Anesth Analg 2006;102:1361-1362
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000204356.88460.80
CARDIOVASCULAR ANESTHESIA
3D Transesophageal Echocardiography: Systolic Anterior Motion with Hypertrophic Obstructive Cardiomyopathy
Jessica L. Willert, MD,
Douglas Shook, MD, and
Michael N. D'Ambra, MD
Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
Address correspondence and reprint requests to Jessica L. Willert, MD, MSc, The Brigham and Women's Hospital, The Department of Anesthesiology, Perioperative, and Pain Medicine, 75 Francis St., Boston, MA 02116. Address e-mail to jwillert{at}partners.org.
A 47-yr-old man presented with exertional angina 20 years after being diagnosed with hypertrophic obstructive cardiomyopathy. Coronary angiography demonstrated widely patent coronary arteries. The patient was scheduled for left ventricular surgical septal myomectomy. The intraoperative transesophageal echocardiography (TEE) examination before cardiopulmonary bypass (CPB) revealed a peak gradient (by continuous wave Doppler) of 100 mm Hg across the left ventricular outflow tract (LVOT). A two-dimensional TEE mid-esophageal long axis view of the aortic valve and LVOT revealed an unusually long anterior mitral leaflet (AML), measuring 4.2 cm from base to tip (normal AML height, 2.8 cm). During systole, a subcoaptation segment of AML extended across the entire width of the LVOT (Fig. 1). During diastole, the interventricular septum (IVS) on two-dimensional images did not appear significantly hypertrophied. Thus, the two-dimensional examination led us to report that the cause of LVOT obstruction was primarily systolic anterior motion (SAM). Based on this information, the surgical team planned to perform mitral valve repair. However, intraoperative review of the three-dimensional data sets revealed a circumferential contraction band not appreciated in the two-dimensional TEE. In the three-dimensional rendering, this muscular band could be seen to preferentially shrink the orifice of the LVOT and draw the IVS toward the AML in systole (Fig. 2; Video Clip1). The three-dimensional data set expanded our understanding of the mechanism of LVOT obstruction, which now seemed to include both SAM and the contraction band. Myomectomy and mitral valve repair were performed, and the patient was successfully weaned from CPB. Two-dimensional TEE imaging after CPB, plus direct LV pressure measurement, demonstrated resolution of LVOT obstruction. The post-procedure three-dimensional data set showed the depth and the location of the myomectomy and cessation of the inward motion of the IVS caused by the contraction band that had been contributing to the LVOT gradient.
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Figure 1. Systolic anterior motion as viewed by two-dimensional transesophageal echocardiography (TEE) in the mid-esophageal aortic valve long-axis view. AML = anterior mitral valve leaflet; SAM = anterior mitral valve leaflet obstructing the left ventricular outflow tract (LVOT) during systole; RCC = right coronary cusp of open aortic valve.
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Figure 2. Systolic anterior motion as viewed by three-dimensional transesophageal echocardiography (TEE) in the mid-esophageal aortic valve long-axis view. AML = anterior mitral valve leaflet; SAM = systolic anterior motion of the anterior mitral valve leaflet obstructing the left ventricular outflow tract (LVOT) in systole; RCC = right coronary cusp of open aortic valve; Band = abnormal contraction band in a patient with hypertrophic obstructive cardiomyopathy.
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EchoView Software (TomTec Imaging Systems, GmbH, Unterschleissheim, Germany) converts axial two-dimensional TEE images into a three-dimensional data set. There is controversy regarding the likelihood of obtaining new data from the three-dimensional rendering that are not contained in two-dimensional images. Qin et al. (1) demonstrated that three-dimensional reconstruction of the mitral valve-LVOT relationship allows an understanding of the geometry of myomectomy in the treatment of SAM and hypertrophic obstructive cardiomyopathy not previously reported in the two-dimensional literature. This present example suggests that the ability to view the dynamic contraction sequence of the entire LV as a three-dimensional entity makes possible the appreciation of a contraction band that was not diagnosed in two-dimensional images. Resolution of the hypothesis that three-dimensional TEE analysis can provide new information not seen in two dimensions awaits publication of additional clinical examples such as these.
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Footnotes
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Accepted for publication December 21, 2005.
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Reference
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- Qin JX, Shiota T, Asher CR, et al. Usefulness of real-time three-dimensional echocardiography for evaluation of myectomy in patients with hypertrophic cardiomyopathy. Am J Cardiol 2004;94:964–6.[Medline]
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