Clinical & Experimental Cardiology
Open Access

Transesophageal Echocardiography in Hypertrophic Cardiomyopathy

Dylan Arthur^{* *}Correspondence: Dylan Arthur, Department of Cardiac Surgery, University of Cyril and Methodius, Skopje, North Macedonia, Email:

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Description

Hypertrophic Cardiomyopathy (HCM) is a genetic disorder characterized by the thickening of the heart muscle, most notably the left ventricle. This thickening, or hypertrophy, can impede the heart’s ability to pump blood effectively and may lead to complications such as arrhythmias, heart failure, and sudden cardiac death. As a result, accurate diagnosis, monitoring, and management of HCM are critical. Among the available diagnostic modalities, echocardiography plays a key role, and Transesophageal Echocardiography (TEE) is one of the most valuable tools in the echocardiographic assessment of HCM. TEE provides a more detailed view of the heart’s structures compared to Transthoracic Echocardiography (TTE) and is often used when TTE provides inadequate information.

HCM is primarily a genetic condition caused by mutations in genes encoding sarcomere proteins, leading to abnormal heart muscle growth. The primary hallmark of HCM is asymmetric hypertrophy of the left ventricle, especially the interventricular septum. This hypertrophy can result in Left Ventricular Outflow Tract (LVOT) obstruction, which affects cardiac output and increases the risk of complications like atrial fibrillation, mitral valve disease, and sudden death due to arrhythmias. HCM presents with a wide range of clinical symptoms, including chest pain, palpitations, dizziness, shortness of breath, and syncope. The condition is often diagnosed during evaluation for these symptoms or in family screening of individuals with known HCM. Given the potentially lethal nature of the disease, especially in undiagnosed cases, it is essential to use advanced diagnostic tools for accurate assessment and management. Echocardiography, the primary imaging modality for assessing HCM, provides information on the morphology and function of the heart. Transthoracic Echocardiography (TTE) is commonly used as a first-line imaging tool because it is non-invasive, widely available, and provides comprehensive information about the heart's anatomy and function. However, TTE has limitations in certain cases, particularly in patients with poor acoustic windows (due to obesity, lung disease, or chest wall deformities) or when detailed visualization of specific heart structures is needed. In these situations, TEE offers superior imaging by bypassing the chest wall and directly visualizing the heart from within the esophagus, providing clearer and more precise images.

One of the key applications of TEE in HCM is in pre-surgical planning. Patients with symptomatic LVOT obstruction who do not respond to medical management may require surgical intervention, such as septal myectomy or alcohol septal ablation. TEE is used to assess the extent and location of hypertrophy, guide the surgical approach, and evaluate the mitral valve apparatus for associated abnormalities that might require concurrent surgical correction. During septal myectomy, the surgeon removes a portion of the hypertrophied septum to relieve LVOT obstruction. TEE can be used intraoperatively to assess the adequacy of the resection and ensure that the obstruction has been resolved. It also helps identify potential complications, such as residual LVOT gradients or mitral valve dysfunction, which may require further intervention.

While TTE remains the first-line tool for diagnosing and managing HCM, TEE offers several advantages, particularly in patients where TTE is suboptimal. TEE provides superior visualization of certain structures, such as the mitral valve, LVOT, and apex, making it the preferred imaging modality in challenging cases. Additionally, TEE is often used in conjunction with other imaging modalities, such as cardiac Magnetic Resonance Imaging (MRI) or Computed Tomography (CT), to provide complementary information. For example, while MRI is excellent for tissue characterization and assessing the extent of myocardial fibrosis, TEE offers superior real-time imaging and is more accessible in the operating room or during procedures like septal ablation. Despite its advantages, TEE is not without risks. The procedure is semi-invasive, requiring the insertion of a probe into the esophagus, which can cause discomfort, throat injury, or, rarely, esophageal perforation. TEE also requires sedation, which carries additional risks, particularly in patients with severe comorbidities. Moreover, TEE may not always provide the full extent of information needed, especially in assessing myocardial fibrosis or detailed tissue characteristics, where cardiac MRI is more informative. Therefore, TEE is often used as part of a multimodality approach to fully assess the complexity of HCM.

Conclusion

Transesophageal echocardiography is a powerful tool in the diagnosis, evaluation, and management of hypertrophic cardiomyopathy. Its ability to provide detailed, high-resolution images of the heart’s structures makes it invaluable in cases where TTE is insufficient or when more precise imaging is needed for surgical planning and postoperative assessment. However, the semi-invasive nature of the procedure and its limitations must be carefully considered in the clinical decisionmaking process. When used appropriately, TEE significantly enhances the care of patients with HCM, contributing to more accurate diagnoses, better management of symptoms, and improved outcomes.