Comparison of Transesophageal and Transthoracic for Diagnosis of Right-Skied Cardiac Lesions

Echocardiography

Cesar J. Herrera. MD. David J. Mehlman., MD. Renee S. Hartz, MD, James V. Talano, MD, and David D. McPherson, MD wo-dimensional transthoracic echocardiography (TTE) is an establishedmethod for the evaluation of cardiac or paracardiac structural abnormalities such as tumors, vegetations and thrombi.1-4 Cardiac structural resolution can be limited with lTE owing to anatomic interference. With transesophageal echocardiography (TEE), regionsof the heart previously difficult to visualiz.e are now readily studied. These regions include the vena cavae, right ventricular outflow tract, pulmonic valve and pulmonary trunk. The usefulnessof TEE as comparedwith TTE in assessingright-sided cardiac pathology has not been clearly determined. We compared both techniqueswith the objectivesof studying their diagnostic ability for the evaluation of right-sided cardiac lesions, and comparing data obtained with those from other confirmatory techniques. In all, 47 hospitalized patients (27 women and 20 men,mean age49 f 20 years) referred to our laboratory with clinically suspectedor incidentally foundright-sided pathology underwent 56 TTE and TEE examinations. Indications included vegetation, thrombus, tumor andforeign body. Eight patients wereimaged more than once. Additional confirmatory methods included blood cultures, pathologic specimens,computerized tomography, magnetic resonanceimaging and nuclear scans. All patients werestudied with routine TTE and TEE using standard phased-array ultrasound imaging units (Acuson 128, Acuson Inc., Mountain View, California, or Hewlett-Packard SONOS 500, Hewlett-Packard Inc., Andover, Massachusetts).Both echocardiographic examinations were performed within 48 hours, after written consent and fasting for 16 hours. Cetacaine

spray and midazolam hydrochloride were usedfor oropharyngeal anesthesiaand sedation, respectively. TEE identified nonartifactual abnormalities in 37 of 56 cases(67%) (Table I). TEE was consistent with the findings in all caseswith conJirmatoTydata availablefor comparison (n = 18: 49%) (6 vegetations,6 thrombi, 5 tumors and 1foreign body); TTE was consistentin 9 of 18 cases (50%) (4 vegetations, 3 thrombi, 2 tumors). Correlation of TTE with TEE data occurred in 3 of 19 cases (16%) with no confirmation. Among all cases, TTE correlated with TEE findings in 12 of 37 (32%). Echocardiographic diagnoses were not clinically suspected (incidental) in 9patients (24%). Among all cases with nonartifactual abnormalities, TEE findings impacted on the managementof 32 (86%), leading to alterations in anticoagulation (n = 15), antibiotic therapy (n = 8), surgery (n = 6) and tumor search (n = 3). Nineteen TTE studies (33%) demonstrated abnormalities that were consideredto be artifactual by TEE (small or narrowed superior vena cava,prominent right atria1 appendage trabeculations, thickened tricuspid valve, intravenous lines, remnants of the superior vena caval valve, right atria1 and ventricular wall indentation causedby localized pericardial effusions and prominent moderator bands). Figure 1 depicts the TEE of a suspected right atria1 massby TTE consistentwith a small superior vena caval entrance into the right atrium. Lesions identified in the right atrium and atria1 appendage, and inferior and superior vena cava included thrombi, vegetationsand tumors. Of 13 caseswith right atria1 thrombus, 5 weredemonstratedby TTE and all by TEE. Figure 2 represents1 such case. Thrombi involving the vena cavae and entering the From Northwestern University, Northwestern Memorial Hospital, 250 right atrium weredelineatedonly by TEE in 3 cases(all East Superior, Suite 524, Chicago, Illinois 60611.Manuscript received February 24, 1992;revised manuscript receivedand acceptedMay 1, related to in-dwelling central lines). In 2 patients with large vegetationswithin the right atrium attached to the 1992. T

TABLE I Comparative Results of Transthoracic, Transesophageal and Other Confirmatory Data Location Right atrial appendage Right atrium Isolated right atrium Superior and inferior vena cava

3 13 4

Tricuspid valve Right ventricle, pulmonary trunk and pulmonic valve Tricuspid valve

4

Right ventricle Pulmonary trunk Pulmonic valve Atrial septum Paracardiac

1 3 1 3 2

TEE

964

Cases

1 2

TTE

TEE

Confirmation

Thrombus

O/3

313

l/3

Thrombus 3 thrombi and 1 tumor Thrombus Vegetation

5113 O/4

13/13 414

Lesion

3 vegetations and 1 flail leaflet Foreign body Thrombus Vegetation Tumor Tumor

O/l

212

l/l 212

O/l l/2

314

414

314

O/l o/3 O/l 213 o/2

l/l 313 l/l 313 212

l/l 313 l/l 213 212

= transesophagealechocardiography;lTE = transthoracicechocardiography.

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3113 l/4

OCTOBER 1, 1992

tricuspid or pulmonic valve, TTE did not fully delineate the extent of the vegetations. Figure 3 illustrates a large enterococcal bacterial vegetation within the right atrium. Although TTE demonstrated the lesion contiguous to the tricuspid valve, TEE identified the attachment to the atria1 septum and the absence of involvement of the tricuspid valve. A case of carcinoma invading the inferior vena cava and entering the right atrium was defined only by TEE. A dilated appendage containing thrombus in the presence of right ventricular volume overload was demonstrated only by TEE in 3 patients. Lesions affecting the atria1 septum, tricuspid and pulmonic valves, and pulmonary trunk were present in 11 cases; all were well-delineated by TEE, but only 5 by TTE. A benign tumor and lymphomatous mass were described as right atria1 and ventricular wall abnormalities, respectively, with TTE; TEE (with subsequent

magnetic resonance imaging and computerized tomography) confirmed their extracardiac locations. A bullet fragment in the right ventricular wall was only demonstrated by TEE and was later found at surgery. Ten of 20patients with thrombi were known or found to have atria1 shunting (1 atria1 septal defect and 9 patent foramen ovale). In 8 additional cases, prosthetic material (valves or chronic in-dwelling lines) were present.

The major findings of this study are that: (1) TEE providesa higher diagnostic yield than doesTTE for the identification of right-sided pathology, (2) TTE often leads to misdiagnosisdue to anatomic artifacts, and (3) clinical managementdecisionsconcerningright-sided pathology can often be made after TEE. The present report is the first systematic attempt to compareTEE with TTE in patients with right-sided cardisc pathology. In this series,TEE correlated in 18 of 37

flGURE 2. Large abid thmmbus @WOW) demonstrated by echocardiography in patient with right ven-4 triadar vohane overload. Transducsr is located in upper to mid-esophagus. Ao = aorta; Ra = right atrium.

FIGURE 3. Large bachid tlhspid valve. Right, trb

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caseswith confirmatory techniques,with little agreement betweenTIE and confirmatory techniques.Our purpose was not to test the value of each echocardiographicmodality in assessinganatomic complications;we attempted to compareboth TEE and ‘ITE for eachright-sided location over a wide range of diagnoses. Although TTE visualized right-sided anatomy, certain regions such as the right atria1 appendage,superior vena cava and pulmonary trunk were not well seen.Furthermore, poor resolution and incorrect transducer angulation may have createdthe artifacts reported here. TEE may be a more reliable technique in assessingright heart lesions,becauseof the absenceof thoracic interference, higher frequency ultrasound and improved visualization of posterior structures. The tricuspid and pulmonic valves, and the pulmonary trunk are anterior to the heart and in the near field in respectto ‘ITE transducers.However, in this series,TEE wasmore useful in 3 casesof pulmonary thromboembolic disease by defining mobility, location and relation of thrombus to lumen. A potential but undefined role for TEE in this diseasehasbeensuggestedby other investigatoIs. Mugge et al6 recently reported the diagnostic potential of TEE in studying cardiac and paracardiac masses. In that study, although most patients had a correct diagnosis by TTE, identification of massesanterior to the heart and invading major vesselswas improved by TEE. We reported 6 casesin which ‘ITE did not help in the diagnosis. It incorrectly identified pericardial tumors, atria1 septal hypertrophy and foreign body within the cardiac chambers. In these structures, computerized to-

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mography and magnetic resonanceimaging were consistent with the TEE findings. In this study, TEE was useful in detecting associated, clinically relevant conditions such as atria1 shunts, malfunctioning intravenous lines or prosthetic valves.We do not have confirmatory data in 50% of patients; however, among those who underwent additional diagnostic techniques,TEE findings correlated in all cases.Our cohort is skewed,becausemost patients were referred with suspectedright-sided abnormalities. Consequently,sensitivity and specificity cannot be determined.The addition of biplane technology may increase the detection rate of abnormalities affecting the superiorvena cava,right atrial appendageor pulmonary trunk. In conclusion,given the unreliability of TTE in assessing right-sided cardiac lesions,if TTE doesnot demonstrate suspectedpathology, TEE should be performed.In the absenceof TEE, other confirmatory techniquessuch asmagnetic resonanceimaging and computerizedtomography are recommended. I. DePaceNL, SoulenRL, Kotler MN, Mintx GS. Two-dimensionalechocardiographic detection of intra-atria1 masses.Am J Cardiol 1981;48:954-960. 2. Felner JM. Knoof WD. Echocardioaraohic recognition of intracardiac and extracardiic &&. E&ocardiogmph~ld85;2:3-5

Comparison of transesophageal and transthoracic echocardiography for diagnosis of right-sided cardiac lesions.

Comparison of Transesophageal and Transthoracic for Diagnosis of Right-Skied Cardiac Lesions Echocardiography Cesar J. Herrera. MD. David J. Mehlman...
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