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Transoesophageal Echocardiography

  • Harald Becher
  • Andreas Helfen
Chapter

Abstract

The Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017 recommends the use of contrast agents to diagnose or exclude left atrial thrombi in the case of non-diagnostic unenhanced images. The chapter includes comprehensive information on the anatomy of the left atrial appendage, the appropriate machine settings and dosages of the contrast agents. Thirty six clinical examples of thrombi and intracardiac tumours are included.

Supplementary material

Video 3.1

Pectinate muscles, which look like the teeth of a comb, mid oesophageal position of the 3D probe, the recordings correspond to a 53° plane of a 2D TEE recording (WMV 445 kb)

Video 3.2

The 3D rendered image shows the recesses between the pectinate muscles (WMV 61 kb)

Video 3.3

Hyperechoic structure in LAA apex at 62° (left) and 154° (right) (WMV 652 kb)

Video 3.4

No thrombus is displayed in the 3-D data set. The hyperechoic structure seen in the 2D images represents a muscular structure (WMV 86 kb)

Video 3.5

Biplane recording of a LAA with ‘chicken wing’ morphology, left 30°, right 122° (WMV 628 kb)

Video 3.6

Biplane recording of a LAA ‘cauliflower’ morphology, left 30°, right 122° plane (WMV 838 kb)

Video 3.7

Biplane recording of a LAA ‘windsock’ morphology, left 30°, right 122° (WMV 1180 kb)

Video 3.8

Biplane recording of a LAA ‘cactus’ morphology, left 54°, 144° (WMV 452 kb)

Video 3.9

Optimal position for measurement of the LAA velocities. The aliasing zone in colour Doppler represents the area with the highest velocities where the sample volume should be placed (WMV 213 kb)

Video 3.10

Colour Doppler: eccentric mitral regurgitation due a P2/P3 prolapse. The regurgitant jet reaches the LAA (MP4 1074 kb)

Video 3.11

Large hyperechoic LAA thrombus recorded at a MI = 0.4 (0.1 dB) without contrast agent. On the right the contrast agent has opacified the LA and LAA. For the contrast recording the MI was set to 0.02 (−32 dB), transmission frequency was 5.0 MHz. Signal intensity of the contrast agent and the thrombus are similar. Hypoechoic and low-contrast zone between the contrast agent in the left atrium and the thrombus probably represents a not yet completely organized layer of the thrombus (WMV 784 kb)

Video 3.12

Transmit frequency 2.9/5.9 MHz, MI = 0.07, early after administration of the contrast agent. The RA is opacified but not yet the LA (WMV 439 kb)

Video 3.13

Same thrombus as in Video 3.12, both atria are opacified. Note the thrombus in the left atrial pouch, see Fig.  1.4 (WMV 632 kb)

Video 3.14

Small right-atrial protruding thrombus attached to the interatrial septum (WMV 804 kb)

Video 3.15

Contrast echocardiography, same patient as in Video 3.14: shadowing artefact (left side of the sector), well opacified superior vena cava (right side of the sector), border artefact. Note the effect of very low MI harmonic imaging (2.9/5.9 MHz, MI = 0.07) and tissue signal cancellation regarding the representation of the interatrial septum (WMV 213 kb)

Video 3.16

After administration of a bolus of 0.3 mL Optison® and a flush of 5 mL saline the LAA is entirely opacified, MI = 0.13 (−14 dB). The dark layer outside the LAA represents a small pericardial effusion (WMV 318 kb)

Video 3.17

High-resolution zoom, biplane recording with 3.0/6.0 MHz, early after injection of the contrast agent: isolated bubbles in the LAA (WMV 17759 kb)

Video 3.18

Transoesophageal contrast echocardiography (mid oesophageal, 70°, MI = 0.3, IE33, Philips) after injection of 0.1 mL Luminity®. The entire LAA is opacified. Note the small pericardial effusion adjacent to the LAA (right side of the sector) (MP4 3151 kb)

Video 3.19

Small mobile thrombi in two recesses between the pectinate muscles (white arrows) (WMV 816 kb)

Video 3.20

LAA thrombus and small pericardial effusion between the LAA and the left superior pulmonary vein, Vivid E9 BT12, 3.0/6.0 MHz, −20 dB (WMV 188 kb)

Video 3.21

Two suspicious areas in the LAA on non-contrast TOE (left): the white arrow points to a hyperechoic structure in the LAA apex and a hypoechoic area on top of it. After administration of the contrast agent the mass in the LAA apex was not opacified which is characteristic for a thrombus. The other suspicious area was opacified which confirms spontaneous echo contrast (right side, Vivid 7, MI = 0.07) (WMV 469 kb)

Video 3.22

Hyperechoic oval thrombus in the LAA apex (WMV 830 kb)

Video 3.23

Hyperechoic thrombus on non-contrast TOE (left) and after injection of 0.5 mL SonoVue® (right) (WMV 845 kb)

Video 3.24

Large LAA thrombus, which fills almost the entire LAA and reaches the left lateral ridge (WMV 657 kb)

Video 3.25

Large LA thrombus on TEE, the transthoracic recording is shown in Video 3.27 (WMV 706 kb)

Video 3.26

Echogenic LAA thrombus protruding from the LAA apex into the left atrium (WMV 965 kb)

Video 3.27

Large thrombus in a severely dilated LA on transthoracic 2D echocardiography. The diagnosis was confirmed by TEE (see Video 3.25) (WMV 393 kb)

Video 3.28

Echogenic structure near the LAA apex and some spontaneous echo contrast (WMV 1040 kb)

Video 3.29

Low-contrast, hypoechoic, mobile thrombus (WMV 222 kb)

Video 3.30

Echogenic, spherical LAA thrombus near the ostium of the LAA (arrows). Figure 3.80 shows a very similar-looking artefact (WMV 638 kb)

Video 3.31

Mobile, low-contrast and hypoechoic thrombus in an inferior lobe (right), Vivid 7, 2.9/5.9 MHz, MI = 0.07, 108°. Native image of the thrombus (WMV 1258 kb)

Video 3.32

Large thrombus in the LAA and LA (WMV 740 kb)

Video 3.33a

Thrombus in the left atrial pouch with extension into the left atrium (WMV 545 kb)

Video 3.33b

Thrombus in the left atrial pouch with extension into the left atrium (WMV 1079 kb)

Video 3.34

Small, filamentous thrombus on the right atrial side of the interatrial septum (WMV 1148 kb)

Video 3.35

Filamentous thrombus at the ostium of the LAA left superior pulmonary vein (WMV 660 kb)

Video 3.36

Large, inhomogeneous LA mass without expansion into the LAA (WMV 3877 kb)

Video 3.37

The same structure as in Video 3.36 (upper row, right) on contrast-enhanced TOE: no contrast is seen in the mass which suggests that the mass is a thrombus. Note the hypoechoic layer of the thrombus between the contrast free centre of the thrombus and the left atrium due to weak harmonic signals with very low MI imaging and the hyperechoic signals on the regular non-contrast enhanced 2D-TOE (WMV 708 kb)

Video 3.38

Contrast enhanced colour Doppler displays vascularization of the mass shown in Video 3.37. This is more likely in tumours. Finally, the histological diagnosis of a thrombus was made after surgery (WMV 3257 kb)

Video 3.39

Hyperechoic, laminated thrombus which is difficult to distinguish from SEC, pericardial effusion between the right and the left superior pulmonary vein (WMV 371 kb)

Video 3.40

Laminated thrombus (type 3) on contrast TOE. Note the contrast free thin layer along the LAA wall, pericardial effusion (WMV 760 kb)

Video 3.41

Type 3 LAA thrombus before and after injection of the contrast agent. The pericardial effusion facilitates the delineation of LAA wall (WMV 1165 kb)

Video 3.42

Spontaneous echo contrast and a structure with similar echogenicity in the LAA apex on non-contrast TOE (left). After contrast injection a small thrombus in the LAA apex is displayed (WMV 310 kb)

Video 3.43

Type 3 LAA thrombus before the start of anticoagulation therapy. On native TOE predominately spontaneous echo contrast is seen. The thrombus is better visualized after administration of the contrast agent (WMV 826 kb)

Video 3.44

Same patient as in Fig. 3.57. Spontaneous echo contrast which is still detected during anticoagulation therapy (left). The LAA thrombus has decreased in size (WMV 645 kb)

Video 3.45

Large type 3 LAA thrombus. The size of the thrombus appears to be smaller on the non-contrast recording (left) than on the contrast echocardiogram (right), 2.9/5.9 MHz without tissue signal cancellation) (WMV 569 kb)

Video 3.46

Three LAA thrombi (WMV 467 kb)

Video 3.47

Contrast TOE during flash (MI = 0.8): lower echogenicity of the three thrombi compared to the bright signals of the contrast agent and the LAA wall. Attenuation of the contrast signal within the left superior pulmonary vein distal to the ostial thrombus and reverberation artefacts distal to the two apical thrombi (WMV 340 kb)

Video 3.48

Spontaneous echo contrast, transmit frequency 8 MHz (WMV 408 kb)

Video 3.49

Spontaneous echo contrast, transmit frequency 3.0/6.0 MHz, same transmit power and gain as in Video 3.48. The spontaneous echo contrast is visible up to the ostium of the LAA (WMV 625 kb)

Video 3.50

Spontaneous echo contrast but no thrombus on non-contrast TOE (left), two well delineated LAA thrombi on contrast TOE, Vivid 7, 2.9/5.9 MHz, MI = 0.09 (WMV 501 kb)

Video 3.51

Patient as in Fig. 6.68, 6 s later. Beginning LAA opacification, there is still a ‘filling defect’ in the apex. In order to avoid misinterpretation further recordings are necessary at later time points (MP4 45605 kb)

Video 3.52

Incomplete LAA opacification after 20 s (MP4 45605 kb)

Video 3.53

Complete LAA opacification after 36 s, no thrombus is visualized (MP4 45605 kb)

Video 3.54

Spontaneous echo contrast, biplane recordings of a patient with persistent atrial fibrillation before cardioversion (WMV 545 kb)

Video 3.55

Contrast TOE before the LAA is filled with the contrast agent. Despite the very low mechanical index (−32 dB) the LAA wall is still displayed, but no spontaneous echo contrast is visualized, Vivid E9, XDclear (WMV 10589 kb)

Video 3.56

Patient as in Video 3.55, 4 s later, beginning LAA opacification of the main lobe of the LAA with ‘chicken wing’ morphology (WMV 10589 kb)

Video 3.57

Patient as in Fig. 3.73, 14 s later, lack of opacification of the LAA apex (WMV 10589 kb)

Video 3.58

Patient as in Video 3.55, 18 s later, still lack of opacification of the LAA apex. The other areas of the atrial appendage are completely opacified (WMV 10589 kb)

Video 3.59

Patient as in Video 3.55, 33 s later, persistent lack of opacification of the LAA apex suggesting a LAA thrombus. Additional scan planes should be recorded to verify that the lack of opacification is due to a thrombus and not to attenuation (WMV 10589 kb)

Video 3.60

Patient as in Video 3.59. Spontaneous echo contrast (left) obscuring an LAA thrombus (left), which was diagnosed on contrast TOE (right) (WMV 481 kb)

Video 3.61a

Hyperechoic spherical structure in the LAA. Exclusion of a thrombus by contrast echocardiography (right) Vivid 7, SonoVue® 0.5 mL bolus, MI = 0.14, tissue signal cancellation (WMV 542 kb)

Video 3.61b

Hyperechoic spherical structure in the LAA. Exclusion of a thrombus by contrast echocardiography (right) Vivid 7, SonoVue® 0.5 mL bolus, MI = 0.14, tissue signal cancellation (WMV 267 kb)

Video 3.62

Hyperechoic ‘mass’ at the LAA ostium adjacent to the left lateral ridge (coumadin ridge) (WMV 559 kb)

Video 3.63

Patient as in Video 3.62. After administration of the contrast agent the LAA is entirely opacified and a thrombus ruled out. Vivid E9, BT12, MI = 0.07 (WMV 342 kb)

Video 3.64

Pericardial effusion on non-contrast TOE (left) and contrast TOE (right), pericardium (echogenic broad line), epicardium of the LAA (irregular line with less echogenicity). No LAA thrombus (WMV 1040 kb)

Video 3.65

Type 1 LAA thrombus in a patient with persistent atrial fibrillation in 2012, small pericardial effusion (WMV 694 kb)

Video 3.66

Watchman-Occluder implanted in 2015 (WMV 413 kb)

Video 3.67

Colour Doppler signals at the edge of the occluder (left), incidental finding of focal high flow in the LAD (>1 m/s) indicating intermediate stenosis of the LAD (right) (WMV 523 kb)

Video 3.68

Shadowing by a LAA occluder, pericardial effusion, questionable contrast signals at the edge of the occluder (WMV 1436 kb)

Video 3.69

Incomplete LAA occlusion evidenced by the intense flow signals at the edge of the occluder on contrast enhanced colour Doppler echocardiography (right). On Video 3.68 it was impossible to detect leaks at the edge of the occluder with contrast imaging alone (WMV 1148 kb)

Video 3.70

Type B aortic dissection, 2D TOE (WMV 2728 kb)

Video 3.71

Patient as in Video 3.70 after injection of 0.5 mL SonoVue®, complete opacification of the true lumen. Delayed opacification of the false lumen via the entry point. Vivid S6, image harmonic imaging, MI 0.15, no tissue signal cancellation (WMV 9111 kb)

Video 3.72

Patient as in Video 3.70, thrombosis in the false lumen just a few minutes after stent implantation (WMV 8384 kb)

Video 3.73

Left-atrial villous myxoma prolapsing through the mitral valve (MOV 4719 kb)

Video 3.74

Large right atrial, mobile myxoma-like thrombus in a patient with post-operative pulmonary embolism. Additional findings are an enlarged right ventricle and a small pericardial effusion (WMV 189 kb)

Video 3.75

Solid myxoma attached to the left atrial side of the interatrial septum (WMV 845 kb)

Video 3.76

Laminated echogenic LA mass at the base of the anterior mitral leaflet and the adjacent LA (left). Low-contrast mass on the contrast-enhanced recording (right) (WMV 865 kb)

Video 3.77

Patient as in Video 3.76, transthoracic contrast echocardiography, small hypoechoic, low-contrast mass attached to the anterior mitral leaflet (WMV 240 kb)

Video 3.78

Solid myxoma attached to the left atrial side of the interatrial septum. Inhomogeneous structure of the myxoma with calcifications and areas with low echogenicity (WMV 752 kb)

Video 3.79

Proof of vascularisation of the mass: Increase of the contrast in the mass after injection of the contrast agent (right) compared to the recording before the injection (left) (WMV 721 kb)

Video 3.80

Biatrial myxoma attached to the interatrial septum. The stalked left-atrial myxoma prolapses into the LV during diastole. The right atrial myxoma has a villous structure (WMV 642 kb)

Video 3.81

Large left atrial myxoma in a 30-year-old female patient with increasing breathlessness on exertion (WMV 559 kb)

Video 3.82

Large right atrial myxoma in 45-year-old patient (WMV 650 kb)

Video 3.83

Right-atrial solid myxoma attached to the lateral tricuspidal ring (WMV 569 kb)

Video 3.84

Patient as in Video 3.83, subcostal view, flash-replenishment sequence. After the flash (consisting of 5 frames with a MI = 0.8) the contrast in the tumour is reduced and replenishes within 5 s (WMV 6258 kb)

References

  1. Asher CR, et al. Transoesophageal echocardiography to guide cardioversion in patients with atrial fibrillation, ACUTE trial update. Card Electrophysiol Rev. 2003;7(4):387–91.CrossRefGoogle Scholar
  2. Beigel R, et al. The atrial appendage: anatomy, function, and noninvasive evaluation; state of the art papers. J Am Coll Cardiol Imaging. 2014;7:1251–65.CrossRefGoogle Scholar
  3. Blackshear J. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorax Surg. 1996;61(2):755–9.CrossRefGoogle Scholar
  4. Di Biase L. Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. Am Coll Cardiol. 2012;60:531–8.CrossRefGoogle Scholar
  5. Grimm RA, et al. Left atrial stunning after electrical cardioversion of atrial flutter. J Am Coll Cardiol. 1997;29:582–9.CrossRefGoogle Scholar
  6. Jung P, et al. Contrast enhanced transesophageal echocardiography in patients with atrial fibrillation referred to electrical cardioversion improves atrial thrombus detection and may reduce associated thromboembolic events. Cardiovasc Ultrasound. 2013;11:1.CrossRefGoogle Scholar
  7. Kanmanthareddy A. Embryology and anatomy of the left atrial appendage. Interv Cardiol Clin. 2014;3:191–201.PubMedGoogle Scholar
  8. Kleemann T. Prevalence of left atrial thrombus und dense spontaneous echo contrast in patients with short-term atrial fibrillation <48 hours undergoing cardioversion: value of transesophageal echocardiography to guide cardioversion. J Am Soc Echocardiogr. 2009;22:1403–8.CrossRefGoogle Scholar
  9. Klein AL, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med. 2001;344:1411–20.CrossRefGoogle Scholar
  10. McGrath E. Transesophageal echocardiography in patients with cryptogenic ischemic stroke: a systematic review. Am Heart J. 2014;168:706–712. E14.CrossRefGoogle Scholar
  11. Oussama M, et al. Cardiovascular imaging in the management of atrial fibrillation. J Am Coll Cardiol. 2006;48:2077–84.CrossRefGoogle Scholar
  12. Porter TR, et al. Clinical application of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography Guidelines update. J Am Soc Echocardiogr. 2018;31(3):241–74.  https://doi.org/10.1016/J.Echo.2017.11.013.CrossRefPubMedGoogle Scholar
  13. Senior R, et al. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017. Eur Heart J Cardiovasc Imaging. 2017;0:1–33.Google Scholar
  14. Shear D. Incidence and Predictors of left atrial thrombus prior to catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2009;20:379–84.CrossRefGoogle Scholar
  15. Steffel J, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39:1330–93.  https://doi.org/10.1093/Eurheartj/ehy136.CrossRefPubMedGoogle Scholar
  16. Thomas JD. Tissue harmonic imaging: why does it work? J Am Soc Echocardiogr. 1998;11(8):803–8.CrossRefGoogle Scholar
  17. Wazni OM. Cardiovascular imaging in the management of atrial fibrillation. J Am Coll Cardiol. 2006;48:2077–84.CrossRefGoogle Scholar
  18. Whaba A, et al. Deutsches Ärzteblatt. 1994;91:A3495–505.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Harald Becher
    • 1
  • Andreas Helfen
    • 2
  1. 1.University of Alberta HospitalEdmontonCanada
  2. 2.St. Marien Hospital, Katholisches Klinikum Lünen GmbHLünenGermany

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