Atlas of Perioperative 3D Transesophageal Echocardiography: Cases and Videos [2nd ed. 2023] 9811967938, 9789811967931

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Atlas of Perioperative 3D Transesophageal Echocardiography Cases and Videos Wei-Hsian Yin Ming-Chon Hsiung Second Edition

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Atlas of Perioperative 3D Transesophageal Echocardiography

Wei-Hsian Yin • Ming-Chon Hsiung

Atlas of Perioperative 3D Transesophageal Echocardiography Cases and Videos Second Edition

Wei-Hsian Yin Division of Cardiology Cheng Hsin General Hospital Division of Cardiology Taipei, Taiwan

Ming-Chon Hsiung Division of Cardiology Cheng Hsin General Hospital Division of Cardiology Taipei, Taiwan

ISBN 978-981-19-6793-1    ISBN 978-981-19-6794-8 (eBook) https://doi.org/10.1007/978-981-19-6794-8 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

Transesophageal echocardiography plays a pivotal role in perioperative management of patients undergoing open heart surgery and interventional transcatheter therapy. It provides information for making therapeutic decisions and post-surgical patient monitoring. Advances in computer technology resulted in the development of 3D images of cardiac structures, which enhanced the usefulness of echocardiography during the operation and played the role of the third eye of the surgeon. To become proficient at perioperative 3D transesophageal echocardiography, understanding of the principles of echocardiography and the pathophysiology is essential. In addition, clinical experience in perioperative 3D transesophageal is the must. This book contains a series of over 50 interesting and unusual cases to enrich your knowledge. In each case, background information is followed by a step-by-step approach to patient diagnosis and postoperative outcomes. The highlight of this book is the large number of illustrations, over 600, which is mainly 3D transesophageal echocardiography combined with 2D transesophageal echocardiography, X-ray, fluoroscopy, computed tomography, etc., to demonstrate the various cardiovascular pathologies. Since the echo images we obtain in clinic practice are moving images, we have also used over 400 videos, which serve as a supplement to the static illustrations in the casebook and are all freely available on the Internet. The atlas is organized into 11 chapters. In Chaps. 1, 2, and 3 abnormalities affecting mitral, aortic, tricuspid, and pulmonary valves are described. Prosthetic valves are discussed in Chap. 4. Chapter 5 details abnormalities of the aorta. Chapters 6, 7, and 8 cover coronary artery diseases, congenital heart diseases, and cardiomyopathies. Cases of infective endocarditis are provided in Chap. 9. Chapter 10 deals with tumors and mass lesions. And the other cases are classified in Chap. 11. It is our hope that this book will offer readers an insider’s view of perioperative 3D transesophageal echocardiography to refresh their clinical training. The second edition is adding more 3D TEE cases with newer technology also more interesting cases. Thankfully, Cheng Hsin General Hospital, Taipei, Taiwan, provided us full clinical support. We also appreciate the Division of Cardiovascular Surgery for facilitating performance of perioperative 3D transesophageal echocardiography. Lastly, the entire Echocardiography Laboratory, especially Li-Na Lee, Fang-Chieh Lee, and Wei-Hsuan Chiang,

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is thanked for compiling the cases and delivering the new book to the public. Taipei, Taiwan Taipei, Taiwan 

Wei-Hsian Yin Ming-Chon Hsiung

Brief Introduction to 3D TEE

The history of echocardiography started with A-mode images derived by a thin ultrasound beam and advanced to M-mode displays and then to 2D examination of the heart in motion. This was followed by Doppler, color Doppler, tissue Doppler, speckle imaging, 3D reconstruction, and ultimately the development of real-time 3D TEE. Echocardiography remains the most commonly requested imaging study of the heart. Combined with portability, noninvasion, low cost, and widespread availability, it is a tribute to decipher clinical problems in cardiac pathology. The key differences between 2D and 3D ultrasound imaging are the arrangement of elements in the transducer and the image processing procedure. In conventional cardiac 2D transducer, 64–128 elements are arranged along a single row, whereas 3D ultrasound used a matrix array transducer containing over 2500 elements. This system could acquire volumetric data rather than single slices of data, which ultimately permitted the display of volumetric 3D images. The piezoelectric elements within the transducers are arranged in a matrix configuration and require a large number of digital channels for these fully sampled elements to be connected. To reduce both power consumption and the diameter of the connecting cable, several miniaturized circuit boards are incorporated into the transducer, allowing partial beam forming to be performed in the probe. The image quality using reconstructive techniques depends critically on the quality of the original 2D images where minor patient or transducer movements or irregular rhythms may result in artifacts. Technological advances led to developments in the acquisition of multiple, gated image planes using ECG and respiratory gating which limit the amount of motion artifacts. To date, the 3D spatial modes may be summarized as follows: live 3D, 3D zoom, 3D full volume, and 3D color Doppler. First, live 3D is a real-time mode that displays a fixed pyramidal dataset which allows quick 3D imaging and live change of movement of the TEE probe. Second, 3D zoom displays a magnified but truncated pyramidal dataset of variable size. To optimize image quality, accurate placement and adjustment of the sector width are important. 3D zoom is preferentially used to display the MV, TV, or the LAA. The en face view of the MV mirrors the surgical view from the LA perspective providing careful information. Third, the 3D full-volume mode allows the acquisition of a pyramidal dataset, including a larger cardiac volume and formed by merging a predefined number of narrower live 3D pyramidal wedges obtained over one to six heartbeats. The full volume can be further processed vii

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Brief Introduction to 3D TEE

offline by rotating and cropping to visualize specific structures inside the pyramid. Lastly, 3D color Doppler is similar to the acquisition of a full-­ volume mode while with a larger dataset. It displays the direction, the range, and the relationship with surrounding structures of the blood flow. In conclusion, the 3D TEE technique improved anatomic definition, diagnostic confidence, and novel views of the complicated cardiovascular pathology encountered in common clinical practice. In addition, live 3D TEE enhances perioperative communication among cardiac surgeons, cardiac physicians, and anesthesiologists. There are many software on board can specific pin point and highlight the pathology of any part of the heart also quantify the size,volume of the leak or mass etc...

Contents

1 Diseases  of the Mitral Valve������������������������������������������������������������   1 1.1 Prolapse of Posterior Mitral Leaflet Having Repair�����������������   1 1.2 Prolapse of Both Mitral Leaflets Having Mitral Replacement������������������������������������������������������������������������������   3 1.3 Barlow Syndrome ��������������������������������������������������������������������   4 1.4 Flail of Anterior Mitral Leaflet Having Mitral Repair��������������   6 1.5 Flail of Posterior Mitral Leaflet Having Mitral Replacement������������������������������������������������������������������������������   8 1.6 Mitral Annulus Calcification Having Mitral Replacement ������  10 1.7 Rheumatic Heart Disease Having Mitral Replacement������������  13 1.8 Systolic Anterior Motion After Mitral Valve Repair����������������  16 1.9 Mitral Anterior Leaflet and Commissural Prolapse Having Mitral Valve Repair������������������������������������������������������  19 1.10 Flail of Posterior Mitral Leaflet Having Mitral Valve Repair����������������������������������������������������������������������������������������  21 1.11 Prolapse of Anterior Mitral Leaflet and Flail of Posterior Mitral leaflet Having Mitral Valve Repair��������������������������������  23 Suggested Reading����������������������������������������������������������������������������  24 2 Diseases of the Aortic Valve������������������������������������������������������������  27 2.1 Prolapse of Noncoronary Cusp ������������������������������������������������  27 2.2 Bicuspid Aortic Valve Having Aortic Valve Repair������������������  29 2.3 Bicuspid Aortic Valve Having Tissue Aortic Valve Replacement������������������������������������������������������������������������������  31 2.4 Bicuspid Aortic Valve Having Mechanical Aortic Valve Replacement������������������������������������������������������������������������������  34 2.5 Rheumatic Heart Disease Having Aortic and Mitral Replacement������������������������������������������������������������������������������  37 2.6 Aortic Stenosis Having Transcatheter Aortic Valve Implantation������������������������������������������������������������������������������  42 2.7 Sinus of Valsalva Aneurysm Having Patch Repair ������������������  49 2.8 Bicuspid Aortic Valve Having Bentall’s Operation������������������  51 2.9 Transcatheter Aortic Valve Implantation Leading Mitral Chordae Rupture ����������������������������������������������������������������������  52 Suggested Reading����������������������������������������������������������������������������  54

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3 Diseases  of the Tricuspid and Pulmonary Valve����������������������������  57 3.1 Prolapse of Posterior Tricuspid Leaflet Having Tricuspid Repair����������������������������������������������������������������������������������������  57 3.2 Prosthetic Tricuspid Valve Stenosis Having Redo Replacement������������������������������������������������������������������������������  59 3.3 Subvalvular Pulmonary Stenosis with Right Atrium Thrombus����������������������������������������������������������������������������������  61 3.4 Carcinoid Syndrome Having Aortic, Tricuspid and Pulmonary Replacement����������������������������������������������������  63 3.5 Tricuspid Valve Incomplete Closure Having Tricuspid Valve Repair������������������������������������������������������������������������������  69 3.6 Ebstein’s Anomaly Having Tricuspid Valve Repair������������������  70 3.7 Tricuspid Valve Prolapse Having Tricuspid Valve Repair��������  72 3.8 Caseous Calcification Mitral Annulus (CCMA) with MR��������  73 Suggested Reading����������������������������������������������������������������������������  75 4 Prosthetic Valves������������������������������������������������������������������������������  77 4.1 Paravalvlular Leakage of Mitral Prosthesis������������������������������  77 4.2 Mitral Prosthesis Dysfunction Having Valve in Valve Replacement������������������������������������������������������������������������������  80 4.3 Aortic Prosthetic Stenosis Having Transcatheter Aortic Valve Implantation��������������������������������������������������������������������  84 4.4 Mitral Valve Repair with Dehiscence of Annuloplasty Ring������������������������������������������������������������������������������������������  86 4.5 Mitral Valve Replacement Dysfunction Having Mitral Valve in Valve���������������������������������������������������������������������������  88 4.6 Transcatheter Aortic Valve Implantation with Paravalvular Aortic Regurgitation ����������������������������������������������������������������  91 4.7 Mitral Valve Replacement with Paravalvular leakage��������������  93 4.8 Dehiscence of Mitral Valve Replacement ��������������������������������  95 4.9 Tricuspid Valve Replacement Stenosis Having Tricuspid Valve in Valve���������������������������������������������������������������������������  96 4.10 S/P MVR Causing LVOT Obstruction��������������������������������������  98 4.11 Transcatheter Aortic Valve Implantation(TAVI) with Paravalvular Leakage Having Occluder���������������������������� 103 Suggested Reading���������������������������������������������������������������������������� 106 5 Diseases of the Aorta������������������������������������������������������������������������ 107 5.1 Dilated Aortic Root Having David’s Operation������������������������ 107 5.2 Type A Aortic Dissection���������������������������������������������������������� 111 5.3 Type A Aortic Dissection Having Bentall Operation���������������� 113 5.4 Type A Aortic Dissection with Intramural Hematoma������������� 117 5.5 Type B Aortic Dissection from Distal Aortic Arch ������������������ 119 5.6 Type B Aortic Dissection from Middle Descending Aorta ���������������������������������������������������������������������������������������� 121 5.7 Aorta-to-Left Ventricular Fistula Having Occluder Implantation������������������������������������������������������������������������������ 124 5.8 Aortic Pseudoaneurysm Having Occluder Implantation���������� 126

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5.9 Ruptured Sinus of Valsalva Aneurysm Having Occluder Implantation������������������������������������������������������������������������������ 129 5.10 Descending Aorta to Left Lower Pulmonary Vein (LLPV) Fistula Having Thoracic Endovascular Aortic Repair (TEVAR) ���������������������������������������������������������������������������������� 131 5.11 Type A Dissection Having Reconstruction ������������������������������ 133 5.12 Type A Dissection with Severe Aortic Regurgitation �������������� 135 Suggested Reading���������������������������������������������������������������������������� 136 6 Coronary Artery Diseases �������������������������������������������������������������� 137 6.1 Ischemic Mitral Regurgitation Having Mitral Repair�������������� 137 6.2 Left Ventricular Apex Akinesis with Thrombus Having Dor Procedure �������������������������������������������������������������������������� 139 6.3 A Post Myocardial Infarction Ventricular Septal Defect Having Occluder Implantation�������������������������������������������������� 141 6.4 Right Coronary Artery Pseudotumor���������������������������������������� 145 6.5 Coronary Fistula������������������������������������������������������������������������ 147 6.6 Post Heart Transplantation Myocardial Infarction VSD���������� 148 Suggested Reading���������������������������������������������������������������������������� 151 7 Congenital Heart Diseases�������������������������������������������������������������� 153 7.1 Patent Foramen Ovale Having Occluder Implantation ������������ 153 7.2 Primum Atrial Septal Defect���������������������������������������������������� 156 7.3 Secundum Atrial Septal Defect Having Occluder Implantation������������������������������������������������������������������������������ 160 7.4 Atrial Septal Defect Occluder Device Embolization���������������� 164 7.5 Supracristal Ventricular Septal Defect Having Patch Repair���������������������������������������������������������������������������������������� 167 7.6 Subaortic Stenosis Having Resection �������������������������������������� 172 7.7 Two Atrial Septal Defects Having Two Occluder Implantation������������������������������������������������������������������������������ 176 7.8 Transitional Type of Atrioventricular Septal Defect ���������������� 178 Suggested Reading���������������������������������������������������������������������������� 179 8 Cardiomyopathies���������������������������������������������������������������������������� 181 8.1 Apical Hypertrophic Cardiomyopathy with Severe Mitral Regurgitation Having Mitral Repair ���������������������������������������� 181 8.2 Hypertrophic Obstructive Cardiomyopathy Having Myectomy and Mitral Replacement������������������������������������������ 185 8.3 Hypertrophic Obstructive Cardiomyopathy Having Aortic, Mitral Replacement and Myectomy ���������������������������� 191 8.4 Hypertrophic Obstructive Cardiomyopathy Having Myectomy �������������������������������������������������������������������������������� 195 8.5 Dilated Cardiomyopathy Having HeartMate III ���������������������� 198 Suggested Reading���������������������������������������������������������������������������� 200 9 Infective Endocarditis���������������������������������������������������������������������� 201 9.1 Mitral Valve Vegetation������������������������������������������������������������ 201 9.2 Status Post Mitral Replacement Endocarditis�������������������������� 203 9.3 Bicuspid Aortic Valve Vegetation���������������������������������������������� 207

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9.4 Ascending Aorta Vegetation������������������������������������������������������ 210 9.5 Right Ventricular Outflow Tract Vegetation������������������������������ 212 9.6 Infective Endocarditis with Ventricular Septal Defect�������������� 214 9.7 Aortic Tissue Prosthetic Valve Vegetation Induced Left Ventricular Outflow Tract to Right Atrium Shunt (Gerbode Defect)���������������������������������������������������������������������� 217 9.8 Mitral Valve Perforation Having Mitral Repair������������������������ 218 9.9 Mitral Valve Vegetation Having Mitral Valve Replacement������������������������������������������������������������������������������ 220 9.10 Tricuspid Valve Vegetation with Aorta to Right Atrium Shunt ���������������������������������������������������������������������������������������� 222 9.11 Transcatheter Aortic Valve Implantation���������������������������������� 225 Suggested Reading���������������������������������������������������������������������������� 228 10 Tumors  and Mass Lesions �������������������������������������������������������������� 231 10.1 Left Atrial Thrombus�������������������������������������������������������������� 231 10.2 Left Atrial Myxoma���������������������������������������������������������������� 234 10.3 Right Atrial Myxoma�������������������������������������������������������������� 236 10.4 Invasive Thymoma Extending into Superior Vena Cava and Right Atrium�������������������������������������������������������������������� 242 10.5 Left Atrial Myxoma���������������������������������������������������������������� 246 10.6 Mitral Valve Tumor ���������������������������������������������������������������� 248 10.7 Extracardiac Tumor���������������������������������������������������������������� 250 Suggested Reading���������������������������������������������������������������������������� 252 11 Others������������������������������������������������������������������������������������������������ 253 11.1 HeartMate II���������������������������������������������������������������������������� 253 11.2 Iatrogenic Aortic Root Perforation������������������������������������������ 256 11.3 Tear of Aortic Valve Having Re-Do Aortic Valve Replacement���������������������������������������������������������������������������� 258 11.4 Ankylosing Spondylitis with Aortic and Mitral Regurgitation�������������������������������������������������������������������������� 260 11.5 Mitral Valve Repair Causing Iatrogenic Heart Rupture���������� 261 11.6 Mitral Stenosis with Mitral Valve Replacement Causing LVOT Obstruciton������������������������������������������������������������������ 263 Suggested Reading���������������������������������������������������������������������������� 268

Abbreviations

2D Two-dimensional 3D Three-dimensional Af Atrial fibrillation AML Anterior mitral leaflet AO Aorta AR Aortic regurgitation AS Aortic stenosis ASD Atrial septal defect AV Aortic valve or atrioventricular AVR Aortic valve replacement BNP Brain natriuretic peptide CABG Coronary artery bypass graft CCA Common carotid artery CT Computed tomography ECG Electrocardiogram FL False lumen HV Hepatic vein ICA Internal carotid artery IVC Inferior vena cava IVS Interventricular septum LA Left atrial LAA Left atrial appendage LAD Left anterior descending coronary artery LCC Left coronary cusp LCX Left circumflex artery LIMA Left internal mammary artery LV Left ventricle LVEF Left ventricular ejection fraction LVOT Left ventricular outflow tract MI Myocardial infarction MR Mitral regurgitation MRSA Methicillin-resistant Staphylococcus aureus MPA Main pulmonary artery MPG Mean pressure gradient MPR Multi-planar reconstruction MS Mitral stenosis MV Mitral valve xiii

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MVR Mitral valve replacement NCC Noncoronary cusp OM Obtuse marginal artery PA Pulmonary artery PCI Percutaneous coronary intervention PFO Patent foramen ovale PML Posterior mitral leaflet PPG Peak pressure gradient PR Pulmonary regurgitation PS Pulmonary stenosis PTCA Percutaneous transluminal coronary angioplasty PV Pulmonary valve PVR Pulmonary valve replacement RA Right atrial RCA Right coronary artery RCC Right coronary cusp RV Right ventricle RVOT Right ventricular outflow tract SAM Systolic anterior motion SMA Superior mesenteric artery SVC Superior vena cava SVG Saphenous vein graft TAVI Transcatheter aortic valve implantation TEE Transesophageal echocardiography TH Thrombus TL True lumen TR Tricuspid regurgitation TS Tricuspid stenosis TV Tricuspid valve TVR Tricuspid valve replacement VSD Ventricular septal defect

Abbreviations

1

Diseases of the Mitral Valve

Abstract

In this chapter, cases of mitral leaflets prolapse, flail, annulus calcification, rheumatic heart disease, and systolic anterior motion received mitral repair or replacement are presented. The TEE assessment always begins with a systematic 2D examination of the MV regardless of the type of the disease. 3D en face view from LA down to the MV can mirror the surgeon’s view and express the MV structure and function carefully. In addition, evaluation of repair in the operating room before chest closure allows further intervention if required therefore improves the outcome.

Fig. 1.1  Two-dimensional transesophageal echocardiography (2D TEE) image, four- chamber view, showed prolapse of posterior mitral leaflet (arrow) and LA dilatation (Video 1.1)

1.1 Prolapse of Posterior Mitral Leaflet Having Repair A 59-year-old woman had valvular heart disease with severe MR suffered from intermittent palpitation and exertional dyspnea. Auscultation: regular heart beat with a grade 3 systolic murmur over apex. ECG: sinus rhythm and nonspecific ST-T change. Chest X ray: cardiomegaly. Operation: MV and TV repair (Figs. 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, and 1.8). Fig. 1.2  2D TEE color Doppler, showed severe eccentric MR (arrow) (Video 1.2) Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-981-19-6794-8_1. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_1

1

2

1  Diseases of the Mitral Valve

Fig. 1.3  3D TEE image, en face view, showed prolapse of P2 scallop (*) and chordae rupture (arrow) (Video 1.3)

Fig. 1.6  3D TEE image, en face view, showed repaired MV with suture (Video 1.5)

Fig. 1.4  3D TEE color Doppler, showed severe eccentric MR (arrow) (Video 1.4)

Fig. 1.7  3D TEE color Doppler, showed repaired MV without MR (Video 1.6)

Fig. 1.5  2D TEE color Doppler, status post MV repair, showed well-closed MV without MR

Fig. 1.8  Picture during MV repair showed prolapse of P2

1.2  Prolapse of Both Mitral Leaflets Having Mitral Replacement

3

cc Tips  Prolapse of P2 scallop is the most common structural causes of MR and it has a very high rate of successful repair. 

1.2 Prolapse of Both Mitral Leaflets Having Mitral Replacement A 73-year-old man has a 10-year-long valvuar heart disease history. He suffered dyspnea, shortness of breath and palpitation. Auscultation: irregular heart beat with a grade 2/6 systolic murmur over apex. ECG: atrial fibrillation with rapid ventricular response and LV hypertrophy. Chest X ray: cardiomegaly. Cardiac catheterization: severe MR, LVEF = 47% with general hypokinesis and dilated LA. Operation: MV replacement, TV repair and atrial fibrillation ablation (Figs. 1.9, 1.10, 1.11, 1.12, 1.13, 1.14, and 1.15).

Fig. 1.9  Two-dimensional transesophageal echocardiography (2D TEE) image, five-chamber view, showed prolapse of both anterior and posterior mitral leaflets (arrows). Dilated LV and enlarged mitral annulus were also noted (Video 1.7)

Fig. 1.10  3D TEE image, long-axis view, showed prolapse of both anterior and posterior mitral leaflets (arrows) (Video 1.8)

Fig. 1.11  3D TEE image, en face view, showed prolapse of A3 (arrow), P1 (o), P2 (.), P3 (▲) scallops and posteromedial commissure (*) (Video 1.9)

4

Fig. 1.12  3D TEE color Doppler, showed severe centric MR (arrow) (Video 1.10)

1  Diseases of the Mitral Valve

Fig. 1.15  3D TEE color Doppler, long-axis view, status post tissue MV replacement, showed no MR (Video 1.12)

cc Tips  The en face view of the MV is a view looks down at the valve from the LA perspective and is closest to the surgeon’s actual view. By convention, the AML is at the top, the PML is at the bottom and the aorta is superior to the MV. 

1.3 Barlow Syndrome

Fig. 1.13  2D TEE image, long-axis view, status post tissue MV replacement, showed normal closure of MV

Fig. 1.14  3D TEE image, en face view, status post tissue MV replacement (MVR), showed normal closure of MV (Video 1.11)

A 62-year-old man with medical-controlled hypertension suffered intermittent chest discomfort with dyspnea. Auscultation: regular heart beat with a grade 3 systolic murmur over apex. ECG: sinus rhythm and ventricular premature beats. Cardiac catheterization: double coronary artery disease and severe MR. Chest CT angiography: extensive atherosclerotic change of the aorta and bilateral iliac arteries, atherosclerotic calcifications at bilateral coronary arteries. Operation: MV replacement and CABG x2 (LAD, RCA) (Figs.  1.16, 1.17, 1.18, 1.19, and 1.20).

1.3  Barlow Syndrome

Fig. 1.16 Two-dimensional transesophageal echocardiography (2D TEE) image, five-chamber view, showed LA dilation and prolapse of both anterior and posterior mitral leaflet (arrows) (Video 1.13)

5

Fig. 1.19  3D TEE image, en face view, showed prolapse of both anterior (*) and posterior (.) mitral leaflet with chordae rupture (arrow) (Video 1.16)

Fig. 1.17  2D TEE image, five-chamber view, showed flail of posterior mitral leaflet (arrow) (Video 1.14)

Fig. 1.20  3D TEE color Doppler, showed severe eccentric MR (arrow) (Video 1.17)

cc Tips  The Carpentier classification of MR is based on MV leaflets’ motion. Type II is the result in this case as the leaflets extend beyond the annular plane in systole. 

Fig. 1.18  2D TEE color Doppler, five-chamber view, showed severe eccentric MR (arrow) (Video 1.15)

6

1  Diseases of the Mitral Valve

1.4 Flail of Anterior Mitral Leaflet Having Mitral Repair The 73-year-old man with valvular heart disease refused surgical intervention. A year later, symptom of exertional dyspnea worsen. Auscultation: regular heart beat with a grade 3/6 systolic murmur. ECG: normal sinus rhythm, left axis deviation and LA enlargement. Cardiac catheterization: severe MR with huge LA, mild LV dysfunction and pulmonary hypertension. Operation: MV and TV repair and CABG x1 (SVG to RCA) (Figs.  1.21, 1.22, 1.23, 1.24, 1.25, 1.26, 1.27, 1.28, 1.29, 1.30, and 1.31). Fig. 1.23  3D TEE image, en face view, showed flail of A2 scallop (*) with chordae rupture (arrow) (Video 1.20)

Fig. 1.21 Two-dimensional transesophageal echocardiography (2D TEE) image, two-chamber view, showed LA dilation and flail of AML (arrow) which floats independently (Video 1.18)

Fig. 1.24  3D TEE color Doppler, showed severe eccentric MR (arrow) (Video 1.21)

Fig. 1.22  2D TEE color Doppler, two-chamber view, showed severe eccentric MR (arrow) (Video 1.19)

1.4  Flail of Anterior Mitral Leaflet Having Mitral Repair

7

Figs. 1.25 and 1.26  2D TEE image, long-axis view, status post MV repair, showed normal MV function with cardiac cycle

Figs. 1.27 and 1.28  2D color Doppler, status post MV repair, showed well-closed MV with trivial MR (left) and normal mitral inflow (right)

Figs. 1.29 and 1.30  3D TEE image, long-axis view, status post MV repair, showed MV normal closing and opening in systole (left) and in diastole (right) (Video 1.22)

1  Diseases of the Mitral Valve

8

Fig. 1.31  3D TEE image, en face view, status post MV repair, showed MV with suture and left atrial appendage (LAA) (Video 1.23)

Fig. 1.32 Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, showed LA dilatation and flail of posterior mitral leaflet (arrow) (Video 1.24)

cc Tips  Flail is a situation where a leaflet float freely into the atrium in systole with one or more ruptured chordae. 

1.5 Flail of Posterior Mitral Leaflet Having Mitral Replacement A 72-year-old man with MV disorder, arrhythmia, heart failure and pulmonary edema suffered exertional dyspnea. Auscultation: irregular heart beat with a grade 3/6 systolic murmur. ECG: atrial fibrillation with moderate ventricular response and early repolarization. Chest X ray: cardiomegaly. Operation: MV replacement, TV repair and atrial fibrillation ablation (Figs.  1.32, 1.33, 1.34, 1.35, 1.36, 1.37, 1.38, 1.39, 1.40, and 1.41).

Fig. 1.33 2D TEE color Doppler, long- axis view, showed severe eccentric MR (arrow) (Video 1.25)

Fig. 1.34  3D TEE image, en face view, showed flail of P2 scallop (*) and ruptured chordae (arrow) (Video 1.26)

1.5  Flail of Posterior Mitral Leaflet Having Mitral Replacement

9

Fig. 1.35  2D TEE image, two-chamber view, status post tissue MV replacement, showed normal mitral prosthesis function

Figs. 1.36 and 1.37  2D TEE color Doppler, two-chamber view, status post tissue MV replacement, showed no MR in systole (left) and normal mitral prosthesis inflow (right)

Figs. 1.38 and 1.39  3D TEE image, en face view, status post tissue MV replacement, showed mitral prosthesis normal closing and opening in systole (left) and in diastole (right) (Video 1.27)

1  Diseases of the Mitral Valve

10

Figs. 1.40 and 1.41  3D TEE color Doppler, status post tissue MV replacement (MVR), showed no MR in systole (left) and slightly accelerated mitral inflow in diastole (right) (Video 1.28)

cc Tips  Eccentric MR jets usually suggest a structural MV abnormalities and need to be carefully investigated. 

1.6 Mitral Annulus Calcification Having Mitral Replacement A 74-year-old woman had a 10-year-long history of mitral regurgitation. She suffered exercise intolerance and generalize weakness. Auscultation: regular heart beat with a grade 3 low pitch murmur over left sternal border. ECG: sinus rhythm. Cardiac catheterization: severe mitral stenosis (PPG is 12  mmHg, MPG is 10  mmHg and MV area is 0.74  cm2) with mild MR. Operation: MV replacement and TV repair (Figs.  1.42, 1.43, 1.44, 1.45, 1.46, 1.47, 1.48, 1.49, 1.50, and 1.51).

Fig. 1.42 Two-dimensional transesophageal echocardiography (2D TEE) image, showed thickened MV (arrows) with mitral annulus calcified (Video 1.29)

Fig. 1.43  2D TEE color Doppler, showed mitral stenosis with high-velocity mosaic mitral inflow (arrow) (Video 1.30)

1.6  Mitral Annulus Calcification Having Mitral Replacement

Fig. 1.44  3D TEE image, long-axis view, showed thickened MV with mitral annulus calcified (arrows) (Video 1.31)

Fig. 1.45  Multi-planar reconstruction (MPR) of 3D TEE image, showed MV area is 0.9 cm2

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1  Diseases of the Mitral Valve

Fig. 1.46  2D TEE image, x-plane view, status post tissue MV replacement, showed normal prosthesis function

Fig. 1.47  2D TEE color Doppler, x-plane view, status post tissue MV replacement, showed normal mitral inflow

Figs. 1.48 and 1.49  3D TEE image, en face view, status post tissue MV replacement, showed normal mitral prosthesis closing in systole (left) and opening in diastole (right) (Video 1.32)

1.7  Rheumatic Heart Disease Having Mitral Replacement

13

Figs. 1.50 and 1.51  3D TEE color Doppler, long-axis view, status post tissue MV replacement, showed no MR in systole (left) and normal mitral inflow in diastole (right) (Video 1.33)

cc Tips  Calcific stenosis is common in elderly patients who have mitral annulus calcification invading leaflets and leading to effective stenosis. 

1.7 Rheumatic Heart Disease Having Mitral Replacement A 45-year-old woman suffered dyspnea on exertion and cough. Rheumatic heart disease with mitral stenosis was told by other hospital. She admitted for surgical treatment. Auscultation: regular heart beat with a grade 4/6 systolic murmur over apex. Chest X ray: LA enlargement. Coronary CT: mild cardiomegaly. Operation: MV replacement and TV repair (Figs. 1.52, 1.53, 1.54, 1.55, 1.56, 1.57, 1.58, 1.59, 1.60, 1.61, and 1.62).

Fig. 1.52 Two-dimensional transesophageal echocardiography (2D TEE) image, four-chamber view, showed thickened MV with hockey sign (arrow). Dilated LA and enlarged mitral annulus were also noted (Video 1.34)

14

Figs. 1.53 and 1.54 2D TEE color Doppler (left) showed high-velocity mosaic flow in diastole (arrow) due to mitral stenosis (MS) and high pressure gradient (PPG

1  Diseases of the Mitral Valve

is16 mmHg) was present by continuous-wave Doppler (right) (Video 1.35)

Fig. 1.55  2D TEE color Doppler, showed severe MR (arrow) in systole (Video 1.35) Fig. 1.56  3D TEE image, long-axis view, showed thickened MV with hockey sign (arrow) (Video 1.36)

1.7  Rheumatic Heart Disease Having Mitral Replacement

15

Figs. 1.57 and 1.58  3D TEE image, en face view (above) and Multi-planar reconstruction (MPR) (below), showed thickened MV and small mitral orifice with area is 1.4 cm2 (Video 1.37)

1  Diseases of the Mitral Valve

16

Figs. 1.59 and 1.60  2D TEE image, long-axis view, status post mechanical MV replacement, showed reverberation (arrows) from the valve and good function in systole (left) and diastole (right)

cc Tips  Rheumatic

mitral stenosis usually presents with restricted mitral leaflets, commissural fusion, and calcification of the subvalvular appartus. Increase of diastolic grdients across the MV are also seen. 

1.8 Systolic Anterior Motion After Mitral Valve Repair

Fig. 1.61  3D TEE image, en face view, status post MV replacement, showed bileaflet mechanical mitral prosthesis with normal opening in diastole

Fig. 1.62 3D TEE color Doppler, status post MV replacement (MVR), showed smooth mitral inflow

A 77-year-old man had a history of severe MR, colon cancer status post operation, multiple cerebral infarctions and hypertension. Auscultation: regular heart beat with a grade 1/6 systolic murmur. ECG: sinus rhythm with occasional supraventricular premature complexes. Chest X ray: cardiomegaly. Cardiac catheterization: severe MR.  Operation: attempted MV repair then MV replacement and TV repair (Figs.  1.63, 1.64, 1.65, 1.66, 1.67, 1.68, 1.69, 1.70, 1.71, 1.72, and 1.73).

1.8  Systolic Anterior Motion After Mitral Valve Repair

Fig. 1.63 Two-dimensional transesophageal echocardiography (2D TEE) color Doppler, long-axis view, showed prolapse of posterior mitral leaflet (red arrow) with severe eccentric MR (yellow arrow). LA dilation and LV hypertrophy were also noted (Video 1.38)

Fig. 1.64  3D TEE image, en face view, showed prolapse of P1 (o) and P3 (*) (Video 1.39)

17

Fig. 1.65  3D TEE color Doppler, showed prolapse of PML with severe eccentric MR (arrow) (Video 1.40)

Fig. 1.66  2D TEE image, long-axis view, status post MV repair, showed intravnetricular septal hypertrophy with mitral leaflet systolic anterior motion (arrow) and LV outflow tract obstruction (Video 1.41)

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Fig. 1.67  2D TEE continuous-wave Doppler with the origin of the velocity at subaortic region, status post MV repair, showed a late-peaking, high-velocity gradient is 86 mmHg (arrow) due to LV outflow tract obstruction

1  Diseases of the Mitral Valve

Fig. 1.68  3D TEE image, long-axis view, status post MV repair, showed interventricular septal (IVS) hypertrophy with mitral leaflet systolic anterior motion (arrow) and LV outflow tract obstruction (Video 1.42)

Fig. 1.70  2D TEE image, long-axis view, status post tissue MV replacement, showed normal prosthesis function without systolic anterior motion of mitral leaflet Fig. 1.69  3D TEE color Doppler, long-axis view, status post MV repair, showed severe MR (yellow arrow) due to mitral leaflet systolic anterior motion and turbulent LV outflow (black arrow) due to subaortic obstruction (Video 1.43)

1.9  Mitral Anterior Leaflet and Commissural Prolapse Having Mitral Valve Repair

19

Fig. 1.71  2D TEE color Doppler, long- axis view, status post tissue MV replacement, showed trivial MR (arrow) and normal LV outflow Fig. 1.73  3D TEE color Doppler, long-axis view, status post tissue MV replacement (MVR), showed trivial MR and normal LV outflow (Video 1.45)

cc Tips  Factors which develop systolic anterior motion after mitral repair include short anterior leaflet, long posterior leaflet, and small LV cavity, etc. 

1.9 Mitral Anterior Leaflet and Commissural Prolapse Having Mitral Valve Repair

Fig. 1.72  3D TEE image, long-axis view, status post tissue MV replacement (MVR), showed normal prosthesis function without mitral leaflet systolic anterior motion (Video 1.44)

A 53-year-old female with history of hypertension and rheumatoid arthritis for years under regular medications. She suffered from exertional chest tightness and malaise for months. ECG: Sinus rhythm. Chest X ray: Tortuosity of the thoracic aorta, mild cardiomegaly. PE: Regular Hb, grade III systolic murmur over the apex and LSB. CAG: VHD with severe MR, Coronary atherosclerosis. Operation: Mitral valve repair (Figs. 1.74, 1.75, 1.76, 1.77, 1.78, and 1.79).

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Fig. 1.74 Two-dimensional transesophageal echocardiography (2-D TEE) image demonstrating possible prolapse of anterior leaflet (arrow) and dilated Left Atrium (Video 1.46)

Fig. 1.75  2D TEE Color Doppler, commissural view, showing severe eccentric mitral regurgitation (arrow) (Video 1.47)

Fig. 1.76  Three-dimensional transesophageal echocardiography (3-D TEE) image, en face view, displaying A3 and commissural prolapse (arrow) (Video 1.48)

1  Diseases of the Mitral Valve

Fig. 1.77  TrueVue 3D TEE image, en face view, showing A3 and commissural prolapse (arrow) (Video 1.49)

Fig. 1.78  TrueVue 3D TEE Color Doppler demonstrating severe regurgitation from posteromedial commissure (arrow) (Video 1.50)

1.10  Flail of Posterior Mitral Leaflet Having Mitral Valve Repair

21

Fig. 1.79  Intraoperative 2D TEE (left) and 3D TEE (right) showing PFO (Videos 1.51 and 1.52)

1.10 Flail of Posterior Mitral Leaflet Having Mitral Valve Repair A 58-year-old female patient denied any systemic disease and experienced severe dyspnea with chest distress. She felt palpitations on exertion especially when going upstairs since 1 month ago, her symptoms could be alleviated by rest within 5 min. Chest X ray: Mild cardiomegaly. Tortuosity of the thoracic aorta. ECG: Sinus rhythm. CAG: Coronary fistula to RA from LCx. VHD with severe MR & moderate to severe TR.  Transthoracic Echocardiography revealed flail of PML and generalized hypokinesis of RV, RVEF = 38%. Operation: MV repair (P1 triangular resection +3 loops of CV4  +  32  mm Memo 3D annuloplasty ring, TV repair (Edwards MC3 Ring 30  mm), LA auricle obliteration(through inside), Ablation of Af with Medtronic Atricure (PV isolation and LAA) (Figs. 1.80, 1.81, 1.82, 1.83, 1.84, 1.85, 1.86, and 1.87).

Fig. 1.80  Intraoperative two-dimensional transesophageal echocardiography (2D TEE) showing flail of posterior mitral leaflet (arrow) (Video 1.53)

Fig. 1.81  2D TEE Color Doppler demonstrating a large flow convergence and severe mitral regurgitation (arrow) (Video 1.54)

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1  Diseases of the Mitral Valve

Fig. 1.82  3D TEE and TrueVue 3D revealing rupture of chordae (arrow) in systole and flail of P1 (Videos 1.55 and 1.56)

Fig. 1.83  3D TEE Color Doppler showing severe mitral regurgitation (Video 1.57)

Fig. 1.85  2D TEE Color Doppler status post showing normal function of repairing mitral leaflet (Video 1.59)

Fig. 1.84  2D TEE, long axis view, status post repair of mitral valve (arrow) (Video 1.58)

Fig. 1.86  TrueVue 3D TEE displaying the annuloplasty ring (arrow) (Video 1.60)

1  Diseases of the Mitral Valve

Fig. 1.87 TrueVue 3D TEE Color Doppler showing repaired of mitral valve without regurgitation (Video 1.61)

23

Fig. 1.88 Two-dimensional Transesophageal echocardiography (2D TEE) in long axis view showing significant prolapse of anterior mitral leaflet (arrow) (Video 1.62)

1.11 Prolapse of Anterior Mitral Leaflet and Flail of Posterior Mitral leaflet Having Mitral Valve Repair A 64-year-old female had history of HCVD and Hyperuricemia with medical control for more than 10  years, but she had stopped taking antiHTN agents by herself for 1  year. She experienced dyspnea on daily activity or emotional stress recently. Heart Echo revealed severe mitral regurgitation and moderate tricuspid regurgitation. ECG: sinus rhythm, atrial premature contraction. CAG: VHD with severe MR and pulmonary hypertension. Operation: s/p MVA (30  mm Physio II Ring)  +  TVA (32  mm Ring) (Figs. 1.88, 1.89, 1.90, 1.91, 1.92, and 1.93).

Fig. 1.89  2D TEE Color Doppler in two chamber view demonstrating eccentric severe mitral regurgitation (arrow) (Video 1.63)

Fig. 1.90  3D TEE, en face view, revealing prolapse of A2 and flail of P3 (Video 1.64)

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1  Diseases of the Mitral Valve

Suggested Reading

Fig. 1.91  3D TEE Color Doppler revealing two jets separately from A2 (red arrowhead) and from P3 (white arrow) (Video 1.65)

Fig. 1.92  TrueVue 3D TEE showing A2 prolapse (red arrowhead) and P3 flail (white arrow) (Video 1.66)

Fig. 1.93 TrueVue 3D TEE Color Doppler showing mitral regurgitation from A2 (red arrowhead) and P3 (white arrow) (Video 1.67)

Addetia K, Mor-Avi V, Weinert L, et  al. A new definition for an old entity: improved definition of mitral valve prolapse using three-dimensional echocardiography and color-coded parametric models. J Am Soc Echocardiogr. 2014;27(1):8–16. Akhter N, Zhao Q, Andrei AC, et al. Identification of prolapsing mitral valve scallops by a three-dimensional multiplanar reconstruction method. Echocardiography. 2015;32(1):106–13. Alfieri O, Lapenna E.  Systolic anterior motion after mitral valve repair: where do we stand in 2015? Eur J Cardiothorac Surg. 2015;48(3):344–6. Ben Zekry S, Spiegelstein D, Sternik L, et al. Simple repair approach for mitral regurgitation in Barlow disease. J Thorac Cardiovasc Surg. 2015;150(5):1071–1077.e1. Butler TC, Sedgwick JF, Burstow DJ. 3-D assessment of infective endocarditis with anterior mitral valve perforation and flail posterior leaflet. Int J Cardiol. 2015;185:249. Colli A, Manzan E, Zucchetta F, et al. Feasibility of anterior mitral leaflet flail repair with transapical beatingheart neochord implantation. JACC Cardiovasc Interv. 2014;7(11):1320–1. Fucci C, Faggiano P, Nardi M, et al. Triple-orifice valve repair in severe Barlow disease with multiple-jet mitral regurgitation: report of mid-term experience. Int J Cardiol. 2013;167(6):2623–9. Fusini L, Ghulam Ali S, Tamborini G, et  al. Prevalence of calcification of the mitral valve annulus in patients undergoing surgical repair of mitral valve prolapse. Am J Cardiol. 2014;113(11):1867–73. Mori M, Yoshimuta T, Ohira M, et al. Impact of real-time three-dimensional transesophageal echocardiography on procedural success for mitral valve repair. J Echocardiogr. 2015;13(3):100–6. Mukit M, Kagalwala DZ, El-Eshmawi A, et  al. Novel presentation of flail mitral valve. J Cardiothorac Vasc Anesth. 2015;29(5):1398–401. Murugesan V, Pulimamidi VK, Rajappa M, Satheesh S, et al. Elevated fibrinogen and lowered homocysteinevitamin determinants and their assodiation with left atrial thrombus in patients with rheumatic mitral stenosis. Br J Biomed Sci. 2015;72(3):102–6. Nanda N, Hsiung MC, Miller AP, et al. Live/real time 3D echocardiography. Oxford: Wiley-Blackwell; 2010. Otto CM.  Textbook of clinical echocardiography. Philadelphia: W. B. Saunders Company; 2000. Oxorn DC. Intraoperative echocardiography. Philadelphia: Elsevier Saunders; 2012. Padala M, Sweet M, Hooson S, et al. Hemodynamic comparison of mitral valve repair: techniques for a flail anterior leaflet. J Heart Valve Dis. 2014;23(2):171–6. Perrino A, Reeves S, Glas K. The practice of perioperative transesophageal echocardiography essential cases. Philadelphia: Lippincott Williams & Wilkins; 2011.

Suggested Reading Pinheiro AC, Mancuso FJ, Hemerly DF, et al. Diagnostic value of color flow mapping and Doppler echocardiography in the quantification of mitral regurgitation in patients with mitral valve prolapse or rheumatic heart disease. J Am Soc Echocardiogr. 2007;20(10):1141–8. Rostagno C, Droandi G, Rossi A, et  al. Anatomic characteristics of bileaflet mitral valve prolapse—Barlow disease—in patients undergoing mitral valve repair. Ital J Anat Embryol. 2014;119(1):20–8.

25 Schaheen LW, Hayanga AJ, Badhwar V. Chordal relocation for repair of anterior mitral leaflet flail: a reproducible option. Multimed Man Cardiothorac Surg. 2014;2014:mmt021. Sidebotham DA, Allen SJ, Gerber IL, et al. Intraoperative tranesophageal esophageal echocardiography for surgical repair of mitral regurgitation. J Am Soc Echocardiogr. 2014;27(4):345–66.

2

Diseases of the Aortic Valve

Abstract

This chapter described AV prolapse, bicuspid AV, rheumatic heart disease, and AS received proper treatments including aortic repair, replacement, or transcatheter AV implantation. The best views for the AV examination are middle esophageal AV short- and long-axis views. 3D echocardiography compared with 2D can assess valvular morphology and provide additional information regarding AS severity with accurate multi-planer reconstruction of the anatomic AV orifice.

Fig. 2.1  Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, showed NCC (arrow) prolapse into LV (Video 2.1)

2.1 Prolapse of Noncoronary Cusp A 58-year-old man had a history of type B WolffParkinson-White syndrome, chronic obstructive pulmonary disease and severe AR with prolapse of NCC. He complained of frequent chest distress and exertional dyspnea recently. Auscultation: regular heart beat with a grade 2/6 diastolic murmur. Chest X ray: cardiomegaly. Operation: AV replacement (Figs. 2.1, 2.2, 2.3, 2.4, 2.5, and 2.6). Fig. 2.2  2D TEE color Doppler, long-axis view, showed severe AR (arrow) (Video 2.2) Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-981-19-6794-8_2. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_2

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2  Diseases of the Aortic Valve

Fig. 2.3  3D TEE image, surgical view, showed NCC (*) prolapse into LV (Video 2.3)

Fig. 2.5  3D TEE image, short-axis view, status post tissue AV replacement (AVR) (Video 2.5)

Fig. 2.4  3D TEE color Doppler, long-axis view, showed severe AR (arrow) (Video 2.4)

Fig. 2.6  3D TEE color Doppler, long-axis view, status post operation, showed trivial AR (Video 2.6)

cc Tips  AV prolapse has the aortic cusp extend beyond the annular plane resulting in eccentric AR in diastole. 

2.2  Bicuspid Aortic Valve Having Aortic Valve Repair

2.2 Bicuspid Aortic Valve Having Aortic Valve Repair A 24-year-old young man had a history of hypertension, bicuspid AV with AR under regular medical treatment. He suffered from shortness of breath, chest distress and malaise. Auscultation: regular heart beat with a grade 1/6 to and fro mur-

29

mur over upper sternal border and a grade 1/6 systolic murmur over apex. ECG: sinus rhythm, counter clockwise rotation and LV hypertrophy. Cardiac catheterization: bicuspid AV and severe aortic regurgitation. Operation: AV repair and ventriculoaortic junction plasty (Figs.  2.7, 2.8, 2.9, 2.10, 2.11, 2.12, and 2.13).

Fig. 2.7  Two-dimensional transesophageal echocardiography (2D TEE) image, x-plane view, showed bicuspid aortic valve (yellow arrows) with oval shape orifice and doming sign (red arrows) in systole (Video 2.7)

30

Fig. 2.8  2D TEE color Doppler, long-axis view, showed severe eccentric AR (arrow) (Video 2.8)

2  Diseases of the Aortic Valve

Fig. 2.11  2D TEE image, long-axis view, status post AV repair and ventriculoaorticplasty

Fig. 2.12  2D TEE color Doppler, long-axis view, status post AV repair, showed no AR in diastole Fig. 2.9  3D TEE image, short-axis view, showed bicuspid AV with oval shape orifice (arrows) (Video 2.9)

Fig. 2.13  Picture during operation showed the bicuspid AV

cc Tips  A thickened, doming valve is common Fig. 2.10  3D TEE color Doppler, showed severe eccentric AR (arrow) (Video 2.10)

in patients with bicuspid AV; however, a calcified valve is uncommon before age 30. 

2.3  Bicuspid Aortic Valve Having Tissue Aortic Valve Replacement

31

2.3 Bicuspid Aortic Valve Having Tissue Aortic Valve Replacement A 61-year-old woman had poor physical activity and poor sleeping quality. She suffered from cough with shortness of breath. Auscultation: regular heart beat with a systolic murmur over apex. ECG: sinus rhythm and clockwise rotation. Chest X ray: mild cardiomegaly. Cardiac catheterization: critical AS with AV area is 0.6  cm2. Operation: AV replacement (Figs.  2.14, 2.15, 2.16, 2.17, 2.18, 2.19, 2.20, 2.21, 2.22, 2.23, 2.24, and 2.25).

Fig. 2.14 Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, showed the bicuspid AV with doming sign (arrows) in systole (Video 2.11)

Fig. 2.15  2D TEE color Doppler, long-axis view, showed aortic stenosis (AS) with high-velocity LV outflow (arrow) (Video 2.12)

Fig. 2.16  2D TEE continuous-wave Doppler, AS with high pressure gradient (peak 60 mmHg) flow (arrow) was present

Fig. 2.17  3D TEE image, short-axis view, showed bicuspid AV (arrows) with small orifice (Video 2.13)

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2  Diseases of the Aortic Valve

Fig. 2.18  Multi-planar reconstruction (MPR) of 3D TEE image, showed the AV area is 0.64 cm2

2.3  Bicuspid Aortic Valve Having Tissue Aortic Valve Replacement

33

Fig. 2.19  3D TEE color Doppler, showed AS with highvelocity LV outflow (arrow) (Video 2.14)

Figs. 2.20 and 2.21  2D TEE color Doppler, long-axis view, status post tissue AV replacement, showed slightly accelerated flow across the prosthesis in systole (left) and no AR in diastole (right)

Fig. 2.22  3D TEE image, long-axis view, status post tissue AV replacement (arrows), showed good prosthesis function (Video 2.15)

Fig. 2.23  3D TEE color suppressed image, en face view of AV, status post AV replacement (AVR), showed good prosthesis function (Video 2.16)

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2  Diseases of the Aortic Valve

cc Tips  Bicuspid AV is the most common congenital heart disease diagnosed in adults. It is asymptomatic in most patients but may develop AS or AR over the lifetime. Today, of valve replacement worldwide, tissue valves are used in 40% or more, predominantly as stented porcine AV and bovine pericardial valves. 

2.4 Bicuspid Aortic Valve Having Mechanical Aortic Valve Replacement Fig. 2.24  3D TEE color Doppler, long- axis view, status post AV replacement, showed slightly accelerated flow across the prosthesis (Video 2.17)

Fig. 2.25  3D TEE color Doppler, short-axis view, status post AV replacement, showed slightly accelerated flow across the prosthesis (Video 2.18)

A 51-year-old woman with a history of schizophrenia, hepatitis C and intestinal adhesions had bicuspid AV and suffered progressive dyspnea on exertion for months. Auscultation: regular heart beat with a grade 2 systolic murmur over the aortic area and left sternal border. ECG: sinus bradycardia. Cardiac catheterization: congenital bicuspid AV with symptomatic critical stenosis. Operation: AV replacement (Figs.  2.26, 2.27, 2.28, 2.29, 2.30, 2.31, 2.32, 2.33, and 2.34).

2.4  Bicuspid Aortic Valve Having Mechanical Aortic Valve Replacement

35

Fig. 2.26  Two-dimensional transesophageal echocardiography (2D TEE) image, x-plane view, showed aorta dilation and bicuspid AV (yellow arrows) with doming sign (red arrows) and small oval-shape orifice (Video 2.19)

Figs. 2.27 and 2.28  2D TEE color Doppler, long-axis (left) and short-axis (right) view, showed bicuspid AV with aortic stenosis (AS) and high AV velocity (arrow) (Videos 2.20 and 2.21)

Fig. 2.29  2D TEE continuous-wave Doppler, AS with pressure gradient (peak gradient is about 20 mmHg) LV outflow (arrow) was present Fig. 2.30  3D TEE, short-axis view, showed bicuspid AV (arrows) with small oval-shape orifice (Video 2.22)

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2  Diseases of the Aortic Valve

Fig. 2.31  Multi-planar reconstruction (MPR) of 3D TEE image, showed AV area is 0.96 cm2

Fig. 2.32  2D TEE image, long-axis view, status post AV replacement with mechanical valve (arrows), showed good prosthesis function

2.5  Rheumatic Heart Disease Having Aortic and Mitral Replacement

37

Figs. 2.33 and 2.34  2D color Doppler, showed AV post operation with slightly accelerated flow across the prosthesis in systole (left) and no AR in diastole (right), mild MR is present

cc Tips  The cusp size is often uneven with an eccentric orifice in bicuspid AV.  The optimal visualization of prosthetic AV is achieved from short-axis and long-axis view at the midesophageal level, while upper-esophageal and trans-gastric views are not helpful due to poor image quality. 

2.5 Rheumatic Heart Disease Having Aortic and Mitral Replacement A 65-year-old woman had a long standing history of rheumatic heart disease with severe mitral, aortic stenosis and Af. She admitted for exertional dyspnea and dizziness off and on. Auscultation: irregular heart beat with a grade 2/6 systolic murmur over apex. ECG: Atrial fibrillation with moderate ventricular response. Chest X ray: Borderline heart size. Cardiac catheterization: mitral and aortic stenosis. Operation: AV and MV replacement, TV repair and Af ablation (Figs. 2.35, 2.36, 2.37, 2.38, 2.39, 2.40, 2.41, 2.42, 2.43, 2.44, 2.45, 2.46, 2.47, 2.48, and 2.49).

Fig. 2.35 Two-dimensional transesophageal echocardiogram (2D TEE) image, long-axis view, showed calcified aortic leaflets with systolic doming (arrows) (Video 2.23)

Fig. 2.36  2D TEE image, long-axis view in diastole, showed restricted motion of mitral leaflet tips with hockey-sign (arrow) (Video 2.23)

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Fig. 2.37  2D TEE color Doppler, long-axis view in systole, showed accelerated flow across the calcified AV (arrow) (Video 2.24)

2  Diseases of the Aortic Valve

Fig. 2.38  2D TEE color Doppler, long-axis view in diastole, showed high-velocity mitral inflow (yellow arrow) and moderate AR (red arrow) (Video 2.24)

Figs. 2.39 and 2.40  3D TEE image, long-axis view in systole (left) and diastole (right), showed rheumatic aortic stenosis occurred concurrently with rheumatic mitral stenosis (arrows) (Video 2.25)

2.5  Rheumatic Heart Disease Having Aortic and Mitral Replacement

39

Figs. 2.41 and 2.42  3D TEE image, short-axis view (above) and MPR (below), showed fusion commissural of aortic leaflets with small AV area which is 0.98 cm2 (Video 2.26)

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2  Diseases of the Aortic Valve

Figs. 2.43 and 2.44  3D TEE image, en face view (above) and MPR (below), showed small mitral orifice with the area is 1.16 cm2 (Video 2.27)

2.5  Rheumatic Heart Disease Having Aortic and Mitral Replacement

Fig. 2.45  3D TEE color Doppler, long- axis view in systole, showed accelerated flow across the calcified AV (arrow) (Video 2.28)

41

Fig. 2.47  3D TEE color Doppler, long-axis view in diastole, showed high-velocity mitral inflow (arrow) (Video 2.29)

Fig. 2.46  3D TEE color Doppler, long-axis view in diastole, showed moderate AR (arrow) (Video 2.28) Fig. 2.48  3D TEE image, long-axis view, status post tissue aortic and mitral replacement, showed normal prosthetic function (Video 2.30)

2  Diseases of the Aortic Valve

42

Fig. 2.49  3D TEE color Doppler, long-axis view, status post tissue aortic and mitral replacement, showed normal mitral inflow (Video 2.31)

Fig. 2.50 Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, showed calcified AV (arrow) with aortic stenosis (AS) (Video 2.32)

cc Tips  Rheumatic heart disease preferentially involves the MV.  Rheumatic AS may be diagnosed concurrently with rheumatic MV disease. 

2.6 Aortic Stenosis Having Transcatheter Aortic Valve Implantation A 73-year-old woman with a history of asthma and left side breast cancer status post mastectomy presented to our ER with complaints of chest pain, dyspnea and dizziness. Auscultation: regular heart beat with a grade 3/6 systolic murmur over apex. ECG: sinus tachycardia, left ventricular hypertrophy with repolarization abnormality, myocardial ischemia. Cardiac catheterization: three-vessel coronary artery disease, critical AS and severe MR. Chest CT: some mural thrombi at the orifice of right CCA, calcified plaques on the coronary arteries, calcified AV and left pleural effusion. Operation: CABG x2 (LAD and RCA), TV repair and emergency transcatheter aortic valve implantation (TAVI) (Figs. 2.50, 2.51, 2.52, 2.53, 2.54, 2.55, 2.56, 2.57, 2.58, 2.59, 2.60, 2.61, 2.62, 2.63, 2.64, 2.65, 2.66, 2.67, 2.68, 2.69, and 2.70).

Fig. 2.51  2D TEE image, short-axis view, showed calcified AV (arrow) with AS (Video 2.33)

Fig. 2.52  2D TEE color Doppler, long-axis view, showed AS with high-velocity mosaic LV outflow (arrow) (Video 2.34)

2.6  Aortic Stenosis Having Transcatheter Aortic Valve Implantation

Fig. 2.53  3D TEE image, long-axis view, showed calcified AV (arrows) with AS (Video 2.35)

43

Fig. 2.54  3D TEE image, short-axis view, showed calcified AV with AS (Video 2.36)

Fig. 2.55  Multi-planar reconstruction (MPR) of 3D TEE image, showed the aortic valve area is 0.87 cm2

44

Fig. 2.56  MPR of 3D TEE image showed the aortic annular area is 4.04 cm2

Fig. 2.57  CT angiogram showed the aortic annular area is 4.14 cm2

2  Diseases of the Aortic Valve

2.6  Aortic Stenosis Having Transcatheter Aortic Valve Implantation Figs. 2.58 and 2.59 MPR of 3D TEE image showed the anatomical relationship among sinus of valsalva, left coronary artery (black arrows) and right coronary artery (red arrow)

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2  Diseases of the Aortic Valve

Fig. 2.60  CT angiogram showed the anatomical relationship between aortic annulus and its surroundings

Fig. 2.61  3D TEE image, long-axis view, during the TAVI procedure, showed the guiding catheter (arrow) crossed AV from aorta to LV (Video 2.37)

Fig. 2.62  3D TEE image, long-axis view, during the TAVI procedure, showed the open core valve (arrows) (Video 2.38)

2.6  Aortic Stenosis Having Transcatheter Aortic Valve Implantation

Fig. 2.63  2D TEE image, long-axis view, during the TAVI procedure, showed the open core valve (arrows)

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Fig. 2.64  2D TEE color Doppler, long-axis view, during the TAVI procedure, showed mild paravalvular leakage (arrows) when the valve was not fully opened

Fig. 2.65  2D TEE image, x-plane view, status post TAVI, showed the core valve (arrows)

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2  Diseases of the Aortic Valve

Fig. 2.66  2D TEE color Doppler, x-plane view, status post TAVI, showed normal LV outflow

Figs. 2.67 and 2.68  3D TEE color Doppler (left) and color suppressed image (right), long-axis view, status post TAVI, showed the core valve (arrows) with normal LV outflow (Videos 2.39 and 2.40)

2.7  Sinus of Valsalva Aneurysm Having Patch Repair

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Figs. 2.69 and 2.70  3D TEE color Doppler (left) and color suppressed image (right), en face view of AV, status post TAVI, showed normal LV outflow and good prosthesis function (Videos 2.41 and 2.42)

cc Tips  TAVI is an alternative to surgical AV replacement in patients who were at unacceptable risk for cardiac surgery requiring a sternotomy. Because TAVI is a relatively new procedure, it is important for both experienced and novice operators to be aware of the echocardiographic appearance of major complications. 

2.7 Sinus of Valsalva Aneurysm Having Patch Repair A 45 years old man presented with progressive exertional dyspnea, bilateral leg swelling, and chest tightness. Patient underwent pacemaker implantation after experiencing syncope induced by a complete atrioventricular block. Auscultation: RHB with SM.  EKG: atrial pacing, ventricular pacing rhythm. Operation: Patch repair of Sinus of Valsalva aneurysm, AVR with SJM metallic valve, 21  mm (Figs.  2.71, 2.72, 2.73, 2.74, 2.75, and 2.76).

Fig. 2.71 Two-dimensional transesophageal echocardiography (2-D TEE) image, long-axis view, revealing the aneurysm (*) dissecting into the interventricular septum (Video 2.43)

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2  Diseases of the Aortic Valve

Fig. 2.72  2-D TEE color Doppler, long-axis view, severe AR gushing into the aneurysm during diastole (Video 2.44)

Fig. 2.73  Intraoperative TrueVue 3D transesophageal echocardiography (TEE) image showing the aneurysm inlet (black arrow) and diastolic flow filling up the inlet (Video 2.45)

Fig. 2.74  TrueVue 3D TEE image displaying the Sinus of Valsalva aneurysm(*) originating from the right coronary sinus. (PV pulmonary valve) (Video 2.46)

Fig. 2.75  Cardiac Magnetic Resonance Imaging showing large Sinus of Valsalva aneurysm bulging into the ventricle

Fig. 2.76  TrueVue photo-realistic 3D TEE revealing the Sinus of Valsalva aneurysm protruding to the left ventricle outflow tract (Video 2.47)

2.8  Bicuspid Aortic Valve Having Bentall’s Operation

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2.8 Bicuspid Aortic Valve Having Bentall’s Operation A 70-year-old man had orthostatic dizziness, poor appetite and chest pain. Under MSCT aortogram, he was admitted for Bentall’s operation and CABG. ECG: sinus rhythm, Left ventricular hypertrophy. Chest X ray: Atherosclerosis of thoracic aorta and cardiomegaly. Cardiac catheterization: double vessel disease, dilated ascending aorta with severe aortic stenosis and regurgitation (Figs. 2.77, 2.78, 2.79, 2.80, 2.81, and 2.82).

Fig. 2.77  Two-dimensional transesophageal echocardiography (2-D TEE) long-axis view showing calcified aortic leaflets with dilated aortic root (Video 2.48)

Fig. 2.78  2D TEE color Doppler in long-axis view revealing severe aortic regurgitation (arrow) (Video 2.49)

Fig. 2.79  2D TEE color Doppler showing accelerated flow crossing the calcified aortic valve during systole (arrow) (Video 2.50)

Fig. 2.80  3D TEE image, long-axis view in systole, showing bicuspid aortic leaflets (arrows) (Video 2.51)

Fig. 2.81  TrueVue photo-realistic 3D TEE revealing the calcified bicuspid aortic valve (arrow) (Video 2.52)

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2  Diseases of the Aortic Valve

2.9 Transcatheter Aortic Valve Implantation Leading Mitral Chordae Rupture

Fig. 2.82  2D TEE color Doppler, long-axis view in diastole, status post tissue aortic showing normal prosthetic function (Video 2.53)

A 90-year-old man patient had history of valvular heart disease with severe AS for years, Hypertension, Diabetes mellitus, and Bronchial asthma. The echocardiogram showed AVA = 0.79 cm2 with PPG of 50 mmHg. LV function was preserved with EF > 55%. Patient suffered dyspnea on exertion for a period of time. Under our impression of severe AS with AR, he was admitted for scheduled TAVI (Figs.  2.83, 2.84, 2.85, 2.86, 2.87, 2.88, 2.89, 2.90, 2.91, 2.92, and 2.93).

Fig. 2.83  Two-dimentional Transesophageal Echocardiography X-plane showing thickened and calcified aortic valve (arrowhead) (Video 2.54)

2.9  Transcatheter Aortic Valve Implantation Leading Mitral Chordae Rupture

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Fig. 2.84  3D TrueVue from ascending aorta to aortic valve showing thickened and small orifice of aortic valve during systole (Video 2.55)

Fig. 2.87  3D TEE Color Doppler in diastole showing moderate aortic regurgitation (arrow) (Video 2.57)

Fig. 2.85  3D TrueVue long axis view revealing calcified aortic valve (arrow) (Video 2.56)

Fig. 2.88  2D TEE Color Doppler demonstrating catheter (arrowhead) through the aortic valve to Left Ventricle (Video 2.58)

Fig. 2.86  3D TEE long axis view showing high velocity mosaic outflow during systole phase (arrow) (Video 2.57)

Fig. 2.89  2D TEE modified two chamber view revealing rupture of chordae (arrow) (Video 2.59)

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Fig. 2.90  3D TEE TrueVue, en face view of mitral vavle, displaying a small chordae falling into the Left Atrium during systole (arrow) (Video 2.60)

2  Diseases of the Aortic Valve

Fig. 2.93  3D TEE Color Doppler showing mild mitral regurgitation (arrow) and normal function of transcatheter aortic valve (Video 2.63)

Suggested Reading

Fig. 2.91  3D TEE TrueVue demonstrating a chordae rupture (arrow) and status post TAVI (Video 2.61)

Fig. 2.92  2D TEE revealing successfully implantation of TAVI (Video 2.62)

Asano R, Nakano K, Kodera K, et  al. Ascendingdescending aortic bypass and aortic valve replacement for aortic coarctation with bicuspid aortic valve and an aberrant right subclavian artery;report of a case. Kyobu Geka. 2015;68(9):777–9. Japanese. Chen GL, Li HT, Li HR, Zhang ZW.  Transcatheter closure of ventricular septal defect in patients with aortic valve prolapse and mild aortic regurgitation: feasibility and preliminary outcome. Asian Pac J Trop Med. 2015;8(4):315–8. Davarpasand T, Hosseinsabet A, Jalali A.  Concomitant coronary artery bypass graft and aortic and mitral valve replacement for rheumatic heart disease: shortand mid-term outcomes. Interact Cardiovasc Thorac Surg. 2015;21(3):322–8. Forteza A, Vera F, Centeno J, et  al. Preservation of the bicuspid aortic valve associated with aneurysms of the aortic root and ascending aorta. Rev Esp Cardiol (Engl Ed). 2013;66(8):644–8. Girdauskas E, Disha K, Rouman M, et al. Aortic events after isolated aortic valve replacement for bicuspid aortic valve root phenotype: echocardiographic follow-up study. Eur J Cardiothorac Surg. 2015;48(4):e71–6. Günaydın ZY, Bektaş O, Karagöz A, Kaya A.  Case images: a rare cause of severe aortic valve regurgitation: isolated aortic valve prolapse. Turk Kardiyol Dern Ars. 2015;43(2):208. Khalique OK, Hamid NB, Kodali SK, et  al. Improving the accuracy of effective orifice area assessment after transcatheter aortic valve replacement: validation of left ventricular outflow tract diameter and pulsed-wave doppler location and impact of threedimensional measurements. J Am Soc Echocardiogr. 2015;28(11):1283–93.

Suggested Reading Looi JL, Lee AP, Fang F, et  al. Abnormal mitral-aortic intervalvular coupling in mitral valve diseases: a study using real-time three-dimensional transesophageal echocardiography. Clin Res Cardiol. 2015;104(10):831–42. Mazzitelli D, Pfeiffer S, Rankin JS, et  al. A regulated trial of bicuspid aortic valve repair supported by geometric ring annuloplasty. Ann Thorac Surg. 2015;99(6):2010–6.

55 Michelena HI, Corte AD, Prakash SK, et al. Bicuspid aortic valve aortopathy in adults: incidence, etiology, and clinical significance. Int J Cardiol. 2015;201:400–7. Rönnerfalk M, Tamás É. Structure and function of the tricuspid and bicuspid regurgitant aortic valve: an echocardiographic study. Interact Cardiovasc Thorac Surg. 2015;21(1):71–6.

3

Diseases of the Tricuspid and Pulmonary Valve

Abstract

Right-sided vlavular disorders are discussed in this chapter, including cases of TV prolapse, tricuspid prosthesis restenosis, subvalvular PS, and carcinoid syndrome. The TV is the largest cardiac valve and the PV has thinner leaflets. 3D zoom mode is preferable for assessment for TV and PV leaflets whereas 3D full volume is better for regurgitation and valvular supporting structures.

3.1 Prolapse of Posterior Tricuspid Leaflet Having Tricuspid Repair

Fig. 3.1  Two-dimensional transesophageal echocardiography (2D TEE) image, four-­chamber view, showed prolapse of posterior tricuspid leaflet (arrow), dilated RA and RV with RV dysfunction (Video 3.1)

A 34-year-old man with previous VSD and TV repair suffered from chest tightness and palpitation off and on. Auscultation: irregular heart beat with a grade 2/6 systolic murmur over apex and left sternal border. ECG: atrial flutter and complete right bundle branch block. Chest X ray: cardiomegaly. Cardiac catheterization: severe TR and RV failure. Abdominal echo: engorged IVC and hepatic vein. Operation: re-do TV repair, partial pericardiectomy and Af ablation (Figs.  3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, and 3.8).

Supplementary Information The online version contains supplementary material available at https://doi. org/10.1007/978-­981-­19-­6794-­8_3.

Fig. 3.2  2D TEE color Doppler, four-chamber view, showed severe eccentric TR (arrow) due to TV prolapse (Video 3.2)

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_3

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Fig. 3.3  3D TEE image, en face view of TV from atrial perspective in systole, showed prolapse of posterior tricuspid leaflet (*) (Video 3.3)

3  Diseases of the Tricuspid and Pulmonary Valve

Fig. 3.4  3D TEE color Doppler, showed severe eccentric TR (arrow) (Video 3.4)

Fig. 3.5  2D abdominal echography showed engorged IVC and hepatic vein (HV)

3.2 Prosthetic Tricuspid Valve Stenosis Having Redo Replacement

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cc Tips  All kinds of TV repairs include an annuloplasty, which is a complete or partial ring placed around the opening of the valve to restore and retain its correct size and shape.

3.2 Prosthetic Tricuspid Valve Stenosis Having Redo Replacement

Fig. 3.6  2D TEE image, RV inflow-outflow view, status post TV repair with annuloplasty (arrow)

A 72-year-old woman had TV replacement 30 years ago. She experienced dyspnea on exertion, abdominal distention and poor appetite recently. Auscultation: regular heart beat without significant murmur. ECG: atrial fibrillation with rapid ventricular response, right axis deviation, counter clockwise rotation and complete right bundle branch block. Chest X ray: mild cardiomegaly and mild calcification of aortic arch. Operation: CABG x2 (SVG to LAD and RCA), TVR and permanent sutureless myocardial screw in lead placement of RV (Figs.  3.9, 3.10, 3.11, 3.12, 3.13, 3.14, 3.15, 3.16, and 3.17).

Fig. 3.7  3D TEE image, en face view of TV from atrial perspective, status post TV repair, showed the suture and ring (arrows) (Video 3.5)

Fig. 3.9  Two-dimensional transesophageal echocardiography (2D TEE) image, status post tissue TV replacement (arrows), showed thickened tissue tricuspid prosthesis (arrows) with dilated RA (Video 3.7)

Fig. 3.8  3D TEE color Doppler, status post TV repair, showed repaired TV with normal RV inflow and mild TR (Video 3.6)

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3  Diseases of the Tricuspid and Pulmonary Valve

Figs. 3.10 and 3.11  2D TEE color Doppler (left) and continuous-wave Doppler (right), showed prosthetic tricuspid stenosis with narrow tricuspid orifice (calculated TV area is 0.59 cm2) and high-velocity mosaic RV inflow (arrow) (peak gradient is 9 mmHg) in diastole (Video 3.8)

Fig. 3.12  3D TEE image, en face view of TV from atrial perspective in diastole, status post TV replacement (TVR), showed thickened tricuspid prosthesis with small TV area (Video 3.9)

Fig. 3.13  2D TEE image, status post redo TV replacement with tissue valve (arrows)

Fig. 3.14  3D TEE image, en face view of TV from atrial perspective, status post redo TV replacement (TVR) (Video 3.10)

Fig. 3.15  3D TEE color Doppler, status post redo TV replacement (TVR), showed normal tricuspid prosthesis function without stenosis (Video 3.11)

3.3 Subvalvular Pulmonary Stenosis with Right Atrium Thrombus

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Figs. 3.16 and 3.17  Gross specimen of the calcified and stenotic tricuspid prosthesis

cc Tips  The prosthetic valve is difficult to image due to shadowing by the valvular graft sometimes, where the Doppler can deal with the situation.

3.3 Subvalvular Pulmonary Stenosis with Right Atrium Thrombus A 61-year-old man had a history of congenital heart disease with severe pulmonic stenosis, single coronary artery disease and chronic atrial fibrillation. He suffered from sudden onset epigastralgia followed by syncope with generalized tonic-seizure like movement. Auscultation: irregular heart beat with a grade 2–6 systolic murmur over left upper sternal border and a grade 3/6systolic murmur over left lower sternal border and apex. Chest X ray: marked cardiomegaly. Operation: CABG x1 (LAD to SVG), carotid endarterectomy of ICA, removal of RA thrombus, myomectomy of RV outflow tract with resection of parietal band, atrial fibrillation ablation and LA & RA auricle obliteration (Figs. 3.18, 3.19, 3.20, 3.21, 3.22, 3.23, 3.24, 3.25, 3.26, and 3.27).

Fig. 3.18 Two-dimensional trsnseosphageal echocardiography (2D TEE) showed RV hypertrophy and a muscle band (arrows) at the junction of RV and infundibulum divided the cavity into two chambers. MPA, main pulmonary artery (Video 3.12)

Fig. 3.19  2D TEE color Doppler showed infundibular pulmonic stenosis with accelerated flow (arrow) in RV outflow tract (Video 3.13)

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3  Diseases of the Tricuspid and Pulmonary Valve

Fig. 3.20  2D TEE continuous-wave Doppler, showed high-velocity pressure (arrow) at RV outflow tract due to infundibular pulmonic stenosis

Fig. 3.21  3D TEE, short-axis view, showed infundibular pulmonic stenosis with a muscle band (arrows) at the junction of RV and infundibulum (Video 3.14)

Fig. 3.22  3D TEE showed RV hypertrophy and a muscle band (arrows) at the junction of RV and infundibulum divided the cavity into two chambers (Video 3.15)

3.4 Carcinoid Syndrome Having Aortic, Tricuspid and Pulmonary Replacement

Fig. 3.23 3D TEE, zoom-mode of short-axis view, showed the stenosis position (arrow) at the infundibulum (Video 3.16)

Fig. 3.24  3D TEE color Doppler showed infundibular pulmonic stenosis with accelerated flow (arrow) in RV outflow tract (Video 3.17)

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Fig. 3.26  3D TEE showed dilated RA with a thrombus (*) in it (Video 3.19)

Fig. 3.27  3D TEE, view from RV perspective, showed a thrombus (*) in RA (Video 3.20)

cc Tips  TEE examination provides useful views to assess RV outflow tract and PV region to identify the pathology of subvalvular or supravalvular pulmonary stenosis. 

3.4 Carcinoid Syndrome Having Aortic, Tricuspid and Pulmonary Replacement

Fig. 3.25  2D TEE showed dilated RA with a thrombus (*) in it (Video 3.18)

A 65-year-old woman with left breast cancer and small intestine carcinoid tumor with liver metastasis status post operation 10 years ago suffered from exertional dyspnea. Auscultation: regular

64

heart beat with a grade 3/6 pan-­systolic murmur over xyphoid process and a grade 2/6 to and fro murmur over PA, left sternal border and aortic area. ECG: sinus rhythm, right axis deviation, clockwise rotation and non-specific ST-T change. Chest X ray: cardiomegaly. Cardiac catheterization: carcinoid heart disease with severe AR, TR and PR. Operation: AV, TV and PV replacement (Figs.  3.28, 3.29, 3.30, 3.31, 3.32, 3.33, 3.34, 3.35, 3.36, 3.37, 3.38, 3.39, 3.40, 3.41, 3.42, 3.43, 3.44, 3.45, 3.46, 3.47, 3.48, 3.49, 3.50, 3.51, 3.52, 3.53, 3.54, 3.55, and 3.56).

Fig. 3.28  Two-dimensional transesophageal echocardiogram (2D TEE) image, carcinoid involvement of the TV, showed retraction and thickening of the leaflets (arrows) that fail to coapt (Video 3.21)

3  Diseases of the Tricuspid and Pulmonary Valve

Fig. 3.30  2D TEE color Doppler showed severe TR (arrow) with the regurgitant jet nearly filling the RA (Video 3.23)

Fig. 3.31  2D TEE color Doppler, modified four-chamber view, showed severe TR through a wide regurgitant orifice (Video 3.24)

Fig. 3.29  2D TEE image, modified four-chamber view during operation, showed the central venous line across TV (white arrows) and carcinoid involvement of the TV with retraction and thickening of the leaflets (yellow arrows). Dilated RA and RV are also noted (Video 3.22) Fig. 3.32  3D TEE color Doppler showed severe TR with the regurgitant jet nearly filling the RA (Video 3.25)

3.4 Carcinoid Syndrome Having Aortic, Tricuspid and Pulmonary Replacement

Fig. 3.33  2D TEE image showed carcinoid involvement of the PV with diminutive and rigid leaflets (arrows). A carcinoid neoplasm at LV outflow tract (*) was present (Video 3.26)

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Fig. 3.36  3D TEE image showed carcinoid involvement of the PV with diminutive and rigid leaflets (arrows). A carcinoid neoplasm at LV outflow tract (*) was present (Video 3.28)

Fig. 3.34  2D TEE color Doppler showed pulmonic stenosis with high-velocity mosaic flow (arrow) across PV in systole (Video 3.27)

Fig. 3.37  3D TEE color Doppler showed severe PR (red arrow) and AR (yellow arrow) (Video 3.29)

Fig. 3.35  2D TEE color Doppler showed severe PR (red arrow) and AR (yellow arrow) in diastole (Video 3.27) Fig. 3.38 2D TEE image, modified long-axis view, showed carcinoid involvement of the left heart with thickened AV (Video 3.30)

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Fig. 3.39  2D TEE color Doppler, modified long-axis view, showed severe AR (yellow arrow) and PR (white arrow) (Video 3.31)

Fig. 3.40  3D TEE image, long-axis view, showed carcinoid involvement of the left heart with thickened AV (Video 3.32)

Fig. 3.41  3D TEE color Doppler, long-axis view, showed severe AR (arrow) (Video 3.33)

3  Diseases of the Tricuspid and Pulmonary Valve

Fig. 3.42  2D TEE image, status post mechanical AV, TV and PV replacement (AVR, TVR & PVR), showed normal aortic and tricuspid prosthetic function

Fig. 3.43  2D TEE color Doppler, status post mechanical AV, TV and PV replacement, showed normal aortic and tricuspid prosthetic function with minimal AR and TR

3.4 Carcinoid Syndrome Having Aortic, Tricuspid and Pulmonary Replacement

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Figs. 3.44 and 3.45  3D TEE image, status post mechanical AV, TV and PV replacement (AVR, TVR & PVR), showed normal aortic and tricuspid prosthetic function with cardiac cycle (Video 3.34)

Fig. 3.46  2D TEE image, short-axis view, status post mechanical AV, TV and PV replacement, showed normal pulmonic prosthetic function (arrows)

Figs. 3.47 and 3.48  2D TEE color Doppler, short-axis view, status post mechanical AV, TV and PV replacement, showed normal pulmonic prosthetic function without pulmonic stenosis or PR

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Fig. 3.49  3D TEE image, short-axis view, status post mechanical AV, TV and PV replacement, showed normal pulmonic prosthetic function (Video 3.35)

3  Diseases of the Tricuspid and Pulmonary Valve

Fig. 3.51  2D TEE image, long-axis view, status post mechanical AV, TV and PV replacement, showed normal aortic prosthetic function

Fig. 3.50  3D TEE color Doppler, short-axis view, status post mechanical AV, TV and PV replacement (AVR, TVR & PVR), showed normal aortic and pulmonic prosthetic function (Video 3.36)

Figs. 3.52 and 3.53  3D TEE image, long-axis view, status post mechanical AV, TV and PV replacement, showed normal aortic prosthetic function (Video 3.37)

3.5 Tricuspid Valve Incomplete Closure Having Tricuspid Valve Repair

69

Figs. 3.54 and 3.55  3D TEE color Doppler, long-axis view, status post mechanical AV, TV and PV replacement, showed normal aortic prosthetic function (Video 3.38)

Fig. 3.56  Delay phase of contrast enhanced CT image showed multiple carcinoid metastatic lesions over liver

cc Tips  Carcinoid syndrome typically affects all

Fig. 3.57  Two-dimensional Transesophageal Echo­ cardiography(2D TEE) demonstrating tenting and noncoaptation of the tricuspid valve(arrow) (Video 3.39)

right heart structures. If liver or lung metastasis was present, the symptoms may invade left heart.

3.5 Tricuspid Valve Incomplete Closure Having Tricuspid Valve Repair A 69-year-old female with history of VHD with severe TR, CAD, Chronic Af, HCVD, Type 2 DM, and Hyperlipidemia for years under medical treatment. The patient suffered from bilateral lower legs edema for a period of time. Cardiac catheterization was done, severe TR and chronic Af was impressed. Transthoracic echocardiography demonstrated incomplete closure of tricuspid valve with RA and RV dilatation. Surgical inter-

Fig. 3.58  2D TEE Color Doppler showing torrential tricuspid regurgitation(arrow) (Video 3.40)

vention was suggested (Figs.  3.57, 3.58, 3.59, 3.60, 3.61, 3.62, and 3.63).

70

3  Diseases of the Tricuspid and Pulmonary Valve

Fig. 3.59  TrueVue 3D TEE showing non-coaptation of the tricuspid valve in systole (Video 3.41)

Fig. 3.62  2D TEE Color Doppler, status post Alfieri stitch, revealing mild tricuspid regurgitation (Video 3.44)

Fig. 3.60  TrueVue 3D TEE Color Doppler in systole revealing torrential tricuspid regurgitation(arrow) (Video 3.42)

Fig. 3.63 TrueVue 3D TEE Color Doppler showing normal tricuspid flow through the Edwards ring (Video 3.45)

3.6 Ebstein’s Anomaly Having Tricuspid Valve Repair

Fig. 3.61 2D TEE demonstrating repaired tricuspid valve annuloplasty (Edwards MC3 Ring 30 mm) (Video 3.43)

A 30-year-old woman denied history of systemic disease presenting mild exertional dyspnea. Transthoracic echocardiography demonstrated the VHD with severe TR, Ebstein’s anomaly was noted and surgical intervention was suggested. ECG: sinus rhythm. Chest X ray: Borderline heart size is noted. No active lung lesion. CAG: RA, RV dilatation, preserved RVEF. Congenital heart disease, Ebstein’s anomaly. Operation: S/P Tricuspid Valve Repair(Cone operation) (Figs.  3.64, 3.65, 3.66, 3.67, 3.68, and 3.69).

3.6 Ebstein’s Anomaly Having Tricuspid Valve Repair

Fig. 3.64  Intraoperative Two-dimensional Transesophageal Echocardiography(2D TEE) showing the presence of Ebstein’s anomaly of the tricuspid valve. Apical displacement of the septal leaflet from the insertion of the anterior leaflet of the mitral valve is 21mm (Video 3.46)

71

Fig. 3.66  3D TEE Color Doppler displaying torrential tricuspid regurgitation (arrow) (Video 3.48)

Fig. 3.67  TruVue 3D TEE status post tricuspid valve Alfieri’s repair (arrow) (Video 3.49) Fig. 3.65  2D TEE Color Doppler showing elongated anterior tricuspid valve leaflet and torrential tricuspid regurgitation(arrow) (Video 3.47)

Fig. 3.68  TruVue 3D TEE Color Doppler, status post tricuspid valve cone operation, the mosaic high velocity flow and PW demonstrating at least moderate tricuspid stenosis (Video 3.50)

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3  Diseases of the Tricuspid and Pulmonary Valve

Fig. 3.69  2D TEE Color Doppler and Power Doppler showing normal tricuspid inflow and mild regurgitation after incision of the Alfieri’s stitch (arrow) (Video 3.51)

3.7 Tricuspid Valve Prolapse Having Tricuspid Valve Repair A 53-year-old female had history of ventricular septal defect s/p operation for more than 40 years ago, she also had cardiac arrhythmia, benign fibroadipose of bilateral breast and anxiety with insomnia. Patient experienced effort chest tightness and dyspnea for several months, severe TR and pulmonary hypertension was diagnosed. Operation: s/p Re-do sternotomy with pericardiectomy & tricuspid valve annuloplasty (decalcification, peel off leaflet fibrotic tissue, lysis of septal chordae, annuloplasty with a 28 mm MC3 ring) (Figs. 3.70, 3.71, 3.72, 3.73, 3.74, and 3.75).

Fig. 3.70 Two-dimensional Transesophageal Echocardiography (2D TEE) showing septal (S) and posterior (P) leaflets of tricuspid valve are prolapse (Video 3.52)

Fig. 3.71  2D TEE Color Doppler displaying torrential tricuspid regurgitation during systole (arrow) (Video 3.53)

3.8  Caseous Calcification Mitral Annulus (CCMA) with MR

Fig. 3.72  3D TEE revealing prolapsing septal (S) and posterior (P) tricuspid leaflets and a significant non coaptation (Video 3.54)

73

Fig. 3.75  2D TEE Color Doppler showing annuloplasty ring (arrow) and normal function of repaired tricuspid valve (Video 3.57)

3.8 Caseous Calcification Mitral Annulus (CCMA) with MR

Fig. 3.73  TrueVue 3D TEE demonstrating three leaflets of the tricuspid valve (A anterior leaflet, S septal leaflet, P posterior leaflet) (Video 3.55)

Fig. 3.74  2D TEE Color Doppler, status post Alfieri’s repair (arrow), revealing mild tricuspid regurgitation (arrowhead) (Video 3.56)

A 79-year-old female had history of Hypothyroidism with Thyroid nodule and Breast cancer s/p under clinic follow. She complained of intermitted dyspnea on exercise, chest tightness, palpitation with both lower leg pains in recent 1 month. CXR: Cardiomegaly is noticed, enlargement of left atrium. CAG: valvular heart disease with severe mitral valve regurgitation. Cardiac echo: prolapse of mitral valve with severe MR.  Surgery intervention was suggested (Figs.  3.76, 3.77, 3.78, 3.79, 3.80, 3.81, and 3.82).

74

Fig. 3.76  2D Transesophageal Echocardiography in long axis view showing severe calcification of mitral annulus (asterisk) with prolapse of posterior mitral leaflet (arrow) (Video 3.58)

Fig. 3.77  2D TEE Color Doppler revealing eccentric severe mitral regurgitation (arrow) (Video 3.59)

Fig. 3.78  3D Transesophageal Echocardiography displaying CCMA (asterisk) and prolapse of posterior mitral leaflet (arrow) (Video 3.60)

3  Diseases of the Tricuspid and Pulmonary Valve

Fig. 3.79  3D TEE Color Doppler, en face view, showing severe mitral regurgitation (arrow) (Video 3.61)

Fig. 3.80  2D TEE status post MVR demonstrating normal function of prosthetic valve in long axis view (Video 3.62)

Fig. 3.81  3D TEE status post MVR, en face view, showing normal mitral prosthetic leaflet (Video 3.63)

Suggested Reading

Fig. 3.82  3D TEE Color Doppler status post MVR revealing lamina flow of prosthetic mitral valve (Video 3.64)

Suggested Reading Desai HM, Amonkar GP.  Idiopathic mitral valve prolapse with tricuspid, aortic and pulmonary valve involvement: an autopsy case report. Indian J Pathol Microbiol. 2015;58(2):217–9. Doğdu O, Baran O, Karaduman O, Yarlıoğlueş M. Subvalvular pulmonary stenosis, right ventricular hypertrophy and patent foramen ovale. Turk Kardiyol Dern Ars. 2011;39(7):626. Elsayed M, Thind M, Nanda NC.  Two- and threedimensional transthoracic echocardiographic assessment of tricuspid valve prolapse with mid-to-late systolic tricuspid regurgitation. Echocardiography. 2015;32(6):1022–5. Kobza R, Kurz DJ, et  al. Aberrant tendinous chords with tethering of the tricuspid leaflets: a congenital anomaly causing severe tricuspid regurgitation. Heart. 2004;90(3):319–23. Kocabay G, Sirma D, Mert M, Tigen K.  Isolated tricuspid valve prolapsed: identification using twoand three- dimensionalechocardiography and transoesophageal echocardiography. Cardiovasc J Afr. 2011;22(5):272–3.

75 Lai YQ, Meng X, et  al. Edge-to-edge tricuspid valve repair: an adjuvant technique for residual tricuspid rgurgitation. Ann Thorac Surg. 2006;81:2179–82. Miles LF, Leong T, McCall P, Weinberg L. Carcinoid heart disease: correlation of echocardiographic and histopathological findings. BMJ Case Rep. 2014;24:2014. Muraru D, Badano LP, Sarais C, et  al. Evaluation of tricuspid valve morphology and function by transthoracic three-dimensionalechocardiography. Curr Cardiol Rep. 2011;13(3):242–9. Nalawadi SS, Siegel RJ, Wolin E, et  al. Morphologic features of carcinoid heart disease as assessed by three-dimensional transesophageal echocardiography. Echocardiography. 2010;27(9):1098–105. Reddy YN, Connolly HM, Ammash NM.  Thrombotic obstruction of a melody valve-­in-­valve used for prosthetic tricuspid stenosis. World J Pediatr Congenit Heart Surg. 2015a;6(4):667–9. Reddy G, Ahmed M, Alli O. Percutaneous valvuloplasty for severe bioprosthetic tricuspid valve stenosis in the setting of infective endocarditis. Catheter Cardiovasc Interv. 2015b;85(5):925–9. Requilé A, Van De Bruaene A, Reenaers V, Dendale P.  A case of carcinoid heart disease with desaturation and no liver metastases. Echocardiography. 2014;31(10):E307–9. Roberts CC, Parmar RJ, Grayburn PA, et  al. Clues to diagnosing carcinoid heart disease as the cause of isolated right-sided heart failure. Am J Cardiol. 2014;114(10):1623–6. Tefera E, Bermudez-Cañete R, Rubio L. Discrete subpulmonic membrane in association with isolated severe pulmonary valvar stenosis. BMC Cardiovasc Disord. 2013;13:43. Waller AH, Chatzizisis YS, Moslehi JJ, et  al. Real-time three-dimensional transesophageal echocardiography enables preoperative pulmonary valvulopathy assessment. Eur Heart J Cardiovasc Imaging. 2014;15(6):713. Yousif M, Elhassan NB, Ali SK, Ahmed Y. Isolated subpulmonic fibrous ring, mirror-image dextrocardia and situs solitus in a young lady unreported and a near miss. Interact Cardiovasc Thorac Surg. 2013;17(6):1043–4.

4

Prosthetic Valves

Abstract

Prosthetic valves are discussed in this chapter. Cases of paravalvular leakage, mitral prosthesis dysfunction having transcatheter valve in valve replacement, and aortic restenosis having transcatheter AV implantation are involved. Bioprosthetic valve may be complicated by dehiscence or tissue degeneration. 3D TEE examination provides valuable information about the exact anatomic characteristics for further operative treatment.

4.1 Paravalvlular Leakage of Mitral Prosthesis

Fig. 4.1  Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, status post mechanical MV replacement (arrows), showed dilated LA (Video 4.1)

A 56-year-old woman status post MV replacement and TV repair 14 years ago suffered from severe shortness of breath and orthopnea. Auscultation: irregular heart beat with a grade 2 systolic murmur over apex. ECG: atrial fibrillation with moderate ventricular response, myocardial ischemia. Chest X ray: cardiomegaly and right pleural effusion. Coronary CT angiography: cardiomegaly and patency of three coronary arteries. Operation: redo MV replacement and TV repair (Figs. 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10, and 4.11).

Supplementary InformationThe online version contains supplementary material available at https://doi.org/ 10.1007/978-981-19-6794-8_4.

Fig. 4.2  2D TEE color Doppler, long-axis view, status post mechanical MV replacement, showed severe mitral paravalvular leakage (arrows) (Video 4.2)

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_4

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Fig. 4.3  2D TEE continuous-wave Doppler, status post MV replacement, high-pressure-gradient mitral paravalvular leakage (arrow) was present

Fig. 4.4  3D TEE image, en face view, status post MV replacement, showed a tear (arrows) is around the mechanical prosthetic mitral annulus (*) from 9 o’clock position to 12 o’clock position (Video 4.3)

Fig. 4.5  3D TEE color Doppler, en face view, status post MV replacement, showed severe mitral paravalvular leakage jet (arrows) (Video 4.4)

4.1  Paravalvlular Leakage of Mitral Prosthesis

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Fig. 4.6  3D TEE color Doppler image, en face view, after cropping down toward MV, showed the origin of the mitral paravalvular leakage (arrows)

Fig. 4.7  Multi-planar reconstruction (MPR) of 3D TEE image, showed the origin of the paravalvular leakage is a crescent-shape orifice which area is 2.6 cm2

4  Prosthetic Valves

80

Figs. 4.8 and 4.9  2D TEE color Doppler, long-axis view, status post redo MV replacement with mechanical valve, showed mild MR (arrow) in systole (left) and normal mitral inflow in diastole (right)

Figs. 4.10 and 4.11  3D TEE image, en face view, status post redo MV replacement (MVR) with mechanical valve, showed normal prosthesis function with cardiac cycle

cc Tips  MV replacement may be complicated by post-operative dehiscence of the valve or annuloplasty ring resulting in clinically significant MR or hemolysis. Real time 3D TEE provides valuable information about the exact anatomic characteristics of the dehiscence. 

4.2 Mitral Prosthesis Dysfunction Having Valve in Valve Replacement A 63-year-old woman had CABGx1 (LAD) and tissue MV replacement 2 years ago. But she suffered dyspnea on exertion and exercise intolerance recurrently. Auscultation: regular heart beat with a systolic murmur over apex and axillary area. ECG: 1 AV block, ST depression which possible indicated myocardial ischemia. Chest X ray: cardiomegaly. Cardiac catheterization: severe MR. Treatment: transcatheter mitral valve in valve replacement (Figs. 4.12, 4.13, 4.14, 4.15, 4.16, 4.17, 4.18, 4.19, 4.20, 4.21, and 4.22).

4.2  Mitral Prosthesis Dysfunction Having Valve in Valve Replacement

Fig. 4.12 Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, status post tissue MV replacement, showed mitral prosthesis dysfunction (arrow) and dilated LA (Video 4.5)

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Fig. 4.13  2D TEE color Doppler, long-axis view, status post tissue MV replacement, showed severe MR (arrow) due to mitral prosthesis dysfunction (Video 4.6)

Fig. 4.14  2D TEE continuous-wave Doppler, status post tissue MV replacement, high pressure gradient MR (arrow) was present

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Fig. 4.15  3D TEE image, en face view, status post tissue MV replacement, showed one of the leaflets is fixed (*) (Video 4.7)

4  Prosthetic Valves

Fig. 4.17  3D TEE, zoom view, during the transcatheter mitral valve in valve replacement, showed the guiding catheter (*) crossed MV (Video 4.9)

Fig. 4.18  2D TEE image, long-axis view, status post re-do tissue mitral valve in valve replacement, showed good mitral prosthesis function Fig. 4.16  3D TEE color Doppler, long-axis view, status post tissue MV replacement, showed severe MR (arrow) due to mitral prosthesis dysfunction (Video 4.8)

4.2  Mitral Prosthesis Dysfunction Having Valve in Valve Replacement

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Fig. 4.19  2D TEE continuous-wave Doppler, status post mitral valve in valve replacement, showed normal mitral inflow pattern (arrow)

Figs. 4.20 and 4.21  3D TEE image, en face view, status post mitral valve in valve replacement, showed the new prosthetic mitral annulus (*) is within the old one (o), normal mitral prosthesis function with cardiac cycle (Video 4.10)

4  Prosthetic Valves

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Fig. 4.22  3D TEE color Doppler, status post mitral valve in valve replacement, showed smooth mitral inflow (Video 4.11)

Fig. 4.23 Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, status post tissue aortic and mitral valve replacement, showed aortic prosthesis failure with aortic stenosis (arrows) and dilated LA (Video 4.12)

cc Tips  Patients need MV reoperations due to prosthetic dysfunction is a high-risk population. Transcatheter techniques may reduce the morbidity and mortality. 

4.3 Aortic Prosthetic Stenosis Having Transcatheter Aortic Valve Implantation A 61-year-old woman had bovine AV and MV replacement, TV repair and atrial fibrillation ablation 4 years ago. She suffered from exertional dyspnea recently. Auscultation: regular heart beat with a grade 2/6 systolic murmur over apex. ECG: atrial fibrillation with moderate ventricular response and right bundle branch block. Chest X ray: cardiomegaly. Contrast-enhanced chest CT: marked cardiomegaly, atherosclerosis of aorta and enlarged both thyroid glands. Treatment: transcatheter aortic valve implantation (TAVI) and temporal pacemaker implantation (Figs. 4.23, 4.24, 4.25, 4.26, 4.27, 4.28, 4.29, 4.30, 4.31, 4.32, 4.33, 4.34, and 4.35).

Fig. 4.24  2D TEE color Doppler, long-axis view, status post tissue aortic and mitral valve replacement, showed flow acceleration (arrow) across the aortic prosthesis (Video 4.13)

Fig. 4.25  3D TEE image, en face view, status post tissue aortic and mitral valve replacement, showed aortic prosthetic stenosis (Video 4.14)

4.3  Aortic Prosthetic Stenosis Having Transcatheter Aortic Valve Implantation

Fig. 4.26  3D TEE image, long-axis view, status post tissue aortic and mitral valve replacement, showed aortic prosthetic valve stenosis plus stent creep (arrows) (Video 4.15)

Fig. 4.27  3D TEE color Doppler, long-axis view, status post tissue aortic and mitral valve replacement, showed flow acceleration (arrow) across the aortic prosthesis (Video 4.16)

Fig. 4.28  2D TEE color Doppler showed a small PFO (arrow) with left to right shunt (Video 4.17)

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Fig. 4.29  3D TEE color Doppler showed a small PFO (arrow) with left to right shunt (Video 4.18)

Fig. 4.30  2D TEE image, long-axis view, during the TAVI procedure, showed the guiding catheter (arrows) crossed the stenosis aortic prosthesis

Fig. 4.31  3D TEE image, long-axis view, during the TAVI procedure, showed the guiding catheter (arrows) crossed the stenosis aortic prosthesis (Video 4.19)

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4  Prosthetic Valves

Fig. 4.32  2D TEE image, long-axis view, status post TAVI, showed the core valve (arrows) was opened to replace the stenosis one Fig. 4.35  3D TEE color Doppler, long- axis view, status post TAVI, showed normal flow within the core valve (arrows) (Video 4.21)

cc Tips  Failure of a bioprosthetic valve usually is a result of progressive tissue degeneration or stent creep. Fibrocalcific changes of the leaflets induce restrictive opening as prosthetic valve stenosis. Transcatheter valve in valve implantation is a reproducible option for the management of bioprothetic valve failure.  Fig. 4.33  2D TEE color Doppler, long-axis view, status post TAVI, showed normal flow within the core valve (arrows)

4.4 Mitral Valve Repair with Dehiscence of Annuloplasty Ring A 69-year-old male with past history of COPD, TVD s/p PTCA/stent to LAD AP and severe MR suffered chest tightness and dyspnea on exertion for weeks. EKG: sinus rhythm. Chest X ray: Borderline heart size. Operation: CABG and MV repair (Figs.  4.36, 4.37, 4.38, 4.39, 4.40, 4.41, and 4.42).

Fig. 4.34  3D TEE image, long-axis view, status post TAVI, showed the core valve (arrows) in ascending aorta (Video 4.20)

4.4  Mitral Valve Repair with Dehiscence of Annuloplasty Ring

87

Fig. 4.39  3D TEE Color Doppler, en face view, revealing mitral regurgitation and prolapse of P2 (*) (Video 4.25) Fig. 4.36 Two-dimensional transesophageal echocardiography (2-D TEE) image demonstrating Posterior Mitral Leaflet (PML) prolapse (Video 4.22)

Fig. 4.40  Immediately after heart started contracting, 2D TEE in two chamber view, status post MV repair showing significant mitral regurgitation (arrow) (Video 4.26) Fig. 4.37  2D TEE color Doppler showing severe mitral regurgitation (arrow) (Video 4.23)

Fig. 4.38  Three-dimensional transesophageal echocardiography (3-D TEE) image, en face view, showing prolapse of PML (*) (Video 4.24)

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Fig. 4.41  3D TEE image revealing significant ring dehiscence (arrow) in en face view (left). 3D TEE Color Doppler showing severe mitral regurgitation (right) (Videos 4.27 and 4.28)

Fig. 4.42  TrueVue photo-realistic 3D TEE demonstrating mitral ring dehiscence (arrow) (Videos 4.29 and 4.30)

4.5 Mitral Valve Replacement Dysfunction Having Mitral Valve in Valve A 50-year-old female who had history of Rheumatic mitral stenosis with CHF s/p MVR (Porcine valve) +TVA. She suffered from severe nausea, vomit, palpitation and dyspnea.

Cardiac catheterization: insignificant CAD, post MVR with MV dysfunction and severe MR. Operation: s/p Mitral Valve in Valve (SAPIEN XT, 29 mm) (Figs. 4.43, 4.44, 4.45, 4.46, 4.47, 4.48, 4.49, 4.50, and 4.51).

4.5  Mitral Valve Replacement Dysfunction Having Mitral Valve in Valve

Fig. 4.43 Two-dimensional transesophageal echocardiography (2-D TEE) image in long axis view demonstrating flail of anterior leaflet (arrow) and posterior leaflet (Video 4.31)

Fig. 4.44 2D TEE Color Doppler showing mitral regurgitation (arrow) with high velocity mosaic (Video 4.32)

Fig. 4.45  2D TEE showing dilated left atrial appendage without thrombus (*) (Video 4.33)

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Fig. 4.46  Three-dimensional transesophageal echocardiography (3-D TEE) revealing flail of one of the prosthetic leaflet (arrow) (Video 4.34)

Fig. 4.47  Via agitated normal saline injection, it is able to visualize appropriate percutaneous positioning during transapical transcatheter mitral valve in valve (Video 4.35)

Fig. 4.48  2D TEE in long axis view demonstrating the new prosthetic valve locating in the previous prosthetic valve (arrow) (Video 4.36)

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Fig. 4.50  3D TEE image, en face view, showing normal mitral flow in diastole (Video 4.38)

Fig. 4.49  3D TEE, status post SAPIEN valve (red arrow) in previous valve (black arrow) (Video 4.37)

Fig. 4.51  TrueVue 3D TEE demonstrating normal valve in valve from LA view (left) and LV view (right) (Video 4.39)

4.6  Transcatheter Aortic Valve Implantation with Paravalvular Aortic Regurgitation

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4.6 Transcatheter Aortic Valve Implantation with Paravalvular Aortic Regurgitation An 87-year-old male with history of multiple acute ischemic infarctions, right pons, right basal ganglia, and right external capsule. Critical AS and moderate to severe AR with Congestive heart failure s/p TAVI (Edwards Sapien XT, 26  mm). Paroxysmal atrial fibrillation. CAD with three vessel disease s/p CABG.  S/P PPM (DDD). According his family statement, easy falling was noted for times and unstable gait. He was admitted for further survey and management to rule out stroke (Figs.  4.52, 4.53, 4.54, 4.55, 4.56, 4.57, and 4.58).

Fig. 4.52  Two-dimensional Transesophageal Echocardiography (2D TEE) showing dilatation of Ascending Aorta (62 mm) (Video 4.40)

Fig. 4.53  2D TEE, X plane, displaying a gap between Aorta and prosthetic valve (arrow) (Video 4.41)

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Fig. 4.54  2D TEE in X plane showing crescent-shape paravalvular leak at 6 o’clock with severe paravalvular regurgitation (arrow) (Video 4.42)

Fig. 4.55  TrueVue 3D TEE displaying a crescent-shape of gap (arrow) (Video 4.43)

4.7  Mitral Valve Replacement with Paravalvular leakage

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Fig. 4.56  Paravalvular leak locating at 6 o’clock (arrow) in 3D TEE and TrueVue 3D TEE (Videos 4.44 and 4.45)

4.7 Mitral Valve Replacement with Paravalvular leakage An 82-year-old male had past history of Hypertrophic obstructive cardiomyopathy and severe mitral regurgitation, s/p MVR (Metallic)+ myectomy of septum over 12 years ago, Complete AV block, s/p Permanent pacemaker implantation. He suffered from DOE and hematuria for months. TEE was performed, which showed Moderate to Severe AR, prosthetic mitral valve with severe paravalvular leakage and moderate TR.  The carFig. 4.57  TrueVue 3D TEE demonstrating severe para- diac catheter was done, which revealed Insignificant valvular leakage through the gap of prosthetic valve CAD. Operation: s/p Re-do MVR (29 mm Tissue) (arrow) (Video 4.46) + Resection of aortic valve cusps + AVR (21 mm SJ tissue) + TVA (Modified DeVega’s method) + Aortaplasty with Bovine pericardium (Figs. 4.59, 4.60, 4.61, 4.62, and 4.63).

Fig. 4.58  TrueVue 3D TEE revealing Aortic plaque in the Aorta (asterisk) (Video 4.47)

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Fig. 4.59 Two-dimensional transesophageal echocardiography (2-D TEE) color Doppler showing severe paravalvular leak (arrow) (Video 4.48)

Fig. 4.60  2D TEE Color Doppler revealing 4–7 o’clock paravalvular leakage (arrow) (Videos 4.49 and 4.50)

Fig. 4.61  TrueVue 3D TEE Color Doppler displaying severe paravalvular leakage from 4 o’clock to 7 o’clock (arrow) (Video 4.51)

Fig. 4.62  2D TEE Color Doppler, long axis view, status post MVR showing normal prosthetic function and mild MR (Video 4.52)

4.8  Dehiscence of Mitral Valve Replacement

Fig. 4.63  2D TEE Color Doppler, en face view, demonstrating normal mitral inflow (Video 4.53)

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Fig. 4.64 Two-dimensional transesophageal echocardiography s(2D TEE) image demonstrating the dehiscence of the prosthetic valve (arrow) (Video 4.54)

4.8 Dehiscence of Mitral Valve Replacement A 64-year-old male with history of hypertension and VHD, s/p tissue MVR under regular medical treatment. In the past few years after the operation, he always felt progressive dyspnea on exertion, symptoms have not improved after treatment. Heart echo revealed severe MR, TR with dehiscence of prosthetic valve. He was admitted for further evaluation and treatment. ECG: atrial fibrillation with moderate ventricular response. Chest X ray: Atherosclerosis of thoracic aorta, Cardiomegaly, Mild infiltration in both lower lobes of lung, S/P median sternotomy post MVR, Pleural thickening over both apices. Operation: s/p Redo MVR (Perimount ME 33  mm)  +  TVA (Edwards MC3 Ring 34  mm), and resection of LA auricle (Figs.  4.64, 4.65, 4.66, 4.67, 4.68, 4.69, and 4.70).

Fig. 4.65  2D TEE Color Doppler showing severe eccentric mitral regurgitation through the dehiscence (arrow) (Video 4.55)

Fig. 4.66  3D TEE en face view revealing the split from 11 o’clock to 1 o’clock (arrow) (Video 4.56)

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Fig. 4.67  TrueVue 3D TEE showing the dehiscence in en face view (arrow) (Video 4.57)

4  Prosthetic Valves

Fig. 4.70  3D TEE Color Doppler en face view showing normal mitral inflow (Video 4.60)

4.9 Tricuspid Valve Replacement Stenosis Having Tricuspid Valve in Valve

Fig. 4.68  TrueVue 3D TEE Color Doppler displaying severe paravalvular leakage from 11 o’clock to 1 o’clock (arrow) (Video 4.58)

Fig. 4.69  2D TEE Color Doppler in long axis view, status post MVR showing normal function of prosthetic tissue valve (Video 4.59)

A 54-year-old female had history of hypertension, VPCs, and Ebstein’s anomaly s/p TVR over 30 years ago. She was relatively stable until months ago when she started to have chest tightness and dyspnea on ordinary activity. Heart echo was performed, severe TS was be told and redo operation was suggested. He was admission for further evaluation and management. Chest X ray: S/P tricuspid valve replacement. Tortuosity of thoracic aorta with cardiomegaly is noticed. ECG: sinus rhythm with first degree AV block, complete right bundle branch block. Operation: s/p Tricuspid Valve in Valve (Figs.  4.71, 4.72, 4.73, 4.74, 4.75, 4.76, 4.77, and 4.78).

4.9  Tricuspid Valve Replacement Stenosis Having Tricuspid Valve in Valve

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Fig. 4.71  Two-dimensional Transesophageal Echocardiography (2D TEE) showing dysfunction of tissue prosthetic tricuspid valve (arrow) (Video 4.61)

Fig. 4.74  TrueVue 3D TEE demonstrating severe stenosis of the tricuspid prosthetic valve (arrow) (Video 4.63)

Fig. 4.72 2D TEE Color Doppler revealing at least moderate valvular regurgitation and mild paravalvular leakage of the tricuspid prosthetic valve in systole (Video 4.62)

Fig. 4.75 3D TEE during TAVI procedure showing catheter across the tricuspid valve (red arrow) (Video 4.64)

Fig. 4.73  2D TEE Color Doppler revealing severe tricuspid stenosis of the tricuspid prosthetic valve in diastole (arrow)

Fig. 4.76  2D TEE Color Doppler, status post TVinV, revealing no valvular regurgitation and mild paravalvular leakage of the new tricuspid prosthetic valve in systole (Video 4.65)

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4  Prosthetic Valves

Fig. 4.77  2D TEE Color Doppler revealing laminar flow through the new tricuspid prosthetic valve in diastole (arrow)

Fig. 4.78  TrueVue 3D TEE, status post Valve in Valve, demonstrating normal function of the new prosthetic valve (Video 4.66)

4.10 S/P MVR Causing LVOT Obstruction A 51-year-old female patient had history of Rheumatic heart disease with Hypertrophic cardiomyopathy, s/p MVR, she suffered from diarrhea, abdominal distention, shortness of breath

for days. CXR showed right pleural effusion. ECG showed Atrial flutter with rapid ventricular response. Cardiac echo showed LVOT obstruction with recurrent MR.  Operation: s/p redo metallic MVR (Figs. 4.79, 4.80, 4.81, 4.82, 4.83, 4.84, 4.85, 4.86, 4.87, 4.88, 4.89, and 4.90).

4.10  S/P MVR Causing LVOT Obstruction

Fig. 4.79  2D Transthoracic Echocardiography showing narrow LVOT due to the pannus formation from the Prosthetic valve (arrowhead) (Video 4.67)

Fig. 4.80  2D Color Doppler Transthoracic Echocardiography displaying mild to moderate aortic regurgitation (arrow) with ring down artifact causing by metallic prosthetic valve (Video 4.68)

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Fig. 4.81  2D TTE modified short axis view revealing the pannus formation from the mitral prosthetic ring (arrowhead) (Video 4.69)

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4  Prosthetic Valves

Fig. 4.82  2D TTE Color Doppler, X-plane view, showing high velocity LVOT flow through the aortic valve during systole (Video 4.70)

Fig. 4.83  2D TTE MPR displaying obstructed LVOT diameter and area

4.10  S/P MVR Causing LVOT Obstruction

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Fig. 4.84  2D Transesophageal echocardiography long axis view demonstrating pannus formation (arrowhead) from the sewing ring of mitral prosthetic valve causing subaortic Aortic Stenosis (Video 4.71)

Fig. 4.85  2D TEE Color Doppler transgastric view showing mosaic flow through the aortic valve (arrow) (Video 4.72)

4  Prosthetic Valves

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Fig. 4.86  2D TEE Power Doppler revealing LVOT obstruction with PG = 90 mmHg

Fig. 4.87  2D TEE status post redo MVR showing normal prosthetic mitral valve (Video 4.73)

Fig. 4.88  2D TEE Color Doppler status post redo MVR demonstrating normal LVOT flow (Video 4.74)

4.11  Transcatheter Aortic Valve Implantation(TAVI) with Paravalvular Leakage Having Occluder

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Fig. 4.89  2D TEE Power Doppler status post redo MVR revealing LVOT PG = 34 mmHg

4.11 Transcatheter Aortic Valve Implantation(TAVI) with Paravalvular Leakage Having Occluder

Fig. 4.90  Intraoperative view of LVOT obstruction causing by the huge pannus formation (arrowhead)

An 80-year-old male patient had history of CAD s/p PTCA, VHD with critical aortic stenosis, Type 2 diabetes mellitus with diet control, Hyperlipidemia, Cardiac arrhythmias with paroxysmal atrial fibrillation. He suffered from dizziness and palpitation intermittent for 1 week. The symptoms got worsen and associated with orthopnea. EKG showed atrial fibrillation with rapid ventricular response. The echocardiogram showed critical aortic stenosis. Operation: TAVR+ Pacemaker implantation (DDDR mode) (Figs. 4.91, 4.92, 4.93, 4.94, 4.95, 4.96, and 4.97).

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Fig. 4.91  Two-dimensional Transesophageal Echocardiography showing x-plane of status post transcatheter aortic valve implantation. Severe calcified annulus and aortic valve was noted (Video 4.75)

Fig. 4.92  2D TEE Color Doppler, long axis view, revealing severe paravalvular leakage (arrow) due to severe calcification of aortic valve (Video 4.76)

Fig. 4.93  3D Glass View Color Doppler showing severe paravalvular aortic regurgitation (arrow) (Video 4.77)

4.11  Transcatheter Aortic Valve Implantation(TAVI) with Paravalvular Leakage Having Occluder

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Fig. 4.94  3D Glass View Color Doppler, en face view, demonstrating paravalvular leakage site (arrow) (Video 4.78)

Fig. 4.95  2D & 3D TEE long axis view showing catheter through the leakage (arrowhead) (Videos 4.79 and 4.80)

Fig. 4.96  2D TEE, long axis view, occluder implantation during pacing rhythm (Video 4.81)

Fig. 4.97  3D TEE Color Doppler revealing occluder (arrowhead) and mild paravalvular aortic regurgitation (Video 4.82)

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Suggested Reading Attizzani GF, Ohno Y, Latib A, et al. Transcatheter aortic valve implantation under angiographic guidance with and without adjunctive transesophageal echocardiography. Am J Cardiol. 2015;116(4):604–11. Bapat V, Asrress KN. Transcatheter valve-in-valve implantation for failing prosthetic valves. Eur Intervent. 2014;10(8):900–2. Bruschi G, De Marco F, Botta L, et  al. Right anterior mini-thoracotomy direct aortic self-expanding transcatheter aortic valve implantation: a single center experience. Int J Cardiol. 2015;181:437–42. Gürsoy OM, Astarcıoğlu MA, Gökdeniz T, et al. Severe mitral paravalvular leakage: echo-morphologic

4  Prosthetic Valves description of 47 patients from real-time three-dimensional transesophageal echocardiography perspective. Anadolu Kardiyol Derg. 2013;13(7):633–40. Lazaro C, Hinojar R, Zamorano JL.  Cardiac imaging in prosthetic paravalvular leaks. Cardiovasc Diagn Ther. 2014;4:307–13. Oyama S, Ohuchi S, Okubo T, Kumagai K.  Usefulness of echocardiography for detecting prosthesic valve dysfunction; report of a case. Kyobu Geka. 2014;67(11):1025–8. Japanese. Ozkan M, Gürsoy OM, Astarcıoğlu MA, et al. Percutaneous closure of paravalvular mitral regurgitation with vascular plug III under the guidance of real-time threedimensional transesophageal echocardiography. Turk Kardiyol Dern Ars. 2012;40(7):632–41.

5

Diseases of the Aorta

Abstract

Abnormalities of the aorta are details in this chapter, which contains aortic root fistula, ruptured sinus of Valsalva, and variants of aortic dissection. The aorta begins at the AV and ends at the bifurcation in abdomen. It can be divided into the aortic root, ascending aorta, aortic arch, descending thoracic aorta, and abdominal aorta. In an aortic dissection patient, a CT angiography must be arranged to collaborate with the TEE assessment to confirm the range of the dissection.

AR. Coronary CT angiography: coronary artery calcium score is 2091, ascending aorta dilatation and three-vessel coronary artery disease with obstructive atherosclerosis. Operation: David’s operation, reconstruction of ascending aorta and CABG x2 (LAD, RCA) (Figs. 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9 and 5.10).

5.1 Dilated Aortic Root Having David’s Operation A 62-year-old man has a longstanding history of gout and hypertension. He suffered orthopnea, progressive shortness of breath and palpitation. Auscultation: regular heart beat with a grade 3 systolic murmur over right sternal border. ECG: sinus rhythm, first degree AV block and early repolarization. Cardiac catheterization: two-vessel coronary artery disease and severe

Fig. 5.1 Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, showed dilated sinus of Valsalva and ascending aorta (Video 5.1)

Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-981-19-6794-8_5. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_5

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Fig. 5.2  2D TEE color Doppler, long-axis view, showed severe AR (arrow) due to sinus of Valsalva dilation (Video 5.2)

5  Diseases of the Aorta

Fig. 5.3  3D TEE image, long-axis view, showed dilated sinus of Valsalva and ascending aorta (Video 5.3)

Figs. 5.4 and 5.5  Multi-planar reconstruction (MPR) of 3D TEE image (left) showed the ascending aorta dilated to 4.72 cm; contrast-enhanced CT image (right) also showed the dilated ascending aorta

5.1  Dilated Aortic Root Having David’s Operation

Fig. 5.6  3D TEE color Doppler, long-axis view, showed severe AR (arrow) due to sinus of valsalva dilation (Video 5.4)

Fig. 5.7  2D TEE, x-plane view, status post David’s operation, showed the artificial graft (arrows)

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Fig. 5.8  2D TEE color Doppler, x-plane view, status post David’s operation, showed mild AR (arrows)

Fig. 5.9  3D TEE color Doppler, en face view of AV, status post David’s operation, showed mild AR (Video 5.5)

Fig. 5.10  Chest X ray, status post David’s operation, showed the artificial graft (arrow) in ascending aorta

5.2  Type A Aortic Dissection

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cc Tips  The type of surgical therapy of an aortic aneurysm depends on the presence of associated lesions of AV, sinus of Valsalva, and sinotubular junction. In brief, the David technique is performed as follows: after excision of the sinuses, the AV is implanted inside a straight Dacron tube in a manner similar to the implantation of an AV homograft. 

5.2 Type A Aortic Dissection A 58-year-old man with hypertension suffered sudden severe chest pain with radiation pain to abdomen and back. Acute type A aortic dissection was told by other hospital, then he was transfer to our hospital for surgical intervention. Auscultation: regular heart beat with a grade 2/6 systolic murmur over ascending aorta. ECG: counter clockwise rotation, non-specific ST-T change. Chest CT: type A aortic dissection from ascending aorta down to all the way extending, left renal artery originating from the false lumen. Operation: emergent reconstruction of ascending aorta, aortic arch and descending aorta, aorto-innominant artery and aorto-left CCA bypass (Figs.  5.11, 5.12, 5.13, 5.14, 5.15, 5.16, 5.17, 5.18 and 5.19).

Fig. 5.11 Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, showed dissection of ascending aorta with a highly mobile intimal flap (arrow) close above AV (Video 5.6)

Figs. 5.12 and 5.13  2D TEE color Doppler, long-axis view, the intimal flap (red arrows) moved back and forth with cardiac cycle. It attached to the AV in diastole (right) causing eccentric AR (yellow arrow) (Video 5.7)

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5  Diseases of the Aorta

Fig. 5.14  2D TEE color Doppler of ascending aorta, short-axis view, showed the intimal flap (arrow) between the true lumen (TL) and the false lumen (FL) Fig. 5.16  3D TEE image showed the intimal flap with a huge irregular tear (arrow) between true lumen (TL) and false lumen (FL) (Video 5.9)

Fig. 5.15  2D TEE color Doppler of ascending aorta, short-axis view, showed blood flow (arrow) from the true lumen (TL) to the false lumen (FL) through the intimal flap tear (Video 5.8) Fig. 5.17  3D TEE image showed the intimal flap with a huge irregular tear (arrows) between true lumen (TL) and false lumen (FL)

5.3  Type A Aortic Dissection Having Bentall Operation

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Figs. 5.18 and 5.19  Contrast-enhanced CT images showed type A aortic dissection from ascending aorta down to all the way extending (arrows)

cc Tips  TEE is an appropriate diagnostic tool for aortic dissection to identify the intimal tear, true lumen, extension of dissection, and potential complications. 

5.3 Type A Aortic Dissection Having Bentall Operation A 62-year-old woman has a history of hypertensive cardiovascular disease, hypothyroidism and type A aortic dissection. She experienced shortness of breath, dyspnea on exertion and chest distress. Auscultation: regular heart beat with a grade 4/6 pan-systolic murmur. ECG: sinus rhythm, left axis deviation and non- specific ST-T change. Chest CT: pericardial effusion and intramural hematoma seen in ascending aorta. Cardiac CT: type A aortic dissection from aortic root (5.7  cm) to distal ascending aorta with mural thrombi in the false lumen and mild pericardial effusion. Operation: Bentall operation (Figs. 5.20, 5.21, 5.22, 5.23, 5.24, 5.25, 5.26, 5.27, 5.28, 5.29, 5.30 and 5.31).

Fig. 5.20  Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, showed dilated aortic root and a dissection flap with tear (arrow) between the true (TL) and false lumen (FL) (Video 5.10)

Fig. 5.21  2D TEE color Doppler, long-axis view, showed blood flow from the true lumen (TL) to the false lumen (FL) through the intimal flap tear (arrow)

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Fig. 5.22  2D TEE color Doppler, x-plane view, showed blood flow from the true lumen (TL) to the false lumen (FL) through the intimal flap tear (arrow) (Video 5.11)

Fig. 5.23  2D TEE color Doppler, long-axis view, showed moderate to severe AR (arrow) due to dilated aortic annulus (Video 5.12)

Fig. 5.24  3D TEE image, long-axis view, showed dilated aortic root and a dissection flap with tear (arrows) (Video 5.13)

5.3  Type A Aortic Dissection Having Bentall Operation

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Fig. 5.25  3D TEE image, en-face view of AV, showed the prominent false lumen (arrow) (Video 5.14) Fig. 5.27  Contrast-enhanced CT image showed type A aortic dissection with flap tear (arrow) in aortic root

Fig. 5.26  3D TEE color Doppler, long-axis view, showed blood flow (arrow) from the true lumen (TL) to the false lumen (FL) through the intimal flap tear (Video 5.15)

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Fig. 5.28  2D TEE image, x-plane view, status post Bentall operation, showed the tissue AV prosthesis (yellow arrow) and the artificial graft (red arrows)

Fig. 5.29  3D TEE image, long-axis view, status post Bentall operation, showed the artificial graft (arrows) (Video 5.16)

Fig. 5.30  3D TEE color Doppler, long- axis view, status post Bentall operation, showed normal LV outflow and no AR (Video 5.17)

5.4  Type A Aortic Dissection with Intramural Hematoma

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Fig. 5.32  Two-dimensional transesophageal echocardiography (2D TEE) image, long-axis view, showed a dissection flap (red arrow) and an intramural hematoma (yellow arrows) in ascending aorta (Video 5.19) Fig. 5.31  3D TEE color Doppler, en face view of AV, status post Bentall operation, showed normal LV outflow and no AR (Video 5.18)

cc Tips  If an aortic dissection is associated with AV disease, which needs repair or replacement, Benetall operation is appropriate to replace the AV along with the ascending aorta. The indication of Bentall operation is the procedure of AV dysfunction severe enough to warrant AV replacement, the aortic root will be replaced if the ascending aorta exceeded by 4.0–4.5 cm in diameter, and the patients’ life expectancy is anticipated to be greater than 10 years. 

Fig. 5.33  2D TEE image, short-axis view, showed a crescent-shape intramural hematoma (arrows) in ascending aorta (Video 5.20)

5.4 Type A Aortic Dissection with Intramural Hematoma A 61-year-old man with medical-controlled hypertension suffered from chest pain and tightness. Auscultation: no significant murmur. ECG: sinus rhythm, LA enlargement and non-specific ST-T change. Chest CT angiography: type A aortic dissection from ascending aorta to aortic arch, atherosclerotic calcification of the thoracic aorta and coronary arteries, cardiomegaly, pericardial effusion and left pleural effusion. Operation: emergency aortic reconstruction (Figs.  5.32, 5.33, 5.34, 5.35, 5.36, 5.37, 5.38 and 5.39).

Fig. 5.34  2D TEE color Doppler, long-axis view, showed mild to moderate AR (arrow)

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Fig. 5.35  3D TEE image, long-axis view, showed an intramural hematoma (arrows) in ascending aorta (Video 5.21)

Fig. 5.36  3D TEE image, en face view of AV, showed an intramural hematoma (arrows) in ascending aorta (Video 5.22)

5  Diseases of the Aorta

Fig. 5.37  3D TEE color Doppler, long-axis view, showed mild to moderate AR (arrow) (Video 5.23)

Fig. 5.38  Contrast-enhanced CT image showed type A aortic dissection with intimal flap between the true (TL) and false lumen and thrombus (*) in false lumen

5.5  Type B Aortic Dissection from Distal Aortic Arch

Fig. 5.39  Chest X ray, status post aortic reconstruction, showed the artificial grafts (arrows) in ascending aorta and aortic arch

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Fig. 5.40  Three-dimensional transesophageal echocardiography (3D TEE) of descending thoracic aorta, shortaxis view, showed the intimal flap with tear (arrow) between the true lumen (TL) and the false lumen (FL) (Video 5.24)

cc Tips  Intramural hematoma is a variant of aortic dissection and appears as a circumferential or crescent-shape thickening of the aortic wall on ascending aorta short axis view. 

5.5 Type B Aortic Dissection from Distal Aortic Arch A 50-year-old man had a history of hypertension, type two diabetes mellitus and hyperlipidemia. He suffered from sudden onset lower back pain. Type B aortic dissection was found and medical treatment was given, but the symptoms worsen. Auscultation: regular heart beat without murmur. ECG: sinus rhythm and counter clockwise rotation. Thoracic and abdominal aorta CT angiography: type B aortic dissection from distal aortic arch, thoracic and abdominal aorta to bilateral common iliac arteries and SMA.  Operation: reconstruction of distal aortic arch and upper thoracic aorta (Figs.  5.40, 5.41, 5.42, 5.43, 5.44, 5.45, 5.46 and 5.47).

Fig. 5.41  3D TEE color Doppler of descending thoracic aorta, short-axis view, showed blood flow from the true lumen (TL) to the false lumen (FL) through the intimal flap tear (arrow) (Video 5.25)

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Figs. 5.42 and 5.43 Contrastenhanced CT images showed type B aortic dissection (arrows) from distal aortic arch, thoracic and abdominal aorta to bilateral common iliac arteries and SMA (Video 5.26)

Fig. 5.44  2D TEE color Doppler of descending aorta, x-plane view, status post aortic reconstruction, showed flow within the artificial graft (arrows)

5.6  Type B Aortic Dissection from Middle Descending Aorta

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cc Tips  In the Stanford classification, type A aortic dissections refers to involvement of the ascending part of the aorta and any extension into other aortic sections, whereas type B refers to dissection involving the descending aorta with distal to the left subclavian artery. 

5.6 Type B Aortic Dissection from Middle Descending Aorta

Fig. 5.45  3D TEE of descending aorta, long-axis view, status post aortic reconstruction, showed the artificial graft (arrows) (Video 5.27)

A 65-year-old man has a history of type B dissection status post right renal artery bypass graft, PAOD status post PTA, single-vessel coronary artery disease, type two diabetes mellitus, hyperlipidemia, hypertension and hyperuricemia. He suffered from sudden severe chest pain with radiation pain to the back, dizziness, general fatigue and cold sweating. Auscultation: RHB.  EKG: sinus rhythm and left axis deviation. CT: type B aortic dissection, dissection extended from proximal portion of the descending aorta to lower abdominal aorta and right renal artery, lower abdominal aorta stenosis. Operation: reconstruction of middle descending thoracic aorta with intraluminal graft (Figs.  5.48, 5.49, 5.50, 5.51, 5.52, 5.53, 5.54 and 5.55).

Fig. 5.46  3D TEE color Doppler of descending aorta, long-axis view, status post aortic reconstruction, showed flow within the artificial graft (arrows) (Video 5.28)

Fig. 5.48 Two-dimensional transesophageal echocardiography (2D TEE) image of descending aorta, longaxis view, showed the intimal flap with tear (arrow) between the true lumen (TL) and the false lumen (FL) (Video 5.29) Fig. 5.47  Non-contrast-enhanced CT images, status post aortic reconstruction, showed artificial graft (arrow) in distal aortic arch

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Fig. 5.49  2D TEE color Doppler of descending aorta, long-axis view, showed blood flow (arrow) from the true lumen (TL) to the false lumen (FL) through the intimal flap tear (Video 5.30)

5  Diseases of the Aorta

Fig. 5.51  3D TEE color Doppler of descending aorta, long-axis view, showed blood flow from the true lumen (TL) to the false lumen (FL) through the intimal flap tear (arrow) (Video 5.32)

Fig. 5.50  3D TEE image of descending aorta, long-axis view, showed the intimal flap with tear (arrow) between the true lumen (TL) and the false lumen (FL) (Video 5.31)

Fig. 5.52  2D TEE color Doppler of descending aorta, x-plane view, status post aortic reconstruction, showed flow within the artificial graft (arrows)

5.6  Type B Aortic Dissection from Middle Descending Aorta

Fig. 5.53 Preoperative contrast-enhanced CT image showed type B aortic dissection from proximal portion of the descending aorta to lower abdominal aorta and intimal flap tear at descending aorta (arrow)

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Fig. 5.54  Contrast-enhanced CT image, status post aortic reconstruction, showed artificial grafts (arrows) in descending aorta

Fig. 5.55  Picture during operation showed an artificial graft in descending aorta

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cc Tips  In aortic dissection, the great vessel is divided into true lumen and false lumen by intimal flap. The false lumen is typically larger than the true lumen. 

5.7 Aorta-to-Left Ventricular Fistula Having Occluder Implantation

5  Diseases of the Aorta

aorta to LV and symptoms of shortness of breath and dyspnea on exertion. Auscultation: regular heart beat with a grade 2/6 low-pitched continuous murmur over left sternal border. ECG: first degree AV block. Cardiac catheterization: sinus of Valsalva aneurysm with an aorta to LV fistula and moderate amount shunt. Treatment: occluder implantation (Figs.  5.56, 5.57, 5.58, 5.59, 5.60, 5.61, 5.62, 5.63, 5.64 and 5.65).

A 54-year-old man had a history of bicuspid AV with infective endocarditis status post AV replacement. He presented with a residual shunt from

Fig. 5.56  Two-dimensional transesophageal echocardiography (2D TEE) color Doppler, x-plane view, status post tissue AV replacement, showed an aorta-to-LV fistula with moderate amount shunts (arrows) (Video 5.33)

Fig. 5.57  3D TEE image, long-axis view, showed dehiscence of the AV replacement. An echolucent space (arrow) was seen posterior to the prosthetic aortic annulus (Video 5.34)

Fig. 5.58  3D TEE color Doppler, long-axis view, showed dehiscence of the AV replacement. An echolucent space (red arrow) was seen posterior to the prosthetic aortic annulus with continuous flow (yellow arrow) from aorta to LV (Video 5.35)

5.7  Aorta-to-Left Ventricular Fistula Having Occluder Implantation

Fig. 5.59 3D TEE image, long-axis view, during occluder implantation, showed the guiding catheter (*) crossed the fistula from aorta to LV (Video 5.36)

Fig. 5.60  2D TEE image, long-axis view, during the procedure, showed the occluder (*) was deployed to occlude the fistula

Fig. 5.61  2D TEE color Doppler, long-axis view, status post occluder (*) implantation, showed only trivial residual shunt

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Fig. 5.62  3D TEE image, long-axis view, status post occluder (*) implantation (Video 5.37)

Fig. 5.63  3D TEE image, viewed from LV perspective, status post occluder (arrow) implantation (Video 5.38)

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5.8 Aortic Pseudoaneurysm Having Occluder Implantation

Fig. 5.64  3D TEE color Doppler, long-axis view, status post occluder (*) implantation, showed only trivial residual shunt (Video 5.39)

A 58-year-old man had a past history of coronary artery disease status post coronary artery bypass graft, valvular disease status post AV replacement and MV repair, chronic atrial fibrillation status post ablation, PFO status post closure and hypertension under medical treatment. He suffered from shortness of breath for a month then a giant ascending aortic pseudoaneurysm was diagnosed. Auscultation: regular heart beat without murmur. ECG: normal sinus rhythm and left axis deviation. Chest X ray: cardiomegaly and enlarged ascending aorta. Cardiac CT angiography: giant ascending aortic aneurysm (7.23 cm × 9.77 cm) and pseudoaneurysm formation with a small hole about 1  cm connected between the true lumen and the false lumen. Treatment: occluder implantation (Figs.  5.66, 5.67, 5.68, 5.69, 5.70, 5.71, 5.72, 5.73, 5.74 and 5.75).

Fig. 5.65  Fluoroscopy status post occluder implantation, showed the deployed occluder (arrows)

cc Tips  The patient had received a bioprosthetic AV followed by a formation of an aorta-to-LV fistula. It may be caused by an episode of endocarditis, but the blood culture test of this patient is negative. 

Fig. 5.66 Two-dimensional transesophageal echocardiography (2D TEE), long-axis view, status post tissue AV replacement (AVR), showed dilated ascending aorta (arrow) with a thrombus (TH) wrapped pseudoaneurysm (*) (Video 5.40)

5.8  Aortic Pseudoaneurysm Having Occluder Implantation

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Fig. 5.67  2D TEE color Doppler, long-axis view, status post tissue AV replacement, showed a flow (arrow) from aorta to the pseudoaneurysm (Video 5.41) Fig. 5.69  3D TEE color Doppler, long-axis view, status post tissue AV replacement, showed a thrombus (TH) wrapped pseudoaneurysmat in proximal ascending aorta with flow (arrow) across the communication (Video 5.43)

Fig. 5.68  3D TEE, long-axis view, status post tissue AV replacement, showed a thrombus (TH) wrapped pseudoaneurysm (*) at proximal ascending aorta (Video 5.42)

Fig. 5.70  3D TEE, viewed from ascending aorta perspective, showed the communication (arrow) between ascending and the pseudoaneurysm

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Fig. 5.71  Contrast-enhanced CT image showed a giant ascending aortic aneurysm (7.23 cm × 9.77 cm) and pseudoaneurysm formation with a small hole about 1 cm connected between the true lumen and the false lumen

5  Diseases of the Aorta

Fig. 5.73  3D TEE, long-axis view, during the procedure, showed the occluder (*) was deployed to occlude the communication between ascending aorta and the pseudoaneurysm (Video 5.45)

Fig. 5.72 2D TEE, long-axis view, during occluder implantation, showed the guiding catheter (arrows) crossed the communication from aorta to pseudoaneurysm (*) (Video 5.44) Fig. 5.74  3D TEE color Doppler, long-axis view, status post occluder (*) implantation, showed only trivial residual shunt (Video 5.46)

5.9  Ruptured Sinus of Valsalva Aneurysm Having Occluder Implantation

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Fig. 5.76  Two-dimensional transesophageal echocardiogram (2D TEE) image, short-axis view, showed a sinus of Valsalva aneurysm (*), which is a “wind sock”-like membranous outpouching of NCC protruded into RA

Fig. 5.75  Chest X ray, status post occluder implantation, showed the deployed occluder (arrows) (Video 5.47)

cc Tips  An aortic pseudoaneurysm is different from an aneurysm. The previous contains rupture of aortic wall that involves all the layers. 

5.9 Ruptured Sinus of Valsalva Aneurysm Having Occluder Implantation

Fig. 5.77 2D TEE color Doppler, short-axis view, showed mosaic-pattern flow (arrow) crossed the ruptured sinus of Valsalva aneurysm (Video 5.48)

A 29-year-old woman was in good health before. She suffered from chest tightness and exertional dyspnea. Auscultation: regular heart beat a with grade 3/6 systolic murmur over left sternal border. ECG: normal sinus rhythm. Treatment: occluder to block the shunt (Figs.  5.76, 5.77, 5.78, 5.79, 5.80, 5.81, 5.82, 5.83, 5.84 and 5.85).

Fig. 5.78  3D TEE image, short-axis view, showed a sinus of Valsalva aneurysm (*) of NCC protruded into RA (Video 5.49)

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Fig. 5.79  3D TEE image, viewed from RA perspective, showed a rupture (arrow) of sinus Valsalva aneurysm (Video 5.50)

Fig. 5.80 3D TEE color Doppler, short-axis view, showed an aorta-to-RA shunt (arrow) through the ruptured sinus of Valsalva aneurysm (Video 5.51)

5  Diseases of the Aorta

Fig. 5.81  Fluoroscopy showed ruptured sinus Valsalva aneurysm with an insignificant shunt (arrow)

Fig. 5.82  2D TEE color Doppler, short-axis view, during occluder implantation, showed the guiding catheter (arrows) crossed the rupture of sinus Valsalva aneurysm from aorta to RA

5.10  Descending Aorta to Left Lower Pulmonary Vein (LLPV) Fistula Having Thoracic Endovascular Aortic… 131

Fig. 5.83  3D TEE image, short-axis view, during the procedure, showed the guiding catheter (*) crossed the rupture of sinus Valsalva aneurysm from aorta to RA (Video 5.52)

Fig. 5.85  3D TEE image, short-axis view, status post occluder (*) implantation, showed no residual shunt (Video 5.54)

cc Tips  Isolated sinus of Valsalvs aneurysm may be congenital or from trauma, endocarditis, Marfan syndrome, or syphilis. A percutaneous approach to repair sinus of Valsalva rupture may be an alternative strategy. 

5.10 Descending Aorta to Left Lower Pulmonary Vein (LLPV) Fistula Having Thoracic Endovascular Aortic Repair (TEVAR) Fig. 5.84  3D TEE image, short-axis view, status post occluder implantation, showed the occluder (*) block the aorta-to-RA fistula (Video 5.53)

A 43-year-old female suffered from intermittent dizziness and chest tightness since 5  years ago, the symptoms got deteriorated in recent 2 years. Chest X ray: Likely tortuous dilated vessels are seen superimposed on medial segment of LLL, rule out vascular malformation. Contrast Chest CT: an abnormal arteriovenous fistula from descending thoracic aorta to left lower pulmonary vein was present. Operation: Repair of Descending aorta to LLPV fistula with TEVAR (Figs.  5.86, 5.87, 5.88, 5.89, 5.90, 5.91, 5.92, 5.93 and 5.94).

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Fig. 5.86  2D TEE revealing abnormal fistula connecting Descending Aorta and Left Lower Pulmonary Vein(arrow) (Video 5.55) Fig. 5.89  Aortic angiography revealing the anomalous systemic artery arising from aorta and reaching the LLPV (Video 5.58)

Fig. 5.87  3D TEE showing aberrant connects between Descending Aorta and LLPV (Video 5.56)

Fig. 5.90  Thoracic Endovascular Aortic Repair(TEVAR) was performed. No more abnormal flow was seen (Video 5.59)

Fig. 5.88 CT angiography in 3D reconstruction, an abnormal communication originating from thoracic aorta and draining into LLPV (Video 5.57)

5.11  Type A Dissection Having Reconstruction

Fig. 5.91  Transthoracic Echocardiography in parasternal long axis view revealing dilated pulmonary venous connecting with Descending Aorta(arrow)

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Fig. 5.94  Post procedure showing a complete occlusion between Descending Aorta and LLPV (Video 5.61)

5.11 Type A Dissection Having Reconstruction

Fig. 5.92  Transthoracic Echocardiography in parasternal long axis view after TEVAR showing the ligated graft obstructing the fistula(arrow)

Fig. 5.93 Stent-graft was seen between Descending Aorta and LLPV(arrow) (Video 5.60)

A 54-year-old woman denied any major systemic disease. She suffered from Chest tightness, palpitation, back pain, dyspnea and arm numbness since 3 days ago. ECG: Sinus rhythm. Chest CT: Aortic dissection with double lumen from the ascending aorta, aortic arch, descending aorta, abdominal aorta to right common iliac artery. Moderate amount of pleural effusion, bilateral. Pericardial effusion. Operation: S/P Emergency reconstruction of ascending aorta from arch to DTA. Aorto-innominate and aorto-LCCA arterial bypass. LCCA-LSCA translocation (Figs.  5.95, 5.96, 5.97, 5.98, 5.99 and 5.100).

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Fig. 5.95  Two-dimensional transesophageal echocardiography (2D TEE) image, showing intimal flap(arrow) retrograde to Sinotubular Junction (Video 5.62)

Fig. 5.96 2-D TEE color Doppler revealing blood flow(arrow) from the true lumen(TL) to the false lumen(FL) through the intimal flap tear (Video 5.63)

Fig. 5.97  Three-dimensional transesophageal echocardiography (3D TEE) image showing true and false lumen with tear(arrow) in dilated ascending aorta (Video 5.64)

5  Diseases of the Aorta

Fig. 5.98  TrueVue 3D TEE displaying tear of intimal flap (Video 5.65)

Fig. 5.99  3D TEE Color Doppler showing blood flow entering from true lumen to false lumen(arrow) (Video 5.66)

Fig. 5.100  TrueVue 3D TEE demonstrating blood flow from true lumen (TL) to false lumen(FL) through intimal medial rupture (Video 5.67)

5.11  Type A Dissection Having Reconstruction

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5.12 Type A Dissection with Severe Aortic Regurgitation A 56-year-old male had history of Hyperuricemia, HCVD and Aortic dissection under medical control. Chest CT without and with contrast injection was performed and revealed intimal flap from the aortic arch to the right common iliac artery with the left renal artery from the false lumen, consistent with the Stanford type B aortic dissection. A suspicious cord in the ascending thoracic aorta. D/D intraluminal fibrous cord or aortic dissection and suggest clinical correlation. Transthoracic Echocardiography showed severe aortic valve regurgitation and Type A aortic dissection with Intimal flap seen in ascending aorta, descending aorta & abdomen aorta. Surgical intervention was suggested and he was admitted for further survey and management. Operation: s/p CABG × 2 (re-implantation of LM & RCA) + AVR (21 mm St Jude metallic valve +22  mm woven Dacron Valsalva valve conduit)  +  Reconstruction of ascending aorta and debranching of aortic vessels (Figs. 5.101, 5.102, 5.103, 5.104 and 5.105).

Fig. 5.102  2D TEE Color Doppler demonstrating severe aortic regurgitation(arrow) with aortic root dilatation (Video 5.69)

Fig. 5.103  2D TEE in descending aorta revealing the thrombus formation in false lumen (Video 5.70)

Fig. 5.101  Two-dimensional Transesophageal Echocardiography (2D TEE) showing a part of the intimal flap(arrow) from aortic root (Video 5.68) Fig. 5.104  2D TEE Color Doppler showing the blood flow across the tear of the intimal flap at descending aorta(arrow) (Video 5.71)

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Fig. 5.105  TrueVue 3D TEE, the view from ascending to aortic valve, revealing the intimal flap separating the true lumen and false lumen (arrow) (Video 5.72)

Suggested Reading Ashoub A, Tang A, Shaktawat S.  Extensive aneurysms of sinuses of Valsalva precluding valve sparing aortic root reimplantation (David procedure). Interact Cardiovasc Thorac Surg. 2011;12(3):500–1. Benedik J, Wendt D, Perrey M, et al. Adjustment of aortic annulus size during David re-implantation (how to do it). Scand Cardiovasc J. 2013;47(4):245–6. Brinster DR, Parrish DW, Meyers KS, et al. Central aortic cannulation for Stanford type a aortic dissection with the use of three-dimensional and two-dimensional transesophageal echocardiography. J Card Surg. 2014;29(5):729–32. Cao X, Zhang F, Wang L, Jing H, Li N.  Transthoracic minimally invasive closure for the treatment of ruptured sinus of Valsalva aneurysm: a case report. J Cardiothorac Surg. 2014;9:27. Červenka L, Melenovský V, Husková Z, et al. Inhibition of soluble epoxide hydrolase does not improve the course of congestive heart failure and the development of renal dysfunction in rats with volume overload induced by aorto-caval fistula. Physiol Res. 2015;64:857–73. Fujita A, Kurazumi H, Suzuki R, et  al. Aortic archdescending aorta bypass for intraoperative lower body malperfusion during chronic type a aortic dissection repair. Kyobu Geka. 2015;68(6):435–8. Japanese Gomero-Cure W, Lowery RC, O’Donnell S. Stent graftinduced new entry tear after endoluminal grafting for aortic dissection repaired with open interposition graft. J Vasc Surg. 2013;58(6):1652–6. Hashimoto K, Itoh S, Tajima Y, et  al. Distal aortic arch aneurysm, acute type B aortic dissection, and acute

5  Diseases of the Aorta bilateral limb ischemia treated by two-stage total arch replacement;report of a case. Kyobu Geka. 2015;68(5):371–4. Japanese İlkay E, Çelebi ÖÖ, Kaçmaz F, Pampal K.  Retrograde approach for percutaneous closure in a patient with ruptured sinus of Valsalva. Turk Kardiyol Dern Ars. 2014;42(8):759–62. Itoga NK, Kakazu CZ, White RA. Enhanced visual clarity of intimal tear using real-time 3D transesophageal echocardiography during TEVAR of a type B dissection. J Endovasc Ther. 2013;20(2):221–2. Kassaian SE, Abbasi K, Mousavi M, Sahebjam M.  Endovascular treatment of acute type B dissection complicating aortic coarctation. Tex Heart Inst J. 2013;40(2):176–81. Kieser TM, Spence FP, Kowalewski R. Iatrogenic aortic root and left main dissection during non-emergency coronary surgery: a solution applicable to heavily calcified coronary arteries. Interact Cardiovasc Thorac Surg. 2015;22:246–8. Lin CH, Murphy J, Balzer DT.  Case report: percutaneous closure of an ascending aortic pseudoaneurysm by 3D angiography guidance. Methodist Debakey Cardiovasc J. 2015;11(2):137–9. Marjanović I, Sarac M, Tomić A, et  al. Visceral hybrid reconstruction of thoracoabdominal aortic aneurysm after open repair of type A aortic dissection by the Bentall procedure with the elephant trunk technique— a case report. Vojnosanit Pregl. 2014;71(9):879–83. Michel S, Hagl C, Juchem G, Sodian R. Type a intramural hematoma often turns out to be a type a dissection. Heart Surg Forum. 2013;16(6):E351–2. Rajan S, Sonny A, Sale S.  Retrograde type a aortic dissection after thoracoabdominal aneurysm repair: early diagnosis with intraoperative transesophageal echocardiography. A A Case Rep. 2015;4(5):58–60. Rossokha OA, Shelestova IA, Boldyrev SI, et  al. Detection of determinants of functional aortic regurgitation in patients with ascending aorta aneurism by transesophagea1 echocardioscopy. Kardiologiia. 2015;55(3):61–6. Russian Sabzi F, Khosravi D.  Huge dissected ascending aorta associated with pseudo aneurysm and aortic coarctation feridoun. Acta Med Iran. 2015;53(7):444–7. Stiver K, Bayram M, Orsinelli D. Aortic root bentall graft disarticulation following repair of type a aortic dissection. Echocardiography. 2010;27(2):E27–9. Thorsgard ME, Morrissette GJ, Sun B, et  al. Impact of intraoperative transesophageal echocardiography on acute type a aortic dissection. J Cardiothorac Vasc Anesth. 2014;28(5):1203–7. Tourmousoglou C, Meineri M, Feindel C, Brister S. Repair of aorto-left ventricular and aorto-right ventricular fistulas following prosthetic valve endocarditis. J Card Surg. 2013;28(6):654–9.

6

Coronary Artery Diseases

Abstract

This chapter, Coronary Artery Disease, covers ischemic MR, LV apex akinesis having Dor’s procedure, and a post myocardial infarction VSD. Complications of myocardial infarction must be aware of besides the wall motion. When evaluating ventricular function in the perioperative period, changes in preload, pacing, respiration, and performance are dynamic and are affected significantly by the physiologic changes.

grade 3 murmur over apex. ECG: sinus rhythm, first degree AV block, clockwise rotation and non-specific ST-T change. Chest X ray: cardiomegaly with LV enlargement. Operation: CABG x4 (LIMA to diagonal branch, SVG to LAD, SVG to OM and SVG to RCA) and MV repair (Figs. 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8 and 6.9).

6.1 Ischemic Mitral Regurgitation Having Mitral Repair A 61-year-old man suffered from chest tightness. Triple coronary artery disease with recent myocardial infarction was diagnosed at another hospital. Auscultation: regular heart beat with a

Fig. 6.1 Two-dimensional transesophageal echocardiography (2D TEE), long-axis view, showed a small apical anterior septal aneurysm (yellow arrows) and “sea gull” sign of anterior mitral leaflet (white arrow) which caused by ischemic tethering of leaflet with chordae (Video 6.1)

Supplementary Information The online version contains supplementary material available at https://doi. org/10.1007/978-­981-­19-­6794-­8_6. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_6

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Fig. 6.2  2D TEE color Doppler, long-axis view, showed severe ischemic MR (arrow) (Video 6.2) Fig. 6.5  3D TEE color Doppler, long-axis view, showed severe ischemic MR (Video 6.5)

Fig. 6.3  3D TEE, long-axis view, showed a small apical anterior septal aneurysm (arrows) (Video 6.3)

Fig. 6.4  3D TEE, long-axis view, showed “sea gull” sign of anterior mitral leaflet (arrow) which caused by ischemic tethering of leaflet with chordae (Video 6.4)

Fig. 6.6  2D TEE, long-axis view, status post CABG and MV repair, showed normal MV function

Fig. 6.7  2D TEE color Doppler, long-axis view, status post CABG and MV repair, showed mild MR

6.2 Left Ventricular Apex Akinesis with Thrombus Having Dor Procedure

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showed LAD coronary aneurysm and thrombus impaction. But PTCA and thrombus suction failed. Auscultation: regular heart beat without significant murmur. ECG: sinus rhythm and old anterior wall myocardial infarction with aneurysm formation. Chest CT: dilated cardiac apex and prominent left coronary artery. Operation: CABG x1 (SVG to LAD), Dor procedure and removal of LV thrombus (Figs. 6.10, 6.11, 6.12, 6.13, 6.14, 6.15 and 6.16).

Fig. 6.8  3D TEE, long-axis view, status post CABG and MV repair, the physic ring (arrow) was seen (Video 6.6)

Fig. 6.10 Two-dimensional transesophageal echocardiography (2D TEE), two-chamber view, showed LV apex akinesis with thrombus (arrow) seen (Video 6.8)

Fig. 6.9  3D TEE color Doppler, long-axis view, status post CABG and MV repair, showed mild MR (Video 6.7)

cc Tips  Examination of mitral leaflet, subvalvular apparatus, and ventricular function are all essential to evaluate the etiology of MR. 

6.2 Left Ventricular Apex Akinesis with Thrombus Having Dor Procedure A 24-year-old man with gout suffered from severe chest pain, cold sweating, vomiting and mild dyspnea. Emergent cardiac catheterization

Fig. 6.11  3D TEE, two-chamber view, showed LV apex akinesis with thrombus (arrow) seen (Video 6.9)

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Fig. 6.12  Contrast-enhanced CT, showed dilated LV apex

6  Coronary Artery Diseases

Fig. 6.14  2D TEE, two-chamber view, status post Dor’s procedure, showed patch repair of LV apex (arrows) to reduce the akinetic region therefore increase the ejection fraction

Fig. 6.13  ECG showed old anterior wall myocardial infarction with aneurysm formation

6.3 A Post Myocardial Infarction Ventricular Septal Defect Having Occluder Implantation

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Fig. 6.15  2D TEE color Doppler, x-plane view, status post Dor’s procedure, showed patch repair of LV apex (arrows) to separate the akinetic apex from normal region and increase the stroke volume

Fig. 6.16  3D TEE, two-chamber view, status post Dor’s procedure, showed patch repair at LV apex (arrows) (Video 6.10)

cc Tips  Poor cardiac function will cause blood deposition and increase the possibility of thrombus formation. Understanding of cardiacmuscular segment model helps determine associated coronary abnormalities. 

6.3 A Post Myocardial Infarction Ventricular Septal Defect Having Occluder Implantation The 49-year-old woman denied any systemic history. She suffered from chest tightness, chest distress, shortness of breath and exertional dyspnea

Fig. 6.17 Two-dimensional transesophageal echocardiography (2D TEE), four-chamber view, showed myocardial infarction with LV apical septum akinesis (arrows) (Video 6.11)

recently. Auscultation: irregular heart beat with a holosystolic murmur over apex. ECG: sinus tachycardia, complete right bundle branch block and anterior wall ST elevation myocardial infarction. Chest X ray: cardiomegaly. Cardiac catheterization: dyskinesis of LV apex and hypokinesis of LV anterior wall, moderate to severe LV systolic dysfunction and a ventricular septal defect (VSD). Treatment: VSD occluder implantation and PCI of LAD (Figs.  6.17, 6.18, 6.19, 6.20, 6.21, 6.22, 6.23, 6.24, 6.25, 6.26, 6.27, 6.28, 6.29 and 6.30).

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Fig. 6.18  2D TEE color Doppler, four-chamber view, showed a post myocardial infarction apical VSD with a left to right shunt (arrow) (Video 6.12) Fig. 6.21  3D TEE color Doppler, four-chamber view, showed a post myocardial infarction apical VSD with a left to right shunt (arrow) (Video 6.15)

Fig. 6.19  2D TEE color Doppler, transgastric short-axis view, showed a post myocardial infarction VSD with a left to right shunt (arrow) (Video 6.13)

Fig. 6.20  3D TEE, four-chamber view, showed myocardial infarction with LV apical septum akinesis (arrows) (Video 6.14)

Figs. 6.22 and 6.23 3D TEE color Doppler (above) and color suppressed image (below), viewed from LV perspective, showed the VSD (arrows) at apex (Videos 6.16 and 6.17)

6.3 A Post Myocardial Infarction Ventricular Septal Defect Having Occluder Implantation

Fig. 6.24  ECG showed anterior wall ST elevation myocardial infarction

Fig. 6.25  3D TEE, four-chamber view, during occluder implantation, showed the guiding catheter (*) in LV

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Fig. 6.26  3D TEE, transgastric short-axis view, during the procedure, showed the occluder (*) was deployed to occlude the apical VSD (Video 6.18)

Fig. 6.28 3D TEE, four-chamber view, status post occluder (*) implantation (Video 6.19)

Fig. 6.27 2D TEE, four-chamber view, status post occluder (*) implantation

Fig. 6.29  3D TEE color Doppler, four-chamber view, status post occluder (*) implantation, showed only trivial residual shunt (Video 6.20)

6.4 Right Coronary Artery Pseudotumor

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Fig. 6.31 Intraoperative Two-dimensional Transesophageal Echocardiography(2D TEE) showing a highly echogenicity lesion(arrow) over RA region with right coronary artery entrapped inside (Video 6.21) Fig. 6.30  Fluoroscopy, status post occluder implantation, showed the deployed occluder (*)

cc Tips  VSD in this case is a complication of myocardial infarction. Transgastric view can show the VSD directly assisted by 3-D TEE in determination of the VSD number, size, location, and associated lesions. 

6.4 Right Coronary Artery Pseudotumor A 76-year-old man with past history of asthma, HTN, BPH. He was admitted to lower abdominal colic pain then gastric ulcer and colon ulcer was diagnosed. ECG: sinus rhythm, left ventricular hypertrophy. Chest X ray: tortuous thoracic aorta with calcification of the aortic knob, borderline cardiomegaly, mild peribronchial infiltration in both lower lungs and suggest clinical correlation, a ground glass opacification in the right middle

Fig. 6.32  2D TEE Color Doppler revealing RCA was completely encased by the lesion(asterisk) (Video 6.22)

lung. Chest CT: an enhancing lesion about 4.9  ×  4.6  cm encasing the RCA.  Operation: s/p sternotomy, removal of paracardiac mass and CABG × 1 (SVG to middle RCA). Histological diagnosis: inflammatory pseudotumor (Figs. 6.31, 6.32, 6.33, 6.34, 6.35 and 6.36).

6  Coronary Artery Diseases

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Fig. 6.33  TrueVue 3D TEE, bi-caval view, revealing the round lesion behind the RA causing RA compression(asterisk) (Videos 6.23 and 6.24)

Fig. 6.34  Chest CT showing mediastinal mass involving the RCA without compromising vessel’s patency(asterisk) but causing RA compression (Videos 6.25 and 6.26)

Fig. 6.35  Coronary Angiography showing RCA feeding artery to anterior mediastinal mass(asterisk)

Fig. 6.36  Status post removal of paracardiac mass showing normal RA motion

6.5 Coronary Fistula

6.5 Coronary Fistula A 63-year-old male with the past medical history of hyperlipidemia and coronary fistula for 7 years under regular medications. He suffered from chest tightness, SOB and dizziness off & on for months. CTA: Four coronary artery-

Fig. 6.37  Two-dimensional transesophageal echo­ cardiography(2D TEE) image, showing multiple coronary artery fistulas forming a network along LAA, and at least one entry site from the MPA

Fig. 6.38  2D TEE Color Doppler revealing multiple fistulas forming a network along LAA, and at least one entry site from the MPA (Video 6.27)

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pulmonary artery fistulas, two originate from LM and two from proximal LAD with aneurysmal formation, ectasia of ascending aorta (4.1 cm in diameter). CAG: Coronary atherosclerosis with LAD to PA, LAA fistula with steal (Figs.  6.37, 6.38, 6.39, 6.40, 6.41, 6.42 and 6.43).

Fig. 6.39  2D TEE Color Doppler, short axis view, a small coronary artery-pulmonary artery fistula originated from aorta (arrow) (Video 6.28)

Fig. 6.40  2D TEE Color Doppler, modified short axis view, showing several entry sites of the coronary fistula (arrow) (Video 6.29)

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6.6 Post Heart Transplantation Myocardial Infarction VSD

Fig. 6.41 TrueVue 3D TEE demonstrating coronary artery-pulmonary artery fistulas forming a network along LAA (Video 6.30)

A 70-year-old male had a history of DCM s/p Heart Transplantation, he suffered from chills and mild chest tightness. ECG: ST elevation in lateral leads. Lab data: Troponin-I: 11.096  ng/ mL, CK-MB: 5.7  ng/mL, CRP-HS: 19.30  mg/ dL.  CXR: Patchy infiltrate over RLL.  Aspirin, Brilinta and Heparin was given. Patient was diagnosed with STEMI and was admitted for Angiography. Cardiogenic shock happened a few days later after PCI, echocardiogram showed post myocardial infarction VSD (Figs. 6.44, 6.45, 6.46, 6.47, 6.48, 6.49 and 6.50).

Fig. 6.44  Two-dimensional transthoracic echocardiography (2-D TTE) four-chamber view showing multiple myocardial defects(arrowhead) (Video 6.32) Fig. 6.42  Heart CT revealing coronary artey-pulmonary artery fistulas

Fig. 6.45  2D-TEE Color Doppler revealing post MI VSD (arrowhead) (Video 6.33) Fig. 6.43  Status post ligation of the coronary fistulas (Video 6.31)

6.6  Post Heart Transplantation Myocardial Infarction VSD

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Fig. 6.46  3D TTE and TrueVue 3D TTE demonstrating the defect (arrow) from the anterior wall of Left ventricular (Videos 6.34 and 6.35)

Fig. 6.47  3D TTE revealing that multiple defects from left ventricular anterior to apex (arrow) (Video 6.36)

Fig. 6.48  2D-TTE, short-axis view, showing the large MI VSD with high velocity flow from LV to RV (Videos 6.37 and 6.38)

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Fig. 6.49  2D-TTE from AV short-axis view reveling the defects (arrowhead) with left to right shunting from the aneurysmal apex of the LV (Videos 6.39 and 6.40)

Fig. 6.50  Multiplanar reconstruction TrueVue 3D-TTE with internal light demonstrating a post MI VSD(arrowhead) from LV apex to RV (Video 6.41)

Suggested Reading

Suggested Reading Baldasare MD, Polyakov M, Laub GW, et al. Percutaneous repair of post-myocardial infarction ventricular septal defect: current approaches and future perspectives. Tex Heart Inst J. 2014;41(6):613–9. Egbe AC, Poterucha JT, Rihal CS, et  al. Transcatheter closure of postmyocardial infarction, iatrogenic, and postoperative ventricular septal defects: the Mayo Clinic experience. Catheter Cardiovasc Interv. 2015;86:1264–70. Fattouch K, Castrovinci S, Murana G, et  al. Relocation of papillary muscles for ischemic mitral valve regurgitation: the role of three-dimensional transesophageal echocardiography. Innovations (Phila). 2014;9(1):54–9. Gianstefani S, Douiri A, Delithanasis I, et  al. Incidence and predictors of early left ventricular thrombus after ST-elevation myocardial infarction in the contemporary era of primary percutaneous coronary intervention. Am J Cardiol. 2014;113(7):1111–6. Grayburn PA, She L, Roberts BJ, et  al. Comparison of transesophageal and transthoracic echocardiographic

151 measurements of mechanism and severity of mitral regurgitation in ischemic cardiomyopathy (from the surgical treatment of ischemic heart failure trial). Am J Cardiol. 2015;116(6):913–8. Osaki S, Edwards NM, Kohmoto T. Strategies for left ventricular assist device insertion after the dor procedure. J Heart Lung Transplant. 2009;28(5):520–2. Shabestari MM, Ghaderi F, Hamedanchi A. Transcatheter closure of postinfarction ventricular septal defect: a case report and review of literature. J Cardiovasc Thorac Res. 2015;7(2):75–7. Trivedi KR, Aldebert P, Riberi A, et al. Sequential management of post-myocardial infarction ventricular septal defects. Arch Cardiovasc Dis. 2015;108(5):321–30. Zeng X, Nunes MC, Dent J, et  al. Asymmetric versus symmetric tethering patterns in ischemic mitral regurgitation: geometric differences from three-dimensional transesophageal echocardiography. J Am Soc Echocardiogr. 2014;27(4):367–75. Zou H, Zhang Y, Tong J, Liu Z.  Multidetector computed tomography for detecting left atrial/left atrial appendage thrombus: a meta-analysis. Intern Med J. 2015;45(10):1044–53.

7

Congenital Heart Diseases

Abstract

Congenital heart diseases are discussed in this chapter, which covers case with subaortic stenosis, and cases with ASDs or VSDs received occluder implantation or patch repair. 3D TEE can carefully measure the morphology and pathology of the ASDs and VSDs from varies perspectives, detect any intraprocedure accidental event which should be solved immediately, and evaluate the result of the treatment to confirm that no residual remains.

Fig. 7.1  Two-dimensional transesophageal (2D TEE), bicaval view, showed a PFO (yellow arrow) covered by a flaplike structure (white arrows) (Video 7.1)

7.1 Patent Foramen Ovale Having Occluder Implantation A 22-year-old man with funnel chest status post operation had a patent foramen ovale (PFO). He admitted for chest discomfort and dizziness. Auscultation: regular heart beat without significant murmur. ECG: sinus bradycardia. Treatment: PFO occluder (Figs.  7.1, 7.2, 7.3, 7.4, 7.5, 7.6, 7.7, 7.8, 7.9 and 7.10).

Fig. 7.2  2D TEE color Doppler, bicaval view, showed a left-to-right shunt (arrow) across the PFO (Video 7.2) Supplementary Information The online version contains supplementary material available at https://doi. org/10.1007/978-­981-­19-­6794-­8_7. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_7

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Fig. 7.3  3D TEE, bicaval view, during the occluder implantation, showed a guiding catheter (arrows) across the PFO (Video 7.3)

Fig. 7.5  3D TEE, view from LA perspective, during the occluder implantation, showed a guiding catheter (black arrows) across the PFO (red arrow) (Video 7.5)

Fig. 7.4  3D TEE color Doppler, bicaval view, during the occluder implantation, showed a guiding catheter across the PFO with a left- to-right shunt (arrow) (Video 7.4)

Fig. 7.6  3D TEE color Doppler, view from LA perspective, during the occluder implantation, showed a left-to-­ right shunt across the PFO (arrow) (Video 7.6)

7.1  Patent Foramen Ovale Having Occluder Implantation

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Fig. 7.7  2D TEE, bicaval view, status post occluder implantation, showed the PFO was blocked by the occluder (arrow) Fig. 7.9  3D TEE color Doppler, bicaval view, status post occluder implantation, showed the PFO was blocked by the occluder without residual (Video 7.8)

Fig. 7.8  3D TEE, view from LA perspective, status post occluder implantation, showed the occluder was successfully deployed (Video 7.7)

Fig. 7.10  Fluoroscopy, status post occluder implantation, showed the occluder (arrow) was successfully deployed

cc Tips  Bicaval view has the advantage of providing high quality image of the interatrial septum as the ultrasound beam is perpendicular to the septum. Transcatheter treatment of PFO is safe, whereas patients with PFO are at high risk of stroke. 

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7.2 Primum Atrial Septal Defect A 48-year-old woman admitted for exertional dyspnea and chest pain. Auscultation: regular heart beat with a grade 3/6 systolic murmur over apex. ECG: sinus rhythm and incomplete right bundle branch block. Chest X ray: mild cardiomegaly. Cardiac catheterization: atrial septal defect (ASD) and moderate to severe MR.  Operation: ASD patch repair, MV and TV repair (Figs.  7.11, 7.12, 7.13, 7.14, 7.15, 7.16, 7.17, 7.18, 7.19, 7.20, 7.21, 7.22, 7.23, 7.24, 7.25, 7.26, 7.27, 7.28, 7.29, 7.30, 7.31 and 7.32). Fig. 7.13  3D TEE, four-chamber view, showed a primum ASD (arrow) with the defect adjacent to the central fibrous body (Video 7.11)

Fig. 7.11 Two-dimensional transesophageal echocardiography (2D TEE), four-chamber view, showed a primum ASD (arrow) with the defect adjacent to the central fibrous body. Dilated RA and RV were also present (Video 7.9) Fig. 7.14  3D TEE color Doppler, four-chamber view, showed a primum ASD with a left-to-right shunt (arrow) across it into enlarged RA and RV (Video 7.12)

Fig. 7.12  2D TEE color Doppler, four-chamber view, showed a primum ASD with a left-to-right shunt (arrow) across it into enlarged RA and RV (Video 7.10)

7.2  Primum Atrial Septal Defect

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Figs. 7.15 and 7.16  3D TEE, view from atrial perspective, showed a primum ASD (arrows) near atrioventricular connection (Videos 7.13 and 7.14)

Fig. 7.17  3D TEE, view from right side perspective, showed a primum ASD (arrows) near atrioventricular connection (Video 7.15)

Fig. 7.18  2D TEE color Doppler, four-chamber view, showed moderate to severe MR (arrow) caused by valve abnormity associated with primum ASD (Video 7.16)

Fig. 7.19  3D TEE, long-axis view, showed MV abnormity (arrow) associated with primum ASD (Video 7.17)

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Fig. 7.20  3D TEE color Doppler, long-axis view, showed moderate to severe MR (arrow) caused by valve abnormity associated with primum ASD (Video 7.18)

Fig. 7.21  3D TEE, en face view, showed cleft MV with discontinuity of the anterior mitral leaflet (arrow) (Video 7.19)

7  Congenital Heart Diseases

Fig. 7.22  3D TEE, view from ventricular perspective, showed cleft MV with discontinuity of the anterior mitral leaflet (arrow) (Video 7.20)

Fig. 7.23  2D TEE, four-chamber view, status post ASD patch repair, MV and TV repair, showed intact interatrial septum and normal MV function (Video 7.21)

Fig. 7.24  2D TEE color Doppler, four-chamber view, status post ASD patch repair, MV and TV repair, showed minimal ASD residual and MR (Video 7.22)

7.2  Primum Atrial Septal Defect

159

Fig. 7.25  3D TEE, four-chamber view, status post ASD patch repair, MV and TV repair, showed intact interatrial septum and normal MV function (Video 7.23)

Figs. 7.26 and 7.27  2D (left) and 3D (right) TEE color Doppler, status post ASD patch repair, MV and TV repair, showed minimal ASD residual (arrow) (Videos 7.24 and 7.25)

Fig. 7.28  2D TEE long-axis view, status post ASD patch repair, MV and TV repair, showed normal MV function

Fig. 7.29  2D TEE color Doppler, long- axis view, status post ASD patch repair, MV and TV repair, showed minimal MR (arrow)

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Fig. 7.30  3D TEE, long-axis view, status post ASD patch repair, MV and TV repair, showed normal MV function (Video 7.26)

7  Congenital Heart Diseases

Fig. 7.32  2D TEE color Doppler, long- axis view, status post ASD patch repair, MV and TV repair, showed minimal MR (arrow) (Video 7.28)

cc Tips  A cleft MV can be seen carefully in 3D TEE from ventricular perspective. There is significant thickening and fibrosis along the edges of the cleft. 

7.3 Secundum Atrial Septal Defect Having Occluder Implantation

Fig. 7.31  3D TEE, en face view, status post ASD patch repair (white arrow) and MV repair (black arrow) (Video 7.27)

An 89-year-old woman with a history of atrial septal defect (ASD) and hypertension suffered from shortness of breath and chest discomfort. Auscultation: regular heart beat with a grade 2/6 systolic murmur over second interspace. ECG: sinus bradycardia, first degree AV block, clock rotation and myocardial ischemia. Chest X ray: cardiomegaly and engorgement of pulmonary trunk and bilateral pulmonary arteries. Cardiac catheterization: single vessel coronary artery disease. Treatment: ASD occluder (Figs. 7.33, 7.34, 7.35, 7.36, 7.37, 7.38, 7.39, 7.40, 7.41, 7.42, 7.43, 7.44, 7.45, 7.46, 7.47, 7.48 and 7.49).

7.3  Secundum Atrial Septal Defect Having Occluder Implantation

Fig. 7.33 Two-dimensional transesophageal echocardiography (2D TEE), short-axis view, showed dilated RA and a secundum ASD (arrow) in midsection of the atrial septum

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Fig. 7.36  3D TEE showed a secundum ASD (arrow) in midsection of the atrial septum (Video 7.31)

Fig. 7.34  2D TEE, short-axis view, showed a secundum ASD (arrow) in midsection of the atrial septum (Video 7.29) Fig. 7.37  3D TEE, view from LA perspective, showed a secundum ASD (arrow) in midsection of the atrial septum (Video 7.32)

Fig. 7.35 2D TEE color Doppler, short- axis view, showed a left-to-right shunt (arrow) across the ASD (Video 7.30)

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Fig. 7.38  3D TEE color Doppler showed a left-to-right shunt (arrow) across the ASD (Video 7.33)

7  Congenital Heart Diseases

Fig. 7.39  3D TEE color Doppler, view from LA perspective, showed a continuous flow (arrow) across the ASD (Video 7.34)

Figs. 7.40 and 7.41  3D TEE color Doppler (left) and color-suppressed (right) showed a continuous flow across the ASD (arrow) (Videos 7.35 and 7.36)

7.3  Secundum Atrial Septal Defect Having Occluder Implantation

Fig. 7.42  Contrast-enhanced CT showed a secundum ASD (arrow) in midsection of the atrial septum

163

Fig. 7.44  3D TEE, view from LA perspective, during the procedure, showed the occluder (arrow) was deployed to occlude the secundum ASD (Video 7.38)

Fig. 7.45  2D TEE, status post occluder implantation, showed the secundum ASD was blocked by the occluder (arrow) Fig. 7.43  3D TEE, view from LA perspective, during the occluder implantation procedure, showed a guiding catheter across the ASD (arrows) (Video 7.37)

Fig. 7.46  2-D TEE color Doppler, status post occluder implantation, showed a trivial residual shunt

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Fig. 7.47  3D TEE, status post occluder implantation, showed the secundum ASD was blocked by the occluder (arrow) (Video 7.39)

7  Congenital Heart Diseases

Fig. 7.49  Fluoroscopy status post occluder implantation showed the deployed occluder (arrow)

cc Tips  Secundum ASDs are located in the central portion of the interatrial septum, which are the most amendable to implant an occluder. A preprocedure TEE examination is essential to evaluate the presence of a rim to ensure that the patient is appropriate for occluder implantation. 

7.4 Atrial Septal Defect Occluder Device Embolization Fig. 7.48  3D TEE, view from LA perspective, status post occluder implantation, showed the secundum ASD was blocked by the occluder (Video 7.40)

A 43-year-old man who was incidentally diagnosed with secundum atrial septal defects (ASDs) (“Swiss cheese” like multiple defects) presented for further evaluation. Auscultation: regular heart beat with a grade 2/4 continuous murmur over sternal border. Chest X ray: borderline cardiomegaly. Contrast-enhanced cardiac CT: coronary artery calcium score is 0 and small defects over interarterial septum. The patient refused surgical repair, percutaneous

7.4  Atrial Septal Defect Occluder Device Embolization

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closure by occluders was arranged. During the procedure, after implantation of two devices, residual defect with significant shunting persisted. When the third device was attempted, the first one dropped into LA, rapidly migrated to the right iliac artery and caused embolization.

The device was pushed back to proximal descending aorta intravascularly. Emergency sternotomy was done to remove the device and to accomplish ASD patch repair (Figs.  7.50, 7.51, 7.52, 7.53, 7.54, 7.55, 7.56, 7.57, 7.58, 7.59, 7.60 and 7.61).

Fig. 7.50  Two-dimensional transesophageal echocardiography (2D TEE) image, x-plane view, showed four defects (arrows) over interarterial septum (Video 7.41)

Fig. 7.51 2D TEE color Doppler, short- axis view, showed four shunts (arrows) from LA to RA through the ASDs (Video 7.42) Fig. 7.52  3D TEE image, viewed from LA perspective to RA, showed four defects (arrows) over interarterial septum (Video 7.43)

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Fig. 7.53 3D TEE color Doppler, short-axis view, showed flows (arrows) from LA to RA through the ASDs (Video 7.44)

Fig. 7.54  Contrast-enhanced cardiac CT showed dilated RA and RV with a small defect (arrow) over interarterial septum

7  Congenital Heart Diseases

Fig. 7.55  3D TEE image, during occluder implantation procedure, after the first implantation of occluder (O 1), defects (* and arrow) persisted (Video 7.45)

Fig. 7.56  3D TEE image, during the procedure, after implantation of the first (O 1) and the second (O 2) occluders, residual defects (arrow) were seen (Video 7.46)

7.5  Supracristal Ventricular Septal Defect Having Patch Repair

Fig. 7.57  2D TEE color Doppler, during the procedure, after implantation of the first (O 1) and the second (O 2) occluders, there were still flows (arrows) through the defects (Video 7.47)

Fig. 7.58  3D TEE image showed the first occluders (O 1) dropped into LA when the third device was attempted (Video 7.48)

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Fig. 7.60  3D TEE showed occluder (O 1) in descending aorta

Fig. 7.61  Picture during removal of the occluder from proximal descending aorta

cc Tips  Occluders can be used to closed ASDs, but the ASDs cannot be too large, too many, and there must be an adequate rim to seat the occluder. 

7.5 Supracristal Ventricular Septal Defect Having Patch Repair

Fig. 7.59  2D TEE showed occluder (O 1) in descending aorta

A 45-year-old man with heart murmur presented with exertional chest tightness, shortness of breath and dyspnea on exertion. Auscultation: regular heart beat with a grade

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7  Congenital Heart Diseases

3/6 pan-systolic murmur over left lower sternal border and pulmonary area. ECG: sinus rhythm and complete right bundle branch block. Cardiac catheterization: ventricular septal

defect (VSD) and LAD myocardial bridge. Operation: patch repair of VSD (Figs.  7.62, 7.63, 7.64, 7.65, 7.66, 7.67, 7.68, 7.69, 7.70, 7.71, 7.72 and 7.73).

Fig. 7.62 Two-dimensional transesophageal echocardiography (2D TEE) color compare, short-axis view, showed a supracristal VSD (arrow) located at the 5

o’clock position and adjacent to the PV with flow from LV outflow tract to RV outflow tract (Video 7.49)

7.5  Supracristal Ventricular Septal Defect Having Patch Repair

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Fig. 7.63  2D TEE color compare, modified long-axis view, showed a supracristal VSD (arrow) located just below the AV with flow from LV outflow tract to RV outflow tract (Video 7.50)

Fig. 7.64  2D TEE color Doppler, modified long-axis view, showed a supracristal VSD located just below the AV with flow (arrow) from LV outflow tract to RV (Video 7.51)

Fig. 7.65  3D TEE, short-axis view, showed a supracristal VSD (arrows) located inferior to the AV and above the crista ventricularis (Video 7.52)

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Figs. 7.66 and 7.67  3D TEE color Doppler, short-axis view in systole (left) and diastole (right), showed a continuous left-to-right shunt (arrow) across the supracristal VSD (Video 7.53)

Fig. 7.68  2D TEE color Doppler, modified long-axis view, showed a left-to-right shunt (arrow) across the supracristal VSD (Video 7.54)

7.5  Supracristal Ventricular Septal Defect Having Patch Repair

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Fig. 7.69  2D TEE color compare, short-axis view, status post VSD patch repair, no abnormal intracardiac shunt was present

Fig. 7.70  2D TEE color compare, long-axis view, status post VSD patch repair, no abnormal intracardiac shunt was present

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Fig. 7.71  3D TEE, short-axis view, status post VSD patch repair (Video 7.55)

7  Congenital Heart Diseases

Fig. 7.73  3D TEE color Doppler, long-axis view, status post VSD patch repair, no abnormal intracardiac shunt was present (Video 7.57)

cc Tips  A supracristal VSD, so called outlet VSD or subatrial VSD, is located in the RVOT portion of septum, above the crista ventricularis, inferior to the AV and below the PV. 

7.6 Subaortic Stenosis Having Resection

Fig. 7.72  3D TEE, long-axis view, status post VSD patch repair (Video 7.56)

A 23-year-old woman is a known case of congenital heart disease with discrete subaortic membranous stenosis since she was born. She suffered from exertional dyspnea and chest tightness for months. Auscultation: a 3/6 systolic murmur over apex with transmission to neck and gallop. ECG: sinus rhythm and non- specific ST-T change. Operation: resection of subaortic membranous tissue (Figs. 7.74, 7.75, 7.76, 7.77, 7.78, 7.79, 7.80, 7.81, 7.82, 7.83, 7.84 and 7.85).

7.6  Subaortic Stenosis Having Resection

Fig. 7.74 Two-dimensional transesophageal echocardiography (2D TEE), long-axis view, showed a subaortic membrane (red arrows) locate 1.5 cm apically to the AV (yellow arrows) (Video 7.58)

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Fig. 7.75  2D TEE color Doppler, long-axis view, showed high-velocity flow in the LV outflow track (LVOT) caused by discrete subaortic membranous stenosis (arrows) (Video 7.59)

Fig. 7.76  2D TEE color compare, long-axis view, showed flow disturbance on the LV side of the AV with the AV leaflets appear normal, which indicated subaortic stenosis (arrows) (Video 7.60)

174

Fig. 7.77  3D TEE, long-axis view, showed a subaortic membrane (red arrows) locate 1.5 cm apically to the AV (black arrows) (Video 7.61)

7  Congenital Heart Diseases

Fig. 7.79  3D TEE color Doppler, long-axis view, showed flow disturbance between the subaortic membrane (red arrows) and AV (black arrow) (Video 7.62)

Fig. 7.78  Multi-planer reconstruction (MPR) of 3D TEE, showed subaortic stenosis area is 0.56 cm2

7.6  Subaortic Stenosis Having Resection

Fig. 7.80  2D TEE color Doppler, long-axis view, status post resection of the subaortic membranous tissue, showed normal flow in the LVOT

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Fig. 7.81  3D TEE, long-axis view, status post resection of the subaortic membranous tissue, no more subaortic stenosis was present (Video 7.63)

Fig. 7.82  MPR of 3D TEE, status post resection, showed LVOT area is 2.02 cm2

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Fig. 7.83  3-D TEE color Doppler, long-axis view, status post resection, showed normal flow in the LVOT (Video 7.64)

Figs. 7.84 and 7.85  Picture during operation (left) and gross specimen of the excised tissue (right)

cc Tips  If aortic acceleration was present with normal AV appearance, subaortic stenosis and dynamic obstruction must be suspected. 

7.7 Two Atrial Septal Defects Having Two Occluder Implantation A 25-year-old lady had history of congenital heart disease with atrial septal defect that was diagnosed since she was born. She complained of

progressive dyspnea and SOB in recent months. Transthoracic echocardiography showed secundum ASD, Qp/Qs: 2.6, Diameter: 1.5  cm. She was admitted for ASD occluder (Figs. 7.86, 7.87, 7.88, 7.89, 7.90, 7.91, 7.92 and 7.93).

7.7  Two Atrial Septal Defects Having Two Occluder Implantation

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Fig. 7.86  Intraoperative Two-dimensional Transesophageal Echocardiography (2D TEE) showing two defects in bicaval view(arrow) (Video 7.65)

Fig. 7.89  3D TEE Color Doppler showing two shunts across from atrial septal defects(arrows) (Video 7.68)

Fig. 7.87  2D TEE Color Doppler demonstrating two shunts crossing from left atrium to right atrium(arrows) (Video 7.66)

Fig. 7.90  2D TEE image displaying two defects blocked by two occluders(arrows) (Video 7.69)

Fig. 7.88  TrueVue 3D TEE revealing two irregular shape of atrial septal defects (Video 7.67)

Fig. 7.91  2D TEE Color Doppler showing trivial residual after occluders implantation (Video 7.70)

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Fig. 7.92  3D TEE image revealing two occluders from LA perspective(left) and RA perspective(right) (Videos 7.71 and 7.72)

Fig. 7.93  TrueVue 3D TEE Color Doppler showing trivial residual between two of the occluders (Video 7.73)

7.8 Transitional Type of Atrioventricular Septal Defect A 24-year-old man was quite well before. He was told having Congenital Heart Disease at company health examination. Echocardiography was performed, which showed Endocardial Cushion Defect (transitional type) with ASD, restrictive VSD and moderate MR, TR. Chest X ray: right side enlargement. EKG: Sinus rhythm. Operation: s/p patch repair of ASD with bovine pericardium, mitral cleft repair, and TV Repair (Devega method) (Figs. 7.94, 7.95, 7.96, 7.97 and 7.98).

Fig. 7.94  Two-dimensional Transesophageal Echocardiography (2D TEE) showing the defect in base of interatrial septum, just above MV and TV annulus(arrowhead) (Video 7.74)

Fig. 7.95 2D TEE color Doppler in modified four-­ chamber view displaying a primum ASD with a left-to-­ right shunt crossing into enlarged RA (arrowhead) (Video 7.75)

Suggested Reading

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Suggested Reading

Fig. 7.96  TrueVue 3D TEE Color Doppler revealing a left-to-right shunt crossing into RA (arrowhead) in modified four-chamber view (Video 7.76)

Fig. 7.97  2D TEE in four-chamber view, status post ASD patch repair, MV and TV repair, showing intact interatrial septum and normal chamber size (Video 7.77)

Fig. 7.98  2D TEE Color Doppler, four-chamber view, status post ASD patch repair, MV and TV repair, showing minimal MR (Video 7.78)

Assaidi A, Sumian M, Mauri L, et  al. Transcatheter closure of complex atrial septal defects is efficient under intracardiac echocardiographic guidance. Arch Cardiovasc Dis. 2014;107(12):646–53. Baruteau AE, Petit J, Lambert V, et  al. Transcatheter closure of large atrial septal defects: feasibility and safety in a large adult and pediatric population. Circ Cardiovasc Interv. 2014;7(6):837–43. Bayar N, Arslan Ş, Çağırcı G, et  al. Assessment of morphology of patent foramen ovale with transesophageal echocardiography in symptomatic and asymptomatic patients. J Stroke Cerebrovasc Dis. 2015;24(6):1282–6. Chen HY, Pan CZ, Shu XH. Partially unroofed coronary sinus diagnosed by real-time dimensional transesophageal echocardiagraphy after operation of secundum atrial septal defect. Int J Cardiovasc Imaging. 2015;31(1):45–6. Choi AD, Ahmad S, Mathias M, et al. Diagnosis and surgical management of subaortic stenosis and mitral valve systolic anterior motion. J Heart Valve Dis. 2013;22(4):599–602. Demirkol S, Barçın C, et al. Percutaneous closure of second secundum atrial septal defect under guidance of three-­dimensional transesophageal echocardiography guidance. Anadolu Kardiyol Derg. 2013;13(4):E22–3. Hartlage GR, Consolini MA, Pernetz MA, et al. Bad company: supracristal VSD presenting with ruptured sinus of valsalva aneurysm. A case presentation with echocardiographic depiction and an analysis of contemporary literature. Echocardiography. 2015;32(3):575–83. Jeng W, Ming CH, Shen KT, et al. Atrial septal occluder device embolization to an iliac artery: a case highlighting the utility of three-dimensional transesophageal echocardiography during percutaneous closure. Echocardiography. 2012;29:1128–31. Jung P, Sohn HY. 35-year-old woman with unclear cardiac surgery in infancy. Operation of atrial septal defect type 1 (ostium primum defect) with mitral valve involvement. Dtsch Med Wochenschr. 2012;137(14):713–4. Kuroda M, Kumakura M, Sato T, Saito S. The usefulness of three-dimensional transesophageal echocardiography for a primum atrial septal defect. Anesth Analg. 2015;121(5):1151–4. Mihara H, Shibayama K, Harada K, et al. LV outflow tract area in discrete subaortic stenosis and hypertrophic obstructive cardiomyopathy: a real-time 3-dimensional transesophageal echocardiography study. JACC Cardiovasc Imaging. 2014;7(4):425–8. Sugasawa Y, Hayashida M, Inada E.  Discrete subaortic stenosis diagnosed intraoperatively. J Anesth. 2014;28(2):311. Zhang S, Zhu D, An Q, et  al. Minimally invasive perventricular device closure of doubly committed sub-arterial ventricular septaldefects: single center long-term follow-up results. J Cardiothorac Surg. 2015;10(1):119.

8

Cardiomyopathies

Abstract

This chapter provides cardiomyopathies. Hypertrophic cardiomyopathies are common genetic cardiac disease with properties of LV hypertrophy most asymmetric. Patients with hypertrophic cardiomyopathy usually generate systemic hypertension or MV systolic anterior motion which should be corrected by surgical therapy.

with worsening symptom. Auscultation: irregular heart beat with a grade 2/6 systolic murmur over apex. ECG: atrial fibrillation, LV hypertrophy with strain and counter clockwise rotation. Cardiac catheterization: LV apical hypertrophy with normal contractility and severe MR. Operation: MV and TV repaired and atrial fibrillation ablation (Figs. 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, 8.9, 8.10, 8.11, and 8.12).

8.1 Apical Hypertrophic Cardiomyopathy with Severe Mitral Regurgitation Having Mitral Repair A 60-year-old man with a history of atrial fibrillation and hyperthyroidism status post partial thyroidectomy suffered dyspnea after exercise

Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-­981-­19-­6794-­8_8. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_8

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Fig. 8.1  Two-dimensional transesophageal echocardiography (2D TEE), x-plane view, showed LV apical hypertrophic cardiomyopathy with normal function (Video 8.1)

Fig. 8.2  2D TEE, long-axis view, showed localized apical hypertrophy with a spade-like shape LV cavity in the whole cardiac cycle (Video 8.2)

Fig. 8.3  2D TEE color Doppler, long-axis view, showed severe MR (Video 8.3)

8.1  Apical Hypertroph Cardiomyopathy with Severe Mitral Regurgitation Having Mitral Repair

Fig. 8.4  3D TEE, long-axis view, showed localized apical hypertrophy with a spade-like shape LV cavity (*) (Video 8.4)

Fig. 8.5  3D TEE, en face view, showed prolapse of A1 (*) and A2 (.) (Video 8.5)

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Fig. 8.6  3D TEE color Doppler, long-axis view, showed severe MR due to prolapse of anterior mitral leaflet (Video 8.6)

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Fig. 8.7  ECG showed atrial fibrillation, LV hypertrophy with strain and counter clockwise rotation

Fig. 8.9  2D TEE color Doppler, long-axis view, status post MV repair, showed mild MR (arrow)

Fig. 8.8  Fluoroscopy showed a spade-like LV demonstrating apical hypertrophic cardiomyopathy

8.2  Hypertrophic Obstructive Cardiomyopathy Having Myectomy and Mitral Replacement

Fig. 8.10  3D TEE, long-axis view, showed repaired MV with suture (arrow) (Video 8.7)

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Fig. 8.12  3D TEE color Doppler, long-axis view, status post MV repair, showed mild MR (Video 8.9)

cc Tips  Apical hypertrophic cardiomyopathy is a rare form of hypertrophic cardiomyopathy which usually involves the apex of the LV and develops cardiac arrhythmias. 

8.2 Hypertrophic Obstructive Cardiomyopathy Having Myectomy and Mitral Replacement

Fig. 8.11  3D TEE, en face view, status post MV repair (MVA) (Video 8.8)

A 42-year-old man with medical-controlled hypertension and type two diabetes mellitus suffered from intermittent chest pain and dyspnea on exertion. Auscultation: regular heart beat with a grade 2/6 systolic murmur over apex. ECG: biatrial enlargement, LV hypertrophy with strain and old septal wall myocardial infarction. Cardiac catheterization: hypertrophic cardiomyopathy with dynamic LV outflow tract obstruction and severe MR, double vessel coronary artery disease. Operation: MV replacement, myectomy of IVS and CABG ×2 (SVG to LAD and D2) (Figs.  8.13, 8.14, 8.15, 8.16, 8.17, 8.18, 8.19, 8.20, 8.21, 8.22, 8.23, 8.24, 8.25, 8.26, 8.27, 8.28, 8.29, 8.30, 8.31, 8.32, 8.33, and 8.34).

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Fig. 8.13  2D TEE, four-chamber view, showed systolic anterior motion of the MV (arrow) at end-systole (Video 8.10)

8 Cardiomyopathies

Fig. 8.16  3D TEE, four-chamber view, showed systolic anterior motion of the MV (arrow) at end-systole (Video 8.13)

Fig. 8.14  2D TEE color Doppler, four-chamber view, showed severe eccentric MR (arrow) due to systolic anterior motion of the MV (Video 8.11)

Fig. 8.17  3D TEE image, long-axis view, showed systolic anterior motion of the MV (arrow) and dynamic outflow tract obstruction. IVS, interventricular septum (Video 8.14)

Fig. 8.15  2D TEE color Doppler, long-axis view, showed turbulence in LV outflow tract (arrow) due to subaortic dynamic obstruction (Video 8.12)

8.2  Hypertrophic Obstructive Cardiomyopathy Having Myectomy and Mitral Replacement

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Fig. 8.18  3D TEE, short-axis view from ventricular perspective, showed LV hypertrophic cardiomyopathy (Video 8.15) Fig. 8.19  3D TEE, view from LA perspective, showed systolic anterior motion (SAM) of the MV indicating LV outflow tract obstruction. LAA left atrial appendage (Video 8.16)

Figs. 8.20 and 8.21  3D TEE color Doppler (left) and color suppressed (right), long-axis view, showed severe eccentric MR (black arrow) and turbulence in LV outflow

tract (red arrow) caused by systolic anterior motion of the MV (yellow arrow) (Videos 8.17 and 8.18)

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Figs. 8.22 and 8.23  Multi-planer reconstruction of 3D TEE color Doppler (left) and color suppressed (right) showed severe eccentric MR and LV outflow tract obstruction with a flow convergence area (arrows) (Videos 8.19 and 8.20)

Fig. 8.24  Two-dimensional transesophageal echocardiography (2D TEE), transgastric x-plane view, showed LV hypertrophic cardiomyopathy with normal function (Video 8.21)

Figs. 8.25 and 8.26  2D TEE (left) and color Doppler (right), transgastric long-axis view, showed systolic anterior motion of MV (white arrow) in association with

severe MR (yellow arrow). Turbulence in outflow tract (red arrow) was seen due to subaortic dynamic obstruction (Video 8.22)

8.2  Hypertrophic Obstructive Cardiomyopathy Having Myectomy and Mitral Replacement

Fig. 8.27 3D TEE, transgastric two-chamber view, showed LV hypertrophic cardiomyopathy

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Fig. 8.29  2D TEE, long axis view, status post mechanical MV replacement and myectomy of IVS, showed normal prosthesis function without systolic anterior motion

Fig. 8.28  ECG showed sinus rhythm, biatrial enlargement, LV hypertrophy with strain and old septal wall myocardial infarction

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Fig. 8.30  3D TEE, long-axis view, status post mechanical MV replacement and myectomy of IVS, showed normal prosthesis function without systolic anterior motion

Figs. 8.31 and 8.32  3D TEE color Doppler, long-axis view, status post mechanical MV replacement and myectomy of IVS, showed normal prosthesis function without MR or LV outflow tract obstruction (Video 8.23)

Fig. 8.33  2D TEE, transgastric x-plane view, status post mechanical MV replacement (MVR) and myectomy of IVS, showed normal prosthesis function (Video 8.24)

8.3  Hypertrophic Obstructive Cardiomyopathy Having Aortic, Mitral Replacement and Myectomy

Fig. 8.34  2D TEE color Doppler, transgastric long-axis view, status post mechanical MV replacement and myectomy of IVS, showed normal prosthesis function without MR or LV outflow tract obstruction

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Fig. 8.35 Two-dimensional transesophageal echocardiography (2D TEE), long-axis view, showed asymmetric septal hypertrophy with systolic anterior motion of mitral leaflet (arrow) (Video 8.25)

cc Tips  Systolic anterior motion occurs only in mid to late systole. The severity of obstruction can be altered by loading conditions. 

8.3 Hypertrophic Obstructive Cardiomyopathy Having Aortic, Mitral Replacement and Myectomy A 74-year-old man had a past history of hyperlipidemia, hypertension, carotid stenosis and valvular heart disease with moderate to severe AR and MR. He suffered from progressive effort angina and chest distress with shortness of breath. Auscultation: regular heart beat without significant murmur. ECG: sinus bradycardia (52 BPM), first degree AV block and LV hypertrophy. Chest X ray: cardiomegaly. Cardiac catheterization: valvular heart disease with moderate to severe AR and MR, insignificant coronary artery disease. Operation: myectomy, AV and MV replacement and CABG ×1 (SVG to LAD) (Figs. 8.35, 8.36, 8.37, 8.38, 8.39, 8.40, 8.41, 8.42, 8.43, 8.44, 8.45, 8.46, 8.47, 8.48, 8.49, 8.50, and 8.51).

Fig. 8.36  2D TEE color Doppler, long-axis view in systole, showed moderate to severe eccentric MR (red arrow) in associated with systolic anterior motion of mitral leaflet; turbulent flow in LV outflow tract (black arrow) was seen due to subaortic dynamic obstruction (Video 8.26)

Fig. 8.37  2D TEE color Doppler, long-axis view, showed moderate to severe AR (arrow) in diastole (Video 8.26)

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Fig. 8.38  3D TEE, long-axis view, showed asymmetric septal hypertrophy with systolic anterior motion of mitral leaflet (arrow). IVS, interventricular septum (Video 8.27)

Fig. 8.39  3D TEE, view from LV perspective, showed mitral leaflet systolic anterior motion (SAM) indicating LV outflow tract obstruction (Video 8.28)

Figs. 8.40 and 8.41  2D TEE color Doppler (left) and color suppressed (right), long-axis view, showed moderate to severe MR (red arrow) and turbulent flow in LV

outflow tract (black arrow) due to systolic anterior motion of the mitral leaflet (yellow arrow) (Video 8.29)

8.3  Hypertrophic Obstructive Cardiomyopathy Having Aortic, Mitral Replacement and Myectomy

Fig. 8.42  3D TEE color Doppler, long-axis view, showed moderate to severe AR (arrow) in diastole (Video 8.29)

193

Fig. 8.44  2D TEE color Doppler, long-axis view, status post myectomy, tissue AV and MV replacement, coronary flow seen drained to LVOT due to myectomy (arrow) (Video 8.30)

Fig. 8.43  2D TEE, long-axis view, status post myectomy, tissue AV and MV replacement, showed normal prosthetic function without systolic anterior motion

Figs. 8.45 and 8.46  2D TEE color (left) and pulsed Doppler (right), status post myectomy, showed a small coronary flow drained to LVOT with continuous flow

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8 Cardiomyopathies

Fig. 8.47  3D TEE, long-axis view, status post myectomy, tissue AV and MV replacement, showed normal prosthetic function without systolic anterior motion (Video 8.31)

Figs. 8.48 and 8.49  3D TEE, en face view, status post tissue AV and MV replacement, showed normal prosthetic function (Video 8.32)

8.4  Hypertrophic Obstructive Cardiomyopathy Having Myectomy

195

Figs. 8.50 and 8.51  3D TEE color Doppler, long-axis view, status post myectomy, tissue AV and MV replacement, showed minimal MR (arrow) and AR (Video 8.33)

cc Tips  Following septal myectomy, it is important to check the complication of the procedure which includes iatrogenic fistula and valvular damage. 

8.4 Hypertrophic Obstructive Cardiomyopathy Having Myectomy A 65-year-old female had history of hypertension and hyperlipidemia for years under medical treatment. She felt sudden onset of headache 3 months

ago. ECG: sinus bradycardia, left bundle branch block. Chest X ray: tortuosity of thoracic aorta with normal heart size is noticed. CAG: CAD with DVD (mLAD, mLCx 70%); LVEF 78%; VHD with severe MR.  Operation: CABG ×2 (RCA  +  LCx), s/p Extended Septal Myectomy (Figs. 8.52, 8.53, 8.54, 8.55, 8.56, and 8.57).

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Fig. 8.52  Two-dimensional Transesophageal Echocardiography (left) and TrueVue 3D TEE (right), long-axis view, showing systolic anterior motion of the mitral valve

Fig. 8.53 2D TEE Color Doppler displaying severe mitral regurgitation with eccentric posteriorly directed jet (arrow) and turbulence in left ventricle outflow tract caused by systolic anterior motion of the mitral valve (Video 8.36)

8 Cardiomyopathies

(arrow) and left ventricle outflow tract obstruction (Videos 8.34 and 8.35)

8.4  Hypertrophic Obstructive Cardiomyopathy Having Myectomy

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Fig. 8.54  2D TEE M-mode showing mid-systolic notching (arrow) of aortic valve due to transient obstruction and reduction of stroke volume

Fig. 8.55  2D TEE, long axis view, status post myectomy of IVS showing normal motion of mitral valve (Video 8.37)

Fig. 8.56  2D TEE Color Doppler demonstrating mild mitral regurgitation after myectomy (Video 8.38)

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8 Cardiomyopathies

Fig. 8.57  2D TEE, transgastric view, pre-myectomy (left) and post-myectomy (right) (Videos 8.39 and 8.40)

8.5 Dilated Cardiomyopathy Having HeartMate III A 49-year-old male had history of DCM with low LVEF, chronic atrial fibrillation, DM type 2 and COPD under regular medical treatment for several years. He suffered from dyspnea on exertion recently, transthoracic echocardiography disclosed LVEF = 24% and dilatation of four chambers, operation was suggested. ECG: Atrial fibrillation with moderate ventricular response. Operation: LVAD implantation (HeartMate III) (Figs. 8.58, 8.59, 8.60, 8.61, 8.62, 8.63, 8.64, and 8.65).

Fig. 8.58  Two-dimensional Transesophageal Echocardiography (2D TEE) in four-chamber view displaying dilatation of four chambers (Video 8.41)

Fig. 8.59  2D TEE Color Doppler showing trivial mitral regurgitation (Video 8.42)

Suggested Reading

199

Fig. 8.60 TrueVue 3D TEE demonstrating Dilated Cardiomyopathy with Atrial fibrillation with rapid ventricular response (Video 8.43)

Fig. 8.63  TrueVue 3D TEE revealing blood flowing into the cannula then exiting the pump to circulate throughout the body (arrows) (Video 8.46)

Fig. 8.61  Intraoperative 2D TEE, status post LVAD implantation (HeartMate III), showing inflow cannula attaching to the apex of the left ventricle with artifact (Video 8.44)

Fig. 8.64  2D TEE Color Doppler demonstrating the blood flows exiting through the outflow graft (arrow) to Ascending Aorta to circulate throughout the body (Video 8.47)

Fig. 8.62  2D TEE Color Doppler showing blood flows from the left ventricle through the inflow cannula into the pump (arrows) (Video 8.45)

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Fig. 8.65  Chest X ray showing DCM Having a new third generation LVAD

Suggested Reading Estep JD, Stainback RF, Little SH, et al. The role of echocardiography and other imaging modalities in patients with left ventricular assist devices. JACC Cardiovasc Imaging. 2010;3:1049–64.

8 Cardiomyopathies Karataş MB, Güngör B, Mutluer FO, et  al. Incremental utility of live/real time three-dimensional transesophageal echocardiography in a case with ventricular septal aneurysm and hypertrophic obstructive cardiomyopathy: a case report. Anadolu Kardiyol Derg. 2014;14(5):478–80. Numata S, Yaku H, Doi K, et  al. Excess anterior mitral leaflet in a patient with hypertrophic obstructive cardiomyopathy and systolic anterior motion. Circulation. 2015;131(18):1605–7. Roy RR, Hakim FA, Hurst RT, et  al. Two cases of apical ballooning syndrome masking apical hypertrophic cardiomyopathy. Tex Heart Inst J. 2014;41(2):179–83. Stainback RF, Estep JD, Angler DA, et  al. Echocardiography in the management of patients with left ventricular assist devices: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2015;28:853–909. Varma PK, Puthuvassery Raman S, Unnikrishnan KP, et  al. Intraoperative transesophageal echocardiography diagnosis of concomitant hypertrophic cardiomyopathy with anomalous insertion of a papillary muscle band to the interventricular septum in a patient for aortic valve replacement. J Cardiothorac Vasc Anesth. 2014;28(6):e56–8. Zeineh NS, Eles G.  Images in clinical medicine. Apical hypertrophic cardiomyopathy. N Engl J Med. 2015;373(19):e22. Zhang LH, Fang LG, Yang J, et al. Infective endocarditis in patients with hypertrophic obstructive cardiomyopathy: five cases report. Zhonghua Xin Xue Guan Bing Za Zhi. 2012;40(3):209–13. Chinese.

9

Infective Endocarditis

Abstract

Infective Endocarditis is an inflammation of the valves and the endocardium. Vegetation formation is an essential evidence of infective endocarditis. The location, morphology, size, number, complications, and the mobility of the vegetation with the cardiac cycle must be assessed. Compared with transthoracic echocardiography, 3D TEE has much more advantages in examining infective endocarditis.

9.1 Mitral Valve Vegetation A 63-year-old man with hypertension and severe MR suffered from shortness of breath and critical leg edema. Congestive heart failure was diagnosed. But after diuretic and inotropic agent therapy, symptoms worsened. Auscultation: irregular heart beat with a grade 3/6 systolic murmur over apex and left sternal border. ECG: atrial fibrillation, anterioseptal myocardial infarction and abnormal right axis deviation. Chest X ray: cardiomegaly with enlarged LV and right pleural effusion. Operation: MV replacement, repair of TV, atrial fibrillation ablation and ligation of RA and LA auricles (Figs. 9.1, 9.2, 9.3, 9.4, 9.5, and 9.6). Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-981-19-6794-8_9.

Fig. 9.1  Two-dimensional transesophageal echocardiography (2D TEE), four-chamber view, showed vegetation attached to the atrial side of both mitral leaflets (arrow) with AML flail into the LA (Video 9.1)

Fig. 9.2  2D TEE color Doppler, four-chamber view, showed severe eccentric MR (arrow) due to the flail leaflet (Video 9.2) 201

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_9

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Fig. 9.3  3D TEE image, long-axis view, showed huge vegetation (arrow) attached to MV (Video 9.3)

Fig. 9.4  3D TEE image, en face view, showed mitral vegetation (*) and flail of AML due to the rupture chordae (arrow) (Video 9.4)

9  Infective Endocarditis

Fig. 9.5  3D TEE color Doppler, two-chamber view, showed severe eccentric MR (arrow) due to the flail leaflet (Video 9.5)

Fig. 9.6  Picture during operation showed the mitral vegetation

cc Tips  Mobile echodense masses attached to valvular leaflets and periannular abscesses are criteria for diagnosis of infective endocarditis. 

9.2  Status Post Mitral Replacement Endocarditis

9.2 Status Post Mitral Replacement Endocarditis

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A 62-year-old woman had a history of rheumatic heart disease with mitral stenosis status post MV replacement 10  years ago and sick sinus syndrome status post permanent pacemaker. She suffered general weakness, chest pain and exertional dyspnea. Auscultation: regular heart beat. ECG: ventricular rhythm. Cardiac CT: marked cardio-

megaly, lobulated masses over MV (2.2 cm × 1.5 cm at LA side, 1.8 cm × 1.3 cm at LV side with calcifications), engorged pulmonary arteries and right pleural effusion. Abdomen echo: engorged IVC and hepatic veins. Operation: redo MV replacement, repair of TV and pericardiectomy. Tissue culture of mitral vegetation confirmed micrococcus luteus (Figs. 9.7, 9.8, 9.9, 9.10, 9.11, 9.12, 9.13, 9.14, 9.15, 9.16, 9.17, 9.18, and 9.19).

Figs. 9.7 and 9.8 Two dimensional transesophageal echocardiography (2D TEE), long-axis view in systole (left) and diastole (right), status post mechanical MV

replacement, showed enlarged LA and irregularly shaped echogenic masses (arrows) attached to the atrial side of the mitral prosthesis (Video 9.6)

Fig. 9.9  2D TEE color Doppler, long-axis view, status post mechanical MV replacement, showed acceleration of mitral inflow (arrow) (Video 9.7)

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9  Infective Endocarditis

Figs. 9.10 and 9.11  3D TEE, en face view in systole (left) and diastole (right), status post mechanical MV replacement, showed the vegetation (arrows) was mobile and close to the prosthetic mitral annulus (Video 9.8)

Figs. 9.12 and 9.13  3D TEE, long-axis view in systole (left) and diastole (right), status post mechanical MV replacement, showed a mobile vegetation (arrows) attached to the atrial side of the mitral prosthesis (Video 9.9)

9.2  Status Post Mitral Replacement Endocarditis

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Fig. 9.16  2D TEE, long-axis view, status post re-do tissue MV replacement, showed normal prosthetic function Fig. 9.14  3D TEE color Doppler, status post mechanical MV replacement, showed acceleration of mitral inflow (Video 9.10)

Fig. 9.15  Contrast-enhanced CT, status post mechanical MV replacement, showed marked cardiomegaly and lobulated masses (arrows) over both LA and LV sides of MV with calcifications

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9  Infective Endocarditis

Fig. 9.17  2D TEE color Doppler, x-plane view, status post re-do tissue MV replacement, showed normal mitral inflow and minimal MR

Fig. 9.18  3D TEE, en face view, status post re-do tissue MV replacement (MVR), showed normal prosthetic function (Video 9.11)

Fig. 9.19  3D TEE color Doppler, long-axis view, status post re-do tissue MV replacement, showed normal mitral inflow (Video 9.12)

cc Tips  The infection of prosthetic valve often involves the area around the sewing ring rather than valvular vegetation. 

9.3  Bicuspid Aortic Valve Vegetation

9.3 Bicuspid Aortic Valve Vegetation A 57-year-old man without any previous medical history suffered from exertional shortness of breath. Auscultation: regular heart beat with a grade 2/6 systolic murmur over aortic area. ECG:

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LA enlargement, left axis deviation and LV hypertrophy. Chest X ray: cardiomegaly and bilateral pleural effusion. Cardiac catheterization: severe AR and pulmonary hypertension. Operation: AV replacement (Figs.  9.20, 9.21, 9.22, 9.23, 9.24, 9.25, 9.26, 9.27, 9.28, 9.29, 9.30, 9.31, 9.32, 9.33, and 9.34).

Figs. 9.20 and 9.21  2D TEE, long-axis view, showed systolic doming (left) and diastolic sagging (right) of AV with a vegetation (arrows) attached to it (Video 9.13)

Figs. 9.22 and 9.23  2D TEE color Doppler, long-axis view, showed aortic stenosis (AS) with high-velocity LV outflow in systole (left) and severe AR in diastole (right) (Video 9.14)

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9  Infective Endocarditis

Figs. 9.24 and 9.25  3D TEE, long-axis view in systole (left) and diastole (right), showed AV vegetation (*) attached to the ventricular side of the leaflet with prolapse into the LV outflow tract in diastole (Video 9.15)

Figs. 9.26 and 9.27  3D TEE, short-axis view (left) and multi-planer reconstruction (right), showed bicuspid AV with vegetation (*) extension into the aortic root in systole and the AV area is 1.8 cm2 (Video 9.16)

9.3  Bicuspid Aortic Valve Vegetation

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Figs. 9.28 and 9.29  3D TEE color Doppler, showed AS with high-velocity LV outflow (arrow) in systole (left) and severe AR in diastole (right) caused by AV vegetation (arrow) (Video 9.17)

Figs. 9.30 and 9.31  2D TEE (left) and color Doppler (right), long-axis view, status post tissue AV replacement, showed normal prosthesis function and LV outflow

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Fig. 9.32  3D TEE, long-axis view, status post tissue AV replacement (AVR), showed normal prosthesis function (Video 9.18)

9  Infective Endocarditis

Fig. 9.34  3D TEE color Doppler, short-axis view, status post tissue AVR, showed normal LV outflow and minimal AR (Video 9.20)

cc Tips  An AV vegetation usually results in AR. A TEE examination is essential in detecting associated pathologies such as aortic abscess. 

9.4 Ascending Aorta Vegetation

Fig. 9.33  3D TEE, short-axis view, status post tissue AVR, showed normal prosthesis function (Video 9.19)

A 68-year-old woman has a history of coronary artery disease status post PCI, type two diabetes mellitus, bilateral pulmonary artery obstructive disease status post PTA with stent, end stage renal disease with regular hemodialysis and hyperlipidemia. She suffered from productive yellowish sputum and tarry stool, progressive shortness of breath and fever after dialysis. At emergency room, lab data showed leukocytosis and NT-pro BNP = 23,202 pg/mL. Auscultation: irregular heart beat without significant murmur. ECG: sinus tachycardia and possible inferior ischemia. Chest X ray: pulmonary congestion, pneumonia and cardiomegaly. Chest CT: heavy calcification of coronary arteries. Operation: removal of vegetation in ascending aorta and CABG ×1 (Figs.  9.35, 9.36, 9.37, 9.38, 9.39, 9.40, and 9.41).

9.4  Ascending Aorta Vegetation

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Figs. 9.35 and 9.36  Two-dimensional transesophageal echocardiography (2D TEE), long-axis view, showed highly mobile vegetation (*) attached to the wall of ascending aorta (Video 9.21)

Fig. 9.37  2D TEE color Doppler, long-axis view, showed vegetation (*) in ascending aorta and mild AR (arrow) Fig. 9.39  3D TEE, long-axis view, showed highly mobile vegetation (*) attached to the wall of ascending aorta (Video 9.23)

Fig. 9.38  2D TEE color Doppler, long-axis view, showed vegetation (arrow) in ascending aorta and flapping back and forth with cardiac cycle (Video 9.22)

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9  Infective Endocarditis

Figs. 9.40 and 9.41  3D TEE, zoom mode, showed highly mobile vegetation (*) attached to the wall of ascending aorta and flapping back and forth with cardiac cycle (Video 9.24)

cc Tips  Although TEE cannot define tissue pathology, the clinical presentation and image properties can help diagnosing vegetation and endocarditis. 

9.5 Right Ventricular Outflow Tract Vegetation A 49-year-old woman with old anterior septal myocardial infarction suffered from chest tightness and dyspnea. After being hospitalized, she experienced fever and Salmonella paratyphoid-A infection was found. Auscultation: regular heart beat without murmur. Cardiac catheterization: insignificant coronary artery disease. Chest CT: bilateral lung septic emboli, pericardial effusion with pericardial thickening and prominent pulmonary trunk with focal thickening over PV.  Operation: emergency removal of RV outflow tract vegetation (Figs. 9.42, 9.43, 9.44, 9.45, 9.46, 9.47, 9.48, and 9.49).

Fig. 9.42 Two-dimensional transesophageal echocardiography (2D TEE), short-axis view, showed a RV outflow tract vegetation (*) which was close to the PV. MPA, main pulmonary artery (Video 9.25)

9.5  Right Ventricular Outflow Tract Vegetation

Fig. 9.43 2D TEE, zoom-mode of short-axis view, showed a RV outflow tract vegetation (*) which was close to the PV (Video 9.26)

Fig. 9.44 2D TEE color Doppler, short-axis view, showed accelerated flow (arrow) in main pulmonary artery (MPA) caused by the RV outflow tract vegetation (Video 9.27)

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Fig. 9.45  3D TEE, short-axis view, showed a RV outflow tract vegetation (*) which was close to the PV (Video 9.28)

Fig. 9.46 3D TEE color Doppler, short-axis view, showed accelerated flow (arrow) in main pulmonary artery caused by the RV outflow tract vegetation (Video 9.29)

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Figs. 9.47 and 9.48  3D TEE color Doppler (left) and color suppressed (right), view from RV perspective, showed accelerated flow (arrow) in main pulmonary artery caused by the RV outflow tract vegetation (*) (Videos 9.30 and 9.31)

9.6 Infective Endocarditis with Ventricular Septal Defect

Fig. 9.49  Picture during the operation, the RV outflow tract vegetation was present

cc Tips  Although endocarditis often results in valvular vegetation, vegetation can arise from any portion of the heart. 

A 27-year-old woman with heart murmur has run a fever since coming back from Thailand. Blood culture growth with MRSA.  After antibiotics treatment, fever persisted. Auscultation: regular heart beat with a grade 2/6 systolic murmur. ECG: sinus tachycardia and nonspecific ST-T abnormality. Chest X ray: borderline cardiomegaly. Operation: TV repair and VSD patch repair (Figs.  9.50, 9.51, 9.52, 9.53, 9.54, 9.55, 9.56, 9.57, and 9.58).

9.6  Infective Endocarditis with Ventricular Septal Defect

Fig. 9.50  Two-dimensional transesophageal echocardiogram (2D TEE), short-axis view, showed perimembranous ventricular septal defect (*) just lateral to the TV and huge TV vegetation (arrow) (Video 9.32)

215

Fig. 9.53 2D TEE color Doppler, short-axis view, showed a left-to-right flow (red arrow) across the ventricular septal defect and mild to moderate TR (yellow arrow) (Video 9.34)

Fig. 9.51  2D TEE, short-axis view, showed multiple highly mobile echodense masses (arrows) attached to both atrial and ventricular sides of the septal tricuspid leaflet with its tail extended to the RV outflow tract Fig. 9.54  3D TEE, short-axis view, showed a perimembranous ventricular septal defect (*) and vegetation (arrows) attached to both atrial and ventricular sides of septal tricuspid leaflet (Video 9.35)

Fig. 9.52  2D TEE, modified four-chamber view, showed multiple highly mobile echodense masses (arrows) attached to both atrial and ventricular sides of the septal tricuspid leaflet (Video 9.33)

216

Fig. 9.55  3D TEE, modified four-chamber view, showed vegetation (arrows) attached to both atrial and ventricular sides of septal tricuspid leaflet (Video 9.36)

9  Infective Endocarditis

Fig. 9.57  3D TEE color Doppler, modified four-chamber view, showed a mild to moderate TR (arrow) (Video 9.38)

Fig. 9.58  Picture during operation, showed the septal tricuspid vegetation (arrow) Fig. 9.56 3D TEE color Doppler, short-axis view, showed a left-to-right flow (arrow) across the ventricular septal defect (Video 9.37)

cc Tips  The differential diagnosis of a large, mobile, echodense mass includes thrombus or a tumor. The pathology should be confirmed by blood culture. 

9.7  Aortic Tissue Prosthetic Valve Vegetation Induced Left Ventricular Outflow Tract to Right Atrium…

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9.7 Aortic Tissue Prosthetic Valve Vegetation Induced Left Ventricular Outflow Tract to Right Atrium Shunt (Gerbode Defect) A 59-year-old male with history of Bicuspid aortic valve s/p AVR (bovine valve Magna 25  mm). He suffered from effort exertional several days and received antibiotic for 6 weeks. ECG: sinus tachycardia. Chest X ray: Tortuous thoracic aorta with calcification of the aortic knob, Borderline cardiomegaly. Operation: re-do AVR (metallic), Reconstruction of Left Ventricular Outflow (Figs.  9.59, 9.60, 9.61, 9.62, 9.63, and 9.64).

Fig. 9.61  2D TEE showing LVOT to Right Atrium Shunt (arrow). (LV: Left Ventricle, AO: Aorta, RV: Right Ventricle, RA: Right Atrium) (Video 9.41)

Fig. 9.59  Two-dimensional transesophageal echocardiogram (2-D TEE), long axis view, showing dehiscence of prosthetic aortic valve (arrow) (Video 9.39)

Fig. 9.62  3D TEE Color Doppler showing high velocity flow through the Left Ventricular Outflow to Right Atrium (arrow) (Video 9.42)

Fig. 9.60  2D TEE, bicaval view, showing Left Ventricular Outflow to Right Atrium Shunt. (LA: Left Atrium, TV: Tricuspid Valve, RA: Right Atrium) (Video 9.40)

Fig. 9.63  TrueVue 3D TEE, short axis view, small floating vegetation near rupture hole (arrow) (Video 9.43)

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9  Infective Endocarditis

Fig. 9.64  TrueVue 3D TEE revealing the defect from Left Ventricular Outflow Tract to Right Atrium (arrow) (Video 9.44)

9.8 Mitral Valve Perforation Having Mitral Repair A 59-year-old male suffered from low back, fever off and on. He received the antibiotic with Unasyn, Rocephin and Ampicillin for

Streptococcus sanguinis of blood culture and was admitted for Mitral Valve Repair. ECG: Sinus rhythm. Chest X ray: Cardiomegaly. CAG: Severe MR with vegetation, Mild AR, and severe pulmonary hypertension. Operation: s/p MV repair with Physio II ring (Figs. 9.65, 9.66, 9.67, 9.68, 9.69, and 9.70).

9.8  Mitral Valve Perforation Having Mitral Repair

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Fig. 9.65  Two-dimensional Transesophageal echocardiography (2D TEE), long axis view, showing anterior leaflet perforation (arrow) in systole (left) and in diastole (right) (Video 9.45)

Fig. 9.66  2D TEE, long axis view, revealing high velocity mosaic flow in systole (arrow) (Video 9.46) Fig. 9.68  3D TEE Color Doppler showing severe mitral regurgitation jet through the perforation (arrow) (Video 9.48)

Fig. 9.67  Three-dimensional Transesophageal echocardiography (3D TEE), en face view, demonstrating anterior leaflet perforation (arrow) (Video 9.47)

Fig. 9.69  TrueVue 3D TEE, showing perforation on mitral anterior leaflet (arrow) (Video 9.49)

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9  Infective Endocarditis

Fig. 9.70  Intraoperative view of the mitral anterior leaflet and significant perforation

9.9 Mitral Valve Vegetation Having Mitral Valve Replacement A 60-year-old male patient with medical history of Hypertension under medical control and Inguinal hernia s/p repair. He suffered from persistent dyspnea on exertion. He did not experience any syncope, fever, chills, or chest pain. A bedside Transthoracic Echocardiography showed severe MR with a 1.3 cm mobile lesion over the anterior mitral leaflet. He was admitted under the impression of infective endocarditis for further management. ECG: Sinus rhythm. R/O left atrial enlargement. Non-specific STT change c/w myocardial ischemia. Chest X ray: Mild cardiomegaly. Operation: S/P Resection of mitral valve leaflet and Reconstruction of mitral chordae with Artificial CV4 loops (2 sets of 2 loops each, 1A1P)  +  MVR (Medtronic metallic ATS valve, 31 mm) + TVA (Edwards MC3) (Figs. 9.71, 9.72, 9.73, 9.74, 9.75, 9.76, 9.77, 9.78, 9.79, 9.80, 9.81, 9.82, and 9.83).

Fig. 9.71  Two-dimensional Transesophageal Echocardiography (2D TEE), two chamber view, revealing vegetation attached to P1 (arrow head) and A2 (arrow) (Video 9.50)

Fig. 9.72  2D TEE transgastric view showing vegetation attaching on the anterior leaflet (arrow) (Video 9.51)

Fig. 9.73  2D TEE Color Doppler showing high turbulent flow through the mitral leaflet (arrow) (Video 9.52)

9.9  Mitral Valve Vegetation Having Mitral Valve Replacement

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Fig. 9.74  2D TEE Color Doppler demonstrating severe mitral regurgitation in transgastric view (Video 9.53)

Fig. 9.77  TrueVue 3D TEE revealing significant vegetation on A2 (arrow) (Video 9.56)

Fig. 9.75  Three-dimensional Transesophageal Echocardiography (3D TEE), en face view, revealing the perforation on A2 leaflet (arrow) (Video 9.54)

Fig. 9.78  TrueVue 3D TEE showing severe mitral regurgitation (arrow) (Video 9.57)

Fig. 9.76  TrueVue 3D TEE showing perforation on the mitral leaflet (arrow) (Video 9.55)

Fig. 9.79  3D TEE Color Doppler demonstrating mosaic turbulence through A2 perforation (arrow) and P1 (Video 9.58)

222

Fig. 9.80  Status post mitral valve replacement, 2D TEE still revealing severe mitral regurgitation (Video 9.59)

9  Infective Endocarditis

Fig. 9.83  TrueVue 3D TEE showing one of the leaflets closing normally in systole (arrow), the other one was stuck by the remaining native leaflets. The patient was reopened, the result was good (Video 9.62)

9.10 Tricuspid Valve Vegetation with Aorta to Right Atrium Shunt

Fig. 9.81  3D TEE Color Doppler in systole showing only one leaflet closed (asterisk) (Video 9.60)

Fig. 9.82  3D TEE showing only one of the prosthetic leaflet motion (asterisk) (Video 9.61)

A 58-year-old male had past history of DM, Chronic hepatitis B, which were irregular follow up. He suffered from defecate with tarry stool for 4 days thus he visited our ER. He had fever to 38.5 °C at ER. Under the impression of Duodenal ulcers with recent bleeding. He was admitted to our GI ward for further evaluation and management. ECG: sinus rhythm, left atrial enlargement, clockwise rotation. Chest X ray: Borderline cardiomegaly, Exaggerated bronchovascular markings in bilateral lower lung fields. Transthoracic echocardiography was done during hospitalization which revealed infective endocarditis of tricuspid valve with severe tricuspid regurgitation and moderate to severe aortic regurgitation. Operation: AVR (21  mm St. Jude mechanical valve) + TVR (33 mm St. Jude porcine valve)  +  Aortic root reconstruction (Sinus Valsalva to RA bovine patch repair)  +  Epicardial lead implantation to RV, single lead (Figs.  9.84, 9.85, 9.86, 9.87, 9.88, 9.89, and 9.90).

9.10  Tricuspid Valve Vegetation with Aorta to Right Atrium Shunt

Fig. 9.84  Two-dimensional Transesophageal Echocardiography (2-D TEE) showing a linear mass attaching to the aortic valve (arrow) (Video 9.63)

223

Fig. 9.86  2D TEE Color Doppler revealing an abnormal shunt between Sinus Valsalva and RA (arrow) (Video 9.65)

Fig. 9.85  2D TEE demonstrating a highly mobile echodensity seen in RA (2.7 × 1.6 cm) (Video 9.64)

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9  Infective Endocarditis

Fig. 9.87  2D TEE Color Doppler X plane displaying the abnormal flow through the aorta (arrow) and severe tricuspid regurgitation (Video 9.66)

Fig. 9.88  TrueVue 3D TEE revealing a significant defect (arrow) from Aorta to RA causing vegetation attaching to tricuspid leaflet (asterisk) (Video 9.67)

9.11  Transcatheter Aortic Valve Implantation

225

Fig. 9.89  3D TEE and 3D TrueVue TEE showing a highly mobile vegetation (asterisk) swinging between sinus of Valsalva and RA through the rupture (arrow) (Videos 9.68 and 9.69)

Fig. 9.90  3D TEE Color Doppler and 3D TrueVue Color Doppler demonstrating the abnormal flow crossing the defect (arrow) (Videos 9.70 and 9.71)

9.11 Transcatheter Aortic Valve Implantation A 77-year-old male had history of end stage renal disease under regular hemodialysis for 1  year, hypertension, and type 2 diabetes mellitus for years with medical treatment. He suffered from syncope for several times in 2 months and dyspnea on exertion last year thus trans-subclavian

artery transcatheter aortic valve implantation (TAVI) was done. This time, fever was noted in 5 days and weakness over four limbs was present for about 3  weeks. Blood culture showed GPC colonization. ECG: Atrial flutter, LBBB. Chest X ray: Cardiomegaly with Prominent both pulmonary hilum (Figs.  9.91, 9.92, 9.93, 9.94, 9.95, 9.96, 9.97, 9.98, and 9.99).

226

Fig. 9.91  Two-dimensional Transesophageal Echocardiography (2D TEE) showing shaggy appearance vegetation attaching aortic valve (white arrowhead) with prolapse of anterior mitral leaflet (arrow). Aortic pseudoaneurysm was also seen (asterisk) (Video 9.72)

9  Infective Endocarditis

Fig. 9.93  2D TEE Color Doppler showing perforated AML on basal portion of MV with severe MR (arrow) (Video 9.74)

Fig. 9.92  2D TEE in X plane revealing vegetation attaching to posterior cuspid and oscillating in posterior aortic root (white arrow) (Video 9.73)

9.11  Transcatheter Aortic Valve Implantation

Fig. 9.94  3D TEE Color Doppler showing perforated AML on basal portion of MV with severe MR (arrow) (Video 9.75)

Fig. 9.95  3D TEE TrueVue revealing a circular rupture at basal mitral valve (arrow) (Video 9.76)

Fig. 9.96  3D TEE Color Doppler showing severe mitral regurgitation crossing through the rupture (arrow) (Video 9.77)

227

Fig. 9.97  2D TEE Color Doppler demonstrating high velocity mosaic flow and ascending aorta pseudo-aneurysm (asterisk) (Video 9.78)

Fig. 9.98  3D TEE Color Doppler showing high velocity flow through into the pseudo-aneurysm during systole (arrow) (Video 9.79)

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9  Infective Endocarditis

Fig. 9.99  TrueVue 3D TEE revealing pseudoaneurysm (asterisk) forming from the aortic root rupture (red arrowhead) (Video 9.80)

Suggested Reading Allred C, Crandall M, Auseon A.  The important but underappreciated transgastric right ventricular inflow view for transesophageal echocardiographic evaluation of cardiac implantable device infections. Echocardiography. 2013;30(1):E1–3. Almdahl SM, Endresen PC, et al. Unusual left atrial vegetation. J Card Surg. 2014;29(5):638. Anwar AM, Nosir YF, et  al. Real time three-dimensional transesophageal echocardiography: a novel approach for the assessment of prosthetic heart valves. Echocardiography. 2014;31(2):188–96. Barton TL, Mottram PM, Stuart RL, et al. Transthoracic echocardiography is still useful in the initial evaluation of patients with suspected infective endocarditis: evaluation of a large cohort at a tertiary referral center. Mayo Clin Proc. 2014;89(6):799–805. Butler TC, Sedgwick JF, Burstow DJ. 3-D assessment of infective endocarditis with anterior mitral valve perforation and flail posterior leaflet. Int J Cardiol. 2015;185:249.

Chen SW, Tsai FC, Chou AH. Adult bicuspid aortic valve endocarditis with extensive paravalvular invasion attributable to disseminated varicella zoster infection. Ann Thorac Cardiovasc Surg. 2012;18(4):382–4. Di Benedetto G, Citro R, Longobardi A, et  al. Giant Candida mycetoma in an ascending aorta tubular graft. J Card Surg. 2013;28(5):557–60. Gurbuz AS, Ozturk S, et al. Perforation of anterior mitral leaflet aneurysm: a rare cause of severe mitral regurgitation. Egyptian Heart J. 2016;68:131–3. Harding D, Cahill TJ, et al. Infective endocarditis complicating transcatheter aortic valve implantation. Heart. 2020;106:493–8. Harinstein ME, Marroquin OC.  External coronary artery compression due to prosthetic valve bacterial endocarditis. Catheter Cardiovasc Interv. 2014;83(3):E168–70. Ikeda A, Nakajima T, et al. Infective endocarditis of aortoright atrial fistula caused by asymptomatic rupture of a sinus of Valsalva aneurysm: a case report. Surg Case Rep. 2016;2:43. Liang M, Pasupati S, Jogia D. Post-transcoronary ethanol septal ablation (TESA) infective endocarditis compli-

Suggested Reading cated by a ventricular septal defect. J Invasive Cardiol. 2011;23(8):348–50. Ouyang H, Wu X, Zhang J.  Giant vegetation in the right ventricle caused by Staphylococcus aureus and Candida mycoderma. Heart Surg Forum. 2014;17(1):E7–9. Patel N, Azemi T, Zaeem F, et al. Vacuum assisted vegetation extraction for the management of large lead vegetations. J Card Surg. 2013;28(3):321–4. Rap MI, Chacko A. Optimising the use of transoesophageal echocardiography in diagnosing suspected infective endocarditis. Acta Cardiol. 2015;70(4):487–91. Suryaprabha T, Kaul S, Alladi S, et  al. Acute posterior circulation infarct due to bicuspid aortic valve vegetation: an uncommon stroke mechanism. Ann Indian Acad Neurol. 2013;16(1):100–2.

229 Tanaka A, Sakamoto T, et  al. Vegetation attached to the elephant trunk. Eur J Cardiothorac Surg. 2013;44(3):565–6. Tanis W, Teske AJ, van Herwerden LA, et al. The additional value of three-dimensional transesophageal echocardiography in complex aortic prosthetic heart valve endocarditis. Echocardiography. 2015;32(1):114–25. Vilacosta I, Olmos C, de Agustín A, et al. The diagnostic ability of echocardiography for infective endocarditis and its associated complications. Expert Rev Cardiovasc Ther. 2015;16:1–12. Yong MS, Saxena P, Killu AM, et  al. The preoperative evaluation of infective endocarditis via 3-dimensional transesophageal echocardiography. Tex Heart Inst J. 2015;42(4):372–6.

Tumors and Mass Lesions

Abstract

This chapter deals with tumors and mass lesions. Cases of thrombus, myxomas, and thymoma are described. 3D TEE allows a full view and better understanding of the mass and its relation with the surrounding anatomic structures. An en face view of the LAA inlet from the LA can be provided to evaluate the LAA thrombus.

10

Auscultation: irregular heart beat with a grade 3 systolic murmur over apex. ECG: atrial fibrillation with rapid ventricular response, clockwise rotation and non-specific STT change. Chest X ray: mild cardiomegaly. Cardiac catheterization: single vessel coronary disease. Operation: removal of LA thrombus, obliteration of LA appendage and atrial fibrillation ablation (Figs. 10.1, 10.2, 10.3, 10.4, 10.5, 10.6, 10.7, and 10.8).

10.1 Left Atrial Thrombus A 73-year-old man had a history of hypertension, hepatitis B and chronic atrial fibrillation. A LA thrombus was told by another hospital.

Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-­981-­19-­6794-­8_10. 231 © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_10

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Fig. 10.1  Two-dimensional transesophageal echocardiography (2D TEE), x-plane view, showed dilated LA with a thrombus (*) in LA appendage (LAA)

Fig. 10.2  2D TEE, two-chamber view, showed dilated LA with a thrombus (*) in LA appendage (LAA) (Video 10.1)

Fig. 10.3  3D TEE, en face view, showed a thrombus (*) in LA (Video 10.2)

Fig. 10.4  3D TEE, view from LA perspective, showed a thrombus (*) in LA appendage (LAA) (Video 10.3)

10.1  Left Atrial Thrombus

233

Figs. 10.5 and 10.6  3D TEE, view from LA perspective in systole (left) and diastole (right), showed a thrombus (*) in LA appendage (LAA) (Videos 10.4 and 10.5)

Fig. 10.7  2D TEE, x-plane view, status post removal of LA thrombus and obliteration of LA appendage, showed no more thrombus in LA

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Fig. 10.8  3D TEE, long-axis view, status post removal of LA thrombus and obliteration of LA appendage, no more thrombus was in LA (Video 10.6)

10  Tumors and Mass Lesions

Fig. 10.9 Two-dimensional transesophageal echocardiography (2D TEE), long-axis view, showed a highly mobile, grape cluster appearance myxoma (M) attached to anterior mitral leaflet (Video 10.7)

cc Tips  In 2D TEE, two- and four-chamber views provide best images of LAA.  But in 3D TEE, multiple viewing perspectives are available to evaluate the thrombus in LAA. 

10.2 Left Atrial Myxoma A 61-year-old man with medical-controlled type two diabetes mellitus suffered from dizziness with heart burn sensation. He was told having a Fig. 10.10 2D TEE color Doppler, long-axis view, LA tumor by other hospital. Auscultation: regular showed the LA myxoma (M) with flow across and caused heart beat without murmur. ECG: non-specific eccentric MR (Video 10.8) ST-T change. Cardiac catheterization: single-­ vessel coronary artery disease. Operation: removal of LA tumor, patch repair of created ASD and CABG ×1 (SVG to OM2). Pathological diagnosis: myxoma (Figs.  10.9, 10.10, 10.11, 10.12, 10.13, 10.14, 10.15, 10.16, and 10.17).

Fig. 10.11  3D TEE, long-axis view, showed the irregular LA myxoma (M) prolapse across the mitral annulus into the LV in diastole (Video 10.9)

10.2  Left Atrial Myxoma

Fig. 10.12  3D TEE, showed the LA myxoma (M) arising from a stalk (arrow) attached to the anterior mitral leaflet (Video 10.10)

235

Fig. 10.13 3D TEE color Doppler, long-axis view, showed eccentric MR and normal LV diastolic filling (Video 10.11)

Fig. 10.14  2D TEE image, x-plane view, status post removal of LA tumor, showed clear LA with normal MV function

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10  Tumors and Mass Lesions

Fig. 10.15  2D TEE color Doppler, long-axis view, status post removal of LA tumor, showed mild MR (arrow) Fig. 10.17  3D TEE color Doppler, five-chamber view, status post removal of LA tumor, showed mild MR (Video 10.13)

cc Tips  Clinical presentation, location, attachment site, mobility, size and shape are key points to elaborate an intracardiac mass. Among which, determination of the attachment site is the most essential for surgical plan for resection. 

10.3 Right Atrial Myxoma Fig. 10.16 3D TEE, five-chamber view, status post removal of LA tumor, showed clear LA with normal MV function (Video 10.12)

A 50-year-old woman presented with RA tumor, numbness of bilateral hand and shortness of breath. Auscultation: regular heart beat. ECG: RA enlargement and right axis deviation. Catheterization: a large RCA branch gave blood supply to the huge RA tumor, positive tumor stain sign. Operation: RA tumor removal. Pathological diagnosis: myxoma (Figs.  10.18, 10.19, 10.20, 10.21, 10.22, 10.23, 10.24, 10.25, 10.26, 10.27, 10.28, 10.29, 10.30, 10.31, 10.32, 10.33, 10.34, and 10.35).

10.3  Right Atrial Myxoma

Fig. 10.18  Two-dimensional transesophageal echocardiography (2D TEE), modified four-chamber view, showed a huge mobile mass (M) in RA with dilated RA and RV (Video 10.14)

Fig. 10.19 2D TEE, modified four-chamber view, showed the mass (M) with non-homogeneous density attached to RA basal posterior wall (Video 10.15)

237

Fig. 10.20 2D TEE color Doppler, modified four-­ chamber view, showed accelerated tricuspid inflow (arrow), partial obstruction to RV diastolic filling, due to the atrial mass (M) (Video 10.16)

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Fig. 10.21  2D TEE continuous-wave Doppler of TV, TS with high gradient tricuspid inflow (arrow) was present

Fig. 10.22 2D TEE color Doppler, modified four-­ chamber view, showed the RA mass (M) had blood supply and nearly filled the chamber

10.3  Right Atrial Myxoma

239

Fig. 10.23  2D TEE color Doppler, x-plane view, showed moderate TR (arrows) due to incomplete TV closure (Video 10.17)

Fig. 10.24 3D TEE, modified four-chamber view, showed the huge mass (M) attached to RA basal posterior wall (Video 10.18)

Fig. 10.25  3D TEE color Doppler, showed the RA mass (M) had blood supply (arrow) (Video 10.19)

240

Figs. 10.26 and 10.27  3D TEE color Doppler, modified four-chamber view, showed moderate TR (yellow arrow) in systole due to incomplete TV closure (left) and acceler-

10  Tumors and Mass Lesions

ated tricuspid inflow (red arrow) in diastole as the mass (M) obstructed the tricuspid orifice (right) (Video 10.20)

Figs. 10.28 and 10.29  Fluoroscopy of RCA, a large conus branch (arrow) gave blood supply to the RA tumor, positive tumor stain sign

10.3  Right Atrial Myxoma

241

Fig. 10.30  2D TEE, x-plane view, status post removal of RA tumor, complete excision was documented

Fig. 10.31 2D TEE color Doppler, modified four-­ chamber view, status post removal of RA tumor, showed mild TR (arrow) Fig. 10.32  3D TEE, modified four-chamber view, status post removal of RA tumor without residual (Video 10.21)

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10  Tumors and Mass Lesions

Fig. 10.33 3D TEE color Doppler, modified four-­ chamber view, status post removal of RA tumor, showed mild TR (arrow) (Video 10.22)

Figs. 10.34 and 10.35  Picture during operation (left) and gross specimen (right) showed the RV myxoma measuring 6 cm × 5 cm × 4 cm in fresh state

cc Tips  Myxomas are the most common primary cardiac tumor, which most often are single and arise from the fossa ovalis of the interatrial septum. 

10.4 Invasive Thymoma Extending into Superior Vena Cava and Right Atrium A 34-year-old man was in good health before. He suffered from facial flush, swelling and dyspnea recently. Lab data showed aspartate transaminase  =  18  IU/L and creatinine  =  0.88  mg/

dL.  Auscultation: regular heart beat without murmur. ECG: normal sinus rhythm. Chest X ray: increased soft tissue density at mediastinum with a space occupied lesion in left pulmonary hilum. Chest CT: a huge anterior mediastinal tumor (10 cm × 7.4 cm) with lung metastasis and superior vena cava (SVC) involvement. Operation: mediastinal tumor resection, wedge resection of right middle lobe lung tumor and SVC repair. Pathological diagnosis: thymoma, type B2, stage IV (Figs. 10.36, 10.37, 10.38, 10.39, 10.40, 10.41, 10.42, 10.43, 10.44, 10.45, 10.46, 10.47, 10.48, 10.49, 10.50, and 10.51).

10.4  Invasive Thymoma Extending into Superior Vena Cava and Right Atrium

Fig. 10.36  Two-dimensional transesophageal echocardiography (2D TEE), showed an invasive thymoma (M) extending into the SVC and protruded into RA (Video 10.23)

243

Fig. 10.37  2D TEE color Doppler, showed an invasive thymoma (M) extending into the SVC with occlusion (Video 10.24)

Fig. 10.38  2D TEE color Doppler, x plane view, showed SVC was occluded by the invasive thymoma (M) (Video 10.25)

Figs. 10.39 and 10.40  3D TEE, showed the thymoma (M) extending into the SVC and protruded into RA (Videos 10.26 and 10.27)

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10  Tumors and Mass Lesions

Fig. 10.41  3D TEE, showed the thymoma (M) extending into the SVC and protruded into RA (Video 10.28)

Figs. 10.42 and 10.43  3D TEE, zoom mode and perspective from RA to SVC (right), showed the thymoma almost filled the SVC and protruded into RA

Fig. 10.44  3D TEE, perspective from RA to RV, showed the thymoma (M) protruded into RA (Video 10.29)

Fig. 10.45  3D TEE color Doppler, showed an invasive thymoma (M) extending into the SVC with occlusion (Video 10.30)

10.4  Invasive Thymoma Extending into Superior Vena Cava and Right Atrium

245

Fig. 10.46  Contrast-enhanced CT images, showed a huge anterior mediastinal tumor with lung metastasis (red arrows) and extended into the SVC and RA (yellow arrows)

Fig. 10.47  Picture during tumor resection, showed the thymoma in SVC (arrow)

Fig. 10.49  3D TEE, status post tumor resection, showed clear RA without residual thymoma (Video 10.31)

Fig. 10.48  2D TEE color Doppler, status post tumor resection, showed clear RA without residual thymoma

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without cold sweating since 2  months ago, the symptom could relieved after taking rest. ECG: sinus rhythm, LVH by voltage. Chest X ray: No cardiomegaly. Chest CT: A well defined filling defect 33  mm at left atrium, attaching to atrial septum suspected myxoma. CAG: CAD with TVD s/p PCI without ISR with native vessel progression. Operation: S/P mini-thoracotomy removal of LA myxoma and patch repair of created ASD (Figs.  10.52, 10.53, 10.54, 10.55, 10.56, 10.57, 10.58, and 10.59). Fig. 10.50  3D TEE, status post tumor resection, showed clear RA without residual thymoma (Video 10.32)

Fig. 10.52  Two-dimensional transesophageal echocardiography (2-D TEE), long-axis view, showing a highly mobile myxoma attaching to anterior mitral leaflet prolapsing into LV (arrow) (Video 10.34)

Fig. 10.51  3D TEE color Doppler, status post tumor resection, showed mild TR (Video 10.33)

cc Tips  Invasive thymoma commonly infiltrates neighboring mediastinal structures. The case with thymoma extension into the SVC and consequent SVC occlusion is rare. 

10.5 Left Atrial Myxoma A 52-year-old man with history of triple vessel disease, hypertension, and hyperlipidemia suffered from intermittent exertional chest tightness

Fig. 10.53  TrueVue 3D TEE showing myxoma in LA (Video 10.35)

10.5  Left Atrial Myxoma

Fig. 10.54 2-D TEE, modified four-chamber view, revealing the irregular shape LA myxoma attaching to atrial septum (arrowhead) (Video 10.36)

247

Fig. 10.55  2-D TEE, long-axis view, showing myxoma crossing into LV in diastole causing mitral stenosis (arrow) (Video 10.37)

Fig. 10.56  2-D TEE continuous-wave Doppler of mitral valve, left atrial myxoma mimicking mitral stenosis

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10.6 Mitral Valve Tumor

Fig. 10.57 Three-dimensional transesophageal echocardiography (3-D TEE), en face view, showing myxoma attaching to atrial septum by stalk (arrow) (Video 10.38)

A 47-year-old female patient had a past medical history of liver tumor with multiple bone and lung metastases s/p targeted therapy, immunotherapy, and Transcatheter Arterial Embolization. She initially experienced palpitation intermittently with severe dyspnea for the past one and a half years, but did not noted peripheral edema, orthopnea, resting dyspnea, or syncope. In the past 2 months, however, her palpitation episodes’ frequency increased from 1 to 2 times every week to once every 1–2  days. Transthoracic echocardiography showed multiple bright small echo density attached to the mitral valve caused mitral stenosis and severe regurgitation. Surgical ­operation was performed and histological examination revealed more than 90% of the tumor cells are reactive to Ki-67. An intimal sarcoma is considered (Figs. 10.60, 10.61, 10.62, 10.63, 10.64, 10.65, 10.66, and 10.67).

Fig. 10.58  2D TEE, status post removal of myxoma, revealing clear LA (Video 10.39)

Fig. 10.60  Two-dimensional Transesophageal Echocardiography (2D TEE) showing plaque-like mass attaching AML and PML with thickened of atrioventricular junction (Video 10.41)

Fig. 10.59  3D TEE Color Doppler showing mild regurgitation after removal of myxoma in systole (arrow) (Video 10.40)

10.6  Mitral Valve Tumor

Fig. 10.61  2D TEE Color Doppler demonstrating severe eccentric mitral regurgitation in systole (arrow) (Video 10.42)

Fig. 10.62  3D TEE, en face view, revealing restrictive motion of AML and PML with mitral stenosis (Video 10.43)

Fig. 10.63  TrueVue 3D TEE showing diffusive mass causing mitral inflow tract obstruction (Video 10.44)

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Fig. 10.64  TrueVue 3D TEE Color Doppler showing severe mitral regurgitation during systole (Video 10.45)

Fig. 10.65  3D TEE showing tumor mass attached on mitral leaflet causing mitral stenosis (arrowhead) (Video 10.46)

Fig. 10.66 3D TEE Color Doppler revealing high velocity through the mitral valve during diastole (Video 10.47)

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Fig. 10.67  3D TEE Continuous wave Doppler parallel to the mitral inflow in apical four chamber view showing mitral stenosis with peak gradient around 16 mmHg

10.7 Extracardiac Tumor A 67-year-old woman denied any systematic history before. She suffered from sudden onset dyspnea for 1  week. Admission was arranged, Transthoracic Echocardiography found severe MR and severe TR.  Operation was suggested. Pre-operative Transesophageal Echocardiography showed continuous flow seen from Superior Vena Cava (SVC). SVC and surrounding area were filled with mass lesion, the operation was immediately canceled. Chest CT was arranged (Figs. 10.68, 10.69, 10.70, 10.71, 10.72, 10.73, 10.74, 10.75, and 10.76).

Fig. 10.68  Two-dimensional Transesophageal Echocardiography (2D TEE), four-chamber view, revealing heart failure with LVEF ~50% (Video 10.48)

10.7  Extracardiac Tumor

Fig. 10.69  2D TEE Color Doppler showing severe MR and severe TR (arrow) (Video 10.49)

Fig. 10.70  Three-dimensional Transesophageal Echocardiography (3D TEE), en face view, displaying noncoaptation of mitral valve (Video 10.50)

251

Fig. 10.72  2D TEE revealing Superior Vena Cava filled with tumor (Video 10.52)

Fig. 10.73  2D TEE Color Doppler showing little blood flow through the SVC (Video 10.53)

Fig. 10.74 2D TEE bubble contrast test showing restricted SVC flow (Video 10.54) Fig. 10.71  TrueVue 3D TEE Color Doppler showing mitral regurgitation during systole (arrow) (Video 10.51)

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Suggested Reading

Fig. 10.75  Chest CT showing extracardiac tumor located in lung, RUL with hilum, RML, RLL, mediastinum, and SVC lumen, patient was referred to oncology for further evaluation and treatment

Fig. 10.76  After biopsy R/I small cell carcinoma of lung, T4N3M1b state IVA metastases with SVC syndrome

Abdelaziz A, Abdelgawad A, et al. A new complication of transesophageal echocardiography: pulmonary embolization of a right atrial myxoma. J Thorac Cardiovasc Surg. 2015;149(5):e79–81. Cannavà G, Currò A.  Left atrial myxoma presenting as acute coronary syndrome. Int J Cardiol. 2015;190:148–50. De Giacomo T, Patella M, et  al. Successful resection of thymoma directly invading the right atrium under cardiopulmonary bypass. Eur J Cardiothorac Surg. 2015;48(2):332–3. Melloni G, Bandiera A, et al. Thymoma with intravascular extension into the right atrium. Eur J Cardiothorac Surg. 2014;45(4):e126. Nishizaki Y, Yamagami S, Daida H.  Left atrial myxoma incidentally discovered on transesophageal echocardiography. Intern Med. 2015;54(5):535. Ried M, Neu R, Schalke B, et al. Radical surgical resection of advanced thymoma and thymic carcinoma infiltrating the heart or great vessels with cardiopulmonary bypass support. J Cardiothorac Surg. 2015;10:137. Yong-Qiang D, Jiang-Shui L, Xiao-Ming Z, et al. Surgical treatment of an invasive thymoma extending into the superior vena cava and right atrium. World J Surg Oncol. 2014;12:6. Zhang H, Wang W, et  al. Undifferentiated sarcoma originating from the mitral valve: a case report. J Cardiothorac Surg. 2016;11:82.

11

Others

Abstract

The other cases are classified as this chapter including a patient received a HeartMate II and the other patient suffered aortic root perforation. A HeartMate II is a LV assistant device which can be alternative to heart transplantation. Perforation of aortic root is an iatrogenic complication during atrial fibrillation ablation. The cases are both interesting and enjoyable.

sion. Cardiac catheterization: severe triple-vessel coronary artery disease, ischemic cardiomyopathy and refractory heart failure, NYHA Fc III–IV.  Heart transplantation was advised, but due to pertinacity of severe hyperglycemia under oral hypoglycaenic agent status, he decided to have a HeartMate II implantation. Operation: CABG x1 (SVG to OM) and HeartMate II implantation (Figs.  11.1, 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, and 11.8).

11.1 HeartMate II A 50-year-old man had a history of ischemic cardiomyopathy with congestive heart failure, old myocardial infarction with triple-vessel coronary artery disease status post PTCA and stenting, LV thrombus, hypertension and type two diabetes mellitus. He suffered from fever with chillness and exertional dyspnea. Auscultation: irregular heart beat with a grade 3/6 murmur over left sternal border. ECG: atrial fibrillation with moderate ventricular response, ventricular premature beats and right axis deviation. Chest X ray: cardiomegaly and bilateral pleural effu-

Fig. 11.1 Two-dimensional transesophageal echocardiography (2D TEE), four-chamber view, showed congestive heart failure with global systolic dysfunction, four-chamber dilation and moderate pericardial effusion (arrows) (Video 11.1)

Supplementary Information The online version contains supplementary material available at https://doi.org/ 10.1007/978-­981-­19-­6794-­8_11. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 W.-H. Yin, M.-C. Hsiung, Atlas of Perioperative 3D Transesophageal Echocardiography, https://doi.org/10.1007/978-981-19-6794-8_11

253

254

Fig. 11.2 2D TEE color-Doppler, long-axis view, showed congestive heart failure with moderate ischemic MR (arrow) (Video 11.2)

Fig. 11.3  2D TEE, long-axis view, status post implantation of LV assistant device, HeartMate II.  The cannula (arrows) inserted into LV apex (Video 11.3)

11 Others

Fig. 11.4  2D TEE color Doppler, long-axis view, status post HeartMate II implantation. Flow out of the ventricle occurred through the HeartMate II (arrows) (Video 11.4)

11.1 HeartMate II

255

Fig. 11.5  2D TEE continuous-wave Doppler through the cannula, proper filling was confirmed

Fig. 11.6 3D TEE, four-chamber view, status post implantation of LV assistant device, HeartMate II.  The cannula (arrows) inserted into LV apex (Video 11.5)

Fig. 11.7  3D TEE color Doppler, long-axis view, status post HeartMate II implantation. Showed diastolic flow in the apical cannula (arrows) (Video 11.6)

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11 Others

Fig. 11.9 Two-dimensional transesophageal echocardiography (2D TEE), short-axis view, during atrial fibrillation ablation, showed the ablation lead (arrows) went through from RA to aortic root at the level of the aortic sinus, just above the non-coronary cusp of the AV (Video 11.7) Fig. 11.8  Chest X ray showed the HeartMate II device was successfully implanted which included an outlet (o) inserted into LV apex, a pump (*), an inlet draining into ascending aorta (yellow arrow) and a wire (red arrow) connecting to external battery

cc Tips  A comprehensive TEE examination is essential both prior to and after the HeartMate II insertion to prevent any contraindication as well as to confirm the placement and function.

11.2 Iatrogenic Aortic Root Perforation A 71-year-old man had a history of coronary artery disease status post PCI (LAD, LCX) and CABG x3 (SVG to first diagonal, posterior lateral branch of RCA and OM), severe MR and TR status post MV replacement and TV repair. He suffered from intermittent palpitation and exertional dyspnea. Auscultation: irregular heart beat without significant heart murmur. ECG: atrial fibrillation with tachycardia and old anterioseptal MI.  He admitted for atrial fibrillation ablation. During procedure, the ablation lead pierced

Fig. 11.10  3D TEE, short-axis view, during the procedure, showed the ablation lead (arrows) pierced through from RA to aortic root (Video 11.8)

through from RA to aorta which resulted in aortic root perforation. Operation: emergent occluder implantation for aorta to RA iatrogenic fistula (Figs.  11.9, 11.10, 11.11, 11.12, 11.13, 11.14, 11.15, and 11.16).

11.2 Iatrogenic Aortic Root Perforation

Fig. 11.11 3D TEE, modified five-chamber view, showed the ablation lead (arrows) pierced through from RA to aortic root (Video 11.9)

257

Fig. 11.14  3D TEE, modified five-chamber view, status post occluder (*) implantation (Video 11.12)

Fig. 11.15  3D TEE color Doppler, short-axis view, status post occluder (*) implantation without residual flow seen Fig. 11.12  3D TEE color Doppler, short-axis view, showed continuous flow (arrow) from aorta to RA (Video 11.10)

Fig. 11.13  3D TEE, short-axis view, showed the occluder (*) was transported by catheter (arrows) and deployed to occlude the iatrogenic aorta to RA fistula (Video 11.11)

Fig. 11.16  Fluoroscopy status post occluder implantation, showed the deployed occluder (arrows)

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cc Tips  TEE examination of aorta assists in the placement of ablation wire by preventing aortic injury and confirming proper positioning.

11.3 Tear of Aortic Valve Having Re-Do Aortic Valve Replacement A 32-year-old men suffered from orthopnea, palpitation and leg edema for 2 weeks, Transthoracic Echocardiography showed dilated four-chambers and RV failure. ECG: Atrial fibrillation with RVR. CAG: VHD with severe MR, TR, and pulmonary hypertension. Chest X ray: Cardiomegaly with Pleural effusion. He was admitted for mitral valve replacement and tricuspid valve repair. After MVR and TV Repair, hemolytic anemia was present. Transthoracic echocardiography revealed moderate to severe aortic regurgitation, suspected iatrogenic. Operation: s/p Re-do AVR (SJM metalic 21 mm) (Figs. 11.17,11.18, 11.19, 11.20, 11.21, and 11.22).

Fig. 11.18  2D TEE Color Doppler showing aortic regurgitation in diastole (arrow) (Video 11.14)

Fig. 11.19  TrueVue 3D TEE, long axis view, showing tear of aortic cusp (arrow) (Video 11.15)

Fig. 11.17 Two-dimensional Transesophageal Echocardiography (2D TEE) displaying mitral mechanical prosthetic valve with reverberation artifact (Video 11.13)

Fig. 11.20  TrueVue 3D TEE, short axis view, revealing NCC tear (arrow) (Video 11.16)

11.3 Tear of Aortic Valve Having Re-Do Aortic Valve Replacement

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Fig. 11.21  3D TEE Color Doppler demonstrating aortic regurgitation through the tear of the aortic valve (arrow) (Video 11.17)

Fig. 11.22  3D TEE Color Doppler image showing aortic regurgitation through the perforation (arrow) (Video 11.18)

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11.4 Ankylosing Spondylitis with Aortic and Mitral Regurgitation A 43-year-old male with the underlying disease of ankylosing spondylitis, hypertension, and hyperlipidemia. He suffered from acute onset dyspnea and intermittent palpitation since 1 week ago. He also complained nausea, poor appetite, and general weakness. Dyspnea gradually progressed in recent 3 days, which can’t relieve by resting, and accompanied with orthopnea, and paroxysmal nocturnal dyspnea. ECG: Sinus rhythm, left ventricular hypertrophy. Chest X ray: Cardiomegaly, bilateral infiltration favor pulmonary edema. Degenerative joint disease with marginal spurs of T-spine and bamboo spine appearance. Preoperative TEE showed Inferior segments of LV relatively hypokinesia. LVEF  =  40–45%. CAG: VHD with severe AR, moderate to severe MR (functional MR), and Moderate TR.  Operation: Resection of aortic valve cusps and AVR (23  mm St Jude metallic valve). Resection of mitral valve cusps and MVR (29  mm St Jude metallic valve). TVA (28  mm MC3 ring) (Figs.  11.23, 11.24, 11.25, 11.26, 11.27, and 11.28).

Fig. 11.24  Aortic valve stiffness causing severe aortic regurgitation (arrow) (Video 11.20)

Fig. 11.25 Mitral valve insufficiency in Ankylosing Spondylitis is rare but can cause cardiac failure. The fibrosis of sub-aortic tissues may reach the mitral valve leaflets therefore decreasing mitral valve mobility (arrow) (Video 11.21)

Fig. 11.23  The cellular inflammatory process that leads to endarteritis around aortic root causing aortic root stiffness (arrow). Sustaining platelet aggregation and fibroblast hyperactivity leading thickened aortic valve (arrow) (Video 11.19)

Fig. 11.26  During systole, 3D TEE revealing severe mitral regurgitation in long axis view (arrow) (Video 11.22)

11.5 Mitral Valve Repair Causing Iatrogenic Heart Rupture

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Fig. 11.27  TrueVue 3D TEE, long axis view, showing severe aortic regurgitation in diastole (left) and severe mitral regurgitation in systole (right) (Video 11.23)

Fig. 11.28  Status post AVR and MVR showing normal prosthetic valve motion (Video 11.24)

11.5 Mitral Valve Repair Causing Iatrogenic Heart Rupture A 66-year-old female had past history of valvular heart disease and atrial fibrillation with bi-­ ventricular dysfunction. She complained of dyspnea on exertion for 2–3 months with progressive during climbing mountain. ECG: Atrial fibrillation with moderate ventricular response, ventricular premature beats. Chest X ray: Tortuosity of thoracic aorta with cardiomegaly, active lung lesion. CAG: VHD with severe MR and LA dila-

Fig. 11.29 Two-Dimensional Transesophageal Echo­ cardiography(2D TEE) in four chamber view showing severe mitral regurgitation (arrow) and dilated Left Atrium, Left Ventricle and Right Atrium (Video 11.25)

tion, Atrial fibrillation. Operation: MV repair (32 mm physio II + ant. neo-chorda) + TV repair (32  mm MC3) + LAAO(inside) with iatrogenic LA rupture and LV rutpure s/p LA repair with self pericardium patch, s/p LV repair with Bovine patch, s/p MVR (31 mm St. Jude Epic porcine), s/p autologous heart transplantation, post Intraaortic balloon pump implantation (Figs.  11.29, 11.30, 11.31, 11.32, 11.33, and 11.34).

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Fig. 11.30  2D TEE, four chamber view, status post mitral repair demonstrating normal mitral valve motion but the hematoma (asterisk) out of the LA was noted (Video 11.26)

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Fig. 11.31  2D TEE Color Doppler, status post mitral repair displaying hematoma (asterisk) besides LA and LV, iatrogenic rupture of lateral myocardium was noted (arrow) (Video 11.27)

Fig. 11.32  2D TEE Color Doppler in X plane showing mosaic flow crossing from LV to pericardium (arrow) (Video 11.28)

11.6 Mitral Stenosis with Mitral Valve Replacement Causing LVOT Obstruciton

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Fig. 11.33  Three-dimensional transesophageal echocardiography and TrueVue revealing a stereotactic view of the rupture (arrow) (Videos 11.29 and 11.30)

Fig. 11.34  Auto transplantation was performed; LA and LV were ruptured during procedure and mitral valve replacement was considered. 2D TEE status post mitral valve replacement showing normal function of prosthetic valve (arrow) (Video 11.31)

Fig. 11.35 Two-dimensional Transesophageal Echocardiography (2D TEE), long axis view, revealing calcification of aortic valve and mitral valve (arrowheads) (Video 11.32)

11.6 Mitral Stenosis with Mitral Valve Replacement Causing LVOT Obstruciton A 78-year-old female had medical history of critical AS, severe MS, CHF and type II DM.  She suffered from dyspnea on exertion with near syncope for months. Surgical intervention was suggested. Operation: AVR (Edwards Magna Ease 21  mm)  +  MVR (Edwards Sapien 3 29 mm) + Myectomy (2 g) + CABG X 1 (SVG to LAD) (Figs.  11.35, 11.36, 11.37, 11.38, 11.39, 11.40, 11.41, 11.42, 11.43, 11.44, and 11.45).

Fig. 11.36  2D TEE Color Doppler showing significant MS with degrading MR under general anesthesia (Video 11.33)

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Fig. 11.37  Due to severe calcified of the mitral annulus, Thoracotomy Valve in Valve was performed. 2D TEE, two-chamber view, demonstrating SAPIEN prosthetic valve locating within mitral annulus (Video 11.34)

Fig. 11.38  2D TEE Color Doppler and 3D TEE showing normal mitral inflow but LVOT obstruction causing by the frame design of SAPIEN valve (arrow) (Videos 11.35 and 11.36)

11.6 Mitral Stenosis with Mitral Valve Replacement Causing LVOT Obstruciton

Fig. 11.39  2D TEE Continuous Wave Doppler showing 100 mmHg peak gradient at LVOT

Fig. 11.40  Three-dimensional Transesophageal Echo­ cardiography (3D TEE) revealing narrowed LVOT (arrowhead) (Video 11.37)

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Fig. 11.41  3D TEE MPR demonstrating only 0.66 cm2 area of the LVOT (Video 11.38)

Fig. 11.42  2D TEE in long axis view showing 1.6  cm IVS should be resected (Video 11.39)

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11.6 Mitral Stenosis with Mitral Valve Replacement Causing LVOT Obstruciton

Fig. 11.43  2D TEE focus view demonstrating 1.02 cm2 area of septum should be removed

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Fig. 11.44 2D TEE Color Doppler revealing less obstructed LVOT after septal myectomy (Video 11.40)

Fig. 11.45  2D TEE Continuous Wave Doppler showing 20 mmHg peak gradient at LVOT after myectomy

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Suggested Reading

11 Others

Ho-Ping Y, An-Ning F, Shen-Kou T, et al. Transcatheter repair of iatrogenic aortic perforation complicating transseptal puncture for a catheter ablation of atrial Bansal RC, Chandrasekaran K.  Real time three-­ arrhythmia. Acta Cardiol Sin. 2014;30:490492. dimensional transesophageal echocardiographic evalMoyssakis I, Gialafos E, et  al. Myocardial perforuation of aortic valve perforation. Echocardiography. mance and aortic elasticity are impaired in patients 2015;32(7):1147–56. with ankylosing spondylitis. Scand J Rheumatol. Cheng RK, Aboulhosn J, Nsair A.  Percutaneous 2009;38:216–21. angioplasty of stenotic outflow graft anastomoOzkan Y. Cardiac involvement in ankylosing spondylitis. sis of HeartMate II.  JACC Cardiovasc Interv. J Clin Med Res. 2016;8(6):427–30. 2014;7(6):700–3. Pauwaa S, Raghuvir R, Kurien S, et al. Intermittent aorCopeland H, Stoletniy L, et al. Implantation of HeartMate tic insufficiency as an aid to diagnosing obstruction in II left ventricular assist device in a single-lung patient. a HeartMate II continuous-flow left ventricular assist Ann Thorac Surg. 2015;99(6):2216–8. device. ASAIO J. 2011;57(3):244–6.