Catheter ablation of atrial fibrillation facilitated by preprocedural three-dimensional transesophageal echocardiography: Long-term outcome

AIM To evaluate the long-term outcome of catheter ablation of atrial fibrillation(AF) facilitated by preprocedural threedimensional(3-D) transesophageal echocardiography.METHODS In 50 patients, 3D transesophageal echocardiography(3D TEE) was performed immediately prior to an ablation procedure(paroxysmal AF: 30 patients, persistent AF: 20 patients). The images were available throughout the ablation procedure. Two different ablation strategies were used. In most of the patients with paroxysmal AF, the cryoablation technique was used(Arctic Front Balloon, Cryo Cath Technologies/Medtronic; group A2). In the other patients, a circumferential pulmonary vein ablation was performed using the CARTO system [Biosense Webster; group A1(paroxysmal AF), group B(persistent AF)]. Success rates and complication rates were analysed at 4-year follow-up.RESULTS A 3D TEE could be performed successfully in all patients prior to the ablation procedure and all four pulmonaryvein ostia could be evaluated in 84% of patients. The image quality was excellent in the majority of patients and several variations of the pulmonary vein anatomy could be visualized precisely(e.g., common pulmonary vein ostia, accessory pulmonary veins, varying diameter of the left atrial appendage and its distance to the left superior pulmonary vein). All ablation procedures could be performed as planned and almost all pulmonary veins could be isolated successfully. At 48-mo followup, 68.0% of all patients were free from an arrhythmia recurrence(group A1: 72.7%, group A2: 73.7%, group B: 60.0%). There were no major complications.CONCLUSION3 D TEE provides an excellent overview over the left atrial anatomy prior to AF ablation procedures and these procedures are associated with a favourable long-term outcome.

Research and Application of Transnasal Transesophageal Echocardiography Probe

The intubation of conventional transesophageal echocardiography（TEE） probes into patients causes serious esophagus irritation, and thus the use of TEE probes in pediatric practice is limited. In this study, we aimed at the development of a special probe which could be inserted through the nasopharyngeal cavity into the esophagus to obtain the same high-quality echocardiography images as those obtained by conventional TEE and improve patients＇ experience. During the examination, the patients felt relaxed for a longer time and cooperated with the sonographers in the process of cardiac catheterization conducted in the surgery room or the intensive care unit（ICU）, resulting in improved accuracy of the diagnosis and timely administration of appropriate treatment. Two years ago, Prof. Xin-fang WANG put theories into practice by inserting the probe through the nasal cavity and pharynx into the esophagus of volunteers to successfully detect the heart and great vessels at the retrocardiac space. Later, Prof. Ming-xing XIE performed the transnasal TEE examination in 12 atrial septal defect（ASD） patients and proved the safety and reliability of this method, which could become a new way for clinical diagnosis and treatment.

Noninvasive Assessment of Cardiac Index with Transesophageal Echocardiography in Patients Undergoing Mitral Valve Replacement: A Comparison between Determinations at the Mitral Valve and the Ascending Aorta

Methods: Sixteen patients with American Society of Anesthesiologists status (ASA) II-III, age ≤ 70 yr, male or female, preoperatively NYHA II-III and EF ≥ 45%, scheduled for mitral valve replacement (MVR) were studied. Complete intravenous general anesthesia was used for induction and anesthesia maintenance. After anesthesia induction we put the TEE probe into the esophagus. The cardiac index was determined at three periods following MVR: T1 30 minutes later following cessation of bypass, T2 60 minutes after cessation of bypass, T3 90 minutes after cessation of bypass. Statistical analysis was made with the Bland and Altman method. Results: Ninety-six measurements were compared. The cardiac index values at the level of prosthesis mitral valve (CIMV) ranged from 1.3 to 5.5 L·min-1·m-2 (mean 2.6 ± 0.9). The Values of cardiac index at aortic valve (CIAA) ranged from 2.7 to8.8 L·min-1·m-2 (mean 4.9 ± 1.7). Bias was -2.3 L·min-1·m-2 and limits of agreement -5.6 to 1.0 L·min-1·m-2. Conclusion: During mitral valve replacement, doubtful correlations were observed between values of cardiac index at the mitral valve and the ascending aorta using TEE.

Surgical Resection of Mitral Valve Papillary Fibroelastoma: A Robot-Assisted, Minimally Invasive Approach with Three-Dimensional Transesophageal Echocardiography Imaging

Papillary fibroelastomas (PFEs) are benign tumors of the endocardium that most frequently affect cardiac valves and typically present with embolic symptoms such as stroke or transient ischemic attack (TIA). Surgical excision is usually recommended for left-sided tumors and is associated with excellent long-term outcomes. The use of a robot-assisted, minimally invasive surgical approach for management of mitral valve disease is growing, and has been associated with shorter hospital stays and improved early quality of life. Three-dimensional (3D) transesophageal echocardiography (TEE) offers several advantages in the assessment of mitral valve disease and cardiac tumors, including the ability to precisely locate the site of attachment of the mass and the spatial relationships to surrounding structures. These factors are particularly important when planning a surgical approach. We report two cases of mitral valve PFEs which were successfully removed using a robot-assisted, minimally invasive surgical approach with 3D TEE imaging. This approach to treatment of PFEs is an attractive alternative to the traditional approach involving median sternotomy.

Role of intraoperative transesophageal echocardiography in coronary artery bypass grafting

Transesophapeal echocardiography （TEE） can be used as a diagnostic tool during cardiac surgery to direct the surgical procedure and diagnose unanticipated problems. TEE has also been one of the most important means of monitoring myocardial ischemia dur- ing coronary artery bypas grafting procedures. The cardiac anesthesiologist can apply intraoperative TEE in evaluating coronary artery anatomy and aorta atherosclerosis, assessing diastolic left ventricular function and preload,measuring intracardiac pressure and cardiac output,detecting ischaemic mitral regurgitation,intracardiac air and pericardial effusion.

Assessment of left atrial appendage function by transesophageal echocardiography in patients two weeks after acute coronary syndromes

For many years in ischemic heart disease, ventricles rather than atria received attention so not much is known about left atrial function in left ventricular ischemia. Objective Our study aimed to evaluate left atrial appendage (LAA)function by means of biplane transesophageal echocardiography in patients ten days after acute coronary syndromes (ACS).Methods The study was performed on 16 adult patients (65.9±9.9 years old) in whom transesophageal echocardiography was done 10 days after ACS. The following left atrial appendage (LAA) planimetric parameters were analyzed: LAA transversal dimension, LAA longitudinal dimension,LAA maximal area, and LAA minimal area. LAA ejection fraction was calculated and analyzed. The following LAA Doppler parameters were analyzed: the peak LAA emptying and the peak LAA filling velocities.The control group consisted of 14 patients (43±14.6 years old) without cardiovascular diseases. Results Both LAA longitudinal dimension and LAA transversal dimension were significantly higher in patients with ACS than in control patients. The same was observed for LAA maximal area. Also LAA ejection fraction was higher in patients with ACS. LAA minimal area did not differ in the patients in either group. LAA peak emptying flow (LAAE) and LAA peak filling flow (LAAF) were significantly higher in patients of the study group than of the control group. Conclusion Our study shows that two weeks after acute coronary syndrome LAA as a reservoir as well as a pump works at a higher level than it does in the control group.

Clinical Application of Three－dimensional Transesophageal Echocardiography in the Diagnosis of Atrial Septal Defect

This paper reports the use of three-dimensional (3-D) transesophageal echocardiography(TEE) in the diagnosis of atrial septal defect. The results displayed that the interatrial septum had integrity in normal persons. The size,shape and position of atrial septal defects could be showed clearly and the type of the defects could be identified. The reconstructed imaging of interatrial septum on 3-D TEE was clear and stereoscopic. The technique is helpful in defining spatial location and extent of atrial septal defects.

Feasibility of percutaneous closure of left atrial appendage under the guidance of transesophageal echocardiography without fluoroscopy

Background In an effort to avoid x-ray and contrast agents for patients of atrial fibrillation(AF)with chronic kidney disease,we developed a method for transcatheter closure of left atrial appendage(LAA)under the guidance of transesophageal echocardiography(TEE)without fluoroscopy.

Is transesophageal echocardiography needed for evaluating tissue-based transient ischemic attack？

Transient ischemic attack（TIA） is a warning signal for stroke.A comprehensive evaluation of TIA may reduce the risk for subsequent stroke.Data on the findings of cardiac evaluation with transesophageal echocardiography（TEE） in patients with TIA are sparse.Our aims were to determine the frequency of TEE performance and to investigate the findings of TEE in patients with TIA based on the new definition of TIA（i.e.,transient neurological symptoms without evidence of infarction）.During a 4-year period（2011–2014）,1071 patients（mean age,70 ± 13 years;female,49.7%） with TIA were included in a prospective study and evaluated.Of 1071 consecutive patients suffering from TIA,288 patients（27%） underwent TEE.The median time between admission and TEE was 6 days.Patients with TIA who were evaluated by TEE were younger（67 vs.71 years,P 〈 0.001） than those who were not evaluated by TEE.They had a higher rate of sensibility disturbance as a TIA symptom（39% vs.31%,P = 0.012） but a lower rate of previous stroke（15% vs.25%,P = 0.001） and atrial fibrillation（2% vs.21%,P 〈 0.001） than those who did not.Foramen ovale was detected in 71 patients（25.7%）,atrial septal aneurysm in 13 patients（4.6%）,and severe atherosclerotic plaques（grade 4 and 5） in the aortic arch in 25 patients（8.7%）.One patient（0.3%） had a fibroma detected by TEE.In 17 of the 288 patients（6%） who underwent TEE,the indication for anticoagulation therapy was based on the TEE results,and 1 patient with fibroma underwent heart surgery.During hospitalization,7 patients experienced a subsequent stroke,and 27 patients had a recurrent TIA.At 3 months following discharge,the rates of readmission,stroke,recurrent TIA,and death were 19%,2.7%,4.2%,and 1.6%,respectively.The rates of mortality（0.9% vs.1.8%,P = 0.7）,stroke risk（1.9% vs.3.0%,P = 0.8）,and recurrent TIA（5.0% vs.3.9%,P = 0.8） were similar in patients who underwent TEE and in those who did not.Performing TEE in patients with tissue-based TIA is helpful in detecting cardiac sources for embolism and may indicate for anticoagulation.

Geometric comparison of the mitral and tricuspid valve annulus:Insights from three dimensional transesophageal echocardiography

AIM To apply real time three-dimensional transesophageal echocardiography(RT3D TEE) for quantitative and qualitative assessment of the mitral valve annulus(MVA) and tricuspid valve annulus(TVA) in the same patient.METHODS Our retrospective cohort study examined the MVA and TVA in 49 patients by RT3 D TEE. MVA and TVA shape were examined by TEE. The MVA and TVA volume data set images were acquired in the mid esophageal 4-chamber view. The MVA and TVA were acquired separately, with optimization of each for the highest frame rate and image quality. The 3D shape of the annuli was reconstructed using the Philips~? Q lab, MVQ ver. 6.0 MVA model software. The end-systolic frame was used. The parameters measured and compared were annular area, circumference, high-low distances(height), anterolateralposterolateral(ALPM), and anteroposterior(AP) axes. RESULTS A total of 49 patients(mean age 61 ± 14 years, 45% males) were studied. The ALPM and the AP axes of the MVA and TVA are not significantly different. The ALPM axis of the MVA was 37.9 ± 6.4 mm and 38.0 ± 5.6 mm for the TVA(P = 0.70). The AP axis of the MVA was 34.8 ± 5.7 mm and 34.9 ± 6.2 mm for the TVA(P = 0.90). The MVA and the TVA had similar circumference and area. The circumference of the MVA was 127.9 ± 16.8 mm and 125.92 ± 16.12 mm for the TVA(P = 0.23). The area of the MVA was 1103.7 ± 307.8 mm^2 and 1131.7 ± 302.0 mm^2 for the TVA(P = 0.41). The MVA and TVA are similar oval structures, but with significantly different heights. The ALPM/AP ratio for the MVA was 1.08 ± 0.33 and 1.09 ± 0.28 for the TVA(P < 0.001). The height for the MVA and TVA was 9.23 ± 2.11 mm and 4.37 ± 1.48 mm, respectively(P < 0.0001). CONCLUSION RT3 D TEE plays an unprecedented role in the management of valvular heart disease. The specific and exclusive shape of the MVA and TVA was revealed in our study of patients studied. Moreover, the intricate codependence of the MVA and the TVA depends on their distinctive shapes. This realization seen from our study will allow us to better understand the role valvular disease plays in disease states such as hypertrophic cardiomyopathy and pulmonary hypertension.

Assessment of Right Coronary Artery Fistula by Multiplane Transesophageal Echocardiography

Coronary artery fistula(CAF) is a relatively uncommon cardiovascular disease. It is an abnormal communication between a coronary artery and a cardiac chamber, great vessels, or other vascular structures. Most are congenital. Multiplane transesophageal echocardiography(multiplane TEE. MTEE) can reveal the proximal dilation, the course and the drainage site of CAF. Presented in this paper was a report of right coronary artery-left ventricle fistula , for the first time,right coronary-left ventricle fistula diagnosed by MTEE and confirmed by angiography.

Upper gastrointestinal bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography during successful cardiopulmonary resuscitation:A case report

BACKGROUND In recent years,it has been recognized that transesophageal echocardiography(TEE)is of great value in resuscitation of cardiac arrest.However,its safety has rarely been reported.CASE SUMMARY We present a 59-year-old male patient scheduled to undergo cardiac surgery for rheumatic heart disease.Upper gastrointestinal bleeding from a Mallory-Weiss tear appeared following cardiopulmonary resuscitation,TEE,and percutaneous cardiopulmonary bypass resuscitation when he suffered from aesthesia-related cardiac arrest.Gastrointestinal injury was diagnosed promptly and treated effectively.However,the exact etiology of gastrointestinal injury was unclear;the interaction of closed-chest cardiac massage and the application of TEE may be involved as a most possible mechanism of injury.CONCLUSION Serious complications should be considered when TEE is used in patients with special pathophysiological conditions.

Large Anterior Mediastinal Mass: Intraoperative Transesophageal Echocardiography Guided Evaluation and Management

The authors report a case of Large Anterior mediastinal mass in which Transoesophageal Echocardiography (TEE) revealed a large mass that was compressing the right atrium, SVC, henceforth, TEE helped in guiding aspiration and surgical resection of the cystic mass. Therefore, through this case report, authors emphasize the importance of performing intraoperative real-time TEE in the mediastinal mass. This imaging technique helps in visualizing the external compression of cardio-vascular structure and aid in their management, obviating the possibility of large vascular structures from being injured by the surgeon during intraoperative manipulation.

Atherosclerotic aortic plaques detected by transesophageal echocardiography

Objective To evaluate the predictive value of atherosclerotic aortic plaques in coronary artery disease (CAD). Methods In 50 patients with suspected coronary artery disease, transesophageal echocardiography was performed to examine their thoracic aortas 2 weeks before or after coronary angiography. In the cases of coronary angiography studied, stenosis of the coronary artery ≥50%was considered to be due to coronary artery disease, whereas the thickness of the intima ≥1.3 mm was taken to be the criteria for the presence of an atherosclerotic aortic plaque on the transesophageal echocardiographic test. Results Among the 50 patients, 37 cases were diagnosed as CAD and 13 cases were considered to be normal. The plaques of the thoracic aorta were observed in 34 cases in the CAD group and 3 cases in the normal group. The sensitivity and specificity of aortic plaques for CAD were 91.9%and 76.9%, respectively. The positive and negative predictive values of the aortic plaques for CAD were 91.9%and 76.9%, respectively. The accuracy was 88.0%. 80 percent of the patients with single-vessel disease had thoracic aortic plaques, 92 percent of the patients with two vessel disease and 100 percent of the patients with three vessel disease had thoracic aortic plaques. There was a significant difference in the thickness of aortic intimas between the normal group and the CAD group. Conclusions Detecting atherosclerotic plaques in the thoracic aorta with transesophageal echocardiography may be of great value in predicting the presence and extent of coronary artery disease.

Evaluate of transesophageal echocardiography during lung transplantation

Objective To investigate the clinical value of transesophageal echocardiography during the lung transplantation. Methods From August 2005 to August 2009, 19 patients with advanced lung diseases received lung transplantation. The average age was (48. 35 ± 13. 04) years. The echocardiographic probe was placed in patient’ s esophagus before surgery. The left and right

Role of real-time three-dimensional transesophageal echocardiography in mitral valve repair

Background and objective Pre-operative assessment of mitral valve (MV) anatomy is essential to surgical design in patients undergoing MV repair.Although 2-dimensional (2D) echocardiography provides precise information regarding MV anatomy,RT-3D TEE could increase the understanding of MV apparatus and individual scallop identification.We aimed to investigate the value of RT- 3DTEE in MV repair.Methods RT-3DTEE was performed in six patients with mitral valve prolapse (MVP) by using Philips 1E33 with X7-2t probe.Preoperative RT-3DTEE studies were compared with surgical findings in patients undergoing surgical mitral valve repair,and quantitative evaluation was performed by QLab 6.0 software before and after surgical mitral valve repair.Results RT- 3DTEE could display dynamic morphology of MV,the location of prolapse,and spatial relation to the surrounding tissue.It could provide surgical views of the valves and the valvular apparatus.These results were consistent with surgical findings.The quantitative evaluation before and after surgical MV repair indicated that anterolateral to posteromedial diameter of annulus,anterior to posterior diameter of annulus,perimeter of annulus,and area of annulus in projection plane were significantly smaller after operation compared with those before operation (P【0.05).The length of posterior leaflet,the area of anterior and posterior leaflet,the maximal prolapse height,the volume of leaflet prolapse and the length of coaptation in projection plane were significantly reduced after operation (P【0. 05).Conclusion RT-3DTEE is a unique new modality for rapid and accurate evaluation ofmitral valve prolapse and mitral valve repair.

Effects of sevoflurane on left ventricular function by speckletracking echocardiography in coronary bypass patients: A randomized trial

The present study aimed to dynamically observe the segmental and global myocardial movements of the left ventricle during coronary artery bypass grafting by transesophageal speckle-tracking echocardiography,and to assess the effect of sevoflurane on cardiac function.Sixty-four patients scheduled for the off-pump coronary artery bypass grafting were randomly divided into a sevoflurane-based anesthesia(AS)group and a propofolbased total intravenous anesthesia(AA)group.The AS group demonstrated a higher absolute value of left ventricular global longitudinal strain than that of the AA group at both T1(after harvesting all grafts and before coronary anastomosis)and T_(2)(30 min after completing all coronary anastomoses)(P<0.05).Moreover,strain improvement in the segment with the highest preoperative strain was significantly reduced in the AS group,compared with the AA group at both T1 and T_(2)(P<0.01).The flow of the left internal mammary artery-left anterior descending artery graft was superior,and the postoperative concentration of troponin T decreased rapidly in the AS group,compared with the AA group(P<0.05).Compared with total intravenous anesthesia,sevoflurane resulted in a significantly higher global longitudinal strain,stroke volume,and cardiac output.Sevoflurane also led to an amelioration in the condition of the arterial graft.Furthermore,sevoflurane significantly reduced strain improvement in the segmental myocardium with a high preoperative strain value.The findings need to be replicated in larger studies.

Utility of Intraoperative Transesophageal Echocardiography in Pulmonary Thromboendarterectomy

Chronic thromboembolic pulmonary hypertension is one of the few forms of pulmonary hypertension that can be cured surgically, being the pulmonary trhomboendarterectomy (PTE) the therapeutic approach of choice, with survival as high as 75% to 90% at 5 years. Our case report focuses on the intraoperative use on the transesophageal echocardiography, which has proven to be of outmost utility in PTE surgery. Two cases of pulmonary thromboendarterectomy are described, in which transesophageal echocardiography was the key factor in the intraoperative management, indicating the initiation time of nitric oxide in case number one and contraindicating the advancement of the pulmonary artery catheter in case number two, due to a mobile thrombus located in the right ventricular outflow tract.

A cadaveric model for transesophageal echocardiography transducer placement training: A pilot study

BACKGROUND: Transesophageal echocardiography(TEE) is used in the emergency department to guide resuscitation during cardiac arrest. Insertion of a TEE transducer requires manual skill and experience, yet in some residency programs cardiac arrest is uncommon, so some physicians may lack the means to acquire the manual skills to perform TEE in clinical practice. For other infrequently performed procedural skills, simulation models are used. However, there is currently no model that adequately simulates TEE transducer insertion. The aim of this study is to evaluate the feasibility and efficacy of using a cadaveric model to teach TEE transducer placement among novice users.METHODS: A convenience sample of emergency medicine residents was enrolled during a procedure education session using cadavers as tissue models. A pre-session assessment was used to determine prior knowledge and confidence regarding TEE manipulation. Participants subsequently attended a didactic and hands-on education session on TEE placement. All participants practised placing the TEE transducer until they were able to pass a standardized assessment of technical skill(SATS). After the educational session, participants completed a post-session assessment. RESULTS: Twenty-five residents participated in the training session. Mean assessment of knowledge improved from 6.2/10 to 8.7/10(95% confidence interval [CI] of knowledge difference 1.6–3.2, P<0.001) and confidence improved from 1.6/5 to 3.1/5(95% CI of confidence difference 1.1–2.0, P<0.001). There was no relationship between training level and the delta in knowledge or confidence.CONCLUSIONS: In this pilot study, the use of a cadaveric model to teach TEE transducer placement methods among novice users is feasible and improves both TEE manipulation knowledge and confidence levels.

OMNIPLANE TRANSESOPHAGEAL ECHOCARDIOGRAPHY IMAGING PLANES EXPLORATION

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