Intraoperative Transesophageal Echocardiographic Guidance in Cardiac Surgery

Figures

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  Figure 1. Beating-heart transapical Neochord implantation. (A) Preoperative assessment of the MV. Note the flail segment in the later part of the P2 (blue arrow). (B) The device (yellow arrow) is introduced into the left ventricle transapically and, using TEE, it is guided within the left atrium. (C) With the device in the left atrium, TEE provides guidance for the proper placement of the chords. (D) Postoperative assessment of the mitral valve. Note the absence of the residual flail part. AL: anterior mitral leaflet; AV: aortic valve; LA: left atrium; LV: left ventricle; MV: mitral valve; PL: posterior mitral leaflet.

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  Figure 2. Essential echocardiographic measurements in patients with MR. (A) In the left panel is a patient with severe primary MR. Measurement of the leaflet length and annulus diameter as well as the calculation of the coaptation index can predict a sufficient coaptation length after an MV repair operation. These measurements are more important in operations without the availability of annular ring placement, as is the case in transapical chord implantation interventions. (B) In the right panel, there is a patient with moderate to severe secondary MR. Increased tenting area and tenting height are associated with increased recurrence rate and worse prognosis after isolated annuloplasty. MR: mitral regurgitation; MV: mitral valve; MVA: mitral valve area.

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  Figure 3. Postoperative assessment of a patient undergoing mitral valve repair with chord implantation and ring placement for primary MR. (A) Using color Doppler, TEE can assess for residual MR or the presence of paravalvular leaks, which were excluded in this case. (B) With continuous Doppler, the transmitral flow is recorded, and the mean gradient can be measured. (C,D) Using a 3D view, TEE can visualize the mitral valve from the “surgical views” with the aorta in the 12th h and the left atrial appendage in the 9th h. In this case, no residual flail segment was noted, and the opening of the mitral valve was also anatomically sufficient. LA: left atrium; LV: left ventricle; MR: mitral regurgitation; RA: right atrium.

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  Figure 4. Postoperative assessment of a patient undergoing bioprosthetic aortic valve implantation. (A,B) Short-axis views. (C,D) Long-axis views. A significant paravalvular leak (red arrow) is noted between the 1st and the 4th h in the anatomical position of the left aortic cusp. Based on the TEE findings, a new valve was implanted. AA: ascending aorta; AV: aortic valve; LVOT: left ventricular outflow tract.

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  Figure 5. Postoperative assessment of a patient undergoing bioprosthetic aortic valve replacement. (A) Diastolic frames showing paravalvular leak in the 7th h. (B) Diastolic frame from long-axis views showing significant regurgitation. (C,D) Systolic frames showing aliasing, which indicated stenotic function of the valve. Based on the TEE findings, a new valve was implanted. AV: aortic valve; LA: left atrium; LVOT: left ventricular outflow tract; RA: right atrium; RV: right ventricle.

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  Figure 6. Assessment of a patient undergoing CABG for anterior STEMI with late presentation and 3-vessel disease on cardiac catheterization. Preoperative assessment revealed a ventricular septal defect (VSD) at the apical part of the intraventricular septum (green arrow). Subsequently, a septal patch was placed, and postoperative assessment revealed complete closure of the VSD. AV: aortic valve; LA: left atrium; LV: left ventricle; MV: mitral valve; RV: right ventricle.