Search

Open in new tab Download slide OBJECTIVES Core temperature monitoring is critical during cardiopulmonary bypass (CPB). In this prospective observational study, we investigated the performance of the transoesophageal echocardiography (TOE) probe for core (oesophageal) temperature monitoring during CPB. METHODS Thirty adult patients, 18–70 years of either gender, undergoing cardiac surgery with CPB were enrolled. All patients received a reusable nasopharyngeal probe for monitoring core temperatures. In addition, the oesophageal temperatures were monitored with the TOE probe. The arterial outlet temperatures at the membrane oxygenator were also monitored and taken as the reference standard. Monitoring was performed every 5 min until 20 min, and then at 30 min during both the cooling and rewarming periods. RESULTS During cooling, the oesophageal and nasopharyngeal temperatures lagged behind the arterial outlet temperatures. However, the intra-class correlation of the oesophageal temperatures with the arterial outlet temperatures was better (range 0.58–0.74) than the correlation of the nasopharyngeal temperatures with the arterial outlet temperatures (range 0.46–0.62). During rewarming, the performance of the TOE probe was significantly superior to the nasopharyngeal probe. After 15 and 20 min of rewarming, there was a difference of ∼1°C between the oesophageal and nasopharyngeal temperatures. At 30 min of rewarming, the oesophageal and the arterial outlet temperatures were similar, while the nasopharyngeal temperatures still lagged by 0.5°C. Bias was significantly less both during cooling and warming between the oesophageal temperatures and arterial outlet temperatures. CONCLUSIONS Performance of the TOE probe as an oesophageal temperature probe is superior to the nasopharyngeal probe during CPB. Clinical trial registration number CTRI no 2020/10/028228; ctri.nic.in. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to simulate and compare the healthcare and economic outcomes associated with routine use of intraoperative transoesophageal echocardiography (TOE) in patients undergoing cardiac surgery with those associated with a scenario where TOE is not routinely used.Methods: The impact of TOE on surgical decision-making was estimated through a systematic literature review. Individual short-term morbidity and mortality estimates were generated by application of the Society of Thoracic Surgeons risk calculator. Long-term event rates, unit costs, and utility weights were sourced from published literature and expert opinion. A discrete-event simulation model was then constructed to simulate both the in-hospital and post-discharge outcomes for patients undergoing cardiac surgery. Robustness of the base case results was examined through deterministic and probabilistic sensitivity analyses. An incremental cost-effectiveness ratio of €30 000 per quality-adjusted life-year gained was assumed to represent acceptable cost-effectiveness.Results: Routine use of intraoperative TOE was associated with lower costs and higher benefits per patient, which indicates that use of TOE is a dominant strategy. The intervention resulted in the avoidance of 299 cardiac complications, 20 strokes, and 11 all-cause deaths per 10 000 patients. Routine intraoperative TOE was associated with an increased occurrence of bleeding owing to more valvular surgery and subsequent long-term anticoagulation.Conclusions: Routine intraoperative TOE is a cost-effective procedure for patients undergoing cardiac surgery, leading to lower overall costs. It was associated with a decrease in long-term complications including stroke, cardiac complications, and death, although there was a slight increase in extracranial bleeding events. [ABSTRACT FROM AUTHOR]

Perioperative management of neurosurgical patients with an underlying myocardial dysfunction poses a unique challenge to the neuroanaesthesiologist and the neurointensivist. Sudden catecholamine surge during the aneurysmal subarachnoid haemorrhage (SAH) can cause severe cardiac dysfunction such as myocardial ischaemia and cardiomyopathy. SAH in a patient with restrictive cardiomyopathy could be hazardous to the myocardium leading to severe cardiac morbidity. We report the successful management of an acute post-operative diastolic heart failure with a milrinone infusion in a patient with restrictive cardiomyopathy, following anterior communicating artery aneurysm clipping. We have discussed the ‘dual beneficial’ role of milrinone on the heart and the brain in this clinical setting. In addition, the importance of peri-operative utilisation of transoesophageal echocardiography and transthoracic echocardiography for the successful management of diastolic heart failure is highlighted.

Sinus venosus Atrial Septal Defect (ASD) is the abnormal drainage of pulmonary veins to right atrium, which can present with symptoms of pulmonary hypertension. Sinus venosus ASD presents a diagnostic challenge considering low detection rates using transthoracic echocardiography. We report a case of a 36-year-old female in whom the sinus venosus ASD was wrongly diagnosed as primary pulmonary hypertension. Also, the role of transoesophageal and bubble contrast saline echocardiography in detecting an adequate closure of sinus venosus ASD after the surgical repair was presented. Based on transthoracic echocardiography and ECG findings, the patient was diagnosed with primary pulmonary hypertension. Because of the persistent symptoms and failure to improve with Bosentan, Sildenafil and diuretics, the patient was advised Transoesophageal Echocardiography (TEE), which revealed superior venacava sinus venosus ASD. The patient had surgical closure of the defect but she developed cyanosis and hypoxemia after the surgery. The bubble contrast saline echocardiography was performed for detecting adequate closure of the defect. The bubble contrast echocardiography showed simultaneous opacification of all the four chambers of heart. Thereby, a repeat surgery was done and patient experienced improvement in her symptoms. The present case concludes that bubble contrast saline echocardiography can be used to detect the presence of intra and extra-cardiac shunt.

The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using transthoracic scanning protocols, such as FUSIC Heart, has empowered non-cardiologists to rapidly identify and treat the major causes of haemodynamic instability. There are, however, circumstances when a transoesphageal, rather than transthoracic approach, may be preferrable. Due to the close anatomical proximity between the oesophagus, stomach and heart, a transoesphageal echocardiogram (TOE) can potentially overcome many of the limitations encountered in patients with poor transthoracic ultrasound windows. These are typically patients with severe obesity, chest wall injuries, inability to lie in the left lateral decubitus position and those receiving high levels of positive airway pressure. In 2022, to provide all acute care practitioners with the opportunity to acquire competency in focused TOE, the Intensive Care Society (ICS) and Association of Anaesthetists (AA) launched a new accreditation pathway, known as Focused Transoesophageal Echo (fTOE). The aim of fTOE is to provide the practitioner with the necessary information to identify the aetiology of haemodynamic instability. Focused TOE can be taught in a shorter period of time than comprehensive and teaching programmes are achievable with support from cardiothoracic anaesthetists, intensivists and cardiologists. Registration for fTOE accreditation requires registration via the ICS website. Learning material include theoretical modules, clinical cases and multiple-choice questions. Fifty fTOE examinations are required for the logbook, and these must cover a range of pathology, including ventricular dysfunction, pericardial effusion, tamponade, pleural effusion and low preload. The final practical assessment may be undertaken when the supervisors deem the candidate's knowledge and skills consistent with that required for independent practice. After the practitioner has been accredited in fTOE, they must maintain knowledge and competence through relevant continuing medical education. Accreditation in fTOE represents a joint venture between the ICS and AA and is endorsed by Association of Cardiothoracic Anaesthesia and Critical care (ACTACC). The process is led by TOE experts, and represents a valuable expansion in the armamentarium of acute care practitioners to assess haemodynamically unstable patients., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© The Intensive Care Society 2023.)

We describe a case of severe left ventricular outflow tract obstruction (LVOTO) with severe mitral incompetence due to systolic anterior motion of the anterior mitral leaflet (SAM) that was recognised thanks to the immediate availability of transoesophageal echocardiography during the resuscitation of anaphylactic shock. The patient rapidly responded to cessation of the epinephrine (adrenaline) infusion and intravascular volume expansion with intravenous crystalloid. The absence of risk factors for developing SAM/LVOTO serve as a warning to clinicians to consider this diagnosis in all cases of epinephrine non-responsive anaphylactic shock. [ABSTRACT FROM AUTHOR]

Background: General anaesthesia and surgically induced changes in cardiac loading conditions may alter flow across the aortic valve. This study examined how echocardiographic assessment of the severity of aortic stenosis (AS) changes during surgery.Methods: Patients who underwent aortic valve replacement for any severity of AS between July 2007 and June 2015 were identified. Peak velocities, mean gradients, and dimensionless indices (DI) measured with preoperative transthoracic echocardiography (TTE) were compared with those measured with intraoperative transoesophageal echocardiography (TOE). Additionally, agreement of preoperative and intraoperative grading of AS based on these measurements was assessed.Results: Data from 319 patients were analysed. On average, intraoperative TOE peak velocity and mean gradient were lower by 0.59 m s -1 and 12.5 mm Hg, respectively ( P <0.0001), compared with preoperative TTE measurements, whereas the difference in mean DI was minimal at 0.008. Preoperative and intraoperative grades of AS severity (mild, moderate, and severe) by peak velocity, mean gradient, and DI agreed in 53.3, 53.7, and 83.3% of patients, respectively. The TOE grade of AS severity by peak velocity and mean gradient was at least one lower than the TTE grade in 45.1 and 42.7% of patients, respectively. Significantly fewer patients had their severity of AS reclassified based on DI ( P <0.0001).Conclusions: Intraoperative TOE peak velocities and mean gradients are often significantly lower than preoperative TTE measurements, leading to underestimation of AS severity in nearly half of our study patients. The DI is a more reliable measurement of AS severity in the intraoperative setting. [ABSTRACT FROM AUTHOR]

Background: The lower superior vena cava (SVC), near its junction with the right atrium (RA), is considered the ideal location for the central venous catheter tip to ensure proper function and prevent injuries. We determined catheter insertion depth with a new formula using the sternoclavicular joint and the carina as radiological landmarks, with a 1.5 cm safety margin. The accuracy of tip positioning with the radiological landmark-based technique (R) and Peres' formula (P) was compared using transoesophageal echocardiography.Methods: Real-time ultrasound-guided central venous catheter insertion was done through the right internal jugular or subclavian vein. Patients were randomly assigned to either the P group (n=93) or the R group (n=95). Optimal catheter tip position was considered to be within 2 cm above and 1 cm below the RA-SVC junction. Catheter tip position, abutment, angle to the vascular wall, and flow stream were evaluated on a bicaval view.Results: The distance from the skin insertion point to the RA-SVC junction and determined depth of catheter insertion were more strongly correlated in the R group [17.4 (1.2) and 16.7 (1.5) cm; r=0.821, P<0.001] than in the P group [17.3 (1.2) and 16.4 (1.1) cm; r=0.517, P<0.001], with z=3.96 (P<0.001). More tips were correctly positioned in the R group than in the P group (74 vs 93%, P=0.001). Abutment, tip angle to the lateral wall >40°, and disrupted flow stream were comparable.Conclusions: Catheter tip position was more accurate with a radiological landmark-based technique than with Peres' formula.Clinical Trial Registration: Clinical Trial Registry of Korea: https://cris.nih.go.kr/cris/index.jsp KCT0001937. [ABSTRACT FROM AUTHOR]

Introduction In response to an ultrasound imaging issue with transoesophageal echocardiography probes, a testing protocol was developed to check features pertinent to the operation of these probes. The imaging problem was detected in multiple probes of the same make and model. Methods Over a two-year period, a series of 26 probes of this model were tested at acceptance, then three to six months later before being replaced due to a defect. A range of visual, mechanical and electrical tests were performed. Image tests comprised low-contrast penetration measurements and a comparison of phantom images at regular intervals to highlight artefacts in both B-mode and colour Doppler imaging. Results Of the 26 defective probes replaced, 7 suffered mechanical/electrical problems, 5 of which prevented imaging results being obtained. Low-contrast penetration reduction of greater than 5% occurred in 14 probes. B-mode artefacts were observed on 12 probes and Doppler noise artefacts on 6 probes. No faults were found on five probes. The manufacturer addressed the imaging problem identified and of the seven subsequent probes supplied, only one suffered an imaging fault. Conclusions The implementation of a quality assurance protocol for transoesophageal echocardiography probes resulted in cost savings on replacements/repairs. When provided with the evidence gathered, the manufacturer supplied 23 probes under warranty or as loan equipment. The regular testing of the probes substantially reduced the impact of downtime and poor diagnosis from this equipment on the clinical service. [ABSTRACT FROM AUTHOR]

Background: The role of transoesophageal echocardiography (TOE) in anaesthetic practice is expanding. We evaluated the effect of a TOE perceptual and adaptive learning module (PALM) on first-yr anaesthesiology residents' performance, in diagnosing cardiac pathology by TOE.Methods: First-yr residents were assigned to a group (n = 12) that used a TOE PALM or a control group that did not (n = 12). Both groups received a TOE pretest that measured their accuracy and response times. The PALM group completed the PALM and a posttest within 30 min and a delayed test six months later. The control group received a delayed test six months after their pretest. Accuracy and fluency (accurate responses within 10 s) were measured.Results: The PALM group had statistically significant improvements for both accuracy and fluency (P < 0.0001) in diagnosing cardiac pathology by TOE. After six months, the PALM group's performance remained significantly higher than their pretest values for accuracy (P = 0.0002, d = 2.7) and fluency (P < 0.0001, d = 2.3).Conclusions: In this pilot study, exposure to a PALM significantly improved accuracy and fluency in diagnosing TOE cardiac pathology, in a group of first-year anaesthesiology residents. PALMs can significantly improve learning and pattern recognition in medical education. [ABSTRACT FROM AUTHOR]

A suggested standard examination (SSE) for intraoperative transoesophageal echocardiography for cardiac surgery was developed at the Green Lane Department of Cardiothoracic and Otorhinolaryngology Anaesthesia at the Auckland City Hospital. The examination includes views to be recorded in all patients pre- and postcardiopulmonary bypass. There are also additional views to be recorded in patients with valvular pathology. Using the SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines, we report an audit comparing acquisition ratios before and after introduction of the SSE. A baseline mean acquisition ratio of 0.62 was achieved, which was not significantly changed by the introduction of the SSE. Nevertheless, we found the SSE to be a useful audit tool and believe it might be of interest to others to assist with perioperative transoesophageal echocardiography quality assurance and education. [ABSTRACT FROM AUTHOR]

In the current era of expanding catheter-based and complex repair procedures to treat aortic valve (AV) diseases, growing consideration is being given to understanding the functional anatomy of the AV complex. Echocardiography is the primary imaging modality to assess and follow-up AV diseases, and the recent three-dimensional (3D) capabilities allow clinicians to appreciate the functional complexity of the aortic root in the beating heart. Despite being subject to several limitations, 3D echocardiography (3DE) holds promise as a more suitable imaging backup for aortic interventions of mounting complexity and for circumventing some of their current complications. In this review, we discuss the key principles of 3DE for assessing the AV pathology and the incremental clinical benefits in comparison with conventional 2DE and Doppler echocardiography, justifying its implementation in the diagnostic workup of aortic diseases. In view of an effective clinical use, a brief section is dedicated to the acquisition modalities, display, and interpretation of various abnormalities by 3DE. [ABSTRACT FROM AUTHOR]

Aims The aim of this study, undertaken in patients who underwent mitral valve (MV) repair surgery, was to evaluate the accuracy of pre-operative three-dimensional (3D) transthoracic echocardiography (TTE) in the evaluation of MV pathology in cases with simple or complex lesions. Methods and results Two hundred consecutive patients with severe mitral regurgitation due to degenerative MV prolapse underwent a complete 3DTTE the day before surgery. Three-dimensional TTE data were compared with MV surgical inspection. Three-dimensional echocardiography was feasible in a relatively short time (5 ± 3 min) with good (67%) and optimal (21%) imaging quality in the majority of cases. Three-dimensional TTE allowed an accurate identification (95% accuracy) of all MV lesions. Seventy-three (36.5%) patients had simple lesions at 3DTTE and 71 of them (97.2%) underwent a simple surgical procedure; 127 (63.5%) had complex lesions at 3DTTE and, in these cases, surgeons performed either simple procedures (48%) or complex procedures (47.2%) or valve replacement in 4.7% (after a first attempt for repair). Conclusion Three-dimensional TTE is feasible, not time-consuming, and accurate in identifying cases with simple vs. complex MV lesions. [ABSTRACT FROM AUTHOR]

Ultrasound evaluation of the heart is primarily assessed using transthoracic echocardiography. There are limitations to this standard assessment and other advanced ultrasound techniques and tools are available. This article provides a basic introduction to three corroborative procedures (transoesophageal echocardiography, stress echocardiography and contrast echocardiography) which contribute to the overall ultrasound assessment of cardiac structure and function. Unlike standard transthoracic imaging these procedures use a multi-disciplinary team and therefore this article highlights these potential roles. [ABSTRACT FROM AUTHOR]

Background: The postoperative monitoring and treatment of the patient undergoing aortic valve replacement is a complex challenge. Echocardiography is the only method which provides dynamic and real-time bedside imaging of the heart. Focused assessed transthoracic echocardiography has been shown to provide a usable window for cardiac imaging in a mixed ICU population. The aim of this study was to evaluate the feasibility of perioperative imaging of the heart and pleura according to the focused assessed transthoracic echocardiography protocol in patients scheduled for aortic valve replacement. Method: Thirty-five adult patients scheduled for aortic valve replacement were followed perioperatively with focused assessed transthoracic echocardiography examinations. A Vivid-7 echo-machine and a 2.5 MHz matrix transducer with second-harmonic imaging were used for data acquisition. The image quality for the cardiac window was graded 1–5 (1 = no image, 2 = poor and unusable image quality, 3 = usable image quality, 4 = good image quality and 5 = perfect image quality). A score ⩾3 equalled an image quality judged to be of sufficient quality to be interpreted and thereby to contribute to clinical decision-making. Results: All patients had at least one usable window preoperatively. At least one usable window was obtained in 88% of patients on the first postoperative day, and in 97% at discharge. The image quality changed over time, with the poorest quality being observed on the first postoperative day. The apical view with the patient in the left lateral position provided the best cardiac window on all occasions. The presence of drains did not significantly affect the achievability of a satisfactory examination. The number of patients with pleural effusion was relatively high. On the first postoperative day, 10 subjects had unilateral and one subject had bilateral pleural effusions. At discharge, 14 patients had unilateral and four patients had bilateral effusions. Conclusions: We conclude that the image quality of the heart and pleura, according to the focused assessed transthoracic echocardiography concept, is sufficient to undergo interpretation and thereby contribute to the perioperative clinical decision-making in patients with aortic stenosis. [ABSTRACT FROM AUTHOR]

Background and objective: To evaluate the feasibility of an abbreviated focus assessed transthoracic echocardiographic protocol, consisting of four standardized acoustic views for cardiopulmonary screening and monitoring. Methods: The protocol was applied in 210 patients in a 20-bed multidisciplinary intensive care unit in a university hospital. When inconclusive, an additional transoesophageal echocardiographic examination was performed. Diagnosis, indication, acoustic window, position and value were recorded. Significant pathology, load, dimensions and contractility were assessed. Results: Two-hundred-and-thirty-three transthoracic and four transoesophageal echoes were performed. The protocol provided usable images of the heart in 97% of the patients, 58% subcostal, 80% apical and 69% parasternal. Images through one window were obtainable in 23%, through two windows in 41% and through three windows in 34%. In 227 patients (97.4%) the focus assessed echo protocol contributed positively. In 24.5% of cases the information was decisive, in 37.3% supplemental and in 35.6% supportive. Conclusions: By means of an abbreviated, focus assessed transthoracic echo protocol it is feasible to visualize the haemodynamic determinants for assessment and optimization. One or more useful images are obtainable in 97% of critically ill patients. [ABSTRACT FROM AUTHOR]

Objective: Transoesophageal Doppler (TOD) has been used in adults to optimise left ventricular filling on the basis of the waveform parameters. We wished to see if a similar relationship exists in children, specifically: (a) whether change in thermodilution stroke volume (SV) following a fluid bolus corresponded to change in Doppler stroke distance, Doppler corrected flow time (FTc), or central venous pressure (CVP); (b) whether a response to fluid challenge (defined as an increase in SV of greater than 10%) can be predicted on the basis of an absolute value for FTc or CVP prior to fluid bolus; and (c) the relationship between FTc and systemic vascular resistance index.Design: Prospective, comparison study.Setting: Sixteen-bed paediatric intensive care unit of a university hospital.Patients: Ninety-four ventilated children were studied, median (range) age 25 months (4 days- 16 years). Diagnoses included: post-cardiac surgery (n = 58), sepsis/multi-organ failure (n = 29), respiratory disease (n = 5), and other (n = 2).Interventions: A 4-MHz, 5.5-mm diameter, flexible TOD probe was placed when patients were haemodynamically stable. Five consecutive measurements of stroke distance and FTc were made and averaged, concurrently with five SV measurements by femoral artery thermodilution. SV was then augmented by administration of fluid (10 ml/kg), and haemodynamic recordings were repeated.Measurements and Main Results: The median (range) SV was 17 ml (2-64 ml). The median coefficients of variation were 3.9 % for SV, 3.5 % for stroke distance, and 3.1% for FTc. Changes in SV were accurately tracked by changes in stroke distance (mean bias 1.8 %, limits of agreement +/- 17%), but not by FTc or CVP. FTc was weakly inversely correlated with systemic vascular resistance (r = -0.15, P < 0.05). Among non-cardiac patients (n = 36), the optimal FTc that predicted an improvement in SV following fluid bolus was 0.394 s (area under ROC curve 0.756), giving a sensitivity of 90 %, specificity of 62 %, positive predictive value of 47 %, and a negative predictive value of 94 %. CVP was a poor predictor for all patient groups.Conclusions: TOD stroke distance is able to follow changes in SV following fluid bolus amongst ventilated children, and can predict when further volume loading is unlikely to improve SV amongst general, but not cardiac ICU patients. CVP is a poor discriminator of volume status in this group of patients. [ABSTRACT FROM AUTHOR]

Papillary fibroelastoma (PFE) is a rare benign tumour that attaches to the endocardial surface, mostly on cardiac valves. Though usually asymptomatic, it can be the source of several complications. To date, 49 cases have been reported of embolic stroke with a PFE as the probable origin. Case reports: (i) a 39-year-old male presented with ischemic embolic stroke; the presence of a PFE was assessed by means of transoesophageal echocardiography and confirmed by pathological findings; (ii) a 32-year-old woman presented with sudden onset of left hemiparesis; a cardiogenic embolic stroke was suspected, and a diagnosis of PFE was made based on echocardiographic and pathological findings. In both cases, surgical excision of the tumours was performed with no recurrences at follow-up. Two mechanisms can explain the formation of emboli in PFE: dislodgement of the tumour leaves or fibrin-platelet aggregation on the endocardial surface of these leaves. Transthoracic echocardiography may lead to the suspicion of a PFE, but transoesophageal echocardiography is required for confirmation. Prompt surgical excision is indicated in most cases. Anticoagulation is only recommended in situations of high surgical risk and during the wait for surgery. [ABSTRACT FROM AUTHOR]

Between April 1985 and December 1989, outpatient transoesophageal echocardiography was performed in 133 adolescent and adult patients (14% of all outpatient transoesophageal studies) (age range 11–78 years; weight 30–95 kg) to determine the value of this technique both in establishing the primary diagnosis (62 patients) and in the post-surgical follow up (71 patients) of congenital heart disease. The results were correlated with the findings of precordial echocardiography, catheterization and surgical inspection. Clear advantages of transoesophageal imaging over precordial imaging include: (1) direct identification of atrial appendage morphology in all patients; (2) delineation of systemic and pulmonary venous connections; (3) atrial baffle function (eight patients); (4) better evaluation of the Fontan-type circulation (five patients); (5) improved morphologic assessment of the atrioventricular junction and valves (29 patients); (6) definition ofsubaortic obstruction (18 patients); and (7) definition of ascending aortic morphology in Marfan's syndrome and supravalvar aortic stenosis (13 patients). The problems encountered with transoesophageal imaging include: (1) limited imaging planes; (2) poor visualization of specific intracardiac regions (antero-apical trabecular septum, right ventricular outflow tract); (3) flow masking behind implanted intracardiac prosthetic material. [ABSTRACT FROM PUBLISHER]

Aims To test the hypothesis that inter-observer variability accounts for the wide variation in reported prevalences of fibrin strands on prosthetic heart valves and to develop criteria for their identification and reporting. Methods and Results A videotape with 30 sequences of prosthetic heart valves imaged by transoesophageal echocardiography and showing abnormalities such as strands, microbubbles, and spontaneous echocardiographic contrast, was assessed in 13 European and three American centres. There were three duplicated examples, unbeknown to the observers. Definitions and reported prevalence rates of the abnormalities were analysed, and inter- and intra-observer agreement estimated with the kappa statistic.Mobile echoes were identified in 40 to 80% of the sequences on the tape. The reported prevalence of mobile echoes correlated with the time spent reporting the tape. There was moderate inter-observer agreement for the identification of any mobile echoes (kappa=0·38), but no agreement for their labelling (kappa=0·22), in spite of similar definitions. Intra-observer reproducibility was good (agreement in 76% of the reduplicated sequences). Conclusions The true prevalence and potential significance of mobile echoes on prosthetic heart valves cannot be assessed unless inter-observer consensus on echocardiographic criteria for identifying such echoes is reached. [ABSTRACT FROM PUBLISHER]

The update of the Echocardiography Core Syllabus of European Association of Cardiovascular Imaging (EACVI) is now available online. The Echocardiography Core Syllabus enumerates the elements of knowledge to be taught, represents a framework for the development of local training curricula and provides expected learning outcomes to the echocardiography learner. [ABSTRACT FROM AUTHOR]

Summary We describe a patient with aortic dissection extending into the right coronary artery who was successfully resuscitated and operated upon after a cardiac arrest during transfer to the operating room. The use of transoesophageal echocardiography was particularly helpful for rapid diagnosis of aortic type A dissection and urgent surgical treatment. [ABSTRACT FROM AUTHOR]

Sinus venosus Atrial Septal Defect (ASD) is the abnormal drainage of pulmonary veins to right atrium, which can present with symptoms of pulmonary hypertension. Sinus venosus ASD presents a diagnostic challenge considering low detection rates using transthoracic echocardiography. We report a case of a 36-year-old female in whom the sinus venosus ASD was wrongly diagnosed as primary pulmonary hypertension. Also, the role of transoesophageal and bubble contrast saline echocardiography in detecting an adequate closure of sinus venosus ASD after the surgical repair was presented. Based on transthoracic echocardiography and ECG findings, the patient was diagnosed with primary pulmonary hypertension. Because of the persistent symptoms and failure to improve with Bosentan, Sildenafil and diuretics, the patient was advised Transoesophageal Echocardiography (TEE), which revealed superior venacava sinus venosus ASD. The patient had surgical closure of the defect but she developed cyanosis and hypoxemia after the surgery. The bubble contrast saline echocardiography was performed for detecting adequate closure of the defect. The bubble contrast echocardiography showed simultaneous opacification of all the four chambers of heart. Thereby, a repeat surgery was done and patient experienced improvement in her symptoms. The present case concludes that bubble contrast saline echocardiography can be used to detect the presence of intra and extra-cardiac shunt. [ABSTRACT FROM AUTHOR]

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.)

Transoesophageal and epicardial echocardiography are indispensible intraoperative imaging modalities to guide paediatric heart disease surgeries and influence surgical decision-making. A less well-described role of intraoperative imaging is its utility in evaluating coronary artery patency and flow. Focused two-dimensional, colour, and spectral Doppler imaging of the coronary arteries should be performed during surgeries involving coronary manipulation or re-implantation, or in cases where there is unexpected ventricular dysfunction or electrographic signs concerning for ischaemia. Intraoperative imaging allows for any anatomical issues to be detected and addressed promptly in the operating room. Imaging of the coronary arteries should identify unobstructed coronary ostia and proximal course without kinking, angulation, narrowing, or significant calibre change to suggest stenosis or extrinsic compression from neighbouring structures. The aim of this review is to highlight the usefulness of transoesophageal and epicardial echocardiography in evaluating coronary artery patency and flow, provide a how-to guide for optimal imaging, and to introduce a practical guideline to achieve best clinical practice.

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.)

Platypnoea-orthodeoxia is a rare, but under-diagnosed clinical entity, characterised by postural hypoxia and breathlessness. Underlying pathology is inter-atrial shunt or pulmonary vascular malformation, but what anatomical distortion / physiological alterations initiates right to left shunt, usually against the pressure gradient remains unknown. [ABSTRACT FROM AUTHOR]

Objective: Normative values of left ventricular (LV) end-diastolic area and diameter (EDA and EDD) for intraoperative transoesophageal echocardiography (TEE) have not been established. We aimed to define the ranges of LV EDA and EDD for intraoperative TEE examinations in patients undergoing coronary artery bypass graft (CABG) surgery., Methods: A MEDLINE search for studies reporting LV EDA and EDD in CABG patients was performed. Individual-level dataset from 333 anaesthetised and mechanically ventilated patients with preserved LV function (study population) were received from 8 studies. EDA and calculated EDD values in the study population were compared with summary mean EDD values obtained by transthoracic echocardiography (TTE) in 2 studies of 500 awake patients with coronary artery disease (CAD). Further, the influence of prespecified factors on EDD was evaluated through a multivariate regression model., Results: LV EDA and EDD values measured by TEE in anaesthetised CABG patients were 16.7±4.7 cm 2 and 4.6±0.6 cm, respectively. EDD values measured by TEE in anaesthetised patients were 10% to 13% less those measured by TTE in 2 studies of awake patients (p<0.001). Body surface area, age and fractional area change but not sex were factors that affected LV EDD., Conclusion: LV EDD values measured by intraoperative TEE in anaesthetised and mechanically ventilated CABG patients were 10% to 13% less than those measured by TTE in awake CAD patients. This finding indicates that independent normative values specific for intraoperative TEE should be established for guiding intraoperative clinical decisions., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

We present the case of an 86-year-old female patient with a history of mitral valve replacement due to relevant stenosis. After surgery, an increasing periprosthetic valvular leak (PVL) became obvious causing regurgitation and an increasing haemolysis. Conventional two-dimensional transoesophageal echocardiography (2D TEE) showed a defect of 15 mm length located from the lateral to the posterior circumference subdivided by two surgical sutures into three parts. The patient refused additional surgical therapy. Hence, we suggested a percutaneous transcatheter occlusion of the leakage with a 12 × 5 mm Amplatzer® Vascular Plug III device (AVP) (AGA Medical Corporation, Plymouth, MA, USA). The placement of the device was supported indispensably by real-time three-dimensional TEE. The device occluded the leakage nearly completely and downgraded the regurgitation from moderate to neglectable. Also haemolytic parameters improved significantly. V-wave decreased promptly from 70 to 35 mmHg after placing AVP. Percutaneous closure of PVL by AVP, a self-expandable nitinol device approved for peripheral vessel occlusion, is described in limited cases with more or less successful results. It is graded as a technically demanding procedure reserved to poor surgical candidates. The main challenge is finding and intubating the leakage and the correct placement of the device. Three-dimensional TEE seems to be superior to conventional 2D TEE as it allows an easier guidance of the device into the defect. Hence, it is strongly recommended for this intracardiac intervention. [ABSTRACT FROM AUTHOR]

The update of the Echocardiography Core Syllabus of European Association of Cardiovascular Imaging (EACVI) is now available online. The Echocardiography Core Syllabus enumerates the elements of knowledge to be taught, represents a framework for the development of local training curricula and provides expected learning outcomes to the echocardiography learner.