Transesophageal echocardiography

TRANSESOPHAGEAL ECHOCARDIOGRAPHY

NEERAJ VARYANI

In 1987, TEE was introduced at Mayo Clinic Rochester.

Accounts for 5-10% of all echocardiography studies.

Semi-invasive procedure. Skillful physician and experienced

sonographer making it extremely safe and well tolerated.

Spacious room which can accommodate a stretcher, oxygen outlet and suction facilities, pulse oximeter and medications. Ensure I.V. access.

TEE probe (modified gastroesophageal endoscopy probe with 3-7 MHz transducer at tip) should be examined before use.

Diameter of transducer tip in adults and pediatric use are 9-14 mm and < 3 mm respectively.

Anterior flexion should exceed 90%, and right and left flexion should approach 90%.

Contact the patient 12 hours, and to fast for at least 4-6 hours before the procedure.

Patient should be accompanied due to effect of sedation.

A STANDARD TEE PROBE

PHOTO OF A TRANSDUCER AND CLOSE UP OF THE BODY OF A TRANSDUCER

Steering the imaging plane using pressure sensitive switch.

Manipulation of anterior-posterior and right-left flexion by control knobs.

TERMINOLOGY USED TO DESCRIBE THE MANIPULATION OF THE PROBE AND TRANSDUCER DURING IMAGE ACQUISITION.

Informed consent, explain transient abdominal discomfort and gagging.

Lidocaine hydrochloride spray for topical anesthesia over pharynx and tongue, and diazepam 2-10mg, midazolam 0.05mg/kg I.V. for light sedation.

Infective endocarditis prophylaxis not required.

o Left lateral decubitus with head of bed elevated by ~30 to avoid aspiration ͦ(elective procedure) and supine position (mechanically ventilated patients).

o Remove dentures

o Patient’s head to be flexed

o Imaging surface of transducer faces tongue. Probe kept in central position to prevent entry into piriform fossa.

POSITIONING OF PATIENT,SONOGRAPHER ,NURSE AND PHYSICIAN FOR PERFORMING TEE

Gentle pressure and instruction to swallow.

If resistance ,withdraw and initiate new attempt.

Bite guard always used to prevent involuntary closure of mouth.

If nausea wait for 10 – 15 seconds and then proceed for imaging.

Start with images from esophagus before gastric views.

GE sphincter reached when probe advanced 40cm from incisor teeth.

Descending thoracic and arch of aorta reserved for the end of study as it causes gagging as probe is in upper esophagus.

Stridor or incessant cough indicates passage into trachea also probe would not advance beyond 30cm and image quality will be poor.

In intubated patients, introduce probe in supine position and mandible pulled forward, if resistance at 25 – 30 cms deflate ET tube cuff.

IMAGE FORMAT No general agreement.

Right sided structures are on the left and left sided on the right.

Apex of the imaging plane with artifact is at the top of the screen.

FOUR BASIC MANEUVERS Advancement and withdrawal : imaging

views are basal, four chamber, transgastric, and aortic views.

Rotation from side to side: useful in longitudinal imaging planes for continuity between vertically aligned structures, SVC and arch vessels.

BASAL VIEWS Probe: midesophagus

Visualizes :Base of heart particularly AV.

Relationship Of Two Great Arteries Till Pulmonary Bifurcation.

Proximal portions of left main and right coronary artery.

Left atrial appendage and left pulmonary veins.

Short-axis view of ascending aorta and main pulmonary artery (MPA), with bifurcation and origin of right pulmonary artery (RPA), from the upper transoesophageal window.

F.A. Flachskampf et al. Eur J Echocardiogr 2010;11:557-576

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: [email protected]

MID-ESOPHAGEAL AV SHORT AXIS VIEW

Transverse view of upper left atrium.



Horizontal plane for 4 pulmonary veins.

Right and left atrial appendages wrap around great arteries anteriorly. Their corrugated endocardial surface can be confused with small thrombi.

150 rightward plane for dilated and tortuous ͦascending aorta.

Long-axis view of the ascending aorta.



ATRIAL SEPTUM

Longitudinal plane at 90-120 for fossa ovalis, ͦ SVC to RA continuity , sinus venosus ASD, foramen ovale at superior aspect of fossa ovalis and left- right rotation for LVOT and RVOT.

Left and right atrium and atrial septum in longitudinal (sagittal) view.



PULMONARY BIFURCATIONo Withdrawal of probe and at 0 . ͦ

o Pulmonary valve (thinner) and artery are superior to aortic valve.

o Entire right and very proximal left pulmonary artery is visualized ( for proximal pulmonary emboli).

FOUR CHAMBER VIEW Middle to low esophagus.

Gentle retroflexion with withdrawal for left ventricle.

For dilated and unfolded aorta rotate by 20-30 .ͦ

Inferior septum and anterolateral wall of LV and continuous sweep from 0-180 for LV ͦglobal and regional function.

Low transoesophageal view of right ventricle (RV), right atrium (RA), and tricuspid valve.



Mitral valve Continuous sweep from 0-180 for scallops of ͦ

anterior and posterior leaflets at long axis view of aortic valve and proximal ascending aorta at 120 . ͦ

Papillary muscles and subvalvular chords visualized ( better in transgastric view).

Four chamber view ideal for MR assessment ( number of jets, direction and severity).

A MID ESOPHAGEAL, FOUR-CHAMBER VIEW SUPERIMPOSED WITH COLOR FLOW DOPPLER SHOWING MITRAL REGURGITATION. THE VENA CONTRACTA (VC) DEPICTS THE REGURGITANT ORIFICE.

LVOT

o At 120-160 , opening and closing of AV and ͦAR assessment, also proximal ascending aorta on slight withdrawal.

o Slight rotation to left for pulmonary valve and RVOT and assessment of PR.

Transoesophageal long-axis view of the left ventricle.



TRANSGASTRIC VIEWS

Slight resistance and liver indicates probe in stomach.

Anterior flexion, leftward rotation and flexion.

Extreme anterior flexion with advancement of probe for 5 chamber view.

LVo Cross section view for intraoperative LV

function optimized by leftward rotation and leftward flexion.

o For LV apex gentle advancement with retroflexion.

o leftward rotation for LVOT and aortic valve alignment for transaortic pressure gradient in AS.

Transgastric short-axis view of the left (LV) and right ventricle (RV).



DEEP TRANSGASTRIC TEE VIEWS OF THE LV OUTFLOW TRACT AT 0° (UPPER PANEL) AND 120° (LOWER PANEL).

Transgastric two-chamber view.



MV: transducer brought close to GE junction with horizontal imaging with anterior flexion and leftward flexion.

Should be attempted in all patients with myxomatous degeneration.

Papillary muscles and chords.

Coronary sinus: near GE junction and flexion knobs in neutral position also by retroflexion in lower esophagus.

Short-axis view of the open mitral valve from the transgastric position.



Transoesophageal two-chamber view.



TRANSGASTRIC MID-PAPILLARY SHORT AXIS VIEW. IN PANEL A THE SEPTAL AND LATERAL WALL AREAS ARE POORLY DEFINED. IN PANEL B BOTH WALL REGIONS ARE ADEQUATELY IMAGED BY INCREASING THE LATERAL GAIN.

CS located posterior to LV at AV groove draining into RA with TV to the right and anterior.

Dilated CS indicates PLSVC which is the most common cause which is visualized with leftward rotation following CS.

In esophageal views PLSVC is sandwiched between LAA and LSPV.

AORTIC VIEWS

Descending thoracic aorta: in horizontal plane with transducer rotated leftward and posterior followed by slow withdrawal from diaphragm to aortic arch with slight rotational adjustment.

Dilated and tortuous aorta adjust imaging plane by 0-90 . ͦ

THE VARIOUS HORIZONTAL AND LONGITUDINAL VIEWS OF THE AORTA THAT CAN BE OBTAINED WITH TEE

Aortic Arch: longitudinal plane at 90 . ͦ

Withdraw slightly for arch vessels( all 3 visualized in one-third patients). Brachiocephalic artery being most difficult due to rightward and anterior location and interposing trachea.

Proximal pulmonary artery seen in suspected PTE.

DOPPLER EXAMINATION No additional information over TTE. EXCEPT:

LAA FLOW: imaged from midesophagus aortic valve short axis view( 30 to 60 ) or ͦmidesophagus two chamber view(80 to 100 ). ͦ

In AF regular atrial contraction wave is absent.

In atrial flutter velocity waves are regular and greater due to slower atrial rate.

Normal LAA velocity: contraction (60±14cm/s),filling (52±13cm/s) and early diastolic filling(20±11cm/s).

In AF with LAA velocity <20cm/s more likely have LA

thrombus and 2.6 fold greater risk of ischemic stroke compared to patient’s with velocity > 20cm/s.

Lower LAA velocity also seen in stroke patients in sinus rhythm.

LAA velocity may predict successful cardioversion of AF and maintenance of sinus rhythm at 1 year.

(A) Left atrial appendage.



PULMONARY VEIN FLOW: Evaluating LV diastolic function MR assessment Differentiating constrictive pericarditis from

restrictive cardiomyopathy Identifying pulmonary vein stenosis after RF

ablation for AF.

Left: left upper pulmonary vein (LUPV) imaged in an approximately longitudinal view.



INDICATIONS FOR TEE Nondiagnostic TTE Evaluation of native valve disease Evaluation of prosthetic valves Evaluation of suspected and definite IE Evaluation of suspected cardioembolic

event(35%) Evaluation of cardiac tumors and masses Evaluation of a atrial septal abnormality Evaluation of acute aortic syndrome or aortic

disease

LEFT: TRANSESOPHAGEAL ECHOCARDIOGRAPHIC VIEW OF A PATIENT WITH SEVERE MITRAL REGURGITATION DUE TO A FLAIL POSTERIOR LEAFLET. THE ARROW POINTS TO THE PORTION OF THE POSTERIOR LEAFLET THAT IS UNSUPPORTED AND MOVES INTO THE LEFT ATRIUM DURING SYSTOLE. RIGHT: COLOR-FLOW IMAGING DEMONSTRATING A LARGE MOSAIC JET OF MITRAL REGURGITATION DURING SYSTOLE.

TRANSESOPHAGEAL STILL-FRAME ECHOCARDIOGRAPHIC VIEW OF A PATIENT WITH A DILATED AORTA, AORTIC DISSECTION, AND SEVERE AORTIC REGURGITATION. THE ARROW POINTS TO THE INTIMAL FLAP THAT IS SEEN IN THE DILATED ASCENDING AORTA. LEFT: THE LONG-AXIS APEX-DOWN VIEW OF THE BLACK-AND-WHITE TWO-DIMENSIONAL IMAGE IN DIASTOLE. RIGHT: COLOR-FLOW IMAGING THAT DEMONSTRATES A LARGE MOSAIC JET OF AORTIC REGURGITATION

A 3D ZOOM MODE IMAGE ROTATED TO DISPLAY THE SURGEONS VIEW FROM THE LEFT ATRIUM ONTO THE MITRAL VALVE, WITH A P2 PROLAPSE AND RUPTURED CHORDAE TENDINAE (RC)

Atrial fibrillation ( TEE-guided strategy for “early” cardioversion) (34%)

Evaluation of naïve and surgically corrected congenital heart disease

Detection of coronary artery anomalies and coronary artery disease

Evaluation of postoperative cardiac tamponade and pericardial disease

Evaluation of the critically ill patient Intraoperative monitoring Guidance of interventional procedures

TRANSESOPHAGEAL STILL-FRAME ECHOCARDIOGRAPHIC IMAGES OF A PATIENT WITH A LEFT ATRIAL MYXOMA. THERE IS A LARGE ECHO-DENSE MASS IN THE LEFT ATRIUM, ATTACHED TO THE ATRIAL SEPTUM. THE MASS MOVES ACROSS THE MITRAL VALVE IN DIASTOLE

CONTRAINDICATIONS TO TEE ABSOLUTE Uncooperative patient Severe respiratory depression Tenuous cardiorespiratory status Esophageal obstruction (stricture, mass) Esophagectomy or esophagogastrectomy Tracheoesophageal fistula Perforated viscus Active upper gi bleed

RELATIVE Esophageal diverticulum Esophageal varices Previous esophageal surgery History of dysphagia Recent upper gi bleed Severe cervical arthritis with restricted

mobility Atlantoaxial joint disease with restricted

mobility Severe Coagulopathy

PROCEDURAL COMPLICATIONS WITH TEE

MAJORo Deatho Esophageal rupture/perforationo Upper gi bleedo Laryngospasm or bronchospasmo Congestive heart failure or pulmonary edemao Sustained ventricular tachycardia

MINORo Excessive retching or vomitingo Sore throat and Hoarsenesso Minor pharyngeal or lip bleedingo Nonsustained or sustained supraventricular

tachycardia/atrial fibrillation, NSVT and Bradycardia or heart block

o Transient hypotension or hypertension and Angina

o Transient hypoxiao Tracheal intubationo Dental injury

1.9% failed esophageal intubation during TEE. Complications occur in 3.5% patients ,

predominantly minor. 0.2-0.5% suffer major complication. < 0.01% TEE-related mortality. Recent review of 17 studies encompassing 42,355

patients identified only 4 TEE procedure deaths. Esophageal perforation and major upper GI

bleeding in 0.01% and 0.03% of TEE studies respectively.

Dental injuries in 0.03% patients.

Minor sore throat may be present for 24 hrs after TEE. 0.1% have persistent odynophagia requiring further

investigation and Laryngospasm in <0.02%. Topical anesthetic agents can cause acute toxic

methemoglobinemia, manifesting clinically in 0.115% of TEE studies.

Agents oxidizes hb and prevents oxygen delivery to tissues -cyanosis, lethargy, tachycardia, dyspnea, and death.

Methylene blue is indicated if methemoglobin levels >30%, or patient has cyanosis, CNS depression, or cardiorespiratory compromise.

Intraoperative TEE complication rate 2.4% (excluding failed intubations).

Transesophageal echocardiography

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