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Introduction: Interventional closure of the left atrial appendage closure (LAAC) has been established as an alternative treatment in patients with atrial fibrillation (AF) and an increased risk of stroke. So far it is unknown whether the use of ultrasound contrast agent (UCA) would influence the correct sizing of the LAA and thereby have an impact on device selection during interventional LAAC., Methods: Between January 2017 and April 2018, 223 transoesophageal echocardiography (TOE) examinations were prospectively performed in adult patients with non-valvular AF (Impact of the use of ultrasound contrast agent on the detection of thrombi in the left atrial appendage during transesophageal echocardiography (CONDOR) study). LAA was examined both with and without the use of UCA. The following measurements were taken at 0 o , 45 o , 90 o and 135 o : diameter of LAA ostium, maximal depth of the LAA, maximal available depth of the LAA orthogonal to the ostial plane and area of the LAA., Results: The use of UCA had no relevant influence on the size determination of the LAA. Additionally, Bland-Altman blots demonstrate a high degree of correlation between the measurements with and without UCA with no evidence for a systematic effect arising from the use of UCA. When comparing the measurements of two independent investigators, the use of UCA rather leads to a higher variability than to an improved precision., Discussion: Despite the fact that the use of UCA during TOE leads to an improved rule out of thrombi, our study shows that there is no advantageous effect of UCA on the size determination of the LAA and should therefore not be used for this purpose., Competing Interests: Competing interests: HE has received honoraria for lectures from Bayer, Novartis, Pfizer, Boehringer Ingelheim and Boston Scientific., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Report predictors and the natural course of paravalvular leak (PVL) following implantation of the ACURATE neo transcatheter heart valve (THV)., Background: Understanding the mechanisms of PVL may help to improve patient selection, patient outcomes and the design of next-generation THVs., Methods: A total of 30 patients (mean age 81±5 years, 47% women) undergoing transcatheter aortic valve replacement with the ACURATE neo were enrolled in the PREDICT PVL study. The effective regurgitant orifice area (EROA, in mm 2 ) of PVL was assessed by transthoracic and transoesophageal echocardiography before discharge and at 6 months follow-up., Results: PVL was none/trace in 10 (33%), mild in 18 (60%) and moderate in 2 (7%) patients and occurred in distinct locations with largest EROAs in the area of the left coronary cusp and its adjacent commissures. Independent predictors for EROA were implantation depth (r coefficient -1.9 mm 2 per mm implantation depth, p=0.01), leaflet calcification (6.2 mm 2 per calcification grade, p=0.03) and THV size L (7.6 mm 2 more than size S or M, p=0.01). At 6 months follow-up, EROA decreased by 29% from 13.7±9.7 mm 2 to 9.5±7.9 mm 2 (p<0.01). Patients with smaller EROAs were more likely to be in New York Heart Association class 1 than patients with larger EROAs (p<0.01)., Conclusions: PVL occurred predominantly in the region of the left coronary cusp and decreased by 29% during 6 months of follow-up. Our results underscore the importance of adequate patient selection and optimal implantation depth., Competing Interests: Competing interests: SFS is a consultant for Alnylam, Astra Zeneca and Pfizer. RK has received institutional grants from Abbott, Biosense-Webster, Biotronik, Boston Scientific, Medtronic and SIS Medical. ST is a consultant and proctor for Boston Scientific, Abbott and New Valve Technology, has received institutional research grants from Boston Scientific and Fumedica and is holding equity in Hi-D Imaging., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Objective of this study was to evaluate the feasibility of the non-invasive dye dilution method to quantify shunt size related to atrial septal defects (ASD).The diagnostic accuracy of shunt size determination in ASD's has been suboptimal with common non-invasive methods. We have previously developed a cost-effective and time-effective non-invasive dye dilution method. In this method, the indocyanine green solution is injected into the antecubital vein and the appearance of the dye is detected with an earpiece densitometer., Methods and Results: We studied 192 patients with an ASD. Mean pulmonary blood flow/systemic blood flow (Qp/Qs) was measured with dye dilution technique and compared with following methods: Fick's invasive oximetry (n=49), transoesophageal echocardiography (TEE) measuring ASD size (n=143) and cardiac MR (CMR) (n=9).For the first 49 patients, Qp/Qs was 2.05±0.70 with the Fick's invasive oximetry and 2.12±0.68 with dye dilution method with an excellent correlation between the two methods (R=0.902, p<0.001). In the second study sample, the ASD size by TEE was 15±6 mm on average, and the mean Qp/Qs 2.16±0.65 measured with dye dilution method with a good correlation between the methods (R=0.674, p<0.001). Qp/Qs measured with CMR was 1.87±0.40 resulting in a good correlation with the dye dilution method (R=0.696, p=0.037)., Conclusion: The dye dilution method with earpiece densitometer recording is a clinically feasible and reliable method to assess shunt size in ASDs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

With rising focus on interventional treatment of the tricuspid valve (TV), the need for good echocardiographic imaging increases. Aim of this study was to develop a scoring system describing how accurate three dimensional (3D) echocardiographic imaging of TV and its anatomical structures is. METHODS AND RESULTS: In this retrospective exploratory cohort study, we analysed data from consecutive patients undergoing transoesophageal echocardiography (TOE) and transthoracic echocardiography (TTE). 3D sequences were stored using eight different views. In each view, scoring focused on visualisation of five (in TOE 6) anatomical structures with a maximum of three points per structure for excellent imaging quality. We compared the scores of patients with and without relevant tricuspid regurgitation (TR) (cut-off effective regurgitant orifice 0.4 cm² measured in two-dimensional (2D) TTE using velocity time integral and proximal isovolumetric velocity area). 108 consecutive patients were examined, 40.7% presented with relevant TR. With the exception of coaptation, a higher score was achieved for all structures in TOE than in TTE. TV ring (TVR) was easiest to visualise with TOE in four-chamber view (4 CV) (2.42±0.67 points) presenting the highest score independent of anatomical structure and view. Posterior leaflet had best imaging scores in TOE in 4 CV (2.0±0.86) compared with TTE in 4 CV (1.64±0.80), p=0.001. Patients with relevant TR had significantly better 3D imaging scores in 4 CV compared with patients without relevant TR (TTE p<0.013, TOE p<0.002). CONCLUSION: 4 CV delivers the most detailed information in TTE, whereas multiple views deliver good scores in TOE. As TVR is easiest to visualise, most of the patients would be suitable for a ring-based echocardiography-guided intervention. The score enables a standardised comparison of image quality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke., Methods: We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings., Results: There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring., Conclusions: This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Atrial fibrillation (AF) carries the risk of thrombus formation in the left atrium and especially in the left atrial appendage (LAA). A transoesophageal echocardiography (TOE) is routinely performed in these patients to rule out thrombi before cardioversion or structural interventions like LAA closure or pulmonary vein isolation. However, in a certain number of cases, inconclusive results of the TOE may result. This study was performed to analyse whether the routine use of ultrasound contrast agent (UCA) has an influence on the frequency of thrombus detection., Methods: In patients with AF who were scheduled for a subsequent interventional procedure, a TOE was initially performed without contrast agent. Then, the TOE was repeated with the use of UCA. The percentage of diagnostic findings regarding the prevalence of thrombus in the LAA with and without UCA were compared (thrombus present (T+), no thrombus (T-) and inconclusive result (T+/-))., Results: 223 patients were prospectively included into the trial. The numbers of thrombus detection were as follows: without UCA: 17 T+ (7.6%), 154 T- (69.1%), 52 T+/- (23,3%); with UCA: 16 T+ (7.2%), 179 T- (80.3%), 28 T+/- (12.6%; χ 2 : p<0.01). In 29 examinations (13.0%), the use of UCA had an impact on the subsequent treatment strategy., Conclusions: The use of UCA during TOE in patients with AF has a significant impact on the subsequent patient management especially due to an improved rule out of LAA thrombi., Competing Interests: Competing interests: HE has received honoraria for lectures from Bayer, Novartis, Pfizer, Boehringer Ingelheim and Boston Scientific. This study was partially supported by a grant from Boston Scientific (Investigator Sponsored Research)., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)