 3D fraction were calculated from mitral and left ventricular outflow tract stroke volumes to further validate 3D VCA against a 3D volumetric reference standard. RESULTS: The optimal 3D VCA cutoff value for predicting severe MR was 0.45 cm2 (specificity, 0.87; sensitivity, 0.90) with an AUC of 0.95 using a multiparametric approach as reference. Three-dimensional VCA had a good linear correlation with EROA-PISA (r = 0.62, P < .05) with larger values compared to EROA-PISA (0.63 cm2 vs 0.44 cm2, P < .05). A cutoff of 0.50 cm2 (AUC of 0.84; sensitivity, 0.78; specificity, 0.78) predicts an EROA-PISA of 0.40 cm2. Three-dimensional VCA had a good linear correlation with 3D RV (r = 0.56, P < .01), with an AUC of 0.86 to predict a 3D fraction >50%. CONCLUSIONS: The present study suggests 0.45 cm2 as the best cutoff value of 3D VCA to define severe MR in patients with MVP, showing an optimal agreement with the reference standard multiparametric approach and 3D RV.

Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis.

INTRODUCTION AND OBJECTIVES: Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. METHODS: From 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. RESULTS: The prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. CONCLUSIONS: Valvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.