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Additional Applications of Transesophageal Echocardiography

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Transesophageal Echocardiography for Congenital Heart Disease

Abstract

While the majority of this book addresses the use of transesophageal echocardiography (TEE) for the evaluation of patients with congenital heart disease (CHD), there are a number of other conditions in which TEE can play a significant role in pediatric and young adult patients. Some conditions, such as infective endocarditis, can occur in patients with a history of CHD. Other pathologies, such as cardiac tumors, can be seen in the absence of coexisting CHD. This chapter addresses additional applications of TEE in the pediatric and young adult population.

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  1. Division of Cardiology, Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Mailstop #34, Los Angeles, CA, 90027, USA

    Pierre C. Wong MD

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Editors and Affiliations

  1. Childrens Hospital Los Angeles Department of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA

    Pierre C. Wong

  2. Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, Houston, USA

    Wanda C. Miller-Hance

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Large vegetation on the anterior leaflet of mitral valve, resulting in chordal destruction and severe mitral regurgitation (MPG 4146 kb)

Aortic valve endocarditis, seen from a mid esophageal aortic valve long axis view (multiplane angle 85°–116°) (MPG 8328 kb)

Endocarditis in a patient with a prosthetic aortic valve (St. Jude). The mid esophageal four chamber view demonstrates a perivalvar abscess that extends into the noncoronary cusp, causing a fistulous tract communicating with the right atrium. A large vegetation has developed in this area and shunting is seen into the right atrium. There is marked aortic regurgitation seen through an area of valve dehiscence (MPG 48550 kb)

Infected sinus of Valsalva aneurysm from aortic valve endocarditis. The preoperative study, obtained from the mid esophageal aortic valve short axis and long axis views, shows a large vegetation of the aortic valve and erosion of the right sinus of Valsalva, with blood filling the aneurysm during diastole. Following aortic valve and aortic root surgery, no residual vegetation is seen and the aortic valve manifests normal function, with no insufficiency (MPG 23246 kb)

Infected pseudoaneurysm off ascending aorta. This TEE was performed to evaluate the aortic valve in a patient with a previous aortic valve surgery and persistent fungemia. A large pseudoaneurysm (arrow) was discovered using the upper esophageal window, multiplane angle 60°. Note that the superior portion of aorta and innominate vein can be seen well in this patient by TEE (MPG 7110 kb)

Thrombus in the left ventricular apex of a patient with Duchenne’s muscular dystrophy and dilated cardiomyopathy. Mid esophageal four chamber view, multiplane angle 0° (MPG 7026 kb)

Thrombus in the superior vena cava, probably associated with a catheter, as seen from mid esophageal bicaval view, (multiplane angle 99°) (MPG 6592 kb)

Thrombus in the left atrial appendage, as viewed from a modified mid esophageal aortic valve short axis view with leftward rotation. There are mobile filamentous strands arising from the thrombus. AoV aortic valve, LA left atrium. Video courtesy of Siemens Medical Systems USA, Inc. © 2012–13 Siemens Medical Solutions USA, Inc. All Rights Reserved (MPG 5100 kb)

Example of spontaneous echo contrast in a patient after repair of D-transposition of the great arteries, with a pseudoaneurysm arising from a previous cannulation site in the aorta. Video obtained from the upper esophageal ascending aorta long axis view. Note the visible swirling of flow due to red cell aggregation. The left pulmonary artery is being compressed by the pseudoaneurysm (MPG 6956 kb)

Wilm’s tumor (arrow) invading the right atrium by direct extension from the inferior vena cava, as seen from the mid esophageal bicaval view, multiplane angle 113°. The multiplane angle is rotated to 55° and all four chambers are visualized. The tumor obstructs IVC inflow. At the end of the video, the extracted tumor is shown (MPG 10052 kb)

Multiple rhabdomyomas in a patient with tuberous sclerosis, including one that caused near complete obstruction of the left ventricular outflow tract. Mid esophageal four chamber view, multiplane angle 0° shows a large tumor in the outflow tract. Turbulent color flow Doppler is seen (MPG 22644 kb)

Fibroma attached to the left ventricular free wall, visualized from mid esophageal aortic valve long axis view, multiplane angle 90°. The fibroma is very large, circumscribed, and has a heterogeneous appearance, studded with echolucent areas most likely representing cystic degeneration or necrosis (MPG 19366 kb)

Left atrial myxoma, seen from mid esophageal four chamber view, multiplane angle 0°. A large, lobulated myxoma is attached to the left atrial wall, just posterior to the aortic root. Multiple fimbriations of the tumor are freely mobile (MPG 17046 kb)

Right atrial hemangioma as seen from the mid esophageal four chamber and mid esophageal right ventricular inflow-outflow view. Note the heterogeneous nature of the large mass in the right atrium. As can be seen by the rapid atrial rate, the patient had an atrial arrhythmia, probably chaotic atrial tachycardia, during the study (MPG 21928 kb)

Prosthetic mitral valve (bileaflet tilting disk). Mid esophageal mitral commissural view, multiplane angle 69°. The multiplane angle is rotated until both leaflets are profiled and open symmetrically in diastole. There is the usual color flow Doppler profile across the valve (MPG 2942 kb)

Prosthetic mitral with a frozen leaflet (arrow), causing stenosis of the valve. Mid esophageal four chamber view, multiplane angle 0° (MPG 11380 kb)

Concentric pannus formation (arrows) above the mitral valve prosthesis, causing significant supravalvar narrowing, seen during diastole. Mid esophageal mitral commissural view, multiplane angle 58° (MPG 12516 kb)

Prosthetic aortic valve (bileaflet tilting disk) viewed from deep transgastric position. At a multiplane angle of 25° the valve is seen from the side, and the usual peri-valvar washing jets can be seen by color flow Doppler. The multiplane angle is then rotated until both leaflets are profiled and symmetric leaflet motion is noted in diastole and systole (about 95°). This view affords a good edge-on view of leaflet motion and flow across the valve, and also provides an excellent angle for spectral Doppler evaluation (MPG 13948 kb)

Paravalvar regurgitation in a child who underwent mitral valve replacement with a mechanical bileaflet prosthesis (the patient previously underwent repair of an atrioventricular septal defect). This video was obtained from a mid esophageal four chamber view. The prosthesis was too large for the annulus and required insertion at an angle, which resulted both in a large area of paravalvular regurgitation (seen to the left of the prosthesis) as well as a very small effective orifice (MPG 13054 kb)

Transcatheter aortic valve replacement/implantation (TAVR/TAVI). This video, obtained from a mid esophageal aortic valve long axis view at 120°–130° first shows the abnormal aortic, which is thickened and has restricted motion. A catheter and then the balloon-mounted valve are seen, with the balloon shown as it is expanded and the valve implanted in the aortic position. During balloon dilation, rapid ventricular pacing is performed to reduce ventricular ejection, thereby stabilizing the valve for placement. Following valve implantation, leaflet motion is seen and there rare two jets of regurgitation seen—one central (transvalvular), one peripheral (paravalvular). LM left main coronary artery (Echocardiographic images were obtained from a Siemens SC 2000 platform and are courtesy of Siemens Medical Systems USA, Inc. © 2012–13 Siemens Medical Solutions USA, Inc. All Rights Reserved) (MPG 39428 kb)

Berlin Heart placement in a patient with dilated cardiomyopathy. Mid esophageal four chamber view. The cannula in the left ventricular apex withdraws blood returning from the left atrium. When the blood has sufficiently filled the chamber in the device, it is pumped into the ascending aorta, as shown from mid esophageal view, multiplane angle 102° (MPG 36604 kb)

Following heart transplantation, imaging in the mid esophageal four chamber view, multiplane angle 0°. The anastomosis of the donor left atrium to the cuff of the recipient left atrium creates an area of echogenicity (arrow) that can be mistaken for thrombus (MPG 29690 kb)

Post-lung transplant, with thrombosis of the right pulmonary veins due to a large lymph node. Mid esophageal view, multiplane angle 0°. There is extensive thrombus in the right pulmonary veins. No flow was seen in the vessel by color flow Doppler. Normal flow is seen in the contralateral left pulmonary veins (MPG 17500 kb)

Dissection of the ascending and descending aorta (DeBakey Type I) in a patient with Marfan’s syndrome. The patient also had a dilated aortic root and significant aortic valve regurgitation. The intimal flap is clearly seen, as well as the true and false lumens. Upper esophageal aortic arch long axis view, multiplane angle 0°, shows the false lumen to be much larger than the true lumen in the ascending aorta and aortic arch. Retrograde diastolic flow reversal is seen only in the true lumen by color flow mapping. Mid esophageal descending aortic long axis view, multiplane angle 90° (probe rotated leftward) shows the dissection extending into descending aorta (MPG 56434 kb)

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Wong, P.C. (2014). Additional Applications of Transesophageal Echocardiography. In: Wong, P., Miller-Hance, W. (eds) Transesophageal Echocardiography for Congenital Heart Disease. Springer, London. https://doi.org/10.1007/978-1-84800-064-3_16

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  • DOI: https://doi.org/10.1007/978-1-84800-064-3_16

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