James K. Kirklin

Usefulness of transesophageal three-dimensional echocardiography in the identification of individual segment/scallop prolapse of the mitral valve.

We evaluated the potential usefulness of three‐dimensional (3D) transesophageal echocardiography (TEE) in assessing individual scallop/segment prolapse in 36 adult patients with mitral valve prolapse (MVP) undergoing surgical correction. Intraoperative 3D TEE correctly identified the location of scallop/segment prolapse in 34 of 36 patients (94%). However, in 6 of these patients 3D TEE images revealed more scallops or segments with prolapse than the surgeon noted intraoperatively. Prolapse of these areas was less prominent and this could possibly explain the lack of correlation with the surgical findings in these patients. In another 2 patients areas of prolapse seen by the surgeon were missed by 3D TEE because some of those scallops/segments could not be well imaged due to image “drop out” and artifacts. Thus, perfect correlation between 3D TEE and surgery was noted in 28 of 36 (78%) patients. Noncoaptation of the MV was also identified in 2 patients. The prolapsed area of posterior (n = 28 observations) and anterior (n = 9 observations) MV leaflets ranged from 1 cm2 to 9 cm2 (mean 3.50 cm2± 2.14) and 1.20 cm2 to 5.99 cm2 (mean 3.21 cm2± 1.33), respectively. Interobserver and intraobserver agreement for location and area of MVP was excellent (r = 0.97 and r = 0.99, respectively; all P values are <0.0001). In conclusion, 3D TEE is useful in identifying the location of MVP. It may also be potentially useful in assessing the extent of individual scallop/segment prolapse and identifying sites of MV noncoaptation. This information could aid the surgeon in deciding the extent of MV resection. (ECHOCARDIOGRAPHY, Volume 20, February 2003)

Initial Experience with Live/Real Time Three‐Dimensional Transesophageal Echocardiography

A new tool has been recently introduced to the echocardiography armamentarium, live/real time three‐dimensional (3D) transesophageal echocardiography (TEE). In these cases, we describe our initial experience in 13 patients studied intraoperatively and in the echocardiography suite. This important technology promises improved anatomic definition, diagnostic confidence, and novel views of the complicated cardiovascular pathology encountered in common clinical practice.

Multiplane Transesophageal Echocardiographic Imaging and Three-Dimensional Reconstruction

This study presents our preliminary experience in multiplanar transesophageal echocardiography. In addition, an attempt was made in one patient to reconstruct the left ventricle in three dimensions using the sequential planes obtained from the multiplanar approach.

Device Related Infections: Are We Making Progress?

Abstractu2002 Infection was identified early in development of mechanical circulatory support devices (MCSDs) as an important cause of morbidity and mortality. Sepsis, infection of implanted pump components, and infections of percutaneous drivelines continue to limit survival and decrease quality of life for patients with a MCSD. This review examines five questions related to whether there has been progress in preventing or managing infection complications in patients with MCSDs. Have changes in patient selection, device design, and surgical implant techniques decreased the incidence of infection? Do smaller implanted blood pumps have a lower risk for infection than larger implanted blood pumps? Will fully implanted circulatory support systems have fewer infection complications than tethered MCSDs? Can optimal design of a driveline together with improvements in surgical techniques and care of the percutaneous driveline diminish the rate and consequences of driveline infections? Have improvements in the preoperative, intraoperative, and immediate postoperative management of patients with MCSDs decreased the risk of sepsis? Although infection remains an important problem for patients with MCSDs, there is evidence that we are making progress as described in this review. It is crucial that we continue. (J Card Surg 2010;25:478‐483)

Usefulness of Live/Real Time Three‐Dimensional Transthoracic Echocardiography in the Characterization of Ventricular Septal Defects in Adults

In this report, we present 12 patients (range 14–76 years, mean 40 ± 22.7 years) who underwent surgical repair of a ventricular septal defect (VSD). Location, size, and surrounding anatomy of the VSD were assessed prior to intervention in all patients with live/real time three‐dimensional transthoracic echocardiography (3DTTE). In 9 patients, measurements of maximum dimension, circumference, and area by 3DTTE correlated well with the same measurements from intraoperative three‐dimensional transesophageal echocardiographic (3DTEE) reconstruction. 3DTTE measurement of maximum dimension of VSDs also agreed well with maximum dimension by surgery in 10 patients. Live/real time 3DTTE accurately defined VSD location, size, and surrounding anatomy in all patients studied by us. VSD characterization by live 3DTTE agreed well with surgery descriptions and 3DTEE measurements.

Intraventricular Tunnel Repair of Double Outlet Right Ventricle

Double outlet right ventricle (DORV) may be divided into subsets according to the position and commitment of the ventricular septal defect (VSD) to the great arteries. In DORV with subaortic VSD, an intraventricular tunnel repair is the recommended operation. The current hospital mortality is 5% with an actuarial survival of 83% at 15 years. DORV with doubly committed VSD should also be repaired with an intraventricular tunnel, and the surgical results are similar to those for DORV and subaortic VSD. In DORV with subpulmonary VSD, an intraventricular tunnel repair is advisable when the distance from the tricuspid to the pulmonary valve exceeds the distance from tricuspid to aortic valve. Otherwise, a spiral intraventicular tunnel or an arterial switch procedure should be considered. In DORV with doubly committed VSD, the results of surgical treatment have been less good, and alternative forms of surgical treatment require further evaluation. The surgical treatment of DORV with pulmonary stenosis and the surgical details of the intraventricular tunnel repair are discussed.

Assessment of Surgically Unroofed Coronary Sinus by Live/Real Time Three-Dimensional Transthoracic Echocardiography

Both two‐dimensional transthoracic echocardiography (2DTTE) and live/real time three‐dimensional transthoracic echocardiography (3DTTE) were attempted in a 25‐year‐old morbidly obese female with total anomalous pulmonary venous return (TAPVR) into the coronary sinus (CS) in whom surgical unroofing of CS with patch closure of CS ostium was performed in infancy to redirect pulmonary venous flow into the left atrium (LA). The patient had become increasingly symptomatic over the past 1 year because of severe left‐to‐right shunting due to dehiscence of the patch used to close the CS ostium. Despite a poor acoustic window, 3DTTE was able to identify a communication between the LA and CS which resulted from surgical unroofing of the CS as well as flow signals moving into the right atrium from the CS. These findings were not detected by 2DTTE.

Two‐ and Three‐Dimensional Transesophageal Echocardiographic Localization of a Right Atrial Lipoma: Importance of Orienting Echocardiographic Images to the Surgeon's View

We present a patient in whom the exact location of a right atrial lipoma identified with two‐ and three‐dimensional transesophageal echocardiography (2‐D and 3‐D TEE) was correlated with the surgical findings. By orienting the 3‐D TEE images to conform to the view of the surgeon from the right side of the patient and referencing the site of attachment of the tumor to the surrounding structures, this lipoma was correctly localized to a 7 oclock position in the right atrium.

Transesophageal Echocardiographic Evaluation of Mechanical Biventricular Assist Device

The usefulness of transesophageal echocardiography in the assessment of mechanical biventricular assist devices is described.

Intraoperative Transesophageal Echocardiographic Diagnosis of a Stuck Bioprosthetic Mitral Valve Leaflet

Stuck (immobilized) leaflet of a metallic mitral prosthetic valve due to obstruction by mitral subvalvular apparatus is a well recognized complication after placement of prosthetic valves. However, a stuck mitral valve leaflet involving a bioprosthetic valve has not been reported so far most likely because of increased pliability of tissue leaflets. We describe the first case of a stuck bioprosthetic mitral valve leaflet in which intraoperative transesophageal echocardiography was useful to make a definitive diagnosis and helped to resolve the problem immediately.