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The document presents research communications from the 34th ECVIM-CA Congress in Lyon, France, focusing on veterinary internal medicine. Studies cover topics such as diagnosing cardiac conditions in companion animals, managing pulmonary thromboembolism in dogs, and evaluating outcomes of cats with subcutaneous ureteral bypass implantation. Other studies explore fecal lipid profiles in dogs with acute hemorrhagic diarrhea syndrome, inflammatory biomarkers in dogs with Angiostrongylus vasorum, and polyarthritis in dogs in a Mediterranean area. Additionally, the document discusses the demographics, clinical presentation, and management of diabetic cats in the UK, as well as sleep-disordered breathing in dogs and feline hyperaldosteronism. [Extracted from the article]

Embolic stroke due to prosthetic valve endocarditis (PVE) caused by Candida parapsilosis is a rare and serious complication. Successful management requires a combination of medical and surgical approaches. We present a case full of complexities in diagnosing and managing Candida PVE, emphasizing the importance of a multidisciplinary approach. A 50 year‐old male presented to the emergency department with vertigo and low‐grade fever and was found to have cerebellar stroke likely from the cardioembolic origin, and the patient had a history of uncontrolled diabetes and double prosthetic valves. The diagnosis was challenging and required transesophageal echocardiography (TEE) which showed two vegetations attached to the mitral valve prosthesis. The management involved antifungal therapy, but surgery was hindered by financial issues. The patient was considered for the AngioVac vegetation aspiration system due to persistent fungemia. Eventually, surgery was not performed, and the patient was discharged with a plan for long‐term suppressive antifungal therapy. [ABSTRACT FROM AUTHOR]

Objective: Challenging differential diagnosis Background: Takotsubo syndrome, or stress-induced cardiomyopathy, is a rare but serious condition that mimics myocardi- al infarction and can cause temporary cardiac dysfunction in the absence of coronary artery disease. General anesthesia can make diagnosis more challenging. Although it has already been described in a context of solid organ transplantation, takotsubo syndrome remains under-reported in lung transplantation, necessitating awareness to avoid diagnostic and management delays. Case Report: We report a case of takotsubo syndrome in a 54-year-old woman undergoing pulmonary transplantation for end-stage chronic obstructive pulmonary disease. Preoperative evaluations showed no cardiac pathology. During surgery, she developed severe left ventricular failure with ST-segment elevations and diffuse hypokinesia, leading to cardiogenic shock and multiorgan dysfunction. Delayed diagnosis of takotsubo syndrome and late initiation of veno-arterial extracorporeal membrane oxygenation worsened her condition. Postoperatively, she developed lung abscesses, broncho-cutaneous fistula, and hemorrhagic shock, resulting in a prolonged intensive care unit stay. Two years after the transplant, left ventricular dysfunction was persistent, significantly affecting her quality of life. Conclusions: This case report highlights the importance of awareness of takotsubo syndrome associated with lung trans- plantation, particularly in at-risk patients. Indeed, early diagnosis and management of this cardiomyopathy are crucial for improving outcomes. Multimodal monitoring, including transesophageal echocardiography and continuous ST-segment monitoring, is essential for timely diagnosis. Although rare, this complex clinical condition should be considered in lung transplant recipients with sudden heart failure to ensure prompt and effective treatment. Further research is needed to understand this stress cardiomyopathy in this specific setting and to develop effective management strategies. [ABSTRACT FROM AUTHOR]

Background: Transesophageal echocardiography (TEE) is a vital diagnostic tool in clinical practice, particularly in transcatheter interventions where it aids in both pre-operative planning and intra-operative guidance. Traditional TEE probes often require general anesthesia due to patient discomfort. However, the development of miniaturized TEE probes presents a promising alternative, enabling routine examinations and interventions with minimal sedation. This study evaluates the feasibility of performing a complete 2D/4D TEE protocol with the new 4D mini-TEE probe in the echocardiography department and its application in transcatheter interventions. Methods: This is a retrospective study that included 30 consecutive patients from two high-volume European hospitals (Interbalkan Medical Center, Thessaloniki, Greece, and Rennes University, France) that underwent TEE or transcatheter interventions. The new 4D mini-TEE 9VT-D probe (GE Healthcare) was utilized. The quality of the images and the tolerance of the probe were assessed in the cath lab during interventions and in the echocardiography department during routine TEE examinations. Results: Direct comparison of the 4D mini-TEE probe with the standard 6VT-D probe confirmed the excellent image quality of this new pediatric probe. Most of the patients required minimal sedation or local oropharyngeal anesthesia, with satisfactory tolerance reported. Most of the transcatheter procedures did not require general anesthesia and intubation, resulting in shorter procedural time. Both 2D and 4D imaging modalities offered adequate intra-operative guidance for transcatheter procedures. Conclusions: The 4D mini-TEE probe delivers exceptional imaging capabilities for routine examinations and transcatheter interventions without needing sedation. Its use reduces esophageal trauma and the need for general anesthesia, enhancing patient comfort and safety. [ABSTRACT FROM AUTHOR]

The article "Unlocking the Potential: Can Point-of-Care Ultrasound-Guided Resuscitation Impact the Clinical Care for Adults With Shock?" published in Critical Care Medicine discusses the use of point-of-care ultrasound (POCUS) in managing critically ill patients with shock. The study found that POCUS-guided resuscitation led to a reduction in 28-day mortality rates, but other outcomes such as hospital length of stay showed mixed results. The article emphasizes the need for enhanced training methods, practical strategies for incorporating POCUS into daily practice, and the appropriate utilization of POCUS throughout a patient's care to fully realize its potential in shock management. [Extracted from the article]

Antegrade cardioplegia is routinely given during cardiac surgery. The delivery of antegrade cardioplegia from the cardiopulmonary bypass machine has many variables. Many perfusionists rely exclusively on cardioplegia system pressure to ensure safe antegrade delivery. Our group reviewed antegrade cardioplegia delivery in 50 patients undergoing coronary artery bypass graft. The data collected included the cardioplegia system pressure and the patient's direct aortic root pressure. The analysis of the data found weak correlation between the two pressures with a large mean difference and a wide standard deviation. The results suggest the direct measurement of aortic root pressure as guidance to antegrade cardioplegia instead of relying solely on cardioplegia system pressure. [ABSTRACT FROM AUTHOR]

Background: Aortic root rupture is a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). Herein, we report a case of aortic root rupture during TAVI that was successfully managed with partial aortic root repair and aortic valve replacement. Case presentation: An 83-year-old woman with severe bicuspid aortic stenosis underwent transfemoral TAVI using a 26 mm SAPIEN 3 Ultra RESILIA valve. Soon after valve implantation, transesophageal echocardiography detected pericardial effusion, which was accompanied by immediate hemodynamic instability. Subxiphoid pericardial drainage was performed, and extracorporeal membrane oxygenation was promptly initiated. Owing to the eruptive hemorrhage, we converted to open-heart surgery. Direct visualization enabled the detection of the aortic root rupture and the performance of partial aortic root repair using bovine pericardium and aortic valve replacement using a 19 mm INSPIRIS RESILIA valve. The patient was transferred to a different hospital 60 days after surgery without complications and is currently doing well as an outpatient. Conclusions: In the present case, prompt treatment decisions and smooth cooperation among the institutional heart team led to the successful repair of aortic root rupture during TAVI and good clinical outcomes. [ABSTRACT FROM AUTHOR]

Background and Objectives: Cancer is associated with an increased risk of acute ischemic stroke (AIS) and venous thromboembolism. The role of a cardiac right-to-left shunt (RLS) as a surrogate parameter for paradoxical embolism in cancer-related strokes is uncertain. We sought to investigate the relationship between the presence of an RLS and cancer in AIS patients. Methods: We included consecutive AIS patients hospitalized at our tertiary stroke center between January 2015 and December 2020 with available RLS status as detected on transesophageal echocardiography (TEE). Active cancers were retrospectively identified and the association with RLS was assessed with multivariable logistic regression and inverse probability of treatment weighting to minimize the ascertainment bias of having a TEE obtained. Results: Of the 2236 AIS patients included, 103 (4.6%) had active cancer, of whom 24 (23%) were diagnosed with RLS. An RLS was present in 774 out of the 2133 AIS patients without active cancer (36%). After adjustment and weighting, the absence of RLS was associated with active cancer (adjusted odds ratio (aOR) 2.29; 95% confidence interval (CI), 1.14–4.58). When analysis was restricted to patients younger than 60 years of age or those with a high-risk RLS (Risk of Paradoxical Embolism Score ⩾ 6), there was no association between RLS and cancer (aOR, 3.07; 95% CI, 0.79–11.88 and aOR, 0.56; 95% CI, 0.10–3.10, respectively). Conclusion: RLS was diagnosed less frequently in AIS patients with cancer than in cancer-free patients, suggesting that arterial sources may play a larger role in cancer-related strokes than paradoxical venous embolization. Future studies are needed to validate these findings and evaluate potential therapeutic implications, such as the general indication, or lack thereof, for patent foramen ovale (PFO) closure in this patient population. [ABSTRACT FROM AUTHOR]

Background: Neurosurgery performed in the semi-sitting position provides advantages for certain procedures. However, this approach is associated with potential complications, particularly venous air embolism. Due to typically negative venous pressure at the wound site, air can be drawn into the veins. This risk is especially high in patients presenting with an intra- or extracardiac right-to-left-shunt. Transoesophageal echocardiography can be used to detect a patent foramen ovale or other possible pulmonary-systemic shunt before placing the patient in the sitting position. Case presentation: In this report, we present two young patients undergoing scheduled microsurgical vestibular schwannoma removal in a semi-sitting position who were diagnosed with congenital heart defects during routine perioperative assessment to detect possible intracardiac right-to-left shunts, using pre- and intraoperative transesophageal echocardiography (TEE) and additionally conducting an agitated saline bubble study under Valsalva manoeuvre. Patient A was diagnosed with a persistent left superior vena cava and Patient B with an unroofed coronary sinus (UCS). These findings confronted the anesthesiological and surgical teams with difficult individual decisions regarding further perioperative management. Conclusions: Perioperative transesophageal echocardiography is a diagnostic tool to both detect intraoperative position-related air embolisms and to rule out intracardiac right-to-left shunts, e.g. a patent foramen ovale, in order to decide for or against a (semi-)sitting position. Depending on the surgical circumstances a semi-sitting positioning of patients presenting with an intracardiac right-to-left-shunt, e.g. a PFO, can be feasible in individual cases if there is an implemented therapeutic algorithm to immediately terminate significant venous air entry. However, since certain other intra- or extracardiac right-to-left-shunts, such as here presented PLSVC or UCS, are rare, there is no definitive way of estimating the amount of entered air through detected shunts or anomalous vessels. Therefore, it is recommended to avoid a (semi-)sitting position in favour of a lateral or prone position for a patient undergoing intracranial surgery, once the perioperative TEE shows air bubbles in the left atrium or ventricle whose origins cannot be defined solely through TEE for certain in order to ensure patient safety by minimizing the risk of intraoperative paradoxical air embolisms. [ABSTRACT FROM AUTHOR]

Background: Interatrial right-to-left shunt flow through a patent foramen ovale (PFO) can be caused by changes in heart position for anastomosis during off-pump coronary artery bypass (OPCAB). We herein present a case in which the direction of PFO shunt flow changed with heart position during OPCAB and the ventilation settings after sternal closure. Case presentation: A 66-year-old man with interstitial pneumonia underwent OPCAB. Preoperative transesophageal echocardiography revealed right-to-left shunt flow through a PFO induced by the Valsalva maneuver. During OPCAB, heart displacement resulted in right-to-left shunting and acute hypoxemia, which quickly improved with increase of inspired oxygen fraction. After chest closure, bidirectional shunt flow developed under increased airway pressure. Conclusions: Vigilant intraoperative monitoring with TEE and postoperative airway pressure management are important to address shunt flow and hypoxemia due to PFO. [ABSTRACT FROM AUTHOR]

Objective: This meta-analysis aimed to compare videolaryngoscope (VL)-assisted transesophageal echocardiography (TEE) probe insertion with conventional methods in terms of efficacy and safety. Methods: Several major databases such as Medline and Embase were systematically searched to identified relevant studies from inception to June 2024. The primary outcome was complication rate, defined as the proportion of patients experiencing complications related to TEE probe insertion. Injuries at specific sites (e.g., posterior hypopharyngeal wall) from both groups were also analyzed. The secondary outcomes included the first-attempt success rate and total insertion time of VL and conventional methods. Results: Seven trials involving 716 participants were identified. The use of VL was found to significantly reduce the complication rate (risk ratio[RR]:0.28, 95% confidence interval[CI]:0.17–0.46, P < 0.00001) and increased the first-attempt success rate [FASR] (RR:1.33, 95%CI: 1.10–1.60, P = 0.003) compared with conventional methods. These findings were confirmed by trial sequential analysis. No significant difference was found in the TEE insertion time among the two techniques (mean difference: −2.94s, 95%CI: −10.28–4.4, P = 0.43). VL significantly reduced the risk of trauma to the hypopharyngeal wall but showed no significant benefits in other areas (e.g., pyriform sinus). The certainty of evidence was moderate for the complication rate, very low for the FAS rate, and low for the TEE insertion time. Conclusion: The use of VL for TEE probe insertion is associated with a significantly lower complication rate and higher FAS rate than conventional methods. These findings suggest that VL enhances patient safety and improves the efficiency of TEE probe insertion. [ABSTRACT FROM AUTHOR]

Background: Echocardiography remains the reference-standard imaging technique for assessing valvular heart disease (VHD), but artifacts like the 'color Doppler stripe' can complicate diagnosis. This artifact is not widely recognized and can mimic severe VHD, leading to potential misdiagnoses. We present two cases where color Doppler stripes mimicked severe VHD, highlighting the need for awareness and accurate interpretation in echocardiographic assessments. Case presentations: Case 1: An 85-year-old patient was referred for mitral valve surgery due to suspected severe mitral regurgitation (MR). Upon evaluation, transthoracic echocardiography (TTE) showed mitral valve prolapse (P3) and a high-echoic, vibrating structure attached to the mitral valve, indicative of chordal rupture. Color Doppler echocardiography revealed strong systolic signals in the left atrium, mimicking severe MR. Transesophageal echocardiography (TEE) also detected the vibrating structure and color Doppler stripes in the left atrium, left ventricle, and outside the cardiac chambers. The PISA method on TEE indicated moderate MR and left ventriculography showed Sellers grade II MR. The artifact was identified as color Doppler stripes caused by the vibrating high-echoic structure from the ruptured chorda. Case 2: A 64-year-old patient with severe aortic stenosis, end-stage kidney disease requiring hemodialysis, and a history of coronary bypass grafting presented for routine follow-up. B-mode echocardiography showed a severely calcified tricuspid aortic valve with a vibrating calcified nodule and restricted opening, corresponding to severe aortic stenosis. During systole, color Doppler signals were observed around the aortic, pulmonary, and tricuspid valves, mimicking significant pulmonary stenosis and tricuspid regurgitation. However, pulmonary stenosis was ruled out as the pulmonary valve opening was normal. Mild tricuspid regurgitation was confirmed in the apical view. Conclusions: These cases highlight the diagnostic challenges posed by color Doppler stripes. Recognizing and understanding this artifact are crucial for the accurate diagnosis and management of VHD, ensuring appropriate treatment and patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: While living donor liver transplantation (LDLT) serves as the predominant method of adult liver transplant (LT) in the Republic of Korea (ROK), it represents a minority of LT in the United States (US). A survey was conducted to gain insight into these nations' anesthetic management. Methods: An electronic questionnaire was distributed to directors of LT anesthesiology overseeing LDLT programs in both countries between May 2021 and October 2021. Results: The response rate was 93.0% (100% [37/37] in the US and 80% [16/20] in the ROK). Both countries mainly adhered to deceased donor LT recipient management practices, including the frequency of routine pulmonary artery catheter use, transesophageal echocardiography, and point‐of‐care coagulation monitoring. Differences were observed in early extubation of recipients (US vs. ROK: 39.7% vs. 14.7% of all cases), participation in donor selection meetings (88.9% [32/36] vs. 6.3% [1/16], p < 0.0001), application of the Enhanced Recovery After Surgery donor protocol (69.4% [25/36] vs. 12.5% [2/16], p < 0.0001), and cell saver usage for donors (94.4% [34/36] vs. 18.8% [3/16], p < 0.0001). More ROK programs implemented simultaneous donor/recipient anesthesia supervision by a single anesthesiologist. Conclusions: Several important differences were identified between the US and the ROK in adult LDLT anesthetic management. [ABSTRACT FROM AUTHOR]

Objective: To predict recurring atrial fibrillation (AF) following radiofrequency catheter ablation by assessing the attributes of the left atrium and the left atrial (LA) appendage (LAA) using transesophageal echocardiography (TEE) and speckle tracking imaging. Methods: The structural and functional indices of the LA and LAA of 80 patients with AF who underwent preoperative transthoracic echocardiography and TEE were measured. Recurrence was recorded postoperatively at 3, 6, and 12 months. The independent determinants of recurring AF were identified by logistic regression, and their optimum cutoff values, sensitivity, and specificity were estimated from the receiver operating characteristic (ROC) curves. Results: The recurrent and nonrecurrent groups comprised 17 and 63 patients, respectively. The LA internal diameter, LA end‐diastolic and end‐systolic volumes, LAA length, diameter and area of the opening of the LAA, and LAA end‐diastolic volume were higher in the recurrent group. The LA strain in the reservoir phase, the ejection fraction and filling velocity of the LAA, the LAA emptying velocity (LAAeV), and the LAA strain (LAAS) reduced considerably. Multifactorial regression analyses demonstrated that the LAAeV and LAAS were independent determinants of recurring AF. ROC curve analysis revealed that the LAAeV and LAAS predicted postoperative recurrence at 34.5 cm/s (area under the curve [AUC]: 0.954, sensitivity: 94.1%, and specificity: 92.1%) and 11.61% (AUC: 0.925, sensitivity: 82.4%, and specificity: 95.2%), respectively, while the AUC, sensitivity, and specificity of the combined predictors (LAAeV + LAAS) were 0.978, 94.1%, and 93.7%, respectively. Conclusion: The LAAeV and LAAS independently influenced the postoperative recurrence of AF. [ABSTRACT FROM AUTHOR]

Purpose: For the repair of atrial/ventricular septal defects (ASD/VSD), transthoracic echocardiography (TTE) is easy to perform, cost‐effective, and does not require general anesthesia and intubation. Still, TTE is not universally accepted. To compare efficacy and safety of TTE versus transesophageal echocardiography (TEE) to guide percutaneous ASD/VSD closure. Methods: PubMed, Embase, and the Cochrane library were searched for articles published from their inception to December 2023. The primary outcome was the procedural success rate. The secondary outcomes were residual shunt, late complications, procedure time, and fluoroscopy time. All meta‐analyses were performed using a random‐effects model. Results: Eight studies and 1295 patients were included. There were no significant differences between TTE and TEE regarding the procedural success rate (OR = 1.93, 95% CI: 0.90–4.13, p = 0.092; I2 = 52.2%, Pheterogeneity = 0.063) and residual shunt rate (OR = 0.81, 95% CI: 0.38–1.76, p = 0.600; I2 = 0%, Pheterogeneity = 0.518). Compared with TEE, TTE reduced the frequency of late complications (OR = 0.25, 95% CI: 0.14–0.43, p < 0.001; I2 = 13.8%, Pheterogeneity = 0.326), reduced the procedure time (WMD = −8.92, 95% CI: −12.08, −5.75, p < 0.001; I2 = 87.4%, Pheterogeneity < 0.001), and reduced the fluoroscopy time (WMD = −5.08, 95% CI: −9.59, −0.56, p = 0.028; I2 = 95.6%, Pheterogeneity < 0.001). The sensitivity analyses showed that the results of the meta‐analyses were robust. Conclusion: Compared with TEE, TTE showed no differences regarding the rates of success and residual shunt, but there were lower rates of late complications and shorter procedure and fluoroscopy times. [ABSTRACT FROM AUTHOR]

Background/Aim: Mitral regurgitation (MR) is frequently observed in non‐valvular atrial fibrillation (NVAF) patients and is a significant risk factor for its progression. This study aims to investigate the three‐dimensional anatomical characteristics of the mitral valve (MV) in patients with different types of NVAF to elucidate the underlying mechanisms of MR. Methods: A retrospective analysis was conducted on 82 paroxysmal atrial fibrillation patients (PAF group) and 66 persistent atrial fibrillation patients (PerAF group) who underwent real‐time three‐dimensional transesophageal echocardiography (RT 3D‐TEE) before initial ablation. Additionally, 30 patients undergoing RT 3D‐TEE for the assessment of patent foramen ovale were selected as the control group. Basic echocardiographic variables were measured, left atrioventricular volume and strain parameters were calculated using automated software (Dynamic‐HeartModel and AutoStrain). MV anatomic features were analyzed using the 4D‐MV Assessment software (TomTec Imaging Systems). Results: The maximum left atrial volume (LAVmax) was highest in the PerAF group, followed by the PAF and control groups, with statistically significant differences (p < 0.01). Left atrial reservoir strain (LASr) showed an opposite trend, being the lowest in the PerAF group (p < 0.01). The proportion of moderate to severe MR was significantly higher in the PerAF group (27.3%) compared to the PAF group (11.0%) (p < 0.01). Compared to controls, the AF groups exhibited mitral annular (MA) dilation, flattening of the MA plane, and increased leaflet area (all p < 0.05). Correlation analysis between effective regurgitant orifice area (EROA) and left atrioventricular structure and function parameters, as well as various annular parameters, showed that EROA was significantly correlated with left ventricular end‐diastolic volume (LVEDV), LAVmax, LASr, anterior and posterior diameter, annular area, ratio of annular height to commissural diameter (AH/CD ratio), posterior leaflet area, posterior leaflet length, and the C‐shaped annulus length (all p < 0.05). Conclusions: Significant remodeling of the MV apparatus occurs in NVAF patients, with more pronounced changes in PerAF patients, contributing to a higher incidence of moderate to severe MR. RT 3D‐TEE‐based MV automated assessment offers significant advantages in accurately diagnosing MV remodeling and supporting the evaluation of MR in NVAF patients. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) is a disease associated with significant morbidity and mortality. It is more commonly caused by Gram-positive cocci, but Gram-positive bacilli may seldom cause the disease. Listeria monocytogenes is an aerobic Gram-positive coccobacillus and a foodborne and opportunistic pathogen most commonly causing gastrointestinal infections, even though bacteremia, sepsis, meningitis, and fetal infections may also occur. Listeria IE has rarely been described, with most reports being case reports or case series. Thus, the characteristics of this disease remain largely unknown. This systematic review aimed to present all published Listeria IE studies and describe their characteristics. A search of PubMed, Scopus, and the Cochrane Library for studies providing information on epidemiology, clinical findings, treatment, and outcome of Listeria IE cases was performed. A total of 54 studies containing data from 62 patients were included. Among all patients, 64.5% were male; the median age was 69 years. Among all patients, 54.8% had a history of a prosthetic valve. The aortic valve was the most commonly affected, followed by the mitral. Fever, heart failure, and embolic phenomena were the most commonly encountered clinical findings. The only isolated species was L. monocytogenes. Antimicrobial resistance was relatively low for aminopenicillins and aminoglycosides, the most commonly used antimicrobials for treating L. monocytogenes IE. Surgery was performed in 27.4% of patients. Mortality was 37.1%. Patients who survived were more likely to have had a prosthetic valve, to have necessitated transesophageal echocardiography for the diagnosis, to have mitral valve IE, and to have had surgical management; however, no factor was identified in a multivariate logistic regression model as an independent factor for overall mortality. [ABSTRACT FROM AUTHOR]

Introduction: Severe obesity presents significant challenges in imaging and delivery of therapy, including pacemaker implant. Methods and Result: We present our experience implanting a leadless pacemaker (LP) in a severely obese man presenting with heart block. We describe our multidisciplinary approach using right internal jugular venous access and transesophageal imaging in lieu of fluoroscopy which failed to provide workable images in this instance. Conclusion: Ultrasound guided LP placement may have wider application in the midst of an ongoing obesity epidemic where fluoroscopy imaging is both limited and unsafe. [ABSTRACT FROM AUTHOR]

To investigate the relationship between left atrial appendage (LAA) morphology, quantified based on fractal dimension (FD), and LAA hemodynamic parameters in patients with atrial fibrillation (AF), in an effort to reveal the effect of LAA shape on blood flow. 225 patients with AF who underwent cardiac computed tomography angiography (CTA) and transesophageal echocardiography (TEE) were enrolled. LAA morphology was quantified based on FD on cardiac CTA images, and LAA hemodynamic parameters, including injection fraction (EF), filling peak flow velocity (FV), maximum speed of emptying (PEV), and wall motion velocity (WMV), were assessed using TEE. We divided the patients with AF into two groups based on a mean LAA FD of 1.32: the low FD group (n=124) and the high FD group (n=101). Compared to the low FD group, there were more patients with LAA circulatory stasis/thrombus (P =0.008) in the high FD group, as well as lower LAA FV (P =0.004), LAA PEV (P =0.007), and LAA WMV (P =0.007). LAA FD was an independent and significant determinant of LAA EF (β = -11.755, P =0.001), LAA FV (β = -17.364, P =0.004), LAA PEV (β = -18.743, P <0.001), and LAA WMV (β = -7.740, P =0.001) in multiple linear regression analysis. LAA FD is an essential determinant of LAA hemodynamic parameters, suggesting that the relatively complex morphology of the LAA may influence its hemodynamics, which can correlate with embolic events. • To investigate the relationship between LAA FD and LAA hemodynamic parameters. • LAA FD was negatively associated with LAA EF, LAA FV, LAA PEV, and LAA WMV. • LAA FD was an independent determinant of LAA EF, LAA FV, LAA PEV, and LAA WMV. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The article revisits marantic endocarditis, or non-bacterial thrombotic endocarditis (NBTE), highlighting a case series of 111 patients from the Mayo Clinic, primarily diagnosed through transesophageal echocardiography. Topics discussed include the high incidence of systemic embolism, the prevalence of mitral valve involvement, and the correlation between cancer types and significant valve regurgitation.

Mitral annular calcification (MAC) is a chronic degenerative process involving the fibrous support structure of the mitral valve. The prevalence of this condition significantly increases with age, and is higher in patients with cardiovascular risk factors or end-stage renal disease. However, patients with systemic lupus erythematosus (SLE) may develop atherosclerosis and MAC at a relatively young age. Caseous calcification of the mitral annulus (CCMA) is a rare subtype of MAC that occurs because of caseous transformation of the inner material. Rarely, CCMA merges with infective endocarditis (IE). This case presented an unusual example of a recurrent mass caused by CCMA after surgery for IE. A 62-year-old Japanese woman was admitted to our hospital with fever of unknown origin. She had a documented history of SLE. Blood cultures were positive, and a transesophageal echocardiography, performed to investigate IE, revealed a mass attached to the CCMA. The patient was diagnosed with IE and underwent lumpectomy. Postoperatively, the patient remained free of fever and embolism; however, the mass recurred. She was considered to have a mass due to CCMA recurrence; although revision surgery was scheduled, the mass resolved spontaneously. Therefore, owing to the risk of recurrence, CCMA requires careful preoperative and postoperative observation. Caseous calcification of the mitral annulus may rarely occur, even in middle-aged patients. This condition carries the risk of infective endocarditis complications and postoperative recurrence, and careful follow-up is required. [ABSTRACT FROM AUTHOR]

Aims: Interatrial shunts are under evaluation as a treatment for heart failure (HF); however, their in vivo flow performance has not been quantitatively studied. We aimed to investigate the fluid dynamics properties of the 0.51 cm orifice diameter Ventura shunt and assess its lumen integrity with serial transesophageal echocardiography (TEE). Methods and results: Computational fluid dynamics (CFD) and bench flow tests were used to establish the flow‐pressure relationship of the shunt. Open‐label patients from the RELIEVE‐HF trial underwent TEE at shunt implant and at 6 and 12 month follow‐up. Shunt effective diameter (Deff) was derived from the vena contracta, and flow was determined by the continuity equation. CFD and bench studies independently validated that the shunt's discharge coefficient was 0.88 to 0.89. The device was successfully implanted in all 97 enrolled patients; mean age was 70 ± 11 years, 97% were NYHA class III, and 51% had LVEF ≤40%. Patency was confirmed in all instances, except for one stenotic shunt at 6 months. Deff remained unchanged from baseline at 12 months (0.47 ± 0.01 cm, P = 0.376), as did the trans‐shunt mean pressure gradient (5.1 ± 3.9 mmHg, P = 0.316) and flow (1137 ± 463 mL/min, P = 0.384). TEE measured flow versus pressure closely correlated (R2 ≥ 0.98) with a fluid dynamics model. At 12 months, the pulmonary/systemic flow Qp/Qs ratio was 1.22 ± 0.12. Conclusions: When implanted in patients with advanced HF, this small interatrial shunt demonstrated predictable and durable patency and performance. [ABSTRACT FROM AUTHOR]

In the dynamic field of interventional cardiology, significant strides have been made in reducing periprocedural complications. Echocardiography, particularly transesophageal echocardiography, plays a key role in ensuring the safety and success of structural heart interventions. Its real‐time imaging capabilities allow for precise monitoring of device positioning, deployment, and procedural outcomes. By adhering to established imaging protocols and acquiring standard imaging planes, periprocedural echocardiography has become an essential tool for the successful performance of many structural heart interventions. In this manuscript, we present a series of unusual yet significant complications that we encountered during structural interventional procedures in our catheter laboratory. These complications, detected through echocardiography, underscore the critical role of imaging guidance in recognizing, and addressing unforeseen challenges, such as device malposition, thrombus formation in cardiac chambers during structural heart interventions, and cardiac tamponade during transcatheter mitral valve procedures. Through these cases, we highlight the effectiveness of transesophageal echocardiography in promptly identifying complications, allowing for timely intervention and resolution. [ABSTRACT FROM AUTHOR]

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Aims As transcatheter mitral valve (MV) interventions are expanding and more device types and sizes become available, a tool supporting operators in pre-procedural planning and the clinical decision-making process is highly desirable. We sought to develop a finite element computational simulation model to predict the results of transcatheter edge-to-edge repair (TEER) interventions. Methods and results We prospectively enrolled patients with secondary mitral regurgitation (MR) referred for a clinically indicated TEER. The 3D trans-oesophageal echocardiograms performed at the beginning of the procedure were used to perform the simulation. On the 3D dynamic model of the MV that was first obtained, we simulated the clip implantation using the same clip type, size, number, and implantation location that was used during the intervention. The 3D model of the MV obtained after the simulation of the clip implantation was compared with the clinical results obtained at the end of the intervention. We analysed the degree and location of residual MR and the shape and area of the diastolic MV area. We performed computational simulation on five patients. Overall, the simulated models predicted well the degree and location of the residual regurgitant orifice(s) but tended to underestimate the diastolic mitral orifice area. Conclusion In this proof-of-concept study, we present preliminary results on our algorithm simulating clip implantation in five patients with functional MR. We show promising results regarding the feasibility and accuracy in terms of predicting residual MR and the need to improve the estimation of the diastolic MV area. [ABSTRACT FROM AUTHOR]

Objective: In the present study, we aimed to explore the association between left atrial appendage emptying velocity (LAAEV) measured by transesophageal echocardiography and atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA) in patients with early persistent atrial fibrillation (PeAF). Methods: We retrospectively analyzed patients with early PeAF who underwent their initial ablation procedure. The echocardiographic and clinical data of the enrolled patients were collected and recorded prior to the operation. Following adjustment for confounding factors, we investigated the relationship between the LAAEV and AF recurrence in patients with early PeAF after radiofrequency ablation. Results: The proportions of AF recurrence in the low, medium, and high LAAEV groups were 48.8%, 16.0%, and 13.1%, respectively. After adjusting for potential confounding factors, we observed a gradual decrease in the risk of AF recurrence with increasing LAAEV (odds ratio: 0.882, 95% confidence interval: 0.842—0.924, p<0.001). This trend was statistically significant (p<0.001), particularly when comparing the high and low LAAEV groups (odds ratio: 0.033, 95% confidence interval: 0.009―0.116, p<0.001). Curve fitting analysis demonstrated an approximate negative linear association between LAAEV and the probability of AF recurrence. Conclusions: Among patients with early PeAF who successfully underwent their first RFCA, we found that the LAAEV within 24 h before the procedure was independently correlated with the risk of AF recurrence. Notably, this association was negative, indicating that higher LAAEV was associated with a lower risk of AF recurrence. [ABSTRACT FROM AUTHOR]

Background: We aimed to compare the procedural efficacy and long-term clinical results of a totally contrast-free Transcatheter Aortic Valve Implantation (TAVI) procedure (i.e., contrast dye was not used for either the pre-procedural assessment or during the procedure) to those of standard practice in patients with severe renal dysfunction. Methods: All consecutive patients with a glomerular filtration rate (GFR) ≤ 35 mL/min and severe aortic stenosis who were treated with transfemoral TAVI at our Institution were included in the registry. The zero-contrast patients underwent carbon dioxide angiography and a non-contrast CT scan for assessment of vascular access suitability, and aortic annulus sizing was performed by a TEE, and the procedural guidance was fluoroscopic and echocardiographic. Procedural outcomes were evaluated, and clinical long-term follow-up was performed for all included patients. Results: A total of 44 patients (median age, 85 (IQR, 80.75–87.00)) were included in the zero-contrast group (TEE guidance and general anesthesia in 37 (84%) patients), while 63 patients were included in the standard practice arm (82 ± 78 mL of contrast dye used). Procedural success was obtained in 100% of cases. There were no differences in procedural outcomes, including final mean aortic gradients (5.5 (IQR, 5.0–10.0) mmHg in the zero-contrast group vs. 6.0 (IQR, 5.0–10.0) mmHg in the standard practice group) and rate of at least a moderate paravalvular leak (0% vs. 1.6% in the zero-contrast and standard practice groups, respectively; p = 0.31). No differences in AKI during the hospital stay were observed. Over a median follow-up of 3.3 years, there was a significantly lower rate of AKI (1.2% vs. 25.9%, p < 0.001) and rehospitalizations (1.6% vs. 35.5%, p < 0.00) in standard practice group. Conclusions: We showed for the first time the feasibility and efficacy of a totally contrast-free strategy compared to standard practice in TAVI patients with severe renal dysfunction. Besides achieving comparable procedural results, the zero-contrast strategy showed a better long-term clinical outcome in reducing hospital readmissions for kidney function deterioration. [ABSTRACT FROM AUTHOR]

Artificial intelligence (AI) has the potential to improve the diagnosis and management of mitral regurgitation (MR), a type of valvular heart disease. Two studies published in Circulation demonstrate the effectiveness of deep learning (DL) models in detecting and classifying MR severity using echocardiographic videos. While these DL models show promise, they currently rely solely on color Doppler videos, which is not recommended by guidelines. However, integrating AI models with echocardiography can enhance accuracy and efficiency in screening and identifying appropriate interventions for MR patients. The article emphasizes the potential of AI to transform the assessment of MR and improve patient outcomes. [Extracted from the article]

Background: The patent foramen ovale (PFO) and interatrial block (IAB) are associated with cryptogenic stroke (CS). However, the role of the interaction between PFO and IAB in CS remains unclear. Methods: This case–control study enrolled 256 patients with CS and 156 individuals without a history of stroke or transient ischemic attack. IAB was defined as P wave duration > 120 ms. PFO was evaluated by contrast transesophageal echocardiography, and classified as no-PFO, low-risk PFO and high-risk PFO. Multiplicative and additive interaction analysis were used to assess the interaction between PFO and IAB in CS. Results: Multiplicative interaction analysis unveiled a significant interaction between IAB and low-risk PFO in CS (OR for interaction = 3.653, 95% CI, 1.115–12.506; P = 0.037). Additive interaction analysis indicated that 68.4% (95% CI, 0.333–1.050; P < 0.001) of the increased risk of CS related to low-risk PFO was attributed to the interaction with IAB. The results were robust in multivariate analysis. However, but no significant multiplicative or additive interaction was observed between IAB and high-risk PFO. When stratified by IAB, high-risk PFO was associated with CS in both patients with IAB (OR, 4.186; 95% CI, 1.617–10.839; P = 0.003) and without IAB (OR, 3.476; 95% CI, 1.790–6.750; P < 0.001). However, low-risk PFO was only associated with CS in patients with IAB (OR, 2.684; 95% CI, 1.007–7.149; P = 0.048) but not in those without IAB (OR, 0.753; 95% CI, 0.343–1.651; P = 0.479). Conclusion: The interaction between IAB and PFO might play an important role in CS, particularly in cases with low-risk PFO. [ABSTRACT FROM AUTHOR]

Background: To date, the relationship between the Transesophageal Echocardiography (TEE) monitoring indicator tricuspid annular plane systolic excursion (TAPSE) and the incidence of postoperative acute kidney injury (AKI) in Coronary Artery Bypass Grafting(CABG) patients remains unknown. The main objective of this study was to explore the relationship between the TAPSE and the incidence of AKI in CABG patients. Methods: This was a multicenter prospective cohort study was conducted between September 2021 and July 2022. Among 266 patients aged at least 18 years who underwent elective CABG, 140 were included. Results: We measured TAPSE via M-mode TEE via the mid-esophageal (ME) right ventricle(RV) inflow-outflow view (60°). All echocardiographic measurements were performed three separate times at each time point: T0 (before the start of CABG), T2 (approximately 5 ∼ 10 min after neutralization of protamine) and T3 (before leaving the operating room), and then averaged. Serum creatinine was measured 1 day before and within 7 days after CABG. There was no statistically significant association between the TEE-monitoring indicator TAPSE and the incidence of postoperative AKI in patients who underwent CABG. Conclusions: The TAPSE was not significantly correlated with postoperative AKI incidence and could not predict the early occurrence of postoperative AKI in CABG patients. TEE needs more evaluation for clinical efficacy of predicting the early occurrence of postoperative AKI in isolated CABG. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to demonstrate the discriminating predictive indicators in peripheral blood and left atrium blood for predicting the risk of left atrial spontaneous echo contrast (LASEC) in atrial fibrillation patients underwent catheter ablation. Methods: A total of 108 consecutive AF patients treated with radiofrequency ablation between July 2022 and July 2023 were enrolled and divided into two groups based on preprocedural transesophageal echocardiography: the non LASEC group (n = 71) and the LASEC group (n = 37). Circulating platelet and endothelial- derived MPs (PMPs and EMPs) in peripheral blood and left atrial blood were detected. Plasma soluble P-selectin (sP-selectin) and von Willebrand factor (vWF) were observed. Diagnostic efficiency was measured using receiver operating characteristic (ROC) curve. Results: Peripheral sP-selectin, vWF and EMPs expressions elevated in all subjects when compared to those in left atrium blood. Levels of sP-selectin and vWF were significantly higher in peripheral blood of LASEC group than those of non LASEC group (p = 0.0018,p = 0.0271). Significant accumulations of peripheral PMPs and EMPs were documented in LASEC group by comparison with non LASEC group (p = 0.0395,p = 0.018). The area under curve(AUC) of combined PMPs and sP-selectin in predicting LASEC was 0.769 (95%CI: 0.678–0.845, sensitivity: 86.49%, specificity: 59.15%), significantly larger than PMPs or sP-selectin alone. Conclusions: Expressions of PMPs, sP-selectin, EMPs and vWF Increased in NVAF patients with LASEC and that might be potential biomarkers for LASEC prediction. [ABSTRACT FROM AUTHOR]

Objective: To analyze the clinical manifestations, imaging characteristics, treatment measures, and efficacy of mitral valve aneurysm (MVA), and to enhance the clinicians' understandings of MVA. Methods: The clinical data of one patient with aortic valve bicuspid malformation leading to mitral valve anterior leaflet aneurysm were collected. The clinical diagnosis was confirmed based on the clinical characteristics and imaging features, the treatment methods were selected, and the efficacy was analyzed. The relevant literatures were reviewed. Results: The patient, a 68-year-old female, was admitted due to palpitations and shortness of breath for 13 years, and the symptoms worsened one month ago. Thirteen years ago, the patient experienced palpitations and shortness of breath without any inducement and was diagnosed with "heart valve disease" in the local hospital. The symptoms worsened one month ago, leading to hospitalization. The transthoracic two-dimensional echocardiography (TTE) results showed the left ventricular hypertrophy, bicuspid aortic valve with thickened and echogenic leaflets, the forward flow velocity was increased, and the aortic valve orifice area was 2. 0 cm²; the mitral valve anterior leaflet margin was slightly thickened and echogenic, presenting a cystic "honeycomb-like" structure closely related to the aortic valve regurgitation jet, which appeared to enter the "sac". The preoperative transesophageal echocardiography (TEE) results showed the bicuspid aortic valve malformation with the anterior leaflet prolapsing into the left ventricular outflow tract during diastole; a "sac-like" structure was detected on the atrial surface of the mitral valve anterior leaflet, changing shape with the cardiac cycle and communicating with left ventricular blood flow. The ultrasound diagnosis was bicuspid aortic valve malformation with transverse fissure, severe regurgitation with mild stenosis, and mitral valve anterior leaflet aneurysm. Intraoperatively, the aortic valve annulus was enlarged with the significant leaflet regurgitation. The leaflets were excised, and a 23 mm bioprosthetic valve was implanted in the aortic position. Upon exploration through the aortic valve orifice, a "sac-like" structure was found on the mitral valve anterior leaflet, which was not specially treated. The postoperative TEE results showed good echo and activity of the aortic bioprosthetic valve, and the "sac-like" structure on the mitral valve remained unchanged. The follow-up results at 10 d and 4 months after operation showed good echo and activity of the aortic bioprosthetic valve, and compared with before operation, there was no significant change in the nature and size of the mitral valve cystic lesion. Conclusion: MVA is clinically rare. TTE is currently the most valuable imaging diagnostic method for MVA, especially when combined with TEE, which is the best diagnostic method and can assist in the treatment and efficacy evaluation. [ABSTRACT FROM AUTHOR]

Firearm-related injuries in the USA are increasing, with over 105,000 cases annually. Gunshot wounds (GSWs), especially those involving retained bullets, present complex challenges due to bullet trajectories and embolization risks. This study reviews two cases of bullet emboli, focusing on bullet localization strategies and timing of removal. Imaging techniques such as chest X-ray, CT scan, intraoperative fluoroscopy, and transesophageal echocardiogram were employed for localization. In Case 1, a stable patient with a left-back GSW had a bullet embolism from the inferior vena cava to the right ventricle, necessitating prompt removal. In Case 2, an unstable patient with thoracoabdominal GSWs experienced a delayed embolism to the aortic root, requiring multiple surgeries. Effective management of retained bullets involves diverse imaging and timely surgical intervention, especially for stable patients, emphasizing individualized and proactive strategies to enhance outcomes in bullet embolization cases. [ABSTRACT FROM AUTHOR]

Aortitis includes both infectious and non-infectious inflammation of the arterial wall. Infectious forms have a worse prognosis, necessitating immediate diagnosis and treatment. We report a case of a patient with prosthetic valve endocarditis complicated with infectious aortitis and multiple embolic lesions, ultimately leading to death. An 81-year-old man with an aortic valve bioprosthesis (Intuity 27 mm) presented with fever, dysuria, and ankle swelling. Laboratory showed leukocytosis, anemia, elevated NT-proBNP, and C-reactive protein. Echocardiography revealed a hyperechogenic mass on the bioprosthesis, confirmed as prosthetic endocarditis by transesophageal echocardiography, which also showed an aortic bulb aneurysm and a 9 mm arterial wall thickening. Blood cultures were positive for Staphylococcus aureus, and intravenous antibiotics were started. Thoracic computed tomography confirmed aortic root dilation and mural thickening, indicating infectious aortitis with multiple embolic lesions in the spleen and kidneys. The patient then suffered an intestinal sub-occlusion. The Heart Team decided against cardiovascular surgery due to frailty and high surgical risk. Despite initial hemodynamic stability, his condition deteriorated, leading to death. This case presents a challenging scenario of prosthetic valvular endocarditis complicated by infectious aortitis, aortic aneurysm, and multiple thromboembolic lesions in a high-risk patient, ultimately resulting in death. [ABSTRACT FROM AUTHOR]

Aortic stenosis is one of the leading causes of valvular disease requiring surgery or transcatheter intervention, with a rising prevalence due to the aging population. Current guidelines recommend transcatheter aortic valve implantation (TAVI) as the first-line treatment for patients with symptomatic severe aortic stenosis and high surgical risk. The indications for TAVI have expanded to low-surgical-risk patients due to increased operator experience and improved implanted devices with a dramatic reduction of complications. Considering the limited durability of bioprostheses, TAVI-in-TAVI procedures have been successfully performed as an alternative to surgery. We present the case of an elderly patient who underwent a successful TAVI-in-TAVI for a degenerated bioprosthetic valve with severe stenosis. Multimodal imaging, including transthoracic echocardiography, transesophageal echocardiography, and cardiac computed tomography, played a crucial role in demonstrating the degeneration of the aortic bioprosthetic valve with severe stenosis. Excellent short- and long-term results were achieved by reducing transaortic gradients and improving the functional NYHA class. This case highlights the importance of proper patient selection using multimodality imaging and suggests the need for TAVI-in-TAVI to become an available and safe option for the management of a failed bioprosthesis valve. [ABSTRACT FROM AUTHOR]

BACKGROUND: Currently, surgery is the mainstay of the clinical treatment of vestibular migraine. OBJECTIVE: To investigate the clinical efficacy and safety of using transesophageal echocardiography-guided interventional closure of the patent foramen ovale (PFO) in the treatment of vestibular migraine. METHODS: The study included 52 patients with vestibular migraine who were admitted to our hospital between June 2019 and June 2021. All selected patients underwent a transesophageal echocardiography-guided interventional closure of the PFO and were followed up for one year after surgery. We observed the clinical efficacy and surgical success rate one year after surgery and compared the improvement in clinical symptoms and perioperative safety at different time points. RESULTS: The overall remission rate and the surgical success rate for the 52 patients with vestibular migraine one year after surgery were 86.54% and 96.15%, respectively. Compared to the pre-surgery levels, there was a significant progressively decreasing trend in the scores on the Headache Impact Test-6 (HIT-6), Visual Analogue Scale (VAS), Migraine Disability Assessment (MIDAS) questionnaire, frequency of headaches, and duration of headaches in patients with vestibular migraine at 1, 3, and 6 months after surgery (P < 0.05). Among the 52 patients, one developed atrial fibrillation three hours after surgery, which then spontaneously converted to sinus rhythm, and none of the other patients had adverse outcomes such as hematoma at the puncture site during the perioperative period. CONCLUSION: Transesophageal echocardiography-guided interventional closure of the PFO for treating vestibular migraine significantly improved the symptoms of migraine in patients, with a high surgical success rate, significant clinical efficacy, and favorable safety. [ABSTRACT FROM AUTHOR]

Introduction: Well-timed explant of veno-arterial extracorporeal life support (V-A ECLS) depends on adequate assessment of cardiac recovery. Often, evaluation of cardiac recovery consists of reducing support flow while visualizing cardiac response using transoesophageal echocardiography (TEE). This method, however, is time consuming and based on subjective findings. The dynamic filling index (DFI) may aid in the quantitative assessment of cardiac load-responsiveness. The dynamic filling index is based on the relationship of support flow and pump speed, which varies with varying hemodynamic conditions. This case series intends to investigate whether the DFI may support TEE in facilitating the assessment of cardiac load-responsiveness. Methods: Measurements for DFI-determination were performed in seven patients while simultaneously assessing ventricular function by measuring the aortic velocity time integral (VTI) using TEE. Measurements consisted of multiple consecutive transient speed manipulations (∼100 r/min) during weaning trials, both at full support and during cardiac reloading at reduced support. Results: The VTI increased between full and reduced support in six weaning trials. In five of these trials DFI decreased or remained equal, and in one case DFI increased. Of the three trials in which VTI decreased between full and reduced support, DFI increased in two cases and decreased in one case. Changes in DFI, however, are mostly smaller than the detection threshold of 0.4 mL/rotation. Conclusion: Even though current level of accuracy of the parameter requires further investigation to increase reliability and possibly predictability, DFI seems likely to be a potential parameter in supporting TEE for the assessment of cardiac load-responsiveness. [ABSTRACT FROM AUTHOR]

Inferior sinus venosus atrial septal defect (SVASD) is the rarest form of the atrial septal defect (ASD) and can sometimes go unnoticed. Although this defect can be associated with other congenital anomalies, its association with hypoplasia of the posterior mitral leaflet is extremely rare. In this case, we present a woman with a history of surgery for an ostium secundum ASD who exhibited persistent right heart chamber dilation. Echocardiography revealed hypoplasia of the posterior mitral leaflet, and cardiac magnetic resonance (CMR) imaging confirmed the presence of a previously undetected inferior sinus venosus ASD. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Recurrence of valvular involvement may occur after Libman–Sacks endocarditis surgery, emphasizing the need for frequent multivalvular evaluations with echocardiography or more sensitive methods to optimize surgical outcomes. This report presented a 32‐year‐old woman, complaining of recurrent fever and chills. Physical examination revealed the presence of a third heart sound (S3), a pan‐systolic murmur (III/VI) at mitral and tricuspid foci, tachycardia, and fine pulmonary crackles. Transesophageal echocardiography (TEE) revealed severe mitral regurgitation (MR) and moderate tricuspid regurgitation (TR) with vegetations on the mitral valve. Initially, intravenous antibiotic therapy was started simultaneously with diagnostic studies. Despite a positive TEE, negative blood cultures on three separate occasions precluded meeting the diagnostic criteria outlined in the modified Duke criteria. Moreover, the patient's condition continued to deteriorate after antibiotic therapy, leading to the diagnosis of Libman–Sacks endocarditis. The patient was considered a candidate for mitral valve surgery. All vegetations were completely debrided and then the mitral valve was reconstructed. Follow‐up post‐surgery echocardiography revealed the absence of MR and mitral stenosis (MS). Four months later, the patient presented again complaining of fatigue, dyspnea, lower extremity edema, and ascites with evidence of pulmonary hypertension and right heart failure on physical examination. TEE was performed, which revealed severe MR, severe TR, detached artificial chordae, and blood leak from the perforated pericardial patch. Therefore, she was necessitated for valvular surgery and underwent mitral and tricuspid valve surgery. The mitral ring and perforated pericardial patch were removed, and a mitral prosthetic valve was implanted. In addition, the tricuspid valve was repaired. Follow‐up post‐surgery echocardiography revealed the absence of MR and TR. To our knowledge, this is the first case of LSE recurrence with multi‐valvular involvement. [ABSTRACT FROM AUTHOR]

Background: Transesophageal echocardiography (TEE) is mandatory before transvenous lead extraction (TLE), but its usefulness remains underestimated. This study aims to describe the broad range of TEE findings in TLE candidates, as well as their influence on procedure complexity, major complications (MCs) and long-term survival. Methods: Preoperative TEE was performed in 1191 patients undergoing TLE. Results: Lead thickening (OR = 1.536; p = 0.007), lead adhesion to heart structures (OR = 2.531; p < 0.001) and abnormally long lead loops (OR = 1.632; p = 0.006) increased the complexity of TLE. Vegetation-like masses on the lead (OR = 4.080; p = 0.44), lead thickening (OR = 2.389; p = 0.049) and lead adhesion to heart structures (OR = 6.341; p < 0.001) increased the rate of MCs. The presence of vegetations (HR = 7.254; p < 0.001) was the strongest predictor of death during a 1-year follow-up period. Conclusions: TEE before TLE provides a lot of important information for the operator. Apart from the visualization of possible vegetations, it can also detect various forms of lead-related scar tissue. Build-up of scar tissue and the presence of long lead loops are associated with increased complexity of the procedure and risk of MCs. Preoperative TEE performed outside the operating room may have an impact on the clinical decision-making process, such as transferring potentially more difficult patients to a more experienced center or having the procedure performed by the most experienced operator. Moreover, the presence of masses or vegetations on the leads significantly increases 1-year and all-cause mortality. [ABSTRACT FROM AUTHOR]

Background/Objective: Whether left atrial appendage thrombus (LAAT) in patients with atrial fibrillation (AF) on chronic anticoagulation significantly increases cardiovascular risk is unknown. This study aimed to assess LAAT prevalence and its predictive role in cardiovascular events among consecutive anticoagulated patients with AF admitted for electrical cardioversion. Methods: This prospective study included 500 patients. The primary outcome was LAAT on transesophageal echocardiography. Patients were followed up for a median of 1927.5 (interquartile range 1004–2643) days to assess cardiovascular events. Results: LAAT was detected in 65 (13%) patients. No significant differences in stroke, transient ischemic attack, systemic thromboembolic events, or myocardial infarction prevalence were observed between patients with AF with and without LAAT. Hospitalization for heart failure (HF) was more frequent in patients with LAAT than in those without LAAT; however, the effect of LAAT on HF hospitalization was not statistically significant. Patients with LAAT had a significantly higher risk of cardiovascular death than those without LAAT. LAAT and greater left atrial (LA) diameter were associated with higher rates of cardiovascular death. The independent HF hospitalization predictors were greater LA diameter, lower left ventricular ejection fraction (LVEF), and estimated glomerular filtration rate (eGFR). Conclusions: Patients with AF who received anticoagulation therapy showed a high prevalence of LAAT. LAAT and greater LA diameter were associated with significantly higher rates of cardiovascular death. LAAT, greater LA diameter, lower LVEF, and lower eGFR were associated with poor prognosis in anticoagulated patients with AF and were predictors of disease severity. [ABSTRACT FROM AUTHOR]

This article explores the management of patients with aneurysmal subarachnoid hemorrhage (aSAH) and the challenges in determining fluid balance and blood transfusion thresholds. The authors analyze a clinical trial and find that positive fluid balance is associated with lower hemoglobin levels and an increased risk of secondary infarctions and unfavorable neurologic outcomes. Packed red cell transfusions are also found to be predictive of worse neurologic outcomes. The study suggests that careful, goal-directed circulation management is crucial for maximizing favorable functional outcomes in patients with aSAH. The article emphasizes the importance of maintaining a mean daily neutral fluid balance and targeting euvolemia, while also highlighting the need for consensus among healthcare professionals on definitions and personalized management. It raises questions about the implementation of fluid balancing and the design of randomized trials for fluid management strategies. Overall, the article provides practical insights for managing patients with aSAH. [Extracted from the article]

This article explores the use of transesophageal echocardiography (TEE) during advanced cardiac life support (ACLS) to enhance the effectiveness of cardiopulmonary resuscitation (CPR). TEE allows for continuous monitoring and improved imaging during CPR, potentially optimizing chest compression quality. However, there is limited evidence on the impact of TEE on patient outcomes. A recent study suggests that avoiding aortic valve compression during CPR may improve the likelihood of achieving and sustaining return of spontaneous circulation (ROSC). Further research is needed to determine long-term outcomes and potential biases in evaluating TEE findings. The article proposes that incorporating TEE as a surrogate for chest compression performance could be beneficial, but more rigorous studies are necessary to demonstrate its effectiveness in improving survival and neurological outcomes. The text also briefly touches on the management of aneurysmal subarachnoid hemorrhage, highlighting the variability in thresholds and triggers for fluid loading and blood transfusions. [Extracted from the article]

OBJECTIVES: Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA. DESIGN: Prospective observational cohort study. SETTING: Single center. PATIENTS: This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Etco2) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Etco2, post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups. CONCLUSIONS: Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear. [ABSTRACT FROM AUTHOR]

This article is the eighth in an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles targeted at the perioperative echocardiographic diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, the articles will target the use of perioperative echocardiography in general. [ABSTRACT FROM AUTHOR]

Background: Hypertrophic obstructive cardiomyopathy (HOCM) is clinically symptomatic and prone to malignant arrhythmias and sudden cardiac death (SCD). Currently, an effective treatment is surgical resection of the hypertrophic ventricular septum to relieve the left ventricular outflow tract (LVOT) obstruction and mitral insufficiency. Our center performs an innovative, minimally invasive right infra‐axillary thoracotomy for transaortic septal myectomy. Minimally invasive procedures rely more on perioperative transesophageal echocardiography (TEE). This study aimed to explore the use of echocardiography during the perioperative period of surgical intervention for HOCM. Methods: Between August 2021 and April 2022, 27 patients with HOCM underwent cardiac surgery at our hospital. Minimally invasive transaortic septal resection (Morrow myectomy) was performed from the right axilla. The extent of myectomy and need for mitral valve repair were based on perioperative TEE assessment and surgical findings. The demographic parameters and clinical data of patients were recorded. The cardiopulmonary bypass time, aortic cross‐clamp, and mechanical ventilation times were calculated. TEE was used to assess ventricular wall thickening and anatomical abnormalities of mitral regurgitation, assist in intravenous catheterization, and assess the postoperative gradients of the LVOT. Results: Among the 27 patients with HOCM who underwent transaortic septal myectomy by minimally invasive right infra‐axillary thoracotomy, 16 had LVOT obstruction, 2 had mid‐LV obstruction, and 9 had both LVOT and mid‐LV involvement. TEE provides information about the fine structure of the LV cavity and the etiology of the obstruction. In all cases, LVOT obstruction and mitral valve systolic anterior motion were resolved postoperatively, and the degree of mitral regurgitation was significantly reduced. Conclusion: Perioperative echocardiography provides valuable information regarding the complex etiology of LVOT obstruction during minimally invasive right infra‐axillary thoracotomy for transaortic septal myectomy. It helps determine the extent of septal resection and assess the need for concomitant mitral valve repair. [ABSTRACT FROM AUTHOR]

Background: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. Methods: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. Results: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. Conclusions: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery. [ABSTRACT FROM AUTHOR]

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