Transesophageal echocardiography – ABC CARDIOL

ABCIC

Review Article

My Approach to VExUS Assessment Using Transesophageal Echocardiography: A Step-by-Step Performance Guide

Angelo Antunes Salgado et al. Marcos Paulo Lacerda Bernardo Marcelo Ramalho Fernandes

ABSTRACT

Monitoring systemic venous congestion has become essential in the management of critically ill patients, enabling accurate diagnosis, severity grading, and prognostic stratification. Literature shows that congestion is strongly associated with the development of acute kidney injury and increased mortality when compared with optimized volume states.

In this setting, intraoperative Transesophageal Echocardiography (TEE) has emerged as an advanced and versatile tool. In addition to allowing detailed assessment of cardiac function, TEE is effective in assessing intravascular volume status and predicting fluid responsiveness through dynamic measurement of stroke volume and the degree of systemic congestion. TEE also enables direct visualization of abdominal vessels, such as the hepatic, portal, and intrarenal veins, thereby facilitating the identification of pathological pulsatile flow patterns even in patients with limited transthoracic acoustic windows.

The integration of protocols such as VExUS (or its modified version, mVExUS) allows for a personalized approach focused on “perfusion without congestion.” This review outlines the practical application of VExUS assessment using TEE, its technical limitations, and how to use it to guide hemodynamic resuscitation, minimizing organ injury and optimizing clinical outcomes.

Read Full Article

ABCIC

Image

Left Atrial Septal Pouch Thrombosis Detected Before Electrical Cardioversion: a Rare Source of Embolism

Andre Barcellos Amon et al. Mariana De Castro Lopes Marina Petersen Saadi Willian R. Menegazzo Angela Barreto Santiago Santos

A 59-year-old male patient with a history of systemic arterial hypertension was admitted to the emergency department with a seven-day history of chest pain and palpitations. On examination, he was hypotensive (93/70 mmHg) and tachycardic (150 bpm). A prominent systolic–diastolic murmur was heard along the right upper sternal border.

The initial investigation included electrocardiography (ECG) and Transthoracic Echocardiography (TTE). The ECG revealed atrial flutter, and the TTE showed biventricular dilation [Left Ventricular (LV) end-diastolic/end-systolic diameters: 60/51 mm; right ventricular (RV) basal diameter: 54 mm] and severe systolic dysfunction (LV ejection fraction: 19%; RV fractional area change: 16%). Additionally, a bicuspid aortic valve with mixed disease was identified: low-flow, low-gradient aortic stenosis (peak velocity: 3.1 m/s; peak/mean gradients: 39/23 mmHg; velocity ratio: 0.15; valve area: 0.7 cm, stroke volume index: 17 ml/m) and severe aortic regurgitation (pressure half-time: 170 ms; holodiastolic reversal in the descending aorta, end-diastolic velocity: 24 cm/s).

[…]

Read Full Article

ABCIC

Review Article

Tricuspid Valve: Anatomical Basis and Patient Selection Criteria for Transcatheter Structural Interventions

Alexandre Costa Souza et al. Halsted Alarcão Gomes Pereira da Silva Alex dos Santos Felix

Abstract

Tricuspid regurgitation has been recognized as a relevant clinical entity, with a direct impact on morbidity and mortality. Recent advances in multimodal cardiovascular imaging have promoted more detailed anatomical and functional assessment of the tricuspid apparatus, guiding the indication and planning of transcatheter interventions. To provide a review of the anatomical basis of the tricuspid valve and discuss echocardiographic and clinical criteria for selecting candidates for transcatheter therapies. This narrative review of the anatomical variability of the tricuspid valve and its subvalvular apparatus incorporates recent recommendations from echocardiography societies and clinical evidence. Special emphasis has been given to three-dimensional echocardiography, transesophageal echocardiography, and computed tomography for morphological and functional characterization of tricuspid regurgitation. Contemporary evidence has demonstrated that up to 45% of patients present with non-classical morphologies (quadricuspid or pentacuspid valves), which impact the viability and outcomes of edge-to-edge repair. The integration of three-dimensional echocardiography enhances accuracy in grading regurgitation severity, enables precise measurement of the vena contracta area, and assists in device selection. Clinical factors including right ventricular function, pulmonary artery systolic pressure, and the presence of intracardiac devices also influence patient selection. Appropriate selection of candidates for transcatheter tricuspid valve therapies requires a systematic approach with integrated application of imaging methods and clinical parameters. Detailed echocardiographic characterization of leaflet morphology, coaptation gap, and annulus geometry is crucial for planning the procedure, selecting the device, and predicting outcomes.

Read Full Article

ABCIC

Editorial

Transesophageal Echocardiogram Always Before TAVI?

Jairo Alves Pinheiro et al. João Lucas Pinheiro Lucas Velloso Dutra Luciano Holanda Renata de Sá Cassar

Cardiovascular imaging is crucial in the selection and planning of interventions for structural heart disease.

Transcatheter aortic valve implantation (TAVI) has transformed the management of severe aortic stenosis (AS) in high-risk surgical populations and is currently being expanded to intermediate- and low-risk populations.

[…]

Read Full Article

ABCIC

Review Article

Role of Transthoracic Echocardiography in Percutaneous Closure of Ventricular Septal Defect

João Batista Masson Silva et al. Cloves Geraldino da Silva Junior

Abstract

Ventricular septal defect (VSD) is the most common congenital heart defect, and its management has evolved with percutaneous closure, a minimally invasive alternative to surgery. In this context, echocardiography has established itself as the primary imaging tool, crucial in all phases of the procedure. Transthoracic echocardiography (TTE) is essential for diagnosis, anatomical classification (perimembranous, muscular, inlet and outlet), initial hemodynamic assessment, and long-term follow-up. Indication for closure is based on such criteria as the left ventricular (LV) volume overload, with Qp:Qs ≥ 1.5:1. For detailed planning and intraprocedural guidance, transesophageal echocardiography (TEE), especially with three-dimensional (3D) reconstruction, is the gold standard. 3D TEE offers an accurate measurement of defect diameters, a border analysis for safe device anchorage, and an assessment of the relationship with adjacent structures, such as the aortic and tricuspid valves. The success of the intervention, both in congenital VSDs and in the rare and complex post-infarction VSDs, depends directly on the quality of the echocardiographic evaluation. The multimodal approach, which integrates TTE and TEE, ensures appropriate patient selection and safe procedure management, optimizing outcomes and expanding the realms of percutaneous VSD treatment.

Read Full Article

ABCIC

Editorial

Impact of Anxiety on Patients Referred for Transesophageal Echocardiography

Augusto Alberto da Costa Jr.

In this issue of ABC Cardiovascular Imaging, anxiety is highlighted not only as a factor in the subjective assessment of patients’ experiences during invasive medical procedures (transesophageal echocardiography, TEE) but also for its influence on the amount of sedative drugs administered during the procedure.

The study The Impact of Anxiety on Patients Referred for Transesophageal Echocardiography, conducted at a tertiary institution, provides a detailed analysis of multiple characteristics of patients undergoing the exam, its influence on sedation, and revisits important aspects of good medical practice. The study results indicate that anxiety, assessed using easily implemented indicators, was present in 62% of patients. Self-assessment tables show mild anxiety in 40%, moderate anxiety in 16%, and severe anxiety in 6%. It is part of the experience of echocardiographers performing transesophageal exams to deal with patient anxiety, especially among younger individuals.^,

[…]

Read Full Article

ABCIC

Original Article

First Percutaneous Orthotopic Tricuspid Valve Implantations using the LuX-Valve Plus Device in Latin America: Report of the First Three Cases

Fernanda Esteves et al. Vinícius Esteves Marcio Mendes Pereira Frederico José Neves Mancuso … Marden Tebet Sergio Kreimer Edmur Carlos de Araújo Francisco Monteiro de Almeida Magalhães

Abstract

Background:

Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality, especially in patients with contraindications for surgery. Transcatheter tricuspid valve replacement has emerged as a minimally invasive alternative for this population, with the LuX-Valve Plus device designed for orthotopic implantation via the transjugular route.

Objective:

To report the first 3 cases of transcatheter tricuspid valve replacement using the LuX-Valve Plus device in Latin America, assessing the feasibility, safety, and immediate clinical outcomes.

Methods:

The study included 3 female patients with torrential TR and high surgical risk. Pre-procedure assessment included transesophageal echocardiography, 3-dimensional transthoracic echocardiography (3D TEE), computed tomography, and cardiac catheterization. The procedure was performed via transjugular access, under general anesthesia, with 3D TEE and fluoroscopy guidance. Implant efficacy was assessed as resolution of TR, transprosthetic gradient, and post-procedure complications.

Results:

The implants were successful in all cases, with complete resolution of TR, absence of paravalvular leaks, and adequate transprosthetic gradient. Right ventricular function was preserved, and all patients were discharged 3 to 4 days after the procedure with no significant complications.

Conclusion:

Transcatheter tricuspid valve replacement using the LuX-Valve Plus was shown to be a viable and safe alternative for patients with severe TR and high surgical risk. The use of 3D TEE was essential to the planning and execution of the implant. Further studies are needed to assess durability and long-term clinical outcomes.

Read Full Article

ABCIC

Review Article

My Approach to Transcranial Doppler Combined With Transthoracic and Transesophageal Echocardiography to Investigate PFO

Gracielly Barros et al. Patrick Ventorim Costa

Abstract

This review article explores the combined use of Transcranial Doppler (TCD) with transthoracic (TTE) and transesophageal (TEE) echocardiography to investigate Patent Foramen Ovale (PFO), a condition found in approximately 25-27% of the adult population. PFO is a remnant of fetal circulation and the most common cause of interatrial shunt. It is associated with clinical complications such as platypnea-orthodeoxia syndrome, obstructive sleep apnea, migraine, and stroke.

PFO assessment is generally performed using TTE and TEE, but TCD, a highly sensitive and less used method, is also important. TCD indirectly detects shunts in awake patients and uses the microembolic signal (MES) grading score to classify shunt severity. This technique involves injecting a contrast solution into the antecubital vein during the Valsalva maneuver to detect intracardiac shunt by observing microbubble appearance in the first cardiac cycles.

The case report illustrates the effectiveness of TCD in the initial screening of a patient with suspected PFO using TTE, TCD and TEE. The conclusion highlights that TCD is a crucial diagnostic tool, particularly relevant for the therapeutic management of patients with cryptogenic stroke. Several scientific publications are referenced, providing a theoretical foundation for the combined use of TCD, TTE, and TEE in PFO investigation.

Read Full Article

ABCIC

Editorial

Transesophageal Echocardiography in Aortic Valve Stenosis: A Pre-Intervention “Toll”?

Antonio de Santis et al. Francisco Monteiro de Almeida Magalhães

Aortic stenosis (AS) has become one of the most relevant valve diseases in cardiology care due to its increasing prevalence, resulting from the positive relationship between the preeminently degenerative etiology and global population aging. In Brazil, we highlight an epidemiological scenario characterized by an etiopathogenic coexistence: rheumatic fever and bicuspid valve disease in younger patients and calcific (degenerative) etiology in elderly patients. Regarding the natural history, AS leads to elevated cardiovascular morbidity and mortality in its symptomatic phase, with unfavorable prognosis when it is not diagnosed correctly and without timely intervention.^–

Echocardiography is still a fundamental tool for diagnosis, allowing both evaluation of etiological characteristics and grading of AS severity using parameters such as aortic valve area, transvalvular pressure gradient, and peak aortic jet velocity. However, there are still questions related to the best window for acquiring echocardiographic data. Is the transesophageal window a necessary “toll” for all patients with AS for whom intervention is planned? In general, transesophageal echocardiography (TEE) has the potential to provide superior image quality to transthoracic echocardiography (TTE) in the evaluation of posterior cardiac structures close to the esophagus, for example, the mitral valve. In this case, the greater distance between these structures and the echocardiographic transducer might make evaluation through the transthoracic window difficult. However, the anterior anatomical topography of the aortic valve allows adequate analysis by TTE in most patients, thus avoiding exposure to sedation and possible complications of the transesophageal modality. Data from the literature have shown that TTE and TEE are comparable, mainly in the anatomical and etiological characterization of AS, with compatible results in estimating the valve area.^– Nonetheless, there is evidence that the determination of the hemodynamic severity of AS, expressed by the transvalvular pressure gradient and aortic jet velocity, may be underestimated in TEE. Variations in blood volume and preload, conditioned by the fasting and sedation required for the exam, could justify these particularities in transesophageal evaluation.

[…]

Read Full Article

ABCIC

Brief Communication

Warning and Recommendations from the Department of Cardiovascular Imaging Regarding Transesophageal Echocardiography in Patients Using GLP-1 Analogs

Alex dos Santos Felix et al. Andre Luiz Cerqueira Almeida Marcelo Dantas Tavares de Melo Silvio Henrique Barberato

Transesophageal echocardiography is a fundamental diagnostic method for evaluating complex heart diseases. It provides essential data for therapeutic definition and, in some cases, assists in evaluation of percutaneous or surgical interventions.

Transesophageal echocardiography exams are performed on outpatients or inpatients, who might be in wards, intensive care units, or even in surgery, with heterogeneous scenarios that need to be individually assessed, not only regarding the exam routine, but also always following precise clinical indications, weighing the risks and benefits for the patient.

[…]

Read Full Article

ABCIC

Case Report

Transesophageal Echocardiogram in the Diagnosis of Superior Vena Cava Syndrome in a Patient With a Long-Term Catheter

Marcus Vinicius Silva Freire de Carvalho et al. Endy de Santana Alves Laila Caroline Gomes Carolina Thé Macêdo … Marco André Moraes Sales Alexandre Costa Souza

Introduction

The superior vena cava syndrome (SVCS) is caused by the obstruction or severe occlusion of the superior vena cava (SVC) and can result in significant morbidity or mortality.^, Malignancy is the most common cause of this obstruction, corresponding to approximately 70% of the cases. However, more recently, the incidence of SVCS related to devices, such as central venous catheters and electrodes of a pacemaker or defibrillator, have increased.^,

These devices, together with states of hypercoagulability, can precipitate the formation of thrombi. In extreme situations, in the context of bacteremia, these can lead to the formation of a complex thrombus-vegetation association.

[…]

Read Full Article

ABC

Editorial

Rhythm Control Interventions in Patients with Atrial Fibrillation – Insights on Preprocedural Anticoagulation and Utility of Left Atrial Imaging

Mirella Facin et al. Nelson Samesima

The most common sustained arrhythmia in clinical practice is atrial fibrillation (AF),^, affecting 2-4% of the adult population worldwide. It is even more frequent with aging, with almost 10% prevalence in individuals older than 80. Current estimates state that one in every three adults aged 55 years will develop AF during their lifetime, leading to substantial healthcare and economic burden. Clinical issues relate primarily to thromboembolic events (TE) and arrhythmic symptoms, both central targets while managing patients with AF.^,

Overall, atrial fibrillation confers a 2-5-fold escalated risk of TE, which is not evenly distributed, depending on unique modifiers. Important risk factors abridged in the CHA₂DS₂-VASc score – Congestive heart failure, Hypertension, Age ≥75 years, Diabetes, Stroke/TIA, Vascular disease, Age 65-74 years, Sex (female) – may predict stroke risk, consistently mitigated in almost 70% by proper anticoagulation. Vitamin K antagonists (VKAs) were the only oral anticoagulants available for over half a century. From 2009 to 2013, pivotal randomized controlled trials acquainted the scientific community with the new/direct oral anticoagulants (DOACs).^– These drugs not only held similar efficacy to VKA in preventing thromboembolic events but also had a better safety profile against major bleeding – notably intracranial hemorrhage – and a more predictable pharmacokinetic and pharmacodynamic profile, ruling out the need for routine laboratory monitoring. However, the applicability of DOACs in off-label backgrounds, including stroke prevention during rhythm control interventions, remained unclear for many years.

[…]

Read Full Article

ABC

Original Article

Left Atrial Thrombus and Dense Spontaneous Contrast in Direct Oral Anticoagulant Therapy of Atrial Fibrillation: Insights from a Reference Center

Thiago Marques et al. Francisco Darrieux Fábio Gouvêa Leandro Garambone … Ana Paula Lindoso João Lage Luciana Sacilotto Ana Lúcia Coimbra Martina Pinheiro Natália Olivetti Sissy Lara Carina Hardy Guilherme Athayde Denise Hachul Cristiano Pisani Tan Chen Wu Maurício Scanavacca

Abstract

Background

In the treatment of atrial fibrillation (AF), the most frequently sustained arrhythmia, with catheter ablation (CA) or electrical cardioversion (ECV), the periprocedural period is one of the most critical phases. Currently, the use of new direct action oral anticoagulants (DOAC) is increasingly frequent; however, in the real world, there are still few data on studies on the thrombus incidence in the left atrium (TrLA) or dense spontaneous contrast (DSC) on transesophageal echocardiogram (TEE).

Objective

To evaluate the prevalence of events and association with risk factors in patients using DOACs. Primary objective: to analyze the prevalence of thrombus in the LA by TEE in patients using DOAC undergoing ECV/CA. Second, evaluate the association of comorbidities with the presence of thrombi and DSC.

Methods

Retrospective cohort, single-center study with patients followed at the Arrhythmia Outpatient Unit (InCor-HCFMUSP). Patients indicated for procedures and using DOACs were selected, and their clinical/echocardiographic data were analyzed. A significance level of 5% was considered.

Results

354 patients were included, a total of 400 procedures, from March 2012-March 2018. Thrombus in the LA was found in 11 patients (2.8%), associated with advanced age (p=0.007) and higher CHA2DS2-VASc (p<0.001) score. DSC in the LA before TEE was found in 29 patients (7.3%), with lower LVEF (p<0.038) and greater LA dimension (p<0.0001).

Conclusion

The incidence of LA thrombus and DSC in patients using DOC in the context of AF ECV/CA, although small, is not negligible. Patients with higher CHA2DS2-VASc scores, especially older and with larger LA diameter, are more prone to these echocardiographic findings.

Read Full Article

ABCIC

Review Article

Risk of Infection Associated with Transesophageal Echocardiography and Prevention Measures: Literature Review

Juliana Barros Becker et al. Fernanda Crosera Parreira Cláudio Henrique Fischer Valdir Ambrósio Moisés

Abstract

Background

Transesophageal echocardiography is an exam widely used in clinical practice for investigation and diagnosis of cardiac and noncardiac diseases. Although safe, it is a semi-invasive and non-risk-free examination. Cases of infection associated with transesophageal echocardiography were described and, due to the potential risk of transmission of infection during its implementation, the objective of this work was to review literature data regarding the transmission of infection during the examination, as well as prevention methods.

Methods

Review of literature on the subject between December 2017 and January 2018, through research in public domain scientific portals, in the different health science databases, including original articles, guidelines, simple and systematic reviews, case reports, published in periodicals indexed in the last 20 years.

Results

Thirteen articles fulfilled the established criteria: a systematic review of transesophageal echocardiography-related complications, six articles describing transesophageal echocardiography-related bacterial outbreaks, the British guideline on cleaning and disinfection for transesophageal echocardiography probes, four articles on adverse reactions to orthophthaldehyde residues in transesophageal echocardiography probes and an article regarding the use of protective covers for the probes.

Conclusion

The risk of infection associated with transesophageal echocardiography exists, although poorly described in the literature. It is recommended to establish specific protocols for disinfection of transesophageal echocardiography probes and routine inspection of probes. The strengthening of infection control teams is also essential for the detection and resolution of transesophageal echocardiography-related outbreaks.

Read Full Article

ABC

Artigo Original

Effective dose of sedation in transesophageal echocardiography: relation to age, body surface area and left ventricle function

Guilherme Moreira José et al. Carlos Eduardo Suaide Silva Luiz Darcy Cortez Ferreira Yara Prosdossini Soares de Novaes … Claudia Gianini Monaco Manuel Adán Gil Renata Rejane Linhares Marcelo Sgrott Rodrigues Antônio S. S. de Moraes Juarez Ortiz

BACKGROUND: Sedation with midazolam and meperidine is widely used in transesophageal echocardiography. However, no mean dose is established for each individual case. OBJECTIVE: To correlate the mean midazolam and meperidine doses for proper sedation for transesophageal echocardiography with age range, body surface area, and left ventricular ejection fraction. METHODS: Retrospective study comprising 1,841 patients undergoing sedation based on the Ramsay scale, with a solution containing midazolam 1.5 mg (1.5 ml), meperidine 1 mg (1 ml) and distilled water (7.5 ml). Four age groups were analyzed: G1: 65 years. Body surface area was calculated using the formula {[(height x 100)0.725] x (weight0.425) x 0.0071}. As regards the left ventricular ejection fraction, two groups were studied: GA: 55%. The statistical analysis was carried out using the Kruskal-Wallis test for the correlation with age and left ventricular ejection fraction, and simple linear correlation for body surface area. RESULTS: As regards age, the mean doses of sedation required were significantly lower in G3 and G4 (p<0.01). The analysis of left ventricular ejection fraction showed that this was significantly lower in GA (p<0.01). The linear correlation coefficient between dose of sedation and body surface area was 0.09 (null). CONCLUSION: The mean dose of sedatives required was lower in older individuals and in those with left ventricular systolic dysfunction. No correlation with body surface area was found.

Read Full Article

ABC

Artigo Original

Patent foramen ovale and ischemic stroke in young people: statistical association or causal relation?

Edson Marcio Negrão et al. Ivar Viana Brandi Simone Vilela Nunes Daniel Gurgel Fernandes Távora … Mauro Nakayama Paulo Sergio Siebra Beraldo

OBJECTIVES: To determine if there are evidences of a causal relation between patent foramen ovale (PFO) x cryptogenic ischemic stroke (IS) in the young population and to analyze this relation in terms of causal criteria. METHODS: A total of 168 young patients with IS was retrospectively evaluated and divided into two groups: cryptogenic and with a defined cause. As a routine procedure, the patients underwent investigation of the PFO by means of transesophageal echocardiogram and/or transcranial Doppler sonography, both of them associated with the bubble test. Multivariate analysis was performed after demonstration of univariate statistical association between PFO x IS. RESULTS: After multivariate analysis, the association between PFO x cryptogenic IS was still statistically significant with odds ratio (adjusted OR = 3.3; 95% CI: 1.5-7.4). The total number of cerebral lesions also presented a significant association with cryptogenic IS (adjusted OR = 0.4; 95% CI: 0.2-0.9). The association between PFO and cryptogenic IS met all the causality criteria. CONCLUSION: The causal relation between PFO and cryptogenic IS in the young population is highly probable. This fact should be considered in the therapeutic decision.

Read Full Article

ABC

Artigo Original

Texture of mitral bioprosthesis, ventricular function and formation of thrombus: analysis through transesophageal echocardiography and use of bioscore

Henry Abensur et al. Max Grinberg José A. F. Ramires

OBJECTIVE: Facing the hypothesis of participation of mechanical stress as a cause of mitral bioprosthesis dysfunction, we decided to assess the relation of preservation of the texture of the mitral bioprosthesis leaflets with left ventricular function, in addition to the casual formation of thrombus in left atrium in patients with left ventricular dysfunction from the implant of mitral bioprosthesis. METHODS: Forty 40 patients with mitral bioprosthesis through multiplane transesophageal echocardiogram were studied and divided in two groups: with left ventricular dysfunction (FE=0.40±0.09) since the bioprosthesis implant (20 patients: age 47.75±11.10 years old and surgery time 5.3±2.6 years) and with normal left ventricular function (FE=0.73±0.06) since the implant (20 patients: age 49.75±13.59 years old and surgery time 5.7±3 years). The texture of bioprosthesis leaflets was analyzed through a transesophageal echocardiographic score (FACIMT Bioscore): 1) Fusion of leaflets (score 1 to 3); 2) Apposition of tissues (score 1 to 3); 3) Calcium in leaflets (score 1 to 5); 4) Integrity of leaflets (score 1 to 3); 5) Motility of leaflets (score 1 to 4) and 6) Thickness of leaflets (score 1 to 3). The presence of thrombi in left atrium was assessed through multiplane scanning of the left atrium and left atrial appendage in the transesophageal study. RESULTS: There was no significant difference in the texture of bioprosthesis mitral position between the groups, for the total score (8.7±2.4 vs. 7.9±2.1, p=0.259), and for each analyzed item. A greater incidence of thrombi in left atrium and left atrial appendage was detected in patients with ventricular dysfunction (65% vs. 20%, p=0.004). CONCLUSION: The left ventricular dysfunction was not a protecting factor of the texture of bioprosthesis leaflets in mitral position in the tardive post-surgery period. The patients with left ventricular dysfunction showed a more favorable environment for the formation of thrombi in left atrium.

Read Full Article

ABC

Artigo Original

Bioprosthetic mitral valve thrombosis: importance of transesophageal echocardiography in the diagnosis and follow-up after treatment

Adelino Parro Jr et al. Marta Lancia Carramona Caio Augusto Ferreira Amaral José Luiz Balthazar Jacob José Carlos Nicolau

OBJECTIVE: To report the clinical and echocardiographic findings of bioprosthetic mitral valve thrombosis and the value of transesophageal echocardiography (TEE) in its diagnosis and monitoring of thrombolysis. METHODS: One hundred and eleven patients with mitral bioprostheses underwent TEE, and 4 out of 7 suspected of having a thrombus on these prostheses were included in the study (mean age = 60.2±10.2 years; 2 men). The diagnosis was confirmed with serial TEE and clinical evolution. The morphologic features of the prosthetic leaflets, as well as the presence and characteristics of attached echogenic masses were investigated. The mean gradient through the prosthesis and the valvular area were obtained. RESULTS: The diagnosis of bioprosthetic mitral valve thrombosis was established 48.7±55.2 months after surgery. Two patients had ischemic stroke in the early postoperative period. The mean overall gradient was high (11.4±3 mmHg) and the valvular area reduced (1.24±0.3 cm²). On TEE, echogenic masses on the left ventricular face of the mitral bioprosthesis suggestive of thrombus were evidenced in all patients. On serial TEE (136±233 days), in 2 patients the thrombus had disappeared and in 2 others it was smaller after treatment, the mean gradient dropped to 6.2±3 mmHg (P = 0.004; 95% CI), and the valvular area increased to 2.07±0.4 (P = NS). CONCLUSION: TEE proved to be useful for detecting bioprosthetic mitral valve thrombosis and was effective in monitoring the treatment in all patients.

Read Full Article

ABC

Artigo Original

Association between the effect of spontaneous contrast in the thoracic aorta and recent ischemic stroke determined by transesophageal echocardiography

Flavio José Petersen Velho et al. Fernanda Dotta Leonora Scherer Eduardo Bartholomay … Daniela Augusta da Silva Jefferson Gomes Fernandes Marco Antonio Rodrigues Torres

OBJECTIVE: To assess the independent association between the presence of spontaneous echo contrast in the aorta and recent stroke events. METHODS: Two hundred and twenty-four individuals with a diagnosis of recent stroke and 85 control individuals who were examined due to various present/suspected heart diseases were studied through transesophageal echocardiography. The effects of spontaneous contrast in the aorta and the presence of other potential sources of cardiac embolism associated with them were researched and a questionnaire was completed about patients’ clinical risk factors at the time of examination. RESULTS: The effects of contrast in the aorta was associated with stroke (OR=2.83; CI = 95%, 1.65-4.46; P 60 years, a history of systemic blood hypertension and smoking, and dyslipidemia were risk factors independently associated with the effects of contrast in the aorta. The presence of a spontaneous contrast effect in the left atrium and Lambl’s excrescences were echocardiographic factors independently associated with the effects of contrast in the aorta. CONCLUSION: The effect of contrast in the aorta was independently associated with recent stroke and with its clinical risk factors. These results reinforce the hypothesis that the phenomenon is a predictor of several risk factors.

Read Full Article

ABC

Artigo Original

Flail mitral valve leaflet diagnosed by transesophageal echocardiography. Report and evolution of 35 cases

Mônica M. C. Caldas et al. Lúcia M. A. Fenelon William A. M. Esteves Tamara Katina … Nilson Maia Márcia M. Barbosa

PURPOSE: To describe transesophageal echocardiographic findings in patients presenting with flail mitral valve and to obtain their clinical follow-up. METHODS: From January/93 to March/97, 1675 patients were submitted to transesophageal echocardiogram at our institution; 35 of them were diagnosed as having flail mitral valve and their clinical follow-up was obtained. RESULTS: Thirty-five patients with the diagnosis of flail mitral valve were studied. Mean age was 65±15 years (12-87) and 27 (77%) were male. The posterior leaflet was involved in 25 (71%) patients. Ruptured chordae tendineae was present in all but one patient in whom flail mitral valve was due to a very elongated and redundant chordae. The etiology was prolapse and/or mixomatous degeneration in 16 patients, degenerative in 10, ischemic in 5, rheumatic in 4 and endocarditis in 3. Mitral regurgitation was severe in 25 (71%) patients and moderate in 10 (29%). The mean follow-up was 375±395 days (1 to 1380). Nineteen patients were followed clinically and 16 were submitted to surgery (transesophageal echocardiogram findings were confirmed in all 16). Overall mortality was high (34%). Among the survivors, 17 are in NYHA class I and 6 in class II. CONCLUSION: The diagnosis of flail mitral valve by transesophageal echocardiography is accurate, allowing for the definition of its mechanism and etiology, as well as the evaluation of hemodynamic compromise. The observed high mortality at the time of diagnosis may be related to the severity of the disease causing the flail mitral valve. Although non-operated survivors are doing well, the observed low functional class in these patients may be related to the short period of follow-up.

Read Full Article

ABC

Artigo Original

Quantification of mitral prosthesis regurgitation by transesophageal echocardiography. Evaluation of different methods

Cláudio Henrique Fischer et al. Orlando Campos Fº Valdir Ambrósio Moisés José Marconi Almeida Sousa … Cristiano Vieira Machado Edgar Bezerra de Lira Fº José Lázaro de Andrade Antonio Carlos de Camargo Carvalho Dirceu Vieira Santos Fº

PURPOSE: To evaluate the different methods for grading mitral regurgitation (MR) by transesophageal echocardiography (TEE) in patients with clinical suspicion of mitral prosthesis dysfunction. METHODS: Cardiac catheterization (Cath) was performed in 15 patients for grading the severity of prosthetic MR, divided in two groups based on the presence or absence of severe MR. Prosthetic MR was quantified by TEE using methods commonly used for MR of native valves: subjective assessment by color Doppler, objective assessment based on absolute jet area and on its relative area (jet area/left atrial area) and assessment based on the presence of systolic flow reversal in pulmonary vein. RESULTS: Prosthetic MR was mostly transprosthetic (14 patients) and eccentric (11 patients). There was significant correlation (p7cm²) and relative (jet area >35% of left atrial area) jet areas did not reveal significant correlation with the angiographic grade and showed clear underestimation by TEE when the last method was used. However, there was good correlation (p30% were considered as cut point. CONCLUSION: TEE correctly identified angiographic severe mitral prosthesis regurgitation, mainly by the presence of systolic flow reversal in pulmonary vein and subjective assessment. The estimation of severity of the prosthetic MR by absolute or relative jet area seems to be limited and should be used with caution due to eccentricity of the regurgitant jet, frequently seen in mitral prosthesis dysfunction.

Read Full Article

ABC

Original Article

Use of transesophageal echocardiography during implantation of aortic endoprosthesis (stent). Initial experience

Cláudio Henrique Fischer et al. Orlando Campos Fº José Honório de Almeida Palma da Fonseca Cláudia Maria Rodrigues Alves … José Augusto Marcondes Sousa Edgar Bezerra de Lira Fº Antonio Carlos de Camargo Carvalho Ângelo Amato Vicenzo de Paola Ênio Buffolo

OBJECTIVE: To report the role played by transesophageal echocardiography during implantation of self-expanding aortic endoprostheses (stent) at a hemodynamics laboratory. METHODS: Thirteen patients underwent stent implantation in the descending thoracic aorta with the aid of transesophageal echocardiography during the entire procedure. Indications for stenting were as follows: 8 aortic dissections, 2 true aneurysms, 2 penetrating atherosclerotic ulcers, and 1 traumatic pseudoaneurysm. RESULTS: No complications resulting from the use of transesophageal echocardiography were observed. In 12 patients, the initial result was considered appropriate, with total or partial resolution of the major lesion confirmed by a posterior examination. In 1 patient, the procedure was suspended after transesophageal echocardiography and angiography showed that the proximal aortic diameter was inappropriate. Transesophageal echocardiography contributed to clarifying relevant points, such as aortic diameter, anatomic detail of the intimal lesion, and location and size of the communicating orifice. In addition, it facilitated placing the stent in the target lesion, reduced the time of exposure to radiation and the use of contrast medium, and provided rapid identification of intercurrent events, possibly reducing the total duration of the procedure. CONCLUSION: The use of transesophageal echocardiography during placement of aortic stents seems appropriate. The actual advantages of the procedure will be defined in a comparative prospective study.

Read Full Article