Echocardiography, Transesophageal

Overall, one-third of thromboembolic events originated from the heart. Left atrial appendage (LAA) and its anatomic complexity has been implicated in 90% of cases of thrombus formation and cardioembolic events in patients with non-valvular atrial fibrillation (AF). Risk scores to predict thromboembolism from AF, such as CHADS₂ and CHA₂DS₂VASc are widely used to guide anticoagulation therapy and varies in relation to comorbidities associated with the thrombogenic substrate; however, because of its clinical conception, they did not include atrial anatomy (atrial enlargement), function (flow velocities) and electrophysiology (atrial fibrillation burden). Patients with CHA₂DS₂VASc score ≥ 2 are at intermediate or higher risk (event rate ≥ 2-3%/year) and anticoagulation is recommended. Left atrial variables such as LAA function and morphology, routinely studied by transesophageal echocardiography (TEE), were not considered in these scores.

In 2012, Di Biase et al.; published a retrospective study of 932 patients with AF and computed tomography (CT)/magnetic resonance imaging (MRI) classification of four different types of LAA morphologies: chicken wing, cactus, windsock and cauliflower. Non-chicken wing categories were 4 to 8 times more likely to have had stroke/TIA. Eight additional cross-sectional studies utilizing this classification for LAA morphology in 2,210 patients (6 with CT and 2 with TEE), found a significant association with non-chicken-wing morphology and stroke in 5 series^– and no significant difference in 3 other studies.^–

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Original Article

Association between Morphodynamic Variables by Transesophageal Echocardiography and CHA2DS2-Vasc Values

Renata Rejane Linhares et al. Dalmo Antonio Ribeiro Moreira Luciana Braz Peixoto Andresa Paes da Cruz … Luara Piovam Garcia Rodrigo Bellio de Mattos Barretto David Costa de Souza Le Bihan Carlos Eduardo Suaide Silva

Abstract

Background:

In atrial fibrillation (AF), the CHA₂DS₂-VASc score calculates the risk for stroke. Di Biase classified the left atrial appendage (LAA), using magnetic resonance imaging, into 4 morphological types and correlated it with cerebrovascular events. Transesophageal echocardiography (TEE) also evaluates LAA and is a more widespread technique.

Objective:

To evaluate, using TEE, the possibility of characterizing LAA and to analyze its morphological aspects using the CHA₂DS₂VASc score.

Methodology:

A total of 247 patients were divided into three groups considering the CHA₂DS₂-VASc score: Group 1: 0 and 1; Group 2: 2 and 3 and, Group 3: ≥ 4 points. TEE produced the echocardiographic data. LAA was classified into thrombogenic and non-thrombogenic morphologies. In the analysis of statistical tests, a significance level of 5% was adopted.

Results:

The average age was 50 and 16.2% presented AF. In Group 1, we observed normal variables with a lower prevalence of AF (8.7%, p < 0.001). In group 2, spontaneous contrast was detected in 26.7%, (p < 0.001), thrombus in 6.7% (p = 0.079) and flow velocity in LAA < 0.4 m/s in 22.7% (p < 0.001) of the cases. Group 3 presented the highest percentages of AF (31.8%, p < 0.001), stroke/TIA (77.3%, p < 0.001), EF < 55% (18.2%, p = 0.010) and higher prevalence of thrombogenic type LAA (72.7%, p = 0.014). A higher occurrence of stroke/TIA was observed in patients with thrombogenic LAA (25.2%) compared to the non-thrombogenic group (11.2%), (p = 0.005).

Conclusions:

The thrombogenic morphology of LAA identified in TEE presented a higher risk of stroke regardless of the CHA₂DS₂VASc score. Patients with higher scores had greater abnormalities in echocardiographic variables.

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Challenging Evaluation of Aortic Regurgitation: More Than a Quadricuspid Valve

Gonçalo Pestana et al. Carla Sousa Teresa Pinho Sara Maia M. Júlia Maciel

A 61-year-old female patient with chronic obstructive pulmonary disease, and no other comorbidities, was referred for cardiological assessment due to aggravated exertional dyspnea (New York Heart Association – NYHA class III) and atypical chest pain. Physical examination disclosed only a diastolic murmur in the second intercostal space in the right sternal border.

The transthoracic echocardiogram (TTE) showed aortic regurgitation (), with non-dilated cardiac chambers and preserved biventricular function. The acoustic window limited the evaluation of the valvular lesion severity and its importance in the context of the complaints, although the continuous Doppler spectrum suggested significant regurgitation (). The evaluation was further impaired by a systolic flow acceleration in the Left Ventricular Outflow Tract (LVOT), with no significant gradient and an undetermined cause. The aortic root had normal size, but it was not possible to carry out an adequate morphological and functional characterization of the valve.

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Cor Triatriatum Sinistrum

Hitesh Raheja et al. Vinod Namana Norbert Moskovits Gerald Hollander Jacob Shani

A 25-year-old male presented to clinic with complaints of palpitations. Transthoracic echocardiogram (TTE) showed presence of a membrane in left atrium suggestive of cor triatriatum []. This finding was confirmed with transesophageal echocardiogram (TEE), which revealed a membrane in the left atrium attaching at the Coumadin ridge and the atrial septum, just caudal to the fossa ovalis [].

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Original Article

Atrial Strain and Strain Rate: A Novel Method for the Evaluation of Atrial Stunning

Hakan Ozkan et al. Suleyman Binici Erhan Tenekecioglu Hasan Ari Tahsin Bozat

Abstract

Background:

Atrial fibrillation (AF) is the most common arrhythmia seen in adults. Atrial stunning is defined as the temporary mechanical dysfunction of the atrial appendage developing after AF has returned to sinus rhythm (SR).

Objectives:

We aimed to evaluate atrial contractile functions by strain and strain rate in patients with AF, following pharmacological and electrical cardioversion and to compare it with conventional methods.

Methods:

This study included 41 patients with persistent AF and 35 age-matched control cases with SR. All the AF patients included in the study had transthoracic and transesophageal echocardiography performed before and after. Septum (SEPsSR), left atrium (LAsSR) and right atrium peak systolic strain rate (RAsSR) were defined as the maximum negative value during atrial contraction and septum (SEPε), left atrium (LAε) and right atrium peak systolic strain (RAε) was defined as the percentage of change. Parameters of two groups were compared.

Results:

In the AF group, 1st hour and 24th hour LAε, RAε, SEPε, LAsSR, RAsSR, SEPsSR found to be significantly lower than in the control group (LAε: 2.61%±0.13, 3.06%±0.19 vs 6.45%±0.27, p<0.0001; RAε: 4.03%±0.38, 4.50%±0.47 vs 10.12%±0.64, p<0.0001; SEPε: 3.0%±0.22, 3.19%±0.15 vs 6.23%±0.49, p<0.0001; LAsSR: 0.61±0.04s-¹, 0.75±0.04s- ¹ vs 1.35±0.04s-¹, p<0.0001; RAsSR: 1.13±0.06s-¹, 1.23±0.07s-¹ vs 2.10±0.08s- ¹, p<0.0001; SEPsSR: 0.76±0.04s- ¹, 0.78±0.04s- ¹ vs 1.42±0.06 s- ¹, p<0.0001).

Conclusion:

Atrial strain and strain rate parameters are superior to conventional echocardiographic parameters for the evaluation of atrial stunning in AF cases where SR has been achieved.

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Case Report

Complicated Sinus of Valsalva Aneurysm Initially Diagnosed as Atrial Myxoma

Rafael Plens Teixeira et al. Pedro Felipe Gomes Nicz Felipe Lourenço Fernandes Renner Augusto Raposo Pereira … Roney Orismar Sampaio Flavio Tarasoutchi

Introduction

Atrial myxoma and sinus of Valsalva aneurysm (SVA) are rare conditions and possibly underdiagnosed in clinical practice. We report an unusual presentation of a left SVA after an episode of infective endocarditis (IE). The SVA extrinsically compressed the left main coronary artery (LMCA), which was initially diagnosed as a left atrial myxoma.

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Left Ventricular Pseudoaneurysm Secondary to Mitral Valve Endocarditis

Bruno Bochard-Villanueva et al. Jordi Estornell-Erill

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Artigo Original

Safety of transesophageal echocardiography in adults: study in a multidisciplinary hospital

Alexandre Ferreira Cury et al. Marcelo Luiz Campos Vieira Claudio Henrique Fischer Ana Clara Tude Rodrigues … Adriana Cordovil Claudia Monaco Gustavo Alberto Naccarato Glaucia Tavares Edgar Bezerra Lira Filho Laise Antonia Guimarães Samira Saady Morhy

BACKGROUND: TEE is a semi-invasive tool broadly used and its utilization associated to sedatives drugs might to affect the procedure safety. OBJECTIVE: to analyze aspects of TEE safety associated to the use of Midazolan (MZ) and Flumazenil (FL) and the influence of the clinical variables on the event rate. METHOD: prospective study with 137 patients that underwent TEE with MZ associated to moderate sedation. We analyzed the following events: complications related with the topical anesthesia, with MZ use and with the procedure. Uni- and multivariate analyses were used to test the influence of the clinical variables: age, sex, stroke, myocardiopathy (MP), duration of the test, mitral regurgitation (MR) and the MZ dose. RESULTS: All patients (65±16 yrs; 58% males) finished the examination. The mean doses of MZ and FL were 4.3±1.9 mg and 0.28±0.2 mg, respectively. The duration of the examination and the mean ejection fraction (EF) were 16.4±6.1 minutes and 60±9%, respectively. Mild hypoxia (SO2<90%) was the most common event (11 patients); 3 patients (2%) presented transient hypoxia due to upper airway obstruction by probe introduction and 8 (5.8%) due to hypoxia caused by MZ use. Transient hypotension (SAP<90mmHg) occurred in 1 patient (0.7%). The multivariate analysis showed that severe MR, MP (EF5mg) were associated with events (p<0.001). The EF was 40%, in the group with MP and 44% in the group with severe MR and it can be a factor associated with clinical events in the last group. CONCLUSION: TEE with sedation presents a low rate of events. There were no severe events and there was no need to interrupt the examinations.

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Case Report

Intraoperative transesophageal echocardiography in septal hypertrophic cardiomyopathy

Giovanni Giannini et al. Petherson S. Grativvol Marcelo L. C. Vieira Marcos de Oliveira … Luis A. Lisboa Sérgio A. de Oliveira

We report the case of a patient with septal hypertrophic cardiomyopathy undergoing surgical correction in which the use of intraoperative transesophageal echocardiography permitted the planning of the surgical approach and an immediate knowledge of the surgical outcome.

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