Presentation on theme: "INSTRUMENTATION & BASIC VIEWS"— Presentation transcript:
1INSTRUMENTATION & BASIC VIEWS TEEINSTRUMENTATION & BASIC VIEWSDr. Sony Manuel MSenior ResidentMCH KOZHIKODE
2References :Recommendations for Performing TEE …. A. Flachskampf… euje.2000A systematic approach to performing a comprehensive TEE…A call to order…. Avinash A et. al …. BMC Cardiovascular Disorders 2009TEE Multimedia Manual .. André Y. Denault, Pierre CoutureTEE….. Partho P Sengupta …..HEART 2005TEE Study Guide and Practice Questions ….Dr Andrew RoscoeVirtual TEE Website … Toronto general hospitalOtto: The Practice of Clinical EchocardiographyACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for TTE & TEE…..jacc 2007
3HISTORYSide and Gosling (1971) …. TEE for CwD of cardiac flowFrazin et al (1976) …. TEE M mode echoHisanaga et al (1977) illustrated the use of cross sectional real time imaging
4Invasive techniqueUSG probe closer to heart & great vessels … allows the use of high frequency transducers [better resolution]Monoplane Biplane MultiplaneFocus initially on the primary area of interest & then do a comprehensive examination [except in emergency settings]Almost all views obtained by TTE can be duplicated by TEE
5ADVANTAGES OF TEETransducer mm from heartCloser to posterior structures…. Better visualization of LA, LAA, PV, MV, LV, AortaFar from surgical area … Intra-operative monitoringHigh resolution images : [Absence of intervening lung or bone tissue……Better signal to noise ratio and decreased image depth – allows use of higher freq (5 and 7 MHz) transducers – enhances image quality]DISADVANTAGES:semi invasive procedure: chances of injury ;needs special setup, technique, preparation, instrumentationneeds orientation and expertise
6Assessment of a suspected cardioembolic event; INDICATIONSAssessment of prosthetic valves; infective endocarditis ; native valve diseaseAssessment of a suspected cardioembolic event;Assessment of cardiac tumors ;Assessment of atrial septal abnormalities ;Assessment of aortic dissection;Evaluation of CHD; CAD ;pericardial diseaseEvaluation of critically ill patientsIntraoperative monitoringMonitoring during interventional proceduresNondiagnostic TTE
7CONTRAINDICATIONSABSOLUTEOesophageal stricture or obstructionSuspected or known perforated viscusInstability of cervical vertebraeGI bleeding not evaluatedRELATIVEEsophageal varices or diverticulaCervical arthritisOropharyngeal distortionBleeding diathesis or over-anticoagulation
8PROCEDURE4- 6 hours fastingWritten consentIntravenous line ; oxygen ; suction equipment ; Remove denture or devices ; 2% lidocaine sprayECG must be monitored throughoutLeft lateral positionIntroduce the probe with some anteflexion through a bite blockRoutine antibiotic prophylaxis before TEE is not advocated [ risk of IE is extremely low]..Recommended in high risk patients ….prosthetic valves, multivalvar involvement or those with a past h/o IE]Persistent resistance to advancing the instrument mandates termination of TEE and endoscopy should be performed before re-examination.After each TEE … Disnfect ; Check for any damage…ensure electrical safety
9Complications Majority are minor. Major complications [death, laryngospasm, sustained VT & CHF occur in ≈ 0.3% of patients]Cardiac complications include SVT or AF, VT, bradycardia, transient hypotension or hypertension, angina ,CHF and pulmonary edema.
10TEE Probe :Modification of standard gastroscope, with transducers in place of fibreopticsConventional rotary controls with inner and outer dialsInner dial guides anteflexion and retroflexionOuter dial controls medial and lateral movementMultiplane probe has a lever control to guide rotationMonoplane TEE provides images in horizontal plane onlyWith biplane orthogonal longitudinal plane alsoMultiplane TEE transducer : single array of crystals [phased array transducers with piezoelectric elements] that can be electronically and mechanically rotated in an arc of 180 °to produce a continuum of transverse and longitudinal images from a single probe position
11Standard imaging plane levels (from the incisors): upper or high esophageal (25–28 cm)mid-esophageal (29–33 cm)gastroesophageal junction (34–37 cm)transgastric (38–42 cm)deep-transgastric (>42 cm)
12Proceed systematically… Proceed systematically….. from mid esophagus [≈35 cms from the incisors] to gradually more distal esophagus, fundus of the stomach after gentle advancement across the cardia [≈40-50 cms from incisors] and ﬁnally slow withdrawal of the probe for complete scan of the thoracic aorta [from high esophageal views].A complete TEE exam usually takes 15–20 min.An abbreviated or problem-focused TEE study may be appropriate in unstable or uncooperative patients…..
13Transducer manipulation options: [video…tee simulation]  Advancement/withdrawal (for inferior or superior structures respectively) Rotation (clockwise to view rightward structures and counter- clockwise for leftward structures)
14 Anteﬂexion and retroﬂexion of the probe shaft (to view structures towards the heart base or towards the apex) Leftward and rightward ﬂexion of the probe shaft (used infrequently with the advent of multiplane probes) Electronic image plane rotation (0–1800)
18ASE & SCA recommend 20 views for a comprehensive TEE.
19Mid Esophagus 4C (0°):position the probe in the mid-esophagus behind the LA. The imaging plane is directed thru the LA, center of the MV and apex of the LVAssess :Chamber size; Ventricular function; Mitral Valve disease; Tricuspid Valve disease; Atrial Septal Defect; Pericardial Effusion
20ME 2C(90°):From ME 4C : Keep the probe tip still and the MV in the center; Rotate omniplane angle forward to °; RA + RV disappear, LAA appears.Retroflex probe tip for true LV apex; adjust depth to see entire LV apexAssess : LAA mass/thrombus; LV size and function; MV disease (A1, A2 & P3 scallops); MV annulus measurement‘Coumadinridge’…betweenLAA & LUPV
21ME Mitral Commissural View(60°): From ME 4C : Keep the probe tip still and MV in the center; Rotate omniplane angle forward to 45-60°;RA,RV disappear,retroflex slightly for LV apex;Imaging plane is directed thru the LA to image the LA, MV and LV apex.The MV is imaged with the P3 scallop (left), P1 scallop (right) and AMVL (usually A2) in the middle forming the intermittently seen "trap door".Assess : MV disease, LV function, LA pathology.
22ME LAX(120°) :Rotate omniplane angle forward to °Imaging plane is directed thru the LA to image the aortic root in LAX and entire LV. The more cephalad structures are lined up on the display right.The LV anteroseptal + inferolateral walls & MV segments, A2 and P2 are seen.Assess : LV function, MV disease, AV and Aortic Root disease, IVS pathology.
23ME AV SAX (30-45°) :From ME 4C (0°) withdraw cephalad to obtain the ME 5C(0°) [Imaging plane is directed thru the LA and aligned parallel to the AV annulus] Rotate to 30-45°; Center aortic valve and aim to make 3 aortic valve cusps symmetricWithdraw probe for coronary ostiaAdvance probe for LVOTAssess : AV disease, OS ASD, LA size, Coronary artery pathology
24ME AV LAX(120°) :From ME AV SAX (30-60°), rotate to °LVOT, AV, proximal ascending Aorta line up.Optimize aortic annulus and make the sinuses of Valsalva symmetricAssess : MV disease, AV disease, Aortic Root dimensions & pathology,LVOT pathology, VSD
25ME RVIO (60-75°)View:From ME AV SAX (30-60°)Rotate the omniplane angle to 60-75°Optimize TV leaflets, open up RVOT,bring PV + main PA into viewFor : P Valve / PA / RVOT /TV pathologyVSD
26ME BCV(90°) :Find ME 2 C (90°)Turn the entire probe rightChange angle or rotate probe slightly to image both the IVC (left) and SVC (right) simultaneouslyFor : ASD (secundum, sinus venosus), Atrial pathology, Lines/wires,Venous Cannula (SVC, IVC)
27ME DA SAX(0°) :Insert the probe to the ME, sector depth 10-12cm, angle 0°;Turn probe to left to find the aorta; Put aorta in middle of display ;Decrease depth to 5cm; Advance + withdraw probeNear field image of the circular aorta represents the right anterior wall of the aortaFor :Aortic PathologyColor flow reversal: AI severityIABP position
28ME DA LAX(90°) :Fro m ME DA SAX…. Rotate to 900 … Aortic walls appear in parallelDistal aorta is to the display left and the proximal aorta to the display right.
29TG mid SAX(0°) :Advance probe until you see stomach (rugae) or liver… Anteflex to contact stomach wall and inferior wall of heart .. Center LV by turning probe R or L .. Image both papillary muscles .Imaging plane ….. transversely thru the mid inferior wall of the LV with all 6 mid LV segments viewed at once from the stomach.For: Left Ventricle size, function, IVS motion, VSD, Pericardial effusion
30TG 2C 90° :From mid TG SAX (0°) .. Rotate omniplane angle to 90°.. Anteflex until LV is horizontalImaging plane ….transversely thru the inferior wall of the LV and subvalvular structures of the mitral valve from the stomach.For : LV function , Mitral Valve subvalvular pathology
31TG Basal SAX(0°) :From TG mid SAX view … Withdraw the probe until MV is seen in SAX … Aim to see symmetric MV commissuresViews MV (with A3 & P3) that is parallel to the annulusFor : LV size, function ; VSD ; MV planimeter orifice area
32TG LAX ( °) :From TG 2 chamber (90°) … Rotate omniplane angle to °Imaging plane is directed longitudinally thru the LV to image the aortic root in LAX.For : MV Pathology ,VSD, LV systolic function, Aortic Valve: spectral and color doppler,LVOT: spectral and color doppler
33Deep TG LAX(0°) :From mid or apical TG SAX view, anteflex and gently advance probe, hugging the stomach mucosa until the LV apex is seen at the top of the displayFor: Paravalvular leak prosthetic aortic valve ; AV gradient spectral doppler ; LVOTgradient spectral doppler
34TG RV inflow(90°):From mid TG SAX (0°) turn probe right to put RV in center … Rotate omniplane angle to 90°… Anteflex until RV is horizontalImaging plane is directed longitudinally thru the posterior RV wall to reveal a long axis view of the RV, with the apex of the RV to the display left and the anterior free wall in the far field.For : RV function; Tricuspid Subvalvular /TV pathology
35UE Aortic Arch LAX (0°):From ME(0°)… ME Descending Aorta SAX (0°) view… Withdraw probe until aorta changes into oval shape…Turn probe slightly to the rightImaging plane is directed thru the longitudinal axis of the transverse aortic arch. The circular shape of the DA changes to an oblong shape of the transverse aortic arch (0°)For : Aortic Pathology
36UE Aortic Arch SAX(60-90°): From UE Aortic Arch LAX (0°) view…. Rotate the omniplane angle to 60-90°…. Bring the pulmonic valve and pulmonary artery in viewImaging plane is directed thru the transverse aortic arch in SAX and the pulmonary artery in LAX.For : Aortic Arch pathology, Pulmonic Valve disease, PDA
37ME Asc A LAX(90°) :Find the ME AV LAX (120°)… Withdraw the probe to bring the right pulmonary artery in view ..Decrease omniplane angle slightly by 10-20° to make the aortic wall symmetricImaging plane is directed thru the right pulmonary artery to image the proximal ascending aorta in LAX.For: Aortic pathology, Pericardial effusion, Pulmonary embolus
38ME Asc A SAX(0°):From ME AV LAX (120°) OR From ME AV SAX (30°)…. withdraw probe (asc aorta ), rotate the omniplane angle back to 0°Imaging plane is directed slightly above the aortic valve thru the RPA(seen in LAX), ascending aorta (seen in SAX) and SVC (SAX).For : PA pathology, Pulmonary Embolus, Ascending Aorta pathologyPDA, Swan-Ganz in SVC
42(1)TEE – multiplane probe @ 1350 roughly corresponds to : a)Parallel to the ascending aortab)Parallel to Long-axis view of cardiac structures (LV and LVOT)c)Parallel to Cardiac short axisd)Parallel to probe long axis
43(2)Identify the structure marked as ‘X’ (a)Asc aorta(b)Des aorta(c)Arch of aorta(d)Pulmonary artery