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Presentation on theme: "INSTRUMENTATION & BASIC VIEWS"— Presentation transcript:


2 References : Recommendations for Performing TEE …. A. Flachskampf… euje.2000 A systematic approach to performing a comprehensive TEE…A call to order…. Avinash A et. al …. BMC Cardiovascular Disorders 2009 TEE Multimedia Manual .. André Y. Denault, Pierre Couture TEE….. Partho P Sengupta …..HEART 2005 TEE Study Guide and Practice Questions ….Dr Andrew Roscoe Virtual TEE Website … Toronto general hospital Otto: The Practice of Clinical Echocardiography ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for TTE & TEE…..jacc 2007

3 HISTORY Side and Gosling (1971) …. TEE for CwD of cardiac flow Frazin et al (1976) …. TEE M mode echo Hisanaga et al (1977) illustrated the use of cross sectional real time imaging

4 Invasive technique USG probe closer to heart & great vessels … allows the use of high frequency transducers [better resolution] Monoplane  Biplane  Multiplane Focus 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

5 ADVANTAGES OF TEE Transducer mm from heart Closer to posterior structures…. Better visualization of LA, LAA, PV, MV, LV, Aorta Far from surgical area … Intra-operative monitoring High 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, instrumentation needs orientation and expertise

6 Assessment of a suspected cardioembolic event;
INDICATIONS Assessment of prosthetic valves; infective endocarditis ; native valve disease Assessment of a suspected cardioembolic event; Assessment of cardiac tumors ; Assessment of atrial septal abnormalities ; Assessment of aortic dissection; Evaluation of CHD; CAD ;pericardial disease Evaluation of critically ill patients Intraoperative monitoring Monitoring during interventional procedures Nondiagnostic TTE

7 CONTRAINDICATIONS ABSOLUTE Oesophageal stricture or obstruction Suspected or known perforated viscus Instability of cervical vertebrae GI bleeding not evaluated RELATIVE Esophageal varices or diverticula Cervical arthritis Oropharyngeal distortion Bleeding diathesis or over-anticoagulation

8 PROCEDURE 4- 6 hours fasting Written consent Intravenous line ; oxygen ; suction equipment ; Remove denture or devices ; 2% lidocaine spray ECG must be monitored throughout Left lateral position Introduce the probe with some anteflexion through a bite block Routine 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

9 Complications 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.

10 TEE Probe : Modification of standard gastroscope, with transducers in place of fibreoptics Conventional rotary controls with inner and outer dials Inner dial guides anteflexion and retroflexion Outer dial controls medial and lateral movement Multiplane probe has a lever control to guide rotation Monoplane TEE provides images in horizontal plane only With biplane orthogonal longitudinal plane also Multiplane 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

11 Standard 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)

12 Proceed 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…..

13 Transducer manipulation options: [video…tee simulation]
[1] Advancement/withdrawal (for inferior or superior structures respectively) [2] Rotation (clockwise to view rightward structures and counter- clockwise for leftward structures)

14 [3] Anteflexion and retroflexion of the probe shaft (to view structures towards the heart base or towards the apex) [4] Leftward and rightward flexion of the probe shaft (used infrequently with the advent of multiplane probes) [5] Electronic image plane rotation (0–1800)

15 TEE probe orientation :

16 By convention, in TEE, the tip of the 2D sector is displayed on top of the screen and left-sided cardiac structures appear on the right side of the display.


18 ASE & SCA recommend 20 views for a comprehensive TEE.

19 Mid 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 LV Assess : Chamber size; Ventricular function; Mitral Valve disease; Tricuspid Valve disease; Atrial Septal Defect; Pericardial Effusion

20 ME 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 apex Assess : LAA mass/thrombus; LV size and function; MV disease (A1, A2 & P3 scallops); MV annulus measurement ‘Coumadin ridge’… between LAA & LUPV

21 ME 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.

22 ME 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.

23 ME 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 symmetric Withdraw probe for coronary ostia Advance probe for LVOT Assess : AV disease, OS ASD, LA size, Coronary artery pathology

24 ME 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 symmetric Assess : MV disease, AV disease, Aortic Root dimensions & pathology, LVOT pathology, VSD

25 ME 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 view For : P Valve / PA / RVOT /TV pathology VSD

26 ME BCV(90°) : Find ME 2 C (90°) Turn the entire probe right Change angle or rotate probe slightly to image both the IVC (left) and SVC (right) simultaneously For : ASD (secundum, sinus venosus), Atrial pathology, Lines/wires, Venous Cannula (SVC, IVC)

27 ME 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 probe Near field image of the circular aorta represents the right anterior wall of the aorta For : Aortic Pathology Color flow reversal: AI severity IABP position

28 ME DA LAX(90°) : Fro m ME DA SAX…. Rotate to 900 … Aortic walls appear in parallel Distal aorta is to the display left and the proximal aorta to the display right.

29 TG 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

30 TG 2C 90° : From mid TG SAX (0°) .. Rotate omniplane angle to 90°.. Anteflex until LV is horizontal Imaging 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

31 TG Basal SAX(0°) : From TG mid SAX view … Withdraw the probe until MV is seen in SAX … Aim to see symmetric MV commissures Views MV (with A3 & P3) that is parallel to the annulus For : LV size, function ; VSD ; MV planimeter orifice area

32 TG 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

33 Deep 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 display For: Paravalvular leak prosthetic aortic valve ; AV gradient spectral doppler ; LVOT gradient spectral doppler

34 TG 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 horizontal Imaging 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

35 UE 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 right Imaging 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

36 UE 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 view Imaging plane is directed thru the transverse aortic arch in SAX and the pulmonary artery in LAX. For : Aortic Arch pathology, Pulmonic Valve disease, PDA

37 ME 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 symmetric Imaging plane is directed thru the right pulmonary artery to image the proximal ascending aorta in LAX. For: Aortic pathology, Pericardial effusion, Pulmonary embolus

38 ME 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 pathology PDA, Swan-Ganz in SVC



41 MCQs

42 (1)TEE – multiplane probe @ 1350 roughly corresponds to :
a)Parallel to the ascending aorta b)Parallel to Long-axis view of cardiac structures (LV and LVOT) c)Parallel to Cardiac short axis d)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

44 (3)Identify this view : (a)UE Aortic arch LAX (b)ME Asc Aorta LAX
(c)ME Asc Aorta SAX (d)UE Aortic arch SAX

45 (4)Identify the view : (a)ME 2C (b)ME LAX (c)ME mitral commissural (d)ME RV inflow

46 (5)Identify the valve marked as ‘X’:
(a)Mitral (b)Tricuspid (c)Aortic (d)Pulmonary

47 (6)Identify the structure :
(a)Asc aorta (b)Desc aorta (c)Aortic arch (d)MPA

48 (7)Identify the ventricular wall :
(a)Anterior (b)Inferior (c)Anteroseptal (d)Anterolateral

49 (8)Not a contraindication for TEE :
(a)Stricture esophagus (b)Patient on anticoagulation (c)Esophageal diverticulum (d)Clear fluids taken with in 2 hrs of TEE

50 (9)TEE won’t show you a part of :
(a)Asc aorta (b)Aortic root ©Arch of aorta (d)Descending thoracic aorta

51 (10)The structure which is indicated by ‘X’ :
(a)RPA (b)Subclavian artery (c)SVC (d)IVC



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