Masses and Devices

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10 Masses and Devices

Massimiliano Meineri, Patricia Murphy

Key Points

• The knowledge of normal anatomic variants is critical. Incorrect identification of a mass as pathologic may lead to unnecessary diagnostic tests and treatments including surgery.
• In the left atrial appendage (LAA), pectinate muscles may be mistaken for thrombus.
• The “coumadin ridge,” if not imaged correctly, may appear as a free-floating structure in the left atrium (LA).
• Lambl’s excrescences are degenerative strands on the aortic valve (AV) and are of no clinical significance.
• The transverse pericardial sinus, when fluid-filled, may appear as a distinct vascular structure.

Several normal cardiac structures may mimic abnormal masses. In this section, we describe some of the structures (Table 10-1) that are frequently mistaken for pathologic entities.

TABLE 10-1 ANATOMIC VARIANTS

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Right Atrium

Crista Terminalis

• Prominent muscle ridge (Figure 10-1A).
• Junction of the right atrium (RA) and the superior vena cava (SVC).
• Trabeculations of the right atrial appendage (RAA) originate from the crista terminalis.
• Can be misinterpreted as tumor or thrombus.
• Characteristic appearance and position confirm correct identification.
• Best seen in the midesophageal (ME) bicaval view, adjusting the probe depth to display the SVC-RA junction.
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Figure 10-1 Several normal anatomic variants can be mistaken for intracardiac masses. In the RA, we can often distinguish the embryologic remnants (arrows): crista terminalis (A) at the junction of the SVC and the RA, eustachian valve (B) at the junction of the IVC and the RA, and Chiari network from the eustachian valve to the interatrial septum (C). Normal variants affecting the IAS are aneurysmal septum (D) and the typically bell-shaped lypomatous septal hypertrophy (E). In the LAA, we can often note a regular network of parallel fine muscle fibers known as pectinate muscles (F). In the LA, the coumadin ridge (G), a prominent muscle bridge, that divides the LAA from the LUPV. Within the RV, a transverse muscle ridge, known as the moderator band (H), characterizes the RV and can be mistaken for thrombus. Distal hypertrophy of the IVS with sigmoidal appearance: normal variant of aging and hypertension (I) is typical of longstanding hypertension. Normal filaments attached to the edges of the AV leaflets are the Lambl’s excrescences (J). They can be mistaken for endocarditic vegetations. The transverse sinus is a pericardial reflection between the ascending aorta and the PA. When expanded by minimal pericardial fluid, it becomes evident in the ME LAX (K) and the ascending aorta SAX (L) views.

Eustachian Valve

• Originates at the junction of the inferior vena cava (IVC) and the RA (see Figure 10-1B).
• Embryologic remnant of the right venous valve.
• Can be misdiagnosed as thrombus.
• Typically appears as a thin and mobile structure attached to the RA wall.
• Can be differentiated from thrombus by its typical location, attachment to the RA, and filamentous appearance.
• Best seen in ME bicaval view, advancing the probe to visualize the IVC-RA junction.

Chiari Network

• Found in 2% to 3% of the patients by transesophageal echocardiography (TEE).
• Vestigial remnant of the IVC valve.
• Fine meshwork of fine fibers that cross the RA (see Figure 10-1C).
• Runs between the eustachian valve and the interatrial septum (IAS).
• Connects the eustachian valve to the thebesian valve at the orifice of the coronary sinus (CS).
• Has no clinical relevance.
• Can be misdiagnosed as thrombus or other atrial mass, or the interatrial septum.
• Typical location and appearance allow correct identification.
• Best seen in the ME four-chamber view by rotating the probe to the right to display the RA and in the ME bicaval view.

Thebesian Valve

• Embryologic remnant of the valve to the CS.
• Prevents regurgitation of blood into the CS.
• May prevent insertion of retrograde cardioplegia cannula in the CS.
• Best seen in the ME four-chamber view by advancing the probe to visualize the CS.
• Can also be visualized in a modified ME bicaval view at 110 degrees adjacent to the septal leaflet of the tricuspid valve (TV).

Interatrial Septum

Interatrial Septal Aneurysm

• Prevalence is between 2% and 10%.
• Mobile or redundant septum.
• IAS right-left displacement of more than 1 cm.
• Fixed IAS bulge of more than 1.5 cm (see Figure 10-1D).
• Increased risk of stroke due to thrombus.
• Fifty percent are associated with patent foramen ovale (PFO).
• Characteristic sigmoid shape of IAS.
• May mimic mobile atrial mass.
• Best viewed in the ME four-chamber focusing on the IAS or in the ME bicaval view.

Lipomatous Hypertrophy of the Interatrial Septum

• Infiltration of the atrial septum by adipocytes.
• It normally spares the fossa ovalis.
• Diagnostic thickness criteria are 1.5 to 2.0 cm.
• Echogenic typical “dumbbell” shaped (see Figure 10-1E).
• Characteristic shape differentiates lipomatous hypertrophy from other structures and masses.
• Fatty deposits cause prominent acoustic shadow.
• Best viewed in the ME four-chamber focusing on the IAS or in the ME bicaval view.

Left Atrium

Pectinate Muscles

• Parallel muscular ridges found in both atria.
• Are prominent in the LAA (see Figure 10-1F) and can simulate an LAA thrombus.
• Typically have a tissue characterization similar to muscle.
• Scanning multiple planes is essential to differentiate from thrombus.
• Trabeculations emanate perpendicular from the LAA wall in a regularly spaced pattern (see Figure 10-1F).

Coumadin Ridge

• A prominent muscular ridge formed between the LAA and the left upper pulmonary vein (LUPV) (see Figure 10-1G).
• Linear structure with bulbous ends that give it the “Q-tip sign.”
• Historically mistaken for a thrombus and triggered anticoagulation therapy, thus, its name.
• Lack of mobility and characteristic location distinguish it from an abnormal structure.
• Best visualized in the standard ME two-chamber view.

Right Ventricle

• Trabeculations: muscle bands in the right ventricle (RV).
• Moderator band: prominent apical muscle band from septum to the anterior papillary muscle (PM; see Figure 10-1H).
• PMs.
• Right ventricular (RV) structures most commonly confused as masses are the RV trabeculations.
• RV is heavily trabeculated, and with right ventricular hypertrophy (RVH) trabeculations, become very prominent.
• Catheters within the RV can appear as small mobile echo densities that resemble intracardiac masses.
• Catheters are echo dense and produce typical reverberations and side lobe artifacts shadowing other structures.

Left Ventricle

• Several normal structures in the left ventricle (LV) may be mistaken as masses.
• PMs: usually two, one in the parachute mitral valve (MV).
• Aberrant chordae tendinae: abnormal extra MV chordae without structural function. Typically attached to the MV leaflets or to primary or secondary chordae. Homogeneous in structure, can be thickened compared with other chordae.
• Distal hypertrophy of the interventricular septum (IVS) with sigmoidal appearance: normal variant of aging and hypertension (see Figure 10-1I).
• False tendons: fine filaments across the left ventricular (LV) near apex.
• If imaged tangentially, PMs can be mistaken for masses.
• The location and attachments of the MV apparatus are distinguishing features of PM.

Aortic Valve

• Nodules of Arantius: points of coaptation of the AV. Seen at the tip of the AV as small globular thickening.
• Lambl’s excrescences: degenerative strands on either side of the AV (see Figure 10-1J). Commonly seen in older patients. They have no pathologic implications.
• Lambl’s excrescences can be misinterpreted for endocarditis.
• Lambl’s excrescences are fine homogeneous filaments attached to the AV closure line of normal AV leaflets.

Pericardium

• Normal pericardium is an echolucent layer with a normal thickness less than 1 mm.
• There is good correlation between TEE and computed tomography (CT) measurements of pericardial thickness.

Transverse Sinus, Fat Pad, Cyst

Transverse Sinus

• A reflection of the pericardium.
• It is a virtual space in absence of any pericardial effusion.
• It is seen as a triangular echo-free space between the ascending aorta, pulmonary trunk, and LA when filled with pericardial fluid.
• May be misinterpreted as a thrombus, cyst, or abscess.
• Pericardial fluid or fat in the transverse sinus can also be misdiagnosed as a mass in the LA
• Best imaged in the ME long axis (LAX) view between the ascending aorta and the right pulmonary artery (PA; see Figure 10-1K).
• Can also be visualized in the ME ascending aorta short axis (SAX) view between the ascending aorta and the PA (see Figure 10-1L).

Fat Pad

• A hypoechoic space anterior to the parietal pericardium. It is most often found adjacent to the RV and the LV apex.
• May be misinterpreted as a pericardial effusion.
• Pericardial fat is slightly more echogenic than an effusion, and it moves in concert with the heart. Pericardial effusion is motionless.

Pericardial Cyst

• Remnant of defect in the embryologic development of the pericardium.
• Normally localized in the right or left costophrenic angle.
• Usually asymptomatic.
• The echo appearance is of a localized echolucent thin-walled spherical structure.
• Differential diagnosis is pericardial effusion and pericardial fat.

Transesophageal Echocardiography Assessment of Intracardiac Masses

• Cardiac pathologic masses are: thrombus, infective vegetations, or tumor.
• TEE allows superior images of the LA, LAA, RA, and aorta.
• TEE is the gold standard in the diagnosis of vegetations and intracardiac thrombi, although visualization of the ventricular apex may not always be accurate.
• TEE allows differentiation of normal variants (see Table 10-1) and pathology.
• It can guide surgical therapy for intracardiac masses.

Systematic Transesophageal Echocardiography Assessment of Intracardiac Masses

Step 1: Describe shape, size, echodensity.
Step 2: Define number, location, and attachment.
Step 3: Identify coexisting pathology.
Step 4: Assess hemodynamic impact (e.g., flow obstruction).
Step 5: Quantify tissue invasion to determine resectability and its impact on adjacent structures.

Intracardiac Thrombi

• Appear as homogeneous and more echogenic than normal myocardium.
• Sessile or pedunculated; can reach a large size.
• Fresh thrombi are more mobile and friable, thus at higher risk of embolization (see Case 10-3 on the Expert Consult website).
• Older thrombi are more stable, are organized in layers, and may present initially with calcification.
• Predispositions to clot formation are blood stasis, hypercoagulable state, and rough surfaces.
• Can be found in all cardiac chambers. Predisposing factors vary (Table 10-2).
• TEE is indicated when transthoracic echocardiography (TTE) is inconclusive.

TABLE 10-2 INTRACARDIAC THROMBI

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Spontaneous Echocardiographic Contrast

• Dense swirling pattern seen in situations of low-flow states resembling smoke (Figure 10-2A) (see Case 10-4 on the Expert Consult website).
• May be a prodrome to clot formation and coexist with thrombi.
• Can be appreciated in the atrial and ventricular cavities during cardiopulmonary bypass (CPB).
• Thick spontaneous contrast in the LA can be confused with thrombus.
• Assess underlying anatomy and valvular and ventricular function.
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Figure 10-2 A, Spontaneous echo contrast indicates stagnant blood flow (arrow) and increased risk of thrombus formation. B, ME two-chamber view in a patient with LAA thrombus (arrow) underwent surgical removal. C, 3D TEE assessment of the LAA for thrombi includes X plane mode that allows simultaneous display of two perpendicular planes; in this example, the second plane (green) is positioned on the first to cut though the center of the LAA. D, Zoom and full-volume modes provide an en face view of the LAA inlet (arrow) from the LA.

Left Atrium

• Thrombi present as irregular masses of variable echogenicity that move with the underlying structure.
• LAA is the most common location of intracardiac thrombi (see Figure 10-2B).
• Very often associated with atrial fibrillation.
• LAA thrombi are rare in patients in sinus rhythm.
• LAA must be carefully assessed in the presence of mitral stenosis, LA enlargement, and stagnant flow with spontaneous echocontrast.
• Can be attached to a prosthetic MV and MV annuloplasty rings.
• TEE is the gold standard in the assessment of LAA.
• Location can help differentiate from tumors because thrombi are rarely attached to the IAS.
• TEE assessment of LAA implies two-dimensional (2D), color flow, and pulse wave (PW) Doppler.
• LAA PW Doppler has a typical biphasic trace. A peak velocity less than 40 cm/s indicates a low-flow risk of thrombus formation.
• 3D TEE allows superior visualization of the LAA using all 3D modalities (see Figure 10-2C and D).

Left Ventricle

• Rare in the absence of severe LV dysfunction.
• LV thrombi coexist with left ventricular wall motion abnormalities, LV dilatation (Figure 10-3C), and aneurysm.
• Attached to the endocardium of the akinetic segment (see Figure 10-3A and B).
• Can be attached to hardware (e.g., left ventricular assist device [LVAD] cannulas).
• Can be surrounded by spontaneous echocontrast.
• Can be sessile or pedunculated.
• Apical thrombi can often be better viewed on TTE.
• Assess underlying ventricular function and presence of hardware.
• Use multiple views and try to visualize the true LV apex.
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Figure 10-3 Patient presented for an LVAD implant in dilated cardiomyopathy. A and B, An independently mobile mass (arrow) is noted in the LV. C, LV function is severely compromised, as shown by end-systolic frame on 3D LV reconstruction.

Inferior Vena Cava, Right Atrium, Right Ventricle

• Appear as irregular masses of variable echogenicity that move with underlying structure.
• Seen in the RA in the presence of venous thromboembolism and pulmonary embolism (Figure 10-4B) (see Case 10-3 on the Expert Consult website).
• Occur on pacer wires and catheters in low-flow states.
• RA thrombi can cross a PFO and result in systemic embolism (see Case 10-3 on the Expert Consult website).
• IVC thrombi are often observed in patients with renal cell carcinoma (Figure 10-5).
• Thrombi in RA are often associated with thrombi in IVC, RV, and PA (see Figure 10-4).
• TEE can visualize the right PA and the proximal left PA; the distal left PA is usually obscured by the left mainstem bronchus.
• The absence of thrombi in the PA by TEE does not exclude pulmonary embolism.
• Assess the right circulation from the IVC to the distal right PA.
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Figure 10-4 Emergent TEE is performed for cardiac arrest following graft reperfusion after liver transplant. A, Modified ME bicaval view displays IVC and IVC-RA junction: thrombotic material (arrow) is noticed in the IVC. B, ME RV inflow-outflow view shows thrombi in the RV. C, Modified ME ascending aorta SAX view shows thrombus (arrow) in the distal right PA.

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Figure 10-5 Patient with renal cell carcinoma (A), scheduled for nephrectomy and IVC thrombectomy. B, IVC thrombus is displayed and the distance between the thrombus and the IVC-RA junction is measured (arrow). C, IVC flow limitation is displayed by color Doppler. D, 3D TEE allowed an en face view of the IVC thrombus from the RA and its relation to the hepatic vein.

Infective Endocarditis

• Infective endocarditis (IE) is a severe condition that carries a 6-month mortality of 25%.
• The diagnosis is based on clinical and echocardiographic data according to the modified Duke Criteria (Table 10-3).
• Positive TTE or TEE is a major criterion.
• TEE is indicated whenever TTE is inconclusive.
• TEE is also indicated in patients with prosthetic valves or elderly patients with valve abnormalities.
• IE can affect normal valves, but it mostly occurs on abnormal cardiac valves.
• Presence of foreign material as well as intravenous drug use increases the risk for IE.
• Advanced forms of IE result in abscess and fistulae, especially when the aortic valve is involved.
• A form of noninfective endocarditis is marantic endocarditis. It may be observed in patients with adenocarcinoma and antiphospholipid syndrome. Lesions are very difficult to differentiate from IE.

TABLE 10-3 MODIFIED DUKE CRITERIA

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Vegetations

• Common appearance is as irregular sessile or pedunculated masses.
• In active endocarditis, masses are more soft and friable.
• In chronic IE, they become more stable and dense.
• Fungal endocarditis presents with larger but less invasive vegetations.
• Independently mobile; embolization is not uncommon.
• TEE has a sensitivity of 90% to 100% and a specificity of 88% to 100% in detecting vegetations.
• Each cardiac valve is affected with a different frequency and pattern.

Aortic Valve

• Commonly attached to the ventricular side of the AV (Figure 10-6A and E).
• Predisposing conditions are bicuspid AV, rheumatic deformities, and valve degeneration.
• Vegetations may move back and forth during the cardiac cycle.
• Common evolution is aortic root abscess (see Figure 10-6A and E) and invasion of the intervalvular fibrosa.
• In case of aortic regurgitation, vegetations may also be found on the chordae tendinae and the anterior MV leaflet.
• IE on the AV can result in leaflet perforation and aortic regurgitation and are at high risk of embolization.
• Assessment of the AV is performed on multiple views. Zoom is used to better assess the AV leaflets.
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Figure 10-6 Patient presented with shortness of breath, fever, and chest pain. Severe AV regurgitation is noticed (A) on a bicuspid AV (B). Large vegetations are attached to the ventricular aspect of the AV. Aortic root is enlarged and presents an abscess of the sinus of Valsalva (arrow in A). C, Color flow Doppler reveals an aortic root to RA fistula with a left-to-right shunt. D, A large, independently mobile mass is noticed at the base of the TV septal leaflet in proximity to the exit point of the ascending aorta fistula. The mass indicates spread of infection to the right side of the heart. Pulmonary valve was spared in this case. E, Discrete abscess.

Mitral Valve

• Most frequently involved valve in IE.
• Commonly attached to the atrial side of the MV (Figure 10-7A).
• Predisposing conditions are rheumatic heart disease, valve degeneration and calcifications.
• MV IE commonly evolves into leaflet perforation and mitral regurgitation (MR; see Figure 10-7B).
• AV has to be assessed for new AR or leaflet abnormalities (see Figure 10-7C).
• Vegetations on the MV can be distinguished from torn chordae because the latter results in flail of the respective MV segment.
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Figure 10-7 Patient scheduled for MV replacement for endocarditis. Vegetations on the atrial aspect of the MV leaflets (arrow in A) and severe MV regurgitation (B) are displayed. All other valves are carefully inspected for vegetations and regurgitant lesions. C, The AV is noticed to be thickened. The AV was surgically inspected and found mildly sclerotic and was not replaced. D, In another patient with MV endocarditis, central coaptation (arrowhead) and a perforation of the anterior mitral leaflet (AML) (arrow) are seen. Two areas of proximal flow acceleration are seen on the ventricular side of the valve (double arrow). In the right panel, 3D TEE replicating the “surgeons view” of the mitral valve demonstrates the perforation (arrow). (D courtersy of Jorg Dziersk and Eliot Fagley.)

Tricuspid Valve

• Commonly attached to the atrial or the ventricular side of the TV.
• Chordae tendinae can also be affected.
• Commonly observed in intravenous drug users.
• Permanent RV catheters such as pacemaker leads are a risk factor (Figure 10-8).
• Result in leaflet perforation and disruption causing tricuspid regurgitation.
• Artifacts from hardware may prevent identification of small vegetations.
• TV can also be involved in presence of ascending aorta-RA (see Figure 10-6D) fistulae as a consequence of AV IE.
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Figure 10-8 In a patient with a recent stroke, a TEE is performed to rule out intracardiac source of emboli. A, A small thrombus is noticed in the RA, attached to a permanent pacemaker wire. B, A small mass is also noticed surrounding the same wire in the SVC (arrow).

Pulmonic Valve

• Less frequently affected by IE.
• In case of involvement of the PV, always suspect congenital heart disease and the presence of intracardiac shunts.

Prosthetic Valves

• Commonly attached to the sewing ring.
• On mechanical valves, it may be difficult to differentiate from pannus.
• IE on prosthetic valves may result in partial dehiscence of the valvular ring and paravalvular regurgitation.
• May cause the destruction of bioprosthetic leaflets and result in valvular regurgitation.
• Vegetations on prosthetic valves are more difficult to identify on TEE owing to echo shadowing from an adjacent valve, especially in patients with concomitant MV and AV prostheses.
• 3D TEE may allow better definition of the number and localization of the vegetations on bioprosthetic valves.

Abscess

• A complication of IE.
• It is defined as a thin-walled cavity containing purulent material as a result of bacterial infiltration.
• A common location is the aortic root as a sequela of AV IE (see Figure 10-6A and E).
• Abscess of the aortic root or the aorta-mitral intravalvular fibrosa may evolve into a pseudoaneurysm: a recess connected to the aortic root or left ventricular outflow tract (LVOT). Pseudoaneurysms expand during systole and are at risk of rupture.
• On TEE, abscesses appear as echo dense areas in continuity with the valvular plane.
• Abscesses can have a cystic component.
• Abscesses are associated with valvular regurgitation or prosthetic valve dehiscence.
• Abscess of the aortic root are commonly seen in the ME AV LAX view (see Figure 10-6A and E).

Fistulae

• The result of ruptured pseudoaneurysms.
• Aortic root abscesses may rupture into LA, RA, LVOT, or right ventricular outflow tract (RVOT) (see Figure 10-6C).
• Color flow Doppler allows identification of fistulae and may help determine the direction of flow within them.
• Dissemination of infection to downstream structures is common.
• May be single or multiple.

Key Points

• Intracardiac thrombi occur most commonly in the presence of atrial fibrillation, as a consequence of intravascular catheters, and in areas of stagnation such as an aneurysmal LV apex.
• TEE is the standard method to assess the LAA for thrombus before cardioversion. A comprehensive examination of both the LAA and the LA proper is required. This is especially present in patients with rheumatic heart disease.
• “Smoke,” or spontaneous echo contrast, indicates a low-flow state and is especially worrisome when it fails to clear from the LAA after several beats.
• TTE is better at assessing the LV apex.
• Valvular masses possess characteristics that make one etiology more likely than another, but the clinical context is the final arbiter.

Cardiac Tumors

• Primary cardiac tumors are relatively rare and found in approximately 0.02% of autopsies.
• Only 15% of primary tumors are malignant.
• Metastatic tumors are more common but rarely referred for surgery.
• Intracavitary tumors are typically seen in the atria.
• Intramural tumors are found in the ventricles and infiltrate the ventricular walls.
• Extracardiac tumors are confined to the visceral and parietal pericardium.
• Tumor location may guide diagnosis (Table 10-4).

TABLE 10-4 PRIMARY CARDIAC TUMOR

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Benign Primary Cardiac Tumors

Myxoma

• Most common benign tumor in adults.
• Localized in the LA (Figure 10-9A) in 75% of the cases; can also be found in the LV or RV in 5% of cases.
• Usually arises from the IAS with a stalk attached to the fossa ovalis (see Figure 10-9B and C).
• Recurrence after resection is rare.
• Smooth surface, homogeneous consistency.
• Can grow to a very large size (see Figure 10-9D).
• May mask underlying MV pathology and cause MV obstruction.
• Location and appearance allow easy differentiation from other masses.
• ME four-chamber, AV SAX, and bicaval allow assessment of the size and attachment of LA myxomas.
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Figure 10-9 Patient with a large left atrial myxoma, scheduled for elective surgical resection. A, In the ME four-chamber view, a large mass is noticed in the LA and prolapses through the MV during diastole. B and C, The attachment of the mass to the IAS is demonstrated in different views. D, 3D TEE allows a full view of the mass (arrow) and its relation with the surrounding anatomic structures.

Rhabdomyoma

• Most common in children.
• Localized on the ventricular side of the atrioventricular valves.
• Often multiple.
• Well-circumscribed homogeneous echogenic mass.
• Spontaneous regression with age is common.

Lipoma

• Well-circumscribed, spherical, or elliptical.
• Homogeneous echo-free structure.
• Localized on endocardial surface of the LV or RA.
• Twenty-five percent of cases can be intramyocardial.
• Magnetic resonance imaging (MRI) is the gold standard for definitive diagnosis.

Papillary Fibroelastoma

• Most common primary valve tumor.
• Common localizations in order of frequency are AV (LVOT or ascending aortic aspect), MV (atrial aspect), TV, and PV.
• Can also be attached to chordae tendinae (Figure 10-10).
• Tend to arise in areas of endocardial damage such as valve degeneration or after surgery.
• Six percent are multiple.
• Smooth, lobulated, pedunculated mass
• May be difficult to differentiate from vegetation.
• Rarely causes valve regurgitation.
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Figure 10-10 Patient scheduled for elective surgical resection of a small MV mass. A, The MV leaflets (arrow) appear normal on 2D and no regurgitation is noticed. B, A small round mass (arrow) is attached to the secondary chordae of the posterior MV leaflet. Pathologic examination confirmed the diagnosis of papillary fibroelastoma.

Fibroma

• Commonly present as a solitary mass (Figure 10-11).
• Normally affects the ventricular myocardium (see Figure 10-11): IVS, apex, or free wall.
• May have central calcification.
• Can be large and present multiple calcifications.
• Difficult to differentiate from rhabdomyoma and apical hypertrophic obstructive cardiomyopathy.
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Figure 10-11 Patient presented for elective surgical resection of RV mass. A, X planes technology displays simultaneous perpendicular views of the RV. A and B, A large mass obliterates the distal RV cavity. Live 3D TEE allows rotation of the 3D image. The mass can thus be viewed from the front (C) and the back (D), allowing better understanding of its relationship with the surrounding structures. The histologic diagnosis was fibroleiomyoma.

Malignant Primary Cardiac Tumors

• Most malignant cardiac tumors are sarcomas (see Case 10-2 on the Expert Consult website).

Angiosarcoma

• Most common sarcoma in adults.
• Most common localization is the RA (80%), but it can also involve the pericardium.
• Rapid progression, poor prognosis.
• It is an intramural mass that extends to the pericardium and vena cava.
• Hemorrhagic pericardial effusion is common.

Rhabdomyosarcoma

• Second most common sarcoma.
• Multiple locations are common.
• Any cardiac chamber can be involved.
• Obstruction of valve orifices is common.
• Rapid growth, poor prognosis.
• Intracavitary and infiltrative growth.
• Local, valvular, and pericardial invasion.

Lymphoma

• Affects all ages.
• Higher incidence in immunocompromised patients (acquired immunodeficiency syndrome [AIDS] and transplant recipients).
• RA and RV are more commonly involved but it can invade any other structure.
• Presents with myocardial infiltration.
• Lesions appear as nodules.
• Tissue diagnosis is required for certain diagnosis.

Mesothelioma

• A malignant tumor of the pericardium more common in adults.
• Originates from visceral or parietal pericardium.
• MRI is the gold standard for diagnosis.
• On TEE, presents as pericardial thickening and effusion.
• Covers the pericardium and encases the heart.
• Invades the heart only superficially.

Secondary Cardiac Tumors

• More common than primary cardiac tumors.
• Cardiac involvement is by direct extension or intravascular spread.
• Typically involve the epicardium.
• Pericardial effusion is common and tamponade may be the clinical presentation.
• Locations are single or multiple.
• All tumors metastasize to the heart, except tumor of the central nervous system.
• Great majority of secondary cardiac localizations are clinically silent.
• Difficult TEE diagnosis of type. Clinical history should guide identification of primary.

Lung

• Direct and intravascular extension to LA through pulmonary veins.
• Most common in men.

Breast

• Direct extension to the RA and LA.
• Most common in women.

Melanoma

• Highest rate of cardiac metastases of all extracardiac tumors.
• Small multiple metastases are common.
• All cardiac chambers and any cardiac structure can be involved.
• Usual incidental diagnosis.

Renal Cell Carcinoma

Uterine Carcinoma

• Venous extension via the IVC to the RA.
• Large occluding masses in the IVC are common.
• TEE is used to guide surgical resection in the IVC.

Intraoperative Echocardiographic Assessment of Cardiac Tumors

• Intraoperative TEE is commonly used to guide surgical resection of cardiac tumors.

Before Cardiopulmonary Bypass

• Confirm presence of tumor before skin incision and exclude embolization.
• Identify appearance and location of tumor (see Case 10-1 on the Expert Consult website).
• Assess the tumor attachment and resectability.
• Define coexisting pathology requiring correction.
• Complete examination to define underlying structures and function.
• 3D TEE provides superior imaging of cardiac tumors allowing better definition of invasion and attachment.
• Careful assessment of the IVC and SVC guides venous cannulation for CPB.

After Cardiopulmonary Bypass

• Assess impact of resection.
• Confirm successful reconstruction and lack of new shunt or damage to cardiac structures.
• Incomplete resection is not uncommon.
• Assess ventricular function and exclude coronary embolization.
• Underlying pathology can be unmasked by tumor resection.

Key Points

• The most common primary benign cardiac tumors are myxomas. They are typically localized in the LA, have a homogeneous appearance, and grow to very large sizes.
• All malignant primary cardiac tumors are sarcomas. The most common sarcomas in adults are the angiosarcomas. They are typically localized in the RA and have a poor prognosis.
• Secondary metastatic tumors are the most common cardiac tumors. They typically involve the epicardium and present with pericardial effusion. The most common primary sources of cardiac metastasis are the lungs for males and the breasts for females. Malignant melanoma has the highest rate of cardiac metastasis.
• Renal and uterine cancers may extend to the heart by extension via the IVC.
• The aim of intraoperative TEE for cardiac tumors is to confirm the presence of the mass before skin incision, define the invasion of cardiac structures, and assess underlying pathology.
• After resection of the tumor, TEE must exclude incomplete resection, confirm successful reconstruction, and exclude new or residual valvular pathology.

Devices for Closure of Intracardiac Shunts

Atrial Septal Defect, Patent Foramen Ovale Device Closure

• Device closure of atrial septal defect (ASD) and PFO has become standard of practice.
• ASD closure is normally performed under fluoroscopy in awake patients.
• Intravascular ultrasound has been used to guide ASD location, size, and device deployment.
• TEE likely requires general anesthesia, and it has been successfully used in this clinical setting.

Before Deployment

• 2D measurement of the defects.
• Analysis of the geometry of the rim for suitability for device closure (maximum diameter < 4 cm).
• 3D TEE provides an en face view of the septal defect and is very accurate in detecting multiple defects.
• TEE can effectively guide positioning of wires across the defect and display deployment of the device.

After Deployment

• Assess stability of the deployed device.
• Assess residual leaks.
• Exclude iatrogenic valvular damage.
• Infection, dislodgment, and erosion into adjacent structures are common long-term complications of IAS devices.
• If present, IAS devices are removed during open heart surgery for other pathologies because manipulation of the heart may cause dislodgment and perforation of adjacent structures.

Mitral Valve Paravalvular Leak Device Closure

• Paravalvular leaks (PLs) are a common complication after prosthetic valve implant.
• PLs accounting for mild regurgitation are not clinically significant but may cause hemolysis.
• Percutaneous closure of MV PLs is becoming the treatment of choice (Figure 10-12).
• TEE is used to guide device positioning and deployment, and it is complementary to fluoroscopy.
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Figure 10-12 A, In a patient with an MV bioprosthesis presenting with a large PL, TEE is used to guide percutaneous closure. B, Color flow Doppler reveals no residual leak after deployment of two Amplatzer devices (arrow). C, The device is clearly seen on 2D (arrow). D, 3D TEE provides an en face view of the MV from the LA and allows easy location of the device along the MV annulus.

Before Deployment

• Localization of the leak and confirmation of severity.
• 3D TEE provides an en face view of the MV in the surgical view and allows prompt location of the PL
• 3D TEE also allows assessment of the leak geometry and provides precise measurements of the defect.
• TEE can effectively guide positioning of wires across the leak before device deployment.
• During deployment, TEE can assess the impact of the device on the prosthetic valve.

After Deployment

• Assess stability of the deployed device.
• Assess residual leaks.
• Exclude valve malfunction.
• The device may prevent complete closure of mechanical leaflets and result in severe intravalvular regurgitation.

Central Venous Catheters

• TEE can effectively locate the wire in the SVC.
• TEE can exclude presence of persistent left SVC and contraindicate left-sided cannulation.
• In cases of persistent left SVC, agitated saline contrast injected in a left arm peripheral vein will reach the RA though the CS.
• ME bicaval view is used to visualize the advancement of the wire into the SVC (Figure 10-13A).
• ME bicaval view allows visualization of the tip of the catheter in respect of the SVC to RA junction.
• Correct central venous catheter (CVC) tip position is approximately 1 cm from the SVC-RA junction.
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Figure 10-13 A, ME bicaval view is used to confirm presence of Seldinger wire (arrow) in the SVC before cannulation of the internal jugular vein. B, ME RV inflow-outflow view can be used to guide positioning of the PAC (arrows) in the PA.

Pulmonary Artery Catheter

• TEE may be used to locate the wire in the SVC.
• ME bicaval view angulated to show the TV is used to guide the PA catheter through the TV.
• ME RV inflow-outflow view is used to guide advancement of the PAC into the PA (see Figure 10-13B).

Cardiopulmonary Bypass

• The use of CPB was first described by Dennis and coworkers in 1951.14
• It allows performing open heart surgery on a bloodless surgical field and a still heart.
• The basic CPB comprises a venous cannula, reservoir, pump, oxygenator, and arterial cannula.
• The blood is passively drained by gravity through the venous cannula into the venous reservoir. A mechanical pump pumps the blood from the venous reservoir through the oxygenator back into the patient’s arterial circulation.
• The heart is arrested in diastole by injecting a cardioplegic solution into the coronary arteries.

Venous Cannulas

• Different types of venous cannulas can be used, depending on the surgical procedure that is performed.
• Peripheral cannulation is performed through the femoral or the internal jugular veins or both and is used for minimally invasive cardiac surgery (Figure 10-14A). Venous cannulas are advanced into the RA (see Figure 10-14B and G).
• Central cannulation can be single or double.
• Single cannulation (see Figure 10-14A) is performed using a two-stage cannula with an opening at the tip and side holes at 5 to 10 cm from the tip. When correctly positioned, the tip is sitting in the IVC and the side ports in the RA. This technique is normally used for surgery on the aorta and AV and well as for coronary artery bypass grafts.
• For surgery on the atrioventricular valves, double cannulation (see Figure 10-14D) is usually performed to effectively deviate all venous blood from the atria. Two single-stage cannulas (without side holes) are inserted in the IVC and in the SVC.
• The ME bicaval view is used to visualize venous cannulas (see Figure 10-14B, F, and G).
• From the ME bicaval view, the TEE probe is advanced to follow the venous cannula into the IVC (see Figure 10-14D).
• TEE can detect malpositioning of the venous cannula into the hepatic veins resulting in poor venous drainage.16
• When peripheral cannulation is performed, the ME bicaval view is commonly used to confirm correct positioning of the tip on venous cannulas in the RA (see Figure 10-14B, F, and G).
image

Figure 10-14 A, Minimally invasive cardiac surgery is often performed using a long femoral venous cannula. B, The cannula is advanced under TEE guidance to the RA and positioned just below the SVC-RA junction. In the ME bicaval view, the cannula can be seen in the RA (arrow). C, A double-stage venous cannula is inserted in the RA and advanced to the IVC to provide venous return for CPB. D, Advancing the probe to follow the cannula and assess the correct position in the IVC. E, Double venous cannulation with single-stage cannulas is used to divert blood flow from the RA and allow a bloodless surgical field. F, ME bicaval view allows visualization of the IVC and SVC cannulas. G, Jugular vein cannulation is performed for minimally invasive cardiac surgery. In the ME bicaval view, the tip of the venous cannula (arrow) can be identified in the RA.

Left Ventricular Vent

• LV vent is placed in the right upper pulmonary vein (RUPV) and advanced into the LV.
• It is used to drain blood from the LV during AV and MV surgery.
• LV vent is commonly seen entering the LA via the RUPV, and is appreciated in most of the ME views displaying the LA.

Coronary Sinus Catheter

• Cannulation of the CS is performed to provide retrograde cardioplegia during CPB.
• It normally is performed after sternotomy with a cannula inserted into the RA.
• For minimally invasive cardiac surgery, a CS cardioplegia cannula is placed percutaneously using a special catheter in the internal jugular vein.
• TEE has been successfully used to guide positioning of CS catheters during both open and minimally invasive surgery.
• A prominent thebesian valve and a small CS make CS cannulation very difficult.
• Possible complications include CS rupture and insufficient cardioplegia resulting in postoperative ventricular dysfunction.
• CS is commonly seen in a modified four-chamber view obtained from a standard four-chamber view by advancing the probe and retroflexing it. The CS is visualized in its long axis, draining into the RA (Figure 10-15A).
• To guide positioning of CS cannulas, a modified bicaval view at 110 degrees is normally used. The CS is seen in its SAX adjacent to the septal leaflet of the TV (see Figure 10-15B).
• Once the catheter is in place, its position should be reconfirmed using the modified four-chamber view.
• LV pressure trace transmission to the CS catheter should be obtained to confirm placement.
• Fluoroscopy and venography are used during minimally invasive surgery to confirm correct position.
image

Figure 10-15 A, The CS is seen in a modified ME four-chamber view advancing the probe to visualize the long axis of the CS (arrow) draining into the RA. B, A modified ME bicaval view is commonly used to guide CS cannulation. In this view, the TV and the CS (arrow) are simultaneously seen. FO, fossa ovalis.

Arterial Cannulas

• The arterial cannula is commonly positioned in the ascending aorta or the proximal aortic arch.
• Retrograde perfusion through the femoral artery is used in specific conditions when direct cannulation of the ascending aorta is contraindicated such as dissection and ascending aortic aneurysms.
• In these circumstances, the axillary artery may be cannulated to provide forward flow.
• For minimally invasive surgery, a long aortic cannula is advanced from the femoral artery into the ascending aorta to provide antegrade flow through a lumen proximal to the aortic endoclamp balloon.
• Aortic cannula can be seen in the ME AV LAX view by withdrawing the probe and increasing the interrogation angle to visualize as much of the ascending aorta as possible.
• The tip of the aortic cannula can commonly be seen in the proximal arch by using the upper esophageal (UE) aortic arch LAX view (Figure 10-16A).
• TEE can identify the aortic cannula, confirm flow using color flow Doppler (see Figure 10-16B), and exclude aortic dissection.
• Continuous wave Doppler can be used to measure the flow velocity in the aortic cannula (see Figure 10-16C).
• In case of aortic dissection and femoral or axillary cannulation, ME thoracic aorta LAX and SAX views are used to confirm perfusion of the true lumen.
• After removal of aortic cannula, ME AV LAX, UE aortic arch LAX, and ME thoracic aorta LAX and SAX views can help rule out aortic dissection.
• ME AV LAX view is also used to visualize ascending aortic plaque and guide cannulation of normal tissue.
image

Figure 10-16 A, The tip of the arterial cannula (arrow) can often be seen in the proximal arch (asterisk) in the UE aortic arch LAX view. B, Color flow Doppler is used to display continuous flow from the cannula. C, Flow velocity and pattern can be assessed using continuous wave Doppler.

Key Points

• TEE is commonly used to guide device closure of ASDs and PLs. 2D and 3D TEE allow precise localization and measurement of the defects for sizing. TEE is also used to guide wire positioning and assess the final result of the procedure.
• TEE is commonly used in the operating room to aid positioning of CVCs. TEE allows confirmation of venous cannulation, continuous visualization of the wire, and guidance for the final positioning of the catheter tip.
• TEE can guide correct positioning of venous cannulas and ensure adequate venous return for CPB. TEE is very useful to assess aortic plaque, guide aortic cannulation, and promptly detect complications at cannulation and decannulation of the aorta.
• Port access systems and minimally invasive approaches rely on TEE guidance for correct positioning of CS catheters for delivery of cardioplegia solution.

Intra-aortic Balloon Pump

• Intra-aortic balloon pump (IABP) is a catheter-mounted balloon of 30 to 50 mL and is used to improve coronary perfusion and diminish LV afterload (Figure 10-17A and B).
• Positioned percutaneously through the femoral artery to the thoracic aorta.
• Inflates at the dicrotic notch and deflates in the early isovolumic phase of systole (see Figure 10-17C).
• Preoperative insertion is indicated in patients with severely impaired LV function.
• Also inserted in the presence of acute ventricular septal defect (VSD) and MR post myocardial infarction.
image

Figure 10-17 A, IABP is a catheter-mounted balloon. The controller (B) inflates the balloon at the dicrotic notch (C1) and deflates it at the isovolumic phase of systole (C2). The electrocardiogram (ECG) or the invasive arterial pressure can trigger IABP inflation. TEE can easily image the IABP catheter in the thoracic aorta. The IABP catheter (arrows) can be visualized in its LAX (D) or SAX (E) view. F, TEE is used to assess good positioning of the IABP, ensuring its tip is distal to the left subclavian artery (arrow).

A, Courtesy of Datascope.

Baseline Assessment

• Define LV and RV function.
• AV insufficiency prevents increases in coronary perfusion with inflation of the IABP.
• Severe aortic insufficiency is an absolute contraindication to IABP insertion.
• Atherosclerotic plaques of the thoracic aorta should be assessed because they can be disrupted by IABP.
• In case of severe peripheral vascular disease, IABP can be inserted intraoperatively in the distal aortic arch and the driveline passed above the sternal notch.
• Aortic dissection and thoracic aneurysms are absolute contraindications to IABP positioning.

Positioning

• Confirm position of the guidewire in the thoracic aorta before catheter advancement to avoid placement in the venous system or the contralateral iliac artery.
• Localize the IABP tip distal to the left subclavian artery.
• ME descending aorta SAX view and ME descending aorta LAX views are normally used to visualize wire and IABP.

Post Positioning

• Assess correct positioning of the IABP distal to the origin of the left subclavian artery (see Figure 10-17F). To do so: identify the IAPB tip in the descending aorta LAX view. Hold the TEE probe handle with one hand and pinch the probe with the other hand at the patient’s teeth. Withdraw the probe until the UE aortic arch LAX view is obtained. The distance from the finger pinching the probe and the patient’s teeth is a good estimate of the distance between the tip of the IAPB and the aortic arch.
• When correctly positioned, the tip of the IABP lies a few centimeters distal to the origin of the left subclavian artery.
• Confirm correct function of IABP with visualization of inflation and deflation of the balloon (see Figure 10-17D and E).
• Exclude complications (e.g., balloon perforation, aortic dissection).
• Exclude new or worsening AV insufficiency and dynamic LVOT obstruction.
• Monitor change in LV function after initiation of IABP.

Weaning

• TEE allows direct assessment of LV and RV function during weaning.
• Normally, the IABP is weaned from 1 : 1 to 1 : 2 mode after a few hours and then to 1 : 3 if hemodynamically stable.
• IABP at 1 : 3 provides minimal hemodynamic support.

Ventricular Assist Devices

Assessment of Left Ventricular Assist Device Placement (Figures 10-18 and 10-19)

• Ventricular assist devices (VADs) provide mechanical support to the left (LVAD), the right (RVAD), or both (BiVAD) ventricles (see Case 10-4 on the Expert Consult website).
• VADs are used as a bridge to transplant or recovery or as a destination therapy.
• RVAD and BiVAD are not commonly used for mid- and long-term treatment.
• VADs can be classified based on the type of flow provided, the duration of support, and the location of the pump (Table 10-5).
image

Figure 10-18 Assessment of LVAD placement. SvO2, venous oxygen saturation.

image

Figure 10-19 Patient after implant of Heartmate II LVAD. A, Laminar flow into the inflow cannula at the apex of the LV is displayed on color flow Doppler. Flow through the inflow cannula is measured using continuous wave (CW) Doppler. B, The CW spectral wave displays pulsatility due to residual LV contraction and augmentation of flow through the LVAD inflow cannula. C, Laminar flow is demonstrated by color flow Doppler from the LVAD outflow cannula into the ascending aorta. D, CW Doppler confirms normal flow velocities.

TABLE 10-5 VENTRICULAR ASSIST DEVICES

image

Cannulation

• The inflow cannula brings blood into the device.
• The outflow cannula brings blood from the device back into the circulation.
• For LVAD, the inflow cannula is usually at the apex of the LV and the outflow cannula in the aorta.
• In LVAD, the inflow cannula may also be attached to the LA either directly or through one of the pulmonary veins.
• For RVAD, the inflow cannula drains blood from the RA, with outflow going to the PA.

Baseline

• Confirm LV dysfunction and/or RV dysfunction.
• Assess RV function and tricuspid regurgitation.
• If there is moderate or severe RV dysfunction that has not been medically addressed (i.e., high central venous pressure [CVP]), reconsideration may be appropriate; however, if this is not the case, then LVAD insertion can probably proceed with the caveat that RVAD placement may be necessary if the unloading provided to the RV by the LVAD is not sufficient.
• Assess for PFO or ASD using color flow Doppler and agitated saline contrast with concomitant Valsalva maneuver. These abnormalities must be corrected at the time of LVAD placement to prevent a postoperative right-to-left shunt. Similarly, the presence of a VSD must be corrected at the time of LVAD placement.
• Quantify aortic insufficiency. Any degree of aortic insufficiency more than mild requires treatment. Moderate and severe AV insufficiency causes a short circuit of the blood stream within the VAD and lack of flow distal to the ascending aorta. If there is minimal chance of myocardial recovery, oversewing the AV is an acceptable practice. In all other cases, AV replacement with a bioprosthetic prosthesis should be performed.
• In patients with a dilated and aneurysmal LV, identify intracavitary thrombi.
• Rule out the presence of LA thrombi.
• Assess the presence of aortic atheroma (ascending, transverse, or descending aorta) to guide outflow cannula positioning.

Weaning from Cardiopulmonary Bypass

• TEE confirms identification of the true LV apex showing invagination when the surgeon presses on the site identified for cannulation.
• Confirm the position of the inflow cannula through the entire myocardial thickness.
• The tip of the inflow cannula should be pointing toward the MV and not toward the IVS.
• Complete and careful deairing of all heart chambers should be obtained before activating the LVAD.
• LVAD inflow cannula is usually well visualized in the ME four-chamber and two-chamber views. These views also allow Doppler measurement of flow.
• LVAD outflow cannula can be seen in the ME LAX view. The same view allows Doppler measurement of flows.

Post Implant

• Confirm absence of PFO; active emptying of the LV may cause opening of previously closed PFOs.
• Assess RV size and function. A failing RV would result in low preload to the LVAD and low output.
• Identify new or worsened tricuspid regurgitation and estimate RV systolic pressures.
• Color Doppler assessment of flow through the inflow (see Figure 10-19A) and outflow (see Figure 10-19C) cannulas.
• Continuous wave Doppler measurement of gradients in the inflow (see Figure 10-19B) and outflow (see Figure 10-19D) cannulas. Peak velocities are usually around 1 meter per second.
• Confirm LV decompression.
• A closed AV through the entire cardiac cycle is a sign of lack of native ejection and effective LV unloading.
• Reassess AV insufficiency.
• Complete TEE examination should confirm LV unloading and adequate RV function in uneventful LVAD implant.

Postoperative Low Device Output and Common Complications

• TEE is useful in the differential diagnosis of low device output.
• Hypovolemia results in empty LV and collapse of the ventricle around the LVAD inflow cannula.
• RV dilatation and hypokinesis may be secondary to the effects of CPB or because of increased venous return due to LVAD performance. RV dilatation is commonly seen in the ME four-chamber view.
• Pericardial effusion causing tamponade is not uncommon after LVAD implant due to the higher risk of bleeding in these patient populations.
• Sudden hypoxia after LVAD implant may be due to a reopened PFO with right-to-left shunt.
• Inflow cannula obstruction would result in high gradient and turbulent flow.
• Outflow cannula obstruction would result in a high gradient and turbulent flow.
• Device thrombosis would result in increased inflow or outflow gradients.
• Pulmonary embolism may be the cause of RV failure.
• In pulsatile devices, prosthetic valve failure is not uncommon. Although the valves cannot be seen by TEE, flow reversal or high gradients can be detected by spectral and color flow Doppler.
• Complete TEE examination can promptly exclude most causes of low device flow.

Weaning

• TEE allows prompt assessment of RV and LV function during weaning of the VAD.
• For long-term LVADs, TTE is usually preferred to TEE.

Extracorporeal Membrane Oxygenation

• Extracorporeal membrane oxygenation (ECMO) comprises a centrifugal pump, a membrane oxygenator, and an arterial and a venous cannula.
• A form of temporary circulatory and respiratory support normally indicated for up to 10 days.

Cannulation

• Cannulation for ECMO can be central or peripheral.
• In case of central cannulation, cannulas are placed in the same fashion as for CPB.
• CPB cannulas are often left in place and the CPB circuits switched to the ECMO.
• For central cannulation, the venous cannula is in the RA and the arterial cannula is in the ascending aorta.
• Peripheral cannulation can be performed with surgical dissection of the vessels or using percutaneous technique.
• In adults, the femoral vein and artery are used. A long venous cannula advanced to the RA is commonly used.
• In case of poor venous drainage, a second venous cannula can be placed in the jugular vein.
• In children, the internal jugular and the carotid artery are used. The venous cannula is advanced to the RA.

Insertion

• Confirm correct position of cannulas (Figure 10-20A and C).
• Assess flow in arterial and venous cannulas with color flow Doppler (see Figure 10-20B and D).
• Venous cannulas are seen in the RA in the modified ME bicaval view (see Figure 10-20A).
• In case of percutaneous cannulation, TEE can guide wire placement and positioning of cannulas.
• TEE is very sensitive in detecting air in the cardiac chambers and should guide careful deairing before initiation of ECMO.
• The arterial catheter is not seen when peripheral cannulation is used but can be seen if placed in the ascending aorta. Color flow Doppler interrogation of the thoracic aorta should confirm continuous laminar flow.
• Always exclude aortic dissection.
• TEE allows optimization of venous drainage by assessing chamber size and distention.
• TEE can immediately assess LV and RV decompression when ECMO is initiated.
• A complete assessment includes new or worsening AV and MV regurgitation.
image

Figure 10-20 A patient is placed on ECMO after failing to wean from CPB. A, The ECMO venous cannula is seen in the RA (arrow). B, Flow is confirmed with color flow Doppler. C, The outflow cannula (arrow) is seen in the arch. The asterisk indicates the distal arch. D, A narrow, continuous, mildly turbulent flow from the arterial cannula is seen on color flow Doppler.

Post Implant Monitoring

• TEE guides fluid management by assessing chamber size and distention.
• Common complications that lead to low flows and hypotension can be detected by TEE and include low filling, tamponade, thrombi, and dislodgment of cannulas.

Weaning

• TEE allows direct assessment of RV and LV function during weaning of ECMO and assessment of myocardial recovery.
• TEE also provides direct measurement of cardiac output in this circumstance when thermodilution is not entirely reliable.

Key Points

• During insertion of IABP, TEE allows visualization of the guidewire in the thoracic aorta and the IABP tip in the correct position distal to the subclavian artery. TEE can also detect absolute contraindications to IABP insertion (e.g., severe aortic insufficiency) and promptly detect complications (e.g., aortic dissection). TEE has also been useful in assessing ventricular function after insertion and during weaning.
• TEE is a useful tool to assist LVAD implant. The focus of TEE examination at baseline is to quantify aortic regurgitation, look for communication between left- and right-sided chambers (ASD, VSD), assess for left-sided thrombi, and determine RV function. After LVAD insertion TEE is used to interrogate adequate flow in the VAD cannulas, assess ventricular filling, look for impending “suction” events, and continue to monitor RV function. TEE is also used to detect postoperative complications (e.g., tamponade) and ventricular function during weaning.
• During ECMO insertion, TEE is used to assess ventricular function and shunts at baseline and guide positioning of the venous cannulas. After initiation of ECMO flow, TEE provides optimal monitoring of ventricular filling and may guide fluid management. TEE assessment of ventricular function is also very useful during weaning.

Suggested Readings

1 Goldman JH, Foster E. Transesophageal echocardiographic (TEE) evaluation of intracardiac and pericardial masses. Cardiol Clin. 2000;18:849-860.

Nice review of TEE imaging of masses.

2 Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: A review of associated conditions and the impact of physiological size. J Am Coll Cardiol. 2001;38:613-623.

Nice clinical and pathologic comparison of the properties and unique characteristics of LV thrombus.

3 Schneider B, Zienkiewicz T, Jansen V, et al. Diagnosis of patent foramen ovale by transesophageal echocardiography and correlation with autopsy findings. Am J Cardiol. 1996;77:1202-1209.

Details the utility of 3D echocardiography in evaluating the LAA for thrombus.

4 Ling LH, Oh JK, Tei C, et al. Pericardial thickness measured with transesophageal echocardiography: Feasibility and potential clinical usefulness. J Am Coll Cardiol. 1997;29:1317-1323.

An excellent clinical and imaging reference for IE.

5 Durand M, Lamarche Y, Denault A. Pericardial tamponade. Can J Anaesth. 2009;56:443-448.

A nice descriptive paper outlining the early experience with percutaneous cardiac interventions.

6 Srichai MB, Junor C, Rodriguez LL, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: A comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J. 2006;152:75-84.

7 Karakus G, Kodali V, Inamdar V, et al. Comparative assessment of left atrial appendage by transesophageal and combined two- and three-dimensional transthoracic echocardiography. Echocardiography. 2008;25:918-924.

These two papers describe the utility of TEE in the placement of cardiac cannulas when operative exposure is limited.

8 Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: Utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med. 1994;96:200-209.

Beautifully illustrated review of continuous flow LVADs and what to look for in the echocardiographic examination.

9 Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation. 2003;108:1146-1162.

10 Bayer AS, Bolger AF, Taubert KA, et al. Diagnosis and management of infective endocarditis and its complications. Circulation. 1998;98:2936-2948.

11 Shapiro LM. Cardiac tumours: Diagnosis and management. Heart. 2001;85:218-222.

12 Balzer J, Kuhl H, Rassaf T, et al. Real-time transesophageal three-dimensional echocardiography for guidance of percutaneous cardiac interventions: first experience. Clin Res Cardiol. 2008;97:565-574.

13 Biner S, Rafique AM, Kar S, Siegel RJ. Live three-dimensional transesophageal echocardiography-guided transcatheter closure of a mitral paraprosthetic leak by Amplatzer occluder. J Am Soc Echocardiogr. 2008;21:1282e7-1282e9.

14 Dennis C, Spreng DSJr, Nelson GE, et al. Development of a pump-oxygenator to replace the heart and lungs: An apparatus applicable to human patients, and application to one case. Ann Surg. 1951;134:709-721.

15 Applebaum RM, Cutler WM, Bhardwaj N, et al. Utility of transesophageal echocardiography during port-access minimally invasive cardiac surgery. Am J Cardiol. 1998;82:183-188.

16 Kirkeby-Garstad I, Tromsdal A, Sellevold OF, et al. Guiding surgical cannulation of the inferior vena cava with transesophageal echocardiography. Anesth Analg. 2003;96:1288-1293. table of contents

17 Lebon JS, Couture P, Rochon AG, et al. The endovascular coronary sinus catheter in minimally invasive mitral and tricuspid valve surgery: A case series. J Cardiothorac Vasc Anesth. 2010;24:746-751.

18 Varadarajan B, Karski J, Vegas A, Heinrich L. A rare complication of intra-aortic balloon pump placement. J Cardiothorac Vasc Anesth. 2005;19:259-260.

19 Deng MC, Edwards LB, Hertz MI, et al. Mechanical circulatory support device database of the International Society for Heart and Lung Transplantation: Third annual report—2005. J Heart Lung Transplant. 2005;24:1182-1187.

20 Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345:1435-1443.

21 Vegas A. Assisting the failing heart. Anesthesiol Clin. 2008;26:539-564.

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