Endoscopy 2007; 39(5): 385-389
DOI: 10.1055/s-2007-966440
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Transesophageal endoscopic ultrasound-guided access to the heart

A.  Fritscher-Ravens1 , A.  Ganbari1 , C.  A.  Mosse2 , P.  Swain3 , P.  Koehler4 , K.  Patel5
  • 1Department of Gastroenterology, Homerton University Hospital, London, United Kingdom
  • 2Department of Medical Physics and Bioengineering, University College, London, United Kingdom
  • 3Department of Surgery, St. Mary’s Hospital, London, United Kingdom
  • 4Institute of Animal Breeding FAL, Mariensee, Germany
  • 5Department of Radiology, Homerton University Hospital, London, United Kingdom
Weitere Informationen

Publikationsverlauf

submitted 6 March 2007

accepted after revision 27 March 2007

Publikationsdatum:
22. Mai 2007 (online)

Background and study aims: Endoscopic ultrasound and fine-needle aspiration of paramural lesions are established diagnostic techniques in gastroenterology and are now also used for therapeutic purposes. The proximity of the heart to the esophagus and the utility of the diagnostic technique of transesophageal echography prompted us to explore the possibilities of approaching the heart through the esophagus. Methods: In acute experiments (n = 2) and survival experiments (n = 6) on anesthetized pigs, the anatomical landmarks were first identified and studied, before introduction of the needle through the posterior cardiac wall into the left atrium, and then beyond, as far as the aortic valve. The smallest structure targeted was the coronary artery. The animals in the survival group were monitored clinically over a 2-week period and also underwent endoscopic and cardiologic re-examinations prior to autopsy. Three patients were also investigated using the technique. Results: No visible damage was observed in the heart in the two animals which were sacrificed immediately or in the six surviving pigs (except for one small hematoma). The needle could be introduced repeatedly into the left atrium, followed by the injection of saline. Reaching the aortic valve was more difficult because of the moving target, but ablation therapy was technically possible. The coronary artery was successfully punctured in three of the animals (all three weighed 40 kg or more); in smaller animals, the needle overshot the lumen of these minute arteries. Of the three patients investigated, pericardial fluid was successfully aspirated in two patients and a left atrial mass was punctured in the third patient (excluding neoplasia, the final diagnosis being thrombus). Conclusion: These animal studies and clinical cases suggest that transesophageal intracardiac procedures could become feasible and that further exploration by gastroenterologists and cardiologists may be justified.

References

  • 1 Eloubeidi M A, Tamhane A, Varadarajulu S, Wilcox C M. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation.  Gastrointest Endosc. 2006;  63 622-629
  • 2 Micames C G, McCrory D C, Pavey D A. et al . Endoscopic ultrasound-guided fine-needle aspiration for non-small cell lung cancer staging: a systematic review and metaanalysis.  Chest. 2007;  131 539-548
  • 3 Annema J T, Veselic M, Rabe K F. Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of sarcoidosis.  Eur Respir J. 2005;  25 405-409
  • 4 Fritscher-Ravens A, Patel K, Shidrawi R, Pelling M. Benign mediastinal lymphadenopathy: Is EUS-FNA for differential diagnosis of tuberculosis and sarcoidosis an option?.  GUT. 2004;  53 (Suppl. IV) A233
  • 5 Seifert H, Wehrmann T, Schmitt T. et al . Retrotroperitoneal endoscopic debridement for infected peripancreatic necrosis.  Lancet. 2000;  356 653-655
  • 6 Fritscher-Ravens A, Mosse C A, Mukherjee D. et al . Transluminal endosurgery: single lumen access anastomosis device for flexible endoscopy.  Gastrointest Endosc. 2003;  58 585-591
  • 7 Fritscher-Ravens A, Mosse C A, Ikeda K, Swain P. Endoscopic transgastric lymphadenectomy using endoscopic ultrasound for selection and guidance.  Gastrointest Endosc. 2006;  63 302-306
  • 8 Kuhl H P, Harath P. The impact of transesophageal echocardiography on daily clinical practice.  Eur J Echocardiogr. 2004;  5 455-468
  • 9 Garcia-Orta R, Moreno E, Vidal M. et al . Three-dimensional versus two-dimensional transesophageal echocardiography in mitral valve repair.  J Am Soc Echocardiogr. 2007;  20 4-12
  • 10 ASGE, SAGES . ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005.  Gastrointest Endosc. 2006;  63 199-203
  • 11 Giday S A, Kantsevoy S V, Kalloo A N. Principle and history of natural orifice translumenal endoscopic surgery (NOTES).  Minim Invasive Ther Allied Technol. 2006;  15 373-377
  • 12 Lichtenstein S V, Cheung A, Ye J. et al . Transapical transcatheter aortic valve implantation in humans: initial clinical experience.  Circulation. 2006;  114 591-596
  • 13 Patel A, Lopez K, Banerjee A. et al . Transcatheter closure of atrial septal defects in adults > or = 40 years of age: immediate and follow-up results.  J Interv Cardiol. 2007;  20 82-88
  • 14 Fritscher-Ravens A, SriRam P VJ, Bobrowski B. et al . Mediastinal lymphadenopathy in patients with and without previous malignancy: EUS-FNA based cytodiagnosis in 153 patients.  Am J Gastroenterol. 2000;  95 2278-2284
  • 15 Fritscher-Ravens A, Swain P, Schirrow L. et al . Urgent bedside endosonography and guided fine-needle aspiration for diagnosis and management of posterior mediastinitis.  Crit Care Med. 2003;  31 126-132
  • 16 Huang C H, Lu C W, Lin T Y. et al . Complications of intraoperative transesophageal echocardiography in adult cardiac surgical patients: experience of two institutions in Taiwan.  J Formos Med Assoc. 2007;  106 92-95
  • 17 Schulmeyer M C, Santelices E, Vega R, Schmied S. Impact of intraoperative transesophageal echocardiography during noncardiac surgery.  J Cardiothorac Vasc Anesth. 2006;  20 768-771
  • 18 Champagne J, Echahidi N, Philippon F. et al . Usefulness of transesophageal echocardiography in the isolation of pulmonary veins in the treatment of atrial fibrillation.  Pacing Clin Electrophysiol. 2007;  30 Suppl 1 S116-S119
  • 19 Saeed M, Rahman A, Afzal A. et al . Role of transesophageal echocardiography guided cardioversion in patients with atrial fibrillation, previous left atrial thrombus and effective anticoagulation.  Int J Cardiol. 2006;  113 401-405

A. Fritscher-Ravens, MD 

Department of Gastroenterology
Homerton University Hospital

Homerton Row
London E9 6SR
United Kingdom

Fax: +44-208-8510849

eMail: fri.rav@btopenworld.com