Introduction to Transesophageal EchocardiographyNakeisha 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
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
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
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
Doppler Flow
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*
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*
Contraindications to Intra-Operative TEE Esophageal disease – stricture, diverticuli, varices,
tumor Prior esophageal or stomach surgery Perforated viscus Difficulty passing the TEE probe Anticoagulation Thrombocytopenia Facial or airway trauma
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
Comprehensive TEE Exam 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
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
Comprehensive TEE Exam 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.
Orientation of the Heart
Comprehensive TEE Exam
Advance
Withdraw
Flex to Left
Anteflex
Retroflex
Flex to Right
Mid.Ant line rotation
ME Asc Aortic SAXAngle: 10-30 degrees
Diagnostic Uses: aortic atherosclerosis, aortic dissection/ dilation, PA pathology (emboli)
ME Asc Aortic LAXAngle: 100 degrees
Diagnostic Uses: aortic atherosclerosis, aortic dissection, asc aortic dilation
Ascending Aorta
Right Pulmonary A.
ME AV SAXAngle:25-45 degrees
Diagnostic Uses: aortic stenosis, valve morphology
NCC
LCC
RCC
ME RV Inflow-OutflowAngle: 50-70 degrees
Diagnostic Uses: PV disease, PA pathology, RVOT pathology
ME BicavalAngle: 105-120 degrees +/- rightward rotation
Diagnostic Uses: right atrial free wall, SVC, interatrial septum, IVC
Positive Bubble Study
ME AV LAXAngle: 115-130degrees
Diagnostic Uses: AV pathology, aorta pathology, LVOT pathology
ME four chamber Angle:0-10 degrees
Diagnostic Uses: ASD, chamber enlargement/dysfxn, LV regional wall motion abnml,mitral dz, tricsupid dz, intracardiac
Lateral Wall
Septal Wall
Mitral Valve
ME Mitral CommissuralAngle: 60-75 degrees
Diagnostic Uses: localization of mitral valve pathology
P1A2
P3
ME two chamberAngle:80-100degrees
Diagnostic Uses: left atrial appendage mass/thrombus,LV apex pathologyLV systolic fxn/RWM
A3A2A1
P3
Coronary Sinus
ME LAXAngle: 110-130 degrees
Diagnostic Uses: MV pathology, LVOT pathology, LV RWM abnml
A2P2
Anteroseptal Wall
Posterior Wall
TG Basal SAXAngle: 0 degrees +/- anteflexion
Diagnostic Uses: LV systolic dysfunction, MV pathology
Posterior Leaflet
Anterior Leaflet
TG Mid(pap) SAXAngle:0 degrees w/ anteflexion
Diagnostic Uses: hemodynamic instability, LV dilation/hypertrophy, LV systolic function, LV RWM
Transgastric Two ChamberAngle: 90 degrees
Diagnostic Uses: LV systolic dysfunction (ant/inf walls)
(ant)
Anterior Wall
Inferior WallInferior
Anterior
TG LAXAngle: 110-130 degrees +/- left rotation
Diagnostic Uses: LV systolic dysfunction, doppler AV
AV
TG RV InflowAngle: 110-130 degrees + right rotation
Diagnostic Uses: RV systolic fxn, tricuspid pathology
RARV
Tricuspid Valve
Deep TG LAXAngle: 0 degrees + anteflexion
Diagnostic Uses: AV pathology, LVOT pathology, doppler AV
Desc Aortic SAXAngle: 0 degrees
Diagnostic Uses: aortic atherosclerosis, aortic dissection
Desc Aortic LAXAngle: 90 degrees
Diagnostic Uses: aortic atherosclerosis, aortic dissection, IABP placement
UE Aortic Arch LAXAngle: 0 degrees + rightward rotation
Diagnostic Uses: aortic atherosclerosis/dissection, measure distal asc aorta
Aortic Arch
UE Aortic Arch SAXAngle: 90 degrees
Diagnostic Uses: aortic atherosclerosis/dissection
Aortic ArchPulmonary
Artery
Pulmonic Valve
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