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Look Familiar?!

Introduction to Transesophageal Echocardiography Nakeisha L. Pierre, M.D Tulane Department Anesthesiology. Look Familiar?!. IVC or SVC ?. Basic Principles of Ultrasound and Doppler. Echocardiography creates images of the heart from reflected sound waves

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Look Familiar?!

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  1. Introduction to Transesophageal EchocardiographyNakeisha L. Pierre, M.DTulane Department Anesthesiology

  2. Look Familiar?! IVC or SVC ?

  3. Basic Principles of Ultrasound and Doppler • Echocardiography creates images of the heart from reflected sound waves • The ultrasound transducer records the time delay and amplitude for each returning transmission • Speed in a medium is constant, so only the distance of the structure from the probe alters the time to receive the reflected wave • Timing the interval between transmissions and the time it takes to receive reflected signals allows the ultrasound system to precisely calculate the location of structures and construct images

  4. Basic Principles of Ultrasound and Doppler • 2-D echo is unable to visualize blood flow.. It’s presented as just black on the display • Doppler ultrasonography overcomes this limitation • The Doppler system determines the velocity of blood flow by assessing the change in frequency of the ultrasound reflected from moving red blood cells • Directing the ultrasound at the flow of blood and listening for those changes in frequency allows Doppler echo to determine direction and speed of blood flow

  5. Basic Principles of Ultrasound and Doppler • Frequency (cycles/s) is a property exclusive to the echo transducer/probe ( 2-10Hz) • Frequency determines signal strength and imaging resolution • Signal strength • Lower freq – stronger signal • Disadvantage is decreased image resolution • Imaging resolution • Higher freq – better image resolution • Disadvantage – decreased penetration/weaker signal

  6. Doppler Flow

  7. Category I Indications for Intra-Operative TEE • Acute, persistent life-threatening disturbances • Valve repair – particularly mitral valve • Aortic valve resuspension in dissection or aneurysm sx • Congenital heart surgery • Obstructive cardiomyopathy • Endocarditis • Thoracic Aortic Aneurysm • Pericardial Window *conditions for which there is evidence and/or general agreement that a given procedure is useful and effective*

  8. Category II Indications for Intra-Operative TEE • Increased risk for MI or unstable hemodynamics • Valve replacement • Myocardial aneurysm repair • Cardiac assist devices • Myocardial/intracardiac mass rsxn • Foreign body detection or removal • Pulmonary endareterctomy • Suspected cardiac trauma • Aortic atheromatous disease • Pericardial surgery • Cardiac or pulmonary transplantation *Conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness or efficacy of procedure/treatment*

  9. Esophageal disease – stricture, diverticuli, varices, tumor Prior esophageal or stomach surgery Perforated viscus Difficulty passing the TEE probe Anticoagulation Thrombocytopenia Facial or airway trauma Contraindications to Intra-Operative TEE

  10. Anatomical Relationships • The esophagus provides an excellent window for visualizing detailed echocardiographic images secondary to its close proximity to the heart • The esophagus extends from the posterior pharynx through the mediastinum where it courses behind the trachea left main bronchus and continues inferiorly where it becomes immediately adjacent to LA and LV Esophagus

  11. 20 views recommended by ASE task force Goal during any exam is to visualize structure and function of heart and not necessarily get all 20 views Comprehensive TEE Exam

  12. Comprehensive TEE Exam

  13. Comprehensive TEE Exam • Views designated by • Echo window • Upper esophageal (20-25cm) • Mid esophageal (30-40cm) • Transgastric (40-45cm) • Deep transgastric (45-50cm) • Main anatomic structure • AV • RV • Imaging plane • Short axis/SAX • Long axis/LAX

  14. At a multiplane angle of 0 degrees (the horizontal or transverse plane), with the imaging plane directed anteriorly from the esophagus through the heart, the patient’s right side appears in the left of the display. Rotating the multiplane angle forward to 90 degrees (vertical or sagittal plane) moves the left side of the display inferiorly, toward the supine patient’s feet. Rotating the multiplane angle to 180 degrees places the patient’s left side to left of the display, the mirror image of 0 degrees. Comprehensive TEE Exam

  15. Orientation of the Heart

  16. Comprehensive TEE Exam Advance Withdraw Retroflex Flex to Left Flex to Right Anteflex Mid.Ant line rotation

  17. ME Asc Aortic SAXAngle: 10-30 degreesDiagnostic Uses: aortic atherosclerosis, aortic dissection/ dilation, PA pathology (emboli)

  18. ME Asc Aortic LAXAngle: 100 degreesDiagnostic Uses: aortic atherosclerosis, aortic dissection, asc aortic dilation Right Pulmonary A. Ascending Aorta

  19. ME AV SAXAngle:25-45 degreesDiagnostic Uses: aortic stenosis, valve morphology NCC LCC RCC

  20. ME RV Inflow-OutflowAngle: 50-70 degreesDiagnostic Uses: PV disease, PA pathology, RVOT pathology

  21. ME BicavalAngle: 105-120 degrees +/- rightward rotationDiagnostic Uses: right atrial free wall, SVC, interatrial septum, IVC

  22. Positive Bubble Study

  23. ME AV LAXAngle: 115-130degreesDiagnostic Uses: AV pathology, aorta pathology, LVOT pathology

  24. ME four chamberAngle:0-10 degrees Diagnostic Uses: ASD, chamber enlargement/dysfxn, LV regional wall motion abnml,mitral dz, tricsupid dz, intracardiac Lateral Wall Septal Wall

  25. Mitral Valve

  26. ME Mitral CommissuralAngle: 60-75 degreesDiagnostic Uses: localization of mitral valve pathology P3 P1 A2

  27. ME two chamberAngle:80-100degreesDiagnostic Uses: left atrial appendage mass/thrombus,LV apex pathologyLV systolic fxn/RWM Coronary Sinus A3A2A1 P3

  28. ME LAXAngle: 110-130 degreesDiagnostic Uses: MV pathology, LVOT pathology, LV RWM abnml A2 P2 Anteroseptal Wall Posterior Wall

  29. TG Basal SAXAngle: 0 degrees +/- anteflexionDiagnostic Uses: LV systolic dysfunction, MV pathology Posterior Leaflet Anterior Leaflet

  30. TG Mid(pap) SAXAngle:0 degrees w/ anteflexionDiagnostic Uses: hemodynamic instability, LV dilation/hypertrophy, LV systolic function, LV RWM

  31. Transgastric Two ChamberAngle: 90 degreesDiagnostic Uses: LV systolic dysfunction (ant/inf walls) InferiorWall Inferior (ant) Anterior Anterior Wall

  32. TG LAXAngle: 110-130 degrees +/- left rotationDiagnostic Uses: LV systolic dysfunction, doppler AV AV

  33. TG RV InflowAngle: 110-130 degrees + right rotationDiagnostic Uses: RV systolic fxn, tricuspid pathology Tricuspid Valve RA RV

  34. Deep TG LAXAngle: 0 degrees + anteflexionDiagnostic Uses: AV pathology, LVOT pathology, doppler AV

  35. Desc Aortic SAXAngle: 0 degreesDiagnostic Uses: aortic atherosclerosis, aortic dissection

  36. Desc Aortic LAXAngle: 90 degreesDiagnostic Uses: aortic atherosclerosis, aortic dissection, IABP placement

  37. UE Aortic Arch LAXAngle: 0 degrees + rightward rotationDiagnostic Uses: aortic atherosclerosis/dissection, measure distal asc aorta Aortic Arch

  38. UE Aortic Arch SAXAngle: 90 degreesDiagnostic Uses: aortic atherosclerosis/dissection Aortic Arch Pulmonary Artery Pulmonic Valve

  39. References • Fleisher, et al. Intraoperative TEE. Philadelphia: Elsevier, 2008 • Perrino, et al. A Practical Approach to Transesophageal Echo. Philadelphia: Lippincott, 2008 • Peak. Nuts and Bolts of Ultrasound Physics. Houston, 2006 • Riedel. Guidelines for Performing a Comprehensive Intraoperative Multiplane TEE exam. Houston, 2006 • Shanewise, et al. ASE/SCA Intraoperative TEE Guidelines. Anethes Analg 1999:89:870-84 • Sidebotham. Practical Perioperative TEE. London: Butterworth Heinmann, 2003

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