Mary E. Arthur

The Feasibility of Simultaneous Orthogonal Plane Imaging with Tilt for Short-Axis Evaluation of the Pulmonic Valve by Transesophageal Echocardiography

Simultaneous orthogonal plane imaging with tilt enables the display of two 2D, real-time images and the evaluation of structures that cannot be seen by conventional single-plane transesophageal echocardiographic (TEE) imaging. After a step-wise examination protocol, we used simultaneous orthogonal plane imaging to obtain the short-axis view of the pulmonic valve (PV) and assessed flow in both images simultaneously using color Doppler imaging in 100 consecutive patients undergoing intraoperative TEE. Our goals were to assess the ability of this technique to visualize all 3 leaflets of the PV, assess feasibility of planimetry to measure valve area, and assess flow using color Doppler imaging. All study images were obtained by anesthesiologists who are diplomates in Advanced Perioperative Transesophageal Echocardiography. All 3 leaflets of the PV were successfully visualized in the short-axis view in 65% of cases, 2 leaflets were visualized in 32% of cases, and only 1 leaflet could be imaged in 3%. The flow across the valve could be evaluated using color Doppler imaging in all cases. Planimetry for valve area was possible when all 3 leaflets were seen. It is important to inspect the PV during a routine TEE examination; however, the orientation of the PV in respect to the esophagus makes this evaluation challenging. We present a simple protocol to evaluate the PV in long-axis and short-axis views simultaneously that can potentially help evaluate for pathologies involving the PV.

Massive thrombus in transit detected by echocardiography.

extraterrestrial visitors to our planet, the intracardiac “unidentified” object shown here displayed a pattern of motion that was inconsistent with any known law of physics and was easily debunked by an alternative viewing perspective. The images reinforce that catheters, cannulae, or pacing electrodes are best examined by using multiple TEE imaging planes in order to definitively exclude imaging artifacts that may otherwise be misidentified as relevant intracardiac structures1,2 or a portent of imminent alien invasion.

“Golf Ball” in the Left Ventricular Outflow Tract?

1 XXX 2017 A 13 × 20 mm mobile vegetation (Panel A) resembling a golf ball, and causing dynamic left ventricular outflow tract (LVOT) obstruction, was found to be attached to the anterior mitral valve leaflet (AMVL) on the ventricular side by transesophageal echocardiography in the midesophageal long-axis view, sparing the posterior mitral valve leaflet (PMVL). Most vegetations on the mitral valve attach to the atrial (low flow, left atrium [LA]) side of the leaflet, but on rare occasions are on the ventricular (high flow) side.1 Vegetation location, regurgitation mechanism, and severity of the LVOT obstruction were assessed by color flow Doppler. The presence of the mass on the leaflet tip prevented leaflet coaptation, resulting in central mitral regurgitation (MR) in systole.2 There was flow convergence within the left ventricle (LV) proximal to the mass as well as flow acceleration that began at the mass proximal to the aortic valve, causing a dynamic LVOT obstruction (Panel B). This large (greater than 10 mm) mass posed a high risk for systemic embolization.3 Hemodynamic management can be challenging in the presence of MR, low systemic vascular resistance in the presence of sepsis, general anesthesia, and dynamic LVOT obstruction. Ensuring adequate coronary and systemic perfusion by optimizing preload and maintaining sinus rhythm with a moderate rate should be the goal. Continuous intraoperative transesophageal echocardiography confirms vegetation size and location; defines the degree of valve involvement and damage to surrounding tissue; facilitates hemodynamic monitoring; and alerts the anesthesiologist to systemic embolization.2

Left Ventricular Outflow Tract Area Measurements by Planimetry Using Two-Dimensional Simultaneous Orthogonal Plane Imaging During Transesophageal Echocardiography

OBJECTIVE Calculations of the left ventricular outflow tract (LVOT) area are typically based on the assumption that the LVOT is circular. This study was conducted to determine whether simultaneous orthogonal plane imaging with tilt during two-dimensional (2D) transesophageal echocardiography provided more accurate measurements of the LVOT area than the standard method. DESIGN The authors prospectively measured the LVOT area in 2D by (1) the standard calculation based on the diameter as viewed on the long axis, and (2) a direct measurement using planimetry of the short axis, in consecutive patients presenting for elective surgery. The authors validated the planimetric technique by obtaining three-dimensional (3D) measurements in a subset of the subjects. SETTING An academic medical center. PARTICIPANTS Adult surgical patients with no evidence of aortic stenosis. INTERVENTIONS Transesophageal images were acquired by anesthesiologists certified by the National Board of Echocardiography. MEASUREMENTS AND MAIN RESULTS Image acquisition and assessment were performed in the operating room and found to be adequate for analysis in 52 of 55 subjects. Simultaneous orthogonal plane imaging with tilt enabled long- and short-axis visualization of the LVOT. The authors found that the standard method underestimated the area by 0.78 cm(2) compared to the direct method (2D planimetry) when measured at the same beat at a similar point in the cardiac cycle. Moreover, 2D planimetry measurements were comparable to 3D planimetry measurements in the last 20 study subjects (R(2) = 0.88, p<0.0001). CONCLUSIONS This study suggested that 2D planimetry may be more accurate than 2D diameter-based calculations.