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Open access

Is transnasal TEE imaging a viable alternative to conventional TEE during structural cardiac interventions to avoid general anaesthesia? A pilot comparison study of image quality

Dimitris Klettas, Emma Alcock, Rafal Dworakowski, Philip MacCarthy, and Mark Monaghan


The role of transoesophageal echocardiography in cardiac interventional structural procedures is well established and appreciated. However, the need for general anaesthesia (GA) throughout the procedure remains a controversial issue. The aim of the present study is to assess the feasibility and imaging quality of using a transnasal microrobe that allows the usage of conscious sedation in patients who undergo cardiac structural interventional procedures without missing the benefits, guidance and navigation of conventional trans-procedural TEE.


We analysed the trans-procedural images of 24 consecutive patients who underwent TAVI, TMVI or ASD/PFO closure, using a transnasal 2D microprobe (PHILIPS) and then we compared them with images taken by using a conventional 3D TEE probe (PHILIPS). In particular, we compared the imaging quality of the two probes regarding: (1) The anatomy, visualisation of valvular calcification and transvalvular colour Doppler of the aortic and mitral valve; (2) the imaging quality of PFO, ASD and interatrial communication colour flow; (3) the imaging of left ventricle systolic function and pericardial space and (4) transgastric imaging.


All images were graded with a scale from 5 to 1. The average grade of imaging quality in the mitral valve was: anatomy, 4.3; calcification, 3.8; colour Doppler, 4.2. The average grade of imaging quality in the aortic valve was: anatomy, 4.3; calcification, 3.7; colour Doppler, 4.3. The average grade of imaging quality in PFO/ASD was 4.3. The average grade of imaging quality in LV/pericardial space was 4.2. The average grade of imaging quality in transgastric imaging was 4.1.


These results suggest that transnasal TEE can provide good anatomical image quality of relevant cardiac structures during cardiac structural interventions and this may facilitate these procedures being performed during conscious sedation without having to lose TEE guidance.

Open access

A case of isolated bicuspid pulmonary valve

Ramasamy Manivarmane, Rebecca Taylor, and Rajdeep Khattar

Our case highlights the finding of an abnormal pulmonary valve on 2D echocardiography, confirmed to be of bicuspid morphology with 3D imaging. The use of biplane imaging both in transthoracic and transoesophageal echocardiography and routine use of three-dimensional views particularly in transoesophageal echocardiography are of incremental value in better delineating pulmonary valve anatomy.

Learning points:

  • Bicuspid pulmonary valve as an isolated clinical entity is a rare finding in clinical practice with an incidence of about 0.1%.

  • The true prevalence of the condition may be underestimated because of difficulty in visualising the pulmonary valve en-face on standard two-dimensional echocardiography.

  • Trans-oesophageal echocardiography may provide better visualization of the pulmonary valve when transthoracic images are affected by interference from the left lung.

  • Routine use of 3D echocardiography with biplane and zoomed views should be advocated for a full morphological assessment of the pulmonary valve, whether imaging via the transthoracic or transoesophageal approach.

Open access

Quadruple valve replacement in a patient with severe rheumatic heart disease

Isaac Adembesa, Adriaan Myburgh, and Justiaan Swanevelder


We present a patient with rheumatic heart disease involving all the heart valves. An intraoperative transoesophageal echocardiography confirmed severe mitral stenosis, severe aortic regurgitation, severe tricuspid regurgitation and stenosis, and severe pulmonary stenosis. The patient underwent successful quadruple valve replacement during a single operation at the Groote Schuur Hospital, Cape Town, South Africa.

Learning points:

  • Rheumatic heart disease can affect all the heart valves including the pulmonary valve.

  • Intraoperative transoesophageal echocardiography is key for diagnosis, monitoring and confirmation of successful surgical result during heart valve surgery.

  • Combined surgical procedure of all four valves is possible though associated with long procedural time.

Open access

A case of right atrial appendage aneurysm mimicking a pericardial cyst on echocardiogram

Mehrnoush Toufan, Leili Pourafkari, Fariborz Akbarzadeh, and Nader D Nader


Right atrial appendage aneurysms (RAAAs) are rarely encountered. If symptomatic, they present with atrial arrhythmias or embolic events. Surgical resection is indicated for symptomatic patients. We describe a 65-year-old man presenting with palpitation for 6 months. Electrocardiogram showed atrial flutter. Transthoracic echocardiography revealed a large thin-walled cystic mass anterior to right ventricular outflow tract, which was confirmed to be a giant RAAA by contrast transoesophageal echocardiography and later by contrast-enhanced computerised tomography. The patient underwent electrocardioversion, following which he remained in sinus rhythm and was asymptomatic during the 3 months follow-up period.

Learning points

  • RAAA can present with atrial flutter.

  • Transoesophageal contrast echocardiography is the most valuable non-invasive tool in diagnosis of RAAA.

  • Although computed tomography scan is not necessary for establishing the diagnosis, it may provide useful information regarding the structural anatomy.

Open access

Echocardiographic approach to catheter closure of atrial septal defects: patient selection, procedural guidance and post-procedural checks

Alexandra Savis and John Simpson

Echocardiography is the imaging modality of choice to diagnose different types of atrial septal defect and to determine which defects are suitable for catheter occlusion. In addition to assessment of defect size and rims, transoesophageal echocardiography may be used to guide the procedure itself including device placement, procedural complications and post-procedural checks. This review covers a practical approach to this subject and is accompanied by online videos illustrating the technique.

Open access

3D transoesophageal echocardiography in the TAVI sizing arena: should we do it and how do we do it?

Caroline Bleakley, Mehdi Eskandari, and Mark Monaghan

Transcatheter aortic valve implantation (TAVI) was initially proven as an alternative to valve replacement therapy in those beyond established risk thresholds for conventional surgery. With time the technique has been methodically refined and offered to a progressively lower risk cohort, and with this evolution has come that of the significant imaging requirements of valve implantation. This review discusses the role of transoesophageal echocardiography (TOE) in the current TAVI arena, aligning it with that of cardiac computed tomography, and outlining how TOE can be used most effectively both prior to and during TAVI in order to optimise outcomes.

Open access

The echocardiography of replacement heart valves

John B Chambers

This is a practical description of how replacement valves are assessed using echocardiography. Normal transthoracic appearances including normal variants are described. The problem of differentiating normal function, patient–prosthesis mismatch and pathological obstruction in aortic replacement valves with high gradients is discussed. Obstruction and abnormal regurgitation is described for valves in the aortic, mitral and right-sided positions and when to use echocardiography in suspected infective endocarditis. The roles of transoesophageal and stress echocardiography are described and finally when other imaging techniques may be useful.

Open access

The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

Shaun Robinson, Liam Ring, Daniel X Augustine, Sushma Rekhraj, David Oxborough, Allan Harkness, Patrizio Lancellotti, and Bushra Rana

Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for valve surgery in Europe and despite the decline of rheumatic fever in Western societies, mitral stenosis of any aetiology is a regular finding in all echo departments. Mitral valve disease is, therefore, one of the most common pathologies encountered by echocardiographers, as both a primary indication for echocardiography and a secondary finding when investigating other cardiovascular disease processes. Transthoracic, transoesophageal and exercise stress echocardiography play a crucial role in the assessment of mitral valve disease and are essential to identifying the aetiology, mechanism and severity of disease, and for helping to determine the appropriate timing and method of intervention. This guideline from the British Society of Echocardiography (BSE) describes the assessment of mitral regurgitation and mitral stenosis, and replaces previous BSE guidelines that describe the echocardiographic assessment of mitral anatomy prior to mitral valve repair surgery and percutaneous mitral valvuloplasty. It provides a comprehensive description of the imaging techniques (and their limitations) employed in the assessment of mitral valve disease. It describes a step-wise approach to identifying: aetiology and mechanism, disease severity, reparability and secondary effects on chamber geometry, function and pressures. Advanced echocardiographic techniques are described for both transthoracic and transoesophageal modalities, including TOE and exercise testing.

Open access

Fibroelastoma in an unusual location: a rare cause of multiple cerebrovascular events

Mary Mashicharan, Zein El-Dean, Viktor Zlocha, and Jeffrey Khoo


Fibroelastomas are rare, primary cardiac tumours with a predilection for valvular endothelium and a propensity to embolise. We present the case of a 72-year-old male with multiple cerebrovascular events (CVA) despite oral anticoagulation. Transoesophageal echocardiography (TOE) revealed a small highly mobile left atrial mass with frond-like projections attached by a stalk to the orifice of the LAA. The mass was surgically excised and confirmed to be a fibroelastoma on histological examination. This case report describes a rare but treatable source of multiple cerebrovascular events and highlights the utility of TOE in the assessment of cardiac embolic source.

Learning points:

  • Fibroelastomas are most commonly found on left-sided heart valves (aortic > mitral) and have the potential to cause systemic emboli associated with significant morbidity and mortality.

  • A left atrial appendage (LAA) mass in a patient presenting with cerebrovascular events does not always represent thrombus. Uncommon aetiologies such as a cardiac tumour should be considered in the differential diagnosis.

  • Transthoracic echocardiography (TTE) does not provide an accurate assessment of the LAA and should not be used to detect pathology within this structure. Transoesophageal echocardiography (TOE) is superior to TTE in imaging the LAA and provides a complete delineation of its anatomy. In addition, TOE can detect very small highly mobile lesions (as described in this case), which may be missed on other imaging modalities.

Open access

Transoesophageal echocardiography (TOE): contra-indications, complications and safety of perioperative TOE

Neil David Hauser and Justiaan Swanevelder

Transoesophageal echocardiography (TOE) has, in certain clinical situations, become an almost universal monitor and diagnostic tool. In the perioperative environment, TOE is frequently used to guide anaesthetic management and assist with surgical decision making for, but not limited to, cardiothoracic, major vascular and transplant operations. The use of TOE is not limited to the theatre environment being frequently used in outpatient clinics, emergency departments and intensive care settings. Two case reports, one of oesophageal perforation and another of TOE utilization in a patient having previously undergone an oesophagectomy, introduce the need for care while using TOE and highlight the need for vigilance. The safe use of TOE, the potential complications and the suggested contra-indications are then considered together with suggestions for improving the safety of TOE in adult and paediatric patients.